Impact of Polypharmacy on Health-Related Quality of Life in Dialysis Patients

INTRODUCTION: Dialysis patients are often prescribed a large number of medications to improve metabolic control and manage coexisting comorbidities. However, some studies suggest that a large number of medications could also detrimentally affect patients' health-related quality of life (HRQoL). Therefore, this study aims to provide insight in the association between the number of types of medications and HRQoL in dialysis patients. METHODS: A multicentre cohort study was conducted among dialysis patients from Dutch dialysis centres 3 months after initiation of dialysis as part of the ongoing prospective DOMESTICO study. The number of types of medications, defined as the number of concomitantly prescribed types of drugs, was obtained from electronic patient records. Primary outcome was HRQoL measured with the Physical Component Summary (PCS) score and Mental Component Summary (MCS) score (range 0–100) of the Short Form 12. Secondary outcomes were number of symptoms (range 0–30) measured with the Dialysis Symptoms Index and self-rated health (range 0–100) measured with the EuroQol-5D-5L. Data were analysed using linear regression and adjusted for possible confounders, including comorbidity. Analyses for MCS and number of symptoms were performed after categorizing patients in tertiles according to their number of medications because assumptions of linearity were violated for these outcomes. RESULTS: A total of 162 patients were included. Mean age of patients was 58 ± 17 years, 35% were female, and 80% underwent haemodialysis. The mean number of medications was 12.2 ± 4.5. Mean PCS and MCS were 36.6 ± 10.2 and 46.8 ± 10.0, respectively. The mean number of symptoms was 12.3 ± 6.9 and the mean self-rated health 60.1 ± 20.6. In adjusted analyses, PCS was 0.6 point lower for each additional medication (95% confidence interval [95% CI]: −0.9 to −0.2; p = 0.002). MCS was 4.9 point lower (95% CI: −8.8 to −1.0; p = 0.01) and 1.0 point lower (95% CI: −5.1–3.1; p = 0.63) for the highest and middle tertiles of medications, respectively, than for the lowest tertile. Patients in the highest tertile of medications reported 4.1 more symptoms than in the lowest tertile (95% CI: 1.5–6.6; p = 0.002), but no significant difference in the number of symptoms was observed between the middle and lowest tertiles. Self-rated health was 1.5 point lower for each medication (95% CI: −2.2 to −0.7; p < 0.001). DISCUSSION/CONCLUSION: After adjustment for comorbidity and other confounders, a higher number of medications were associated with a lower PCS, MCS, and self-rated health in dialysis patients and with more symptoms

Health-related quality of life and symptom burden in patients on haemodialysis

BACKGROUND: Patients on haemodialysis generally experience poor health-related quality of life (HRQoL) and a broad range of physical and mental symptoms, but it is unknown whether this differs between younger and older patients. We aimed to describe the trajectories of HRQoL and symptom burden of patients &lt; 70 and ≥ 70 years old, and to assess the impact of symptom burden on HRQoL.METHODS: In incident Dutch haemodialysis patients, HRQoL and symptoms were measured with the 12-item Short Form Health Survey and Dialysis Symptom Index. We used linear mixed models for examining the trajectories of HRQoL and symptom burden during the first year of dialysis, and linear regression for the impact of symptom burden on HRQoL.RESULTS: In 774 patients, the trajectories of physical HRQoL, mental HRQoL, and symptom burden were stable during the first year of dialysis. Compared with patients aged &lt; 70 years, patients ≥ 70 years reported similar physical HRQoL (mean difference -0.61, 95% CI -1.86; 0.63), better mental HRQoL (1.77, 95% CI 0.54; 3.01), and lower symptom burden (-2.38, 95% CI -5.08; 0.32). With increasing symptom burden, physical HRQoL declined more in older than in younger patients (β -0.287 versus -0.189, respectively, p-value for interaction = 0.007). For mental HRQoL, this decrease was similar in both age groups (β -0.295 versus -0.288, P = 0.847).CONCLUSIONS: Older haemodialysis patients generally experience a better mental HRQoL and a (non-statistically significant) lower symptom burden, compared to younger patients. Their physical HRQoL declines more rapidly with increasing symptom burden.</p

End-stage kidney disease: towards shared decision-making and patient-reported outcomes

Over 12% of the Dutch population has chronic kidney disease. As chronic kidney disease progresses toward end-stage kidney disease, patients receive education on treatment options (kidney transplantation, dialysis, conservative care), with an increased focus on shared decision-making in recent years. This education process may lead to the choice of a form of dialysis, namely hemodialysis (dialysis through the bloodstream) or peritoneal dialysis (abdominal dialysis). Many studies have been done in the past on the risk of morbidity/mortality of dialysis patients, but there is increasing demand for studies on patient-reported outcomes, such as health-related quality of life. The aim of this thesis is to gain insights in (1) patient education and shared decision-making, (2) traditional clinical outcomes of dialysis such as bleeding, hospitalization, technique failure and peritoneal dialysis peritonitis, and (3) an important patient-reported outcome; health-related quality of life. Part I of this thesis shows that the commitment of healthcare professionals and availability of effective systems, that incorporate good practices, are vital for optimal patient education and shared decision-making. Part II shows that that the occurrence of certain ‘traditional’ clinical outcomes differs between dialysis modalities, with a higher bleeding risk for hemodialysis patients but a higher hospitalization risk for peritoneal dialysis patients, mainly related to infections. Moreover, peritoneal dialysis-related infections lead to a high technique failure rate, which calls for more attention to infection prevention or a different approach to the treatment of specific peritoneal dialysis-related infections. Part III shows that health-related quality of life is an important patient-reported outcome, but the effect of different dialysis modalities on health-related quality of life is not yet clear. In summary, this thesis shows a shifts toward shared decision-making and the importance of patient-reported outcomes for patients with end-stage kidney disease

Good practices for dialysis education, treatment, and eHealth: A scoping review

Background Recommendations regarding dialysis education and treatment are provided in various (inter)national guidelines, which should ensure that these are applied uniformly in nephrology and dialysis centers. However, there is much practice variation which could be explained by good practices: practices developed by local health care professionals, which are not evidence-based. Because an overview of good practices is lacking, we performed a scoping review to identify and summarize the available good practices for dialysis education, treatment, and eHealth. Methods Embase, Pubmed, the Cochrane Library, CINAHL databases and Web of Science were searched for relevant articles using all synonyms for the words 'kidney failure', 'dialysis', and 'good practice'. Relevant articles were structured according to the categories dialysis education, dialysis treatment or eHealth, and assessed for content and results. Results Nineteen articles (12 for dialysis education, 3 for dialysis treatment, 4 for eHealth) are identified. The good practices for education endorse the importance of providing complete and objective predialysis education, assisting peritoneal dialysis (PD) patients in adequately performing PD, educating hemodialysis (HD) patients on self-management, and talking with dialysis patients about their prognosis. The good practices for dialysis treatment focus mainly on dialysis access devices and general quality improvement of dialysis care. Finally, eHealth is useful for HD and PD and affects both quality of care and health-related quality of life. Conclusion Our scoping review identifies 19 articles describing good practices and their results for dialysis education, dialysis treatment, and eHealth. These good practices could be valuable in addition to guidelines for increasing shared-decision making in predialysis education, using patients' contribution in the implementation of their dialysis treatment, and advanced care planning. Copyright

Good practices for dialysis education, treatment, and eHealth: A scoping review

Background Recommendations regarding dialysis education and treatment are provided in various (inter)national guidelines, which should ensure that these are applied uniformly in nephrology and dialysis centers. However, there is much practice variation which could be explained by good practices: practices developed by local health care professionals, which are not evidence-based. Because an overview of good practices is lacking, we performed a scoping review to identify and summarize the available good practices for dialysis education, treatment, and eHealth. Methods Embase, Pubmed, the Cochrane Library, CINAHL databases and Web of Science were searched for relevant articles using all synonyms for the words 'kidney failure', 'dialysis', and 'good practice'. Relevant articles were structured according to the categories dialysis education, dialysis treatment or eHealth, and assessed for content and results. Results Nineteen articles (12 for dialysis education, 3 for dialysis treatment, 4 for eHealth) are identified. The good practices for education endorse the importance of providing complete and objective predialysis education, assisting peritoneal dialysis (PD) patients in adequately performing PD, educating hemodialysis (HD) patients on self-management, and talking with dialysis patients about their prognosis. The good practices for dialysis treatment focus mainly on dialysis access devices and general quality improvement of dialysis care. Finally, eHealth is useful for HD and PD and affects both quality of care and health-related quality of life. Conclusion Our scoping review identifies 19 articles describing good practices and their results for dialysis education, dialysis treatment, and eHealth. These good practices could be valuable in addition to guidelines for increasing shared-decision making in predialysis education, using patients' contribution in the implementation of their dialysis treatment, and advanced care planning. Copyright

Health-Related Quality of Life in Home Dialysis Patients Compared to In-Center Hemodialysis Patients: A Systematic Review and Meta-analysis

Rationale & Objective: Dialysis patients judge health-related quality of life (HRQoL) as an essential outcome. Remarkably, little is known about HRQoL differences between home dialysis and in-center hemodialysis (HD) patients worldwide. Study Design: Systematic review and meta-analysis. Setting & Study Populations: Search strategies were performed on the Cochrane Library, Pubmed, and EMBASE databases between 2007 and 2019. Home dialysis was defined as both peritoneal dialysis and home HD. Selection Criteria for Studies: Randomized controlled trials and observational studies that compared HRQoL in home dialysis patients versus in-center HD patients. Data Extraction: The data extracted by 2 authors included HRQoL scores of different questionnaires, dialysis modality, and subcontinent. Analytical Approach: Data were pooled using a random-effects model and results were expressed as standardized mean difference (SMD) with 95% CIs. Heterogeneity was explored using subgroup analyses. Results: Forty-six articles reporting on 41 study populations were identified. Most studies were cross-sectional in design (90%), conducted on peritoneal dialysis patients (95%), and used the 12-item or 36-item Short-Form Health Survey questionnaires (83%). More than half the studies showed moderate or high risk of bias. Pooled analysis of 4,158 home dialysis patients and 7,854 in-center HD patients showed marginally better physical HRQoL scores in home dialysis patients compared with in-center HD patients (SMD, 0.14; 95% CI, 0.04 to 0.24), although heterogeneity was high (I2>80%). In a subgroup analysis, Western European home dialysis patients had higher physical HRQoL scores (SMD, 0.39; 95% CI, 0.17 to 0.61), while home dialysis patients from Latin America had lower physical scores (SMD, −0.20; 95% CI, −0.28 to −0.12). Mental HRQoL showed no difference in all analyses. Limitations: No randomized controlled trials were found and high heterogeneity among studies existed. Conclusions: Although pooled data showed marginally better physical HRQoL for home dialysis patients, the quality of design of the included studies was poor. Large prospective studies with adequate adjustments for confounders are necessary to establish whether home dialysis results in better HRQoL. Trial Registration: PROSPERO 95985

Key elements in selection of pre-dialysis patients for home dialysis

Background: Most pre-dialysis patients are medically eligible for home dialysis, and home dialysis has several advantages over incentre dialysis. However, accurately selecting patients for home dialysis appears to be difficult, since uptake of home dialysis remains low. The aim of this study was to investigate which medical or psychosocial elements contribute most to the selection of patients eligible for home dialysis. Methods: All patients from a Dutch teaching hospital, who received treatment modality education and subsequently started dialysis treatment, were included. The pre-dialysis programme consisted of questionnaires for the patient, nephrologist and social worker, followed by an assessment of eligibility for home dialysis by a multidisciplinary team. Clinimetric assessment and logistic regression were used to identify domains and questions associated with home dialysis treatment. Results: A total of 135 patients were included, of whom 40 were treated with home dialysis and 95 with incentre haemodialysis. The key elements associated with long-term home dialysis treatment were part of the domains ‘suitability of the housing’, ‘self-care’, ‘social support’ and ‘patient capacity’, with adjusted odds ratios ranging from 0.13 for negative to 18.3 for positive associations. Conclusion: The assessment of contraindications by a nephrologist followed by the assessment of possibilities by a social worker or dialysis nurse who investigates four key elements, ideally during a home visit, and subsequent detailed education offered by specialized nurses is an optimal way to select patients for home dialysis

Key elements in selection of pre-dialysis patients for home dialysis

Background: Most pre-dialysis patients are medically eligible for home dialysis, and home dialysis has several advantages over incentre dialysis. However, accurately selecting patients for home dialysis appears to be difficult, since uptake of home dialysis remains low. The aim of this study was to investigate which medical or psychosocial elements contribute most to the selection of patients eligible for home dialysis. Methods: All patients from a Dutch teaching hospital, who received treatment modality education and subsequently started dialysis treatment, were included. The pre-dialysis programme consisted of questionnaires for the patient, nephrologist and social worker, followed by an assessment of eligibility for home dialysis by a multidisciplinary team. Clinimetric assessment and logistic regression were used to identify domains and questions associated with home dialysis treatment. Results: A total of 135 patients were included, of whom 40 were treated with home dialysis and 95 with incentre haemodialysis. The key elements associated with long-term home dialysis treatment were part of the domains ‘suitability of the housing’, ‘self-care’, ‘social support’ and ‘patient capacity’, with adjusted odds ratios ranging from 0.13 for negative to 18.3 for positive associations. Conclusion: The assessment of contraindications by a nephrologist followed by the assessment of possibilities by a social worker or dialysis nurse who investigates four key elements, ideally during a home visit, and subsequent detailed education offered by specialized nurses is an optimal way to select patients for home dialysis

Supplementary Material for: Impact of Polypharmacy on Health-Related Quality of Life in Dialysis Patients

Introduction: Dialysis patients are often prescribed a large number of medications to improve metabolic control and manage coexisting comorbidities. However, some studies suggest that a large number of medications could also detrimentally affect patients’ health-related quality of life (HRQoL). Therefore, this study aims to provide insight in the association between the number of types of medications and HRQoL in dialysis patients. Methods: A multicentre cohort study was conducted among dialysis patients from Dutch dialysis centres 3 months after initiation of dialysis as part of the ongoing prospective DOMESTICO study. The number of types of medications, defined as the number of concomitantly prescribed types of drugs, was obtained from electronic patient records. Primary outcome was HRQoL measured with the Physical Component Summary (PCS) score and Mental Component Summary (MCS) score (range 0–100) of the Short Form 12. Secondary outcomes were number of symptoms (range 0–30) measured with the Dialysis Symptoms Index and self-rated health (range 0–100) measured with the EuroQol-5D-5L. Data were analysed using linear regression and adjusted for possible confounders, including comorbidity. Analyses for MCS and number of symptoms were performed after categorizing patients in tertiles according to their number of medications because assumptions of linearity were violated for these outcomes. Results: A total of 162 patients were included. Mean age of patients was 58 ± 17 years, 35% were female, and 80% underwent haemodialysis. The mean number of medications was 12.2 ± 4.5. Mean PCS and MCS were 36.6 ± 10.2 and 46.8 ± 10.0, respectively. The mean number of symptoms was 12.3 ± 6.9 and the mean self-rated health 60.1 ± 20.6. In adjusted analyses, PCS was 0.6 point lower for each additional medication (95% confidence interval [95% CI]: −0.9 to –0.2; p = 0.002). MCS was 4.9 point lower (95% CI: −8.8 to –1.0; p = 0.01) and 1.0 point lower (95% CI: −5.1–3.1; p = 0.63) for the highest and middle tertiles of medications, respectively, than for the lowest tertile. Patients in the highest tertile of medications reported 4.1 more symptoms than in the lowest tertile (95% CI: 1.5–6.6; p = 0.002), but no significant difference in the number of symptoms was observed between the middle and lowest tertiles. Self-rated health was 1.5 point lower for each medication (95% CI: −2.2 to –0.7; p &lt; 0.001). Discussion/Conclusion: After adjustment for comorbidity and other confounders, a higher number of medications were associated with a lower PCS, MCS, and self-rated health in dialysis patients and with more symptoms

Impact of Polypharmacy on Health-Related Quality of Life in Dialysis Patients

Introduction: Dialysis patients are often prescribed a large number of medications to improve metabolic control and manage coexisting comorbidities. However, some studies suggest that a large number of medications could also detrimentally affect patients' health-related quality of life (HRQoL). Therefore, this study aims to provide insight in the association between the number of types of medications and HRQoL in dialysis patients. Methods: A multicentre cohort study was conducted among dialysis patients from Dutch dialysis centres 3 months after initiation of dialysis as part of the ongoing prospective DOMESTICO study. The number of types of medications, defined as the number of concomitantly prescribed types of drugs, was obtained from electronic patient records. Primary outcome was HRQoL measured with the Physical Component Summary (PCS) score and Mental Component Summary (MCS) score (range 0-100) of the Short Form 12. Secondary outcomes were number of symptoms (range 0-30) measured with the Dialysis Symptoms Index and self-rated health (range 0-100) measured with the EuroQol-5D-5L. Data were analysed using linear regression and adjusted for possible confounders, including comorbidity. Analyses for MCS and number of symptoms were performed after categorizing patients in tertiles according to their number of medications because assumptions of linearity were violated for these outcomes. Results: A total of 162 patients were included. Mean age of patients was 58 ± 17 years, 35% were female, and 80% underwent haemodialysis. The mean number of medications was 12.2 ± 4.5. Mean PCS and MCS were 36.6 ± 10.2 and 46.8 ± 10.0, respectively. The mean number of symptoms was 12.3 ± 6.9 and the mean self-rated health 60.1 ± 20.6. In adjusted analyses, PCS was 0.6 point lower for each additional medication (95% confidence interval [95% CI]:-0.9 to-0.2; p = 0.002). MCS was 4.9 point lower (95% CI:-8.8 to-1.0; p = 0.01) and 1.0 point lower (95% CI:-5.1-3.1; p = 0.63) for the highest and middle tertiles of medications, respectively, than for the lowest tertile. Patients in the highest tertile of medications reported 4.1 more symptoms than in the lowest tertile (95% CI: 1.5-6.6; p = 0.002), but no significant difference in the number of symptoms was observed between the middle and lowest tertiles. Self-rated health was 1.5 point lower for each medication (95% CI:-2.2 to-0.7; p < 0.001). Discussion/Conclusion: After adjustment for comorbidity and other confounders, a higher number of medications were associated with a lower PCS, MCS, and self-rated health in dialysis patients and with more symptoms