Jenny Stenberg

Background: Optimizing volume status is central to hemodialysis care and may influence patient‐reported outcome measures as recovery time. We evaluated the implementation of a structured decision aid (Recova) integrating symptom assessment with bioimpedance spectroscopy in routine hemodialysis practice. Methods: A prospective multicenter pre–post within‐subjects study was conducted in 10 Swedish hemodialysis clinics. Clinics adopted the intervention on a staggered schedule based on local readiness. Participants were assessed at baseline and after 12 weeks. Outcomes included bioimpedance spectroscopy‐derived overhydration and extracellular water, patient‐reported recovery time (hours to resume usual activities), and a fluid‐related symptom score. Paired measurements were compared. Results: Of 404 screened patients, 129 consented and 123 initiated the intervention. Recovery time data were available at both time points for 110 participants. Overhydration decreased from 2.6 ± 1.7 to 2.3 ± 2.0 L ( p = 0.04) and extracellular water from 18.4 ± 4.0 to 18.0 ± 3.8 L ( p = 0.01). Mean recovery time did not change significantly (6.7 ± 7.1 to 5.8 ± 6.2 h; p = 0.22) and median recovery time remained 4 h (IQR 1–10). Fluid‐related symptom burden declined over the intervention period. No harms were reported; 13 participants did not complete the 12‐week intervention. Conclusions: In this multicenter pre–post evaluation, implementation of Recova was associated with modest improvements in bioimpedance spectroscopy‐derived volume metrics and fluid‐related symptoms, while recovery time did not change significantly. Controlled studies are needed to determine effectiveness and to identify which patients may benefit.

Background: Brain natriuretic peptide (BNP) is a hormone secreted from the heart in response to fluid overload. In patients with chronic kidney disease (CKD), inadequate fluid management during haemodialysis may cause fluid overload and overhydration (OH), risk factors for mortality. The aim of this exploratory pilot study was to analyse the relationships between BNP, OH and all-cause mortality in patients with CKD and haemodialysis. Methods: In this prospective observational study, five-year survival was analysed in 64 patients with CKD and haemodialysis. Bivariate correlations were performed to analyse the relationships between BNP, OH, and all-cause mortality. Cox regression analysis was performed to adjust the relationship between BNP and all-cause mortality for selected clinical and biochemical characteristics, collected at baseline. Results: By the end of the study, 33 patients (52%) had died. In bivariate correlation analysis age (r = 0.38), BNP (r = 0.48), handgrip strength (r=-0.34), lean tissue index (r=-0.41) and CRP level (r=-0.34, p = 0.007) were significantly associated with all-cause mortality. In a linear regression model, BNP was found to be a significant predictor of all-cause mortality (HR 2.61). However, after adjusting for age, handgrip strength, and CRP, BNP was no longer a statistically significant predictor of all-cause mortality. Instead, age, handgrip strength and CRP were significant predictors of all-cause mortality (HR 1.04; HR 0.95 and HR 2.61, respectively). Conclusions: In this study, BNP was correlated with all-cause mortality in patients with CKD and haemodialysis, but OH was not. When adjusting for other clinical and biochemical factors, age, inflammation, and handgrip strength were found to be independent and more important predictors of all-cause mortality than BNP.

Introduction: Transplantation with a kidney from a living donor has superior long‐term patient and graft survival compared to a kidney from a deceased donor. For a kidney donor, feelings of stress may exist at different stages of the donation process. The aim of the study was to evaluate living kidney donors’ perceived and measured stress levels before and after donation. Methods: In this prospective observational cohort study with longitudinal follow‐up, kidney donors were invited to answer three self‐rating questionnaires targeting stress, vital exhaustion, and depressive symptoms the day before and two and six months after kidney donation. At the same time points, blood and saliva samples of insulin, glucose, and cortisol were collected. Results: Analyses were based on data from seventy‐five individuals, with a mean age 46.5 (11) years, 60% women. The kidney donors scored low in self‐rating stress, exhaustion and depression both pre‐ and two and six months post‐donation, and no correlations were established between self‐reported measures and metabolic stress biomarkers. Post‐donation, however, a gender difference emerged, with women reporting decreased vitality scores 32.1 (9.3) and 30.7 (11.6) at two and six months versus men reporting increased scores 35.8 (6.9) and 36.9 (7.1). Six months post‐donation, women also reported more symptoms of depression than men, 12.2 (12.5) versus 6.4 (8.2) ( p = 0.058). Conclusions: Kidney donors’ self‐reported and measured stress levels and depressive symptoms were low and did not change from pre‐donation up to six months after donation. The low levels of subjective and objective stress reported by the donors support the limited risks associated with living kidney donation. However, six months post‐donation, women reported more feelings of exhaustion and depression than did men. Practitioner points: (1) The low levels of subjective and objective stress reported by kidney donors support the limited risks associated with living kidney donation. (2) Because most kidney donors are women, the gender difference in perceived stress levels presented in this study is of clinical relevance. (3) A more structured psychosocial follow‐up could enable the identification of individuals in need of more psychological follow‐up post‐donation.

Background: Hypertension in patients with haemodialysis is mainly characterised by high pre‐dialysis blood pressure (BP) due to body fluid retention before dialysis, and the BP tends to decrease after dialysis due to removal of water during dialysis. Intervals between haemodialysis treatments vary and a long inter‐dialytic interval dialysis is associated with increased mortality.Objective: To examine variations in BP; how ambulatory BP vary during a dialysis treatment performed after the long inter‐dialytic interval, that is, the first treatment of the week, compared to dialysis after a short inter‐dialytic interval, and in the interval between the two dialysis sessions.Design: Exploratory non‐interventional observational.Participants: Eleven patients with chronic kidney disease Stage 5 treated with haemodialysis were enroled. The mean age was 69 years (range 48–87) and mean dialysis duration 65 months (range 4–128).Measurements: Ambulatory BP was recorded for 52 h including two haemodialysis treatments and one inter‐dialytic interval. For statistical analyses the Wilcoxon signed ranks test was used.Results: Significant differences in systolic and diastolic BPs were observed between dialyses after long inter‐dialytic interval and short inter‐dialytic interval, respectively (systolic 122 mmHg vs. 114 mmHg, p = 0.012 and diastolic 62 mmHg vs. 61 mmHg, p = 0.036). In addition, the BP declined during the first 90 min during dialysis in both settings.Conclusions: Measuring ambulatory BP for 52 h in patient with chronic kidney disease and haemodialysis is feasible and show that both systolic and diastolic BP differ between dialysis treatments following inter‐dialytic intervals of diverse length. These findings should be replicated in larger studies.

Introduction: The surprise question (SQ) “Would I be surprised if this patient died within the next xx months” can be used by different professions to foresee the need of serious illness conversations in patients approaching end of life. However, little is known about the different perspectives of nurses and physicians in responses to the SQ and factors influencing their appraisals. The aim was to explore nurses' and physicians' responses to the SQ regarding patients on hemodialysis, and to investigate how these answers were associated with patient clinical characteristics.Methods: This comparative cross‐sectional study included 361 patients for whom 112 nurses and 15 physicians responded to the SQ regarding 6 and 12 months. Patient characteristics, performance status, and comorbidities were obtained. Cohen's kappa was used to analyze the interrater agreement between nurses and physicians in their responses to the SQ and multivariable logistic regression was applied to reveal the independent association to patient clinical characteristics.Findings: Proportions of nurses and physicians responding to the SQ with “no, not surprised” was similar regarding 6 and 12 months. However, there was a substantial difference concerning which specific patient the nurses and physicians responded “no, not surprised”, within 6 (κ = 0.366, p < 0.001, 95% CI = 0.288–0.474) and 12 months (κ = 0.379, p < 0.001, 95% CI = 0.281–0.477). There were also differences in the patient clinical characteristics associated with nurses' and physicians' responses to the SQ.Discussion: Nurses and physicians have different perspectives in their appraisal when responding to the SQ for patients on hemodialysis. This may reinforce the need for communication and discussion between nurses and physicians to identify the need of serious illness conversations in patients approaching the end of life, in order to adapt hemodialysis care to patient preferences and needs.

Aims and objectives: To describe migrant family caregivers' experiences and perceptions of caring for a family member with dementia.Background: There are demographic trends of aging populations and increased migration between countries. Age‐associated diseases, such as dementia, are expected to increase, with migrants being at significantly increased risk. Knowledge of how dementia care is provided within migrant families is scarce.Design: Systematic review and thematic synthesis of qualitative research were performed to inform the development of interventions that can acknowledge and respond to the needs, concerns and preferences of migrant family caregivers.Methods: Searches were performed in PubMed, PsycINFO and CINAHL and reference lists in published articles were reviewed for the period 2000–October 2020. The CASP checklist for qualitative research was used to assess evidence quality, and the ENTREQ framework was used as a guide for study reporting.Results: Twenty‐six articles from 10 Western countries, including 360 informal migrant caregivers from more than 30 countries of origin, were eligible. Within four areas of construct—perceptions of dementia and initial help‐seeking; barriers to accessing and using formal dementia care; caregiver burden and coping and resilience—12 descriptive themes were identified. Several concepts cut across the themes, such as language difficulties; the role of the family in relation to care and support; cultural perceptions of dementia and care; stigma, pride and shame; the importance of religion and the importance of trust.Conclusions: The review revealed commonalities among migrant family caregivers that resulted in reduced understanding of dementia and the importance of diagnosis and treatment.Relevance to clinical practice: To prevent a negative trajectory in caregiving, with perceived demands causing high levels of stress and strain, several barriers to migrants accessing and using formal care need to be assessed and addressed.

Fluid overload is associated with mortality in haemodialysis patients, and 30% of patients remain fluid-overloaded after dialysis. The aim of this study was to evaluate if implementation of Recova®...

SUMMARY: Background: About a third of patients undergoing haemodialysis have poorly controlled fluid status, which may affect survival. Clinical assessment is subjective and imprecise, which has led to the increasing use of devices based on bioimpedance spectroscopy (BIS). However, BIS cannot provide a simple target applicable to all patients. Our aim was to develop and validate a decision aid combining clinical assessment of fluid status with information from BIS in target weight determination.Methods: The decision aid was based on empirical experience and a literature review identifying physiological parameters already used in the clinical assessment of fluid status. Content validity was established by patient representatives, interdisciplinary stakeholders and external experts, who assessed item relevance and comprehensiveness. Reliability was assessed by inter‐rater agreement analysis between nurses assessing typical patient cases.Results: The decision aid for Recognition and Correction of Volume Alterations (RECOVA) consists of three parts (1) a scoring system; (2) thresholds and triggers; (3) a decision aid algorithm. Agreement between raters in the assessment of symptoms was almost perfect, with Intraclass Correlation Coefficient > 0.90. Agreement in clinical response was only fair, but increased to moderate, with training and self‐reported confidence.Conclusion: RECOVA may enable systematic clinical assessment of fluid status, facilitating early recognition of fluid alterations, and incorporation of bioimpedance into target weight management. However, implementation into clinical practice will require training of staff. Clinical intervention studies are required to evaluate if RECOVA facilitates response to and correction of recognised fluid alterations.