Symptoms among patients receiving in-center hemodialysis: A qualitative study.

INTRODUCTION: Assessment of dialysis-related symptoms is not currently a requirement for hemodialysis (HD) providers in the United States. The purpose of this study was to describe patients' perspectives on symptoms associated with end-stage chronic kidney disease treated with thrice-weekly, in-center HD. METHODS: We performed a qualitative study using interpretive description. Interview questions were based on a KDIGO (Kidney Disease Improving Global Outcomes) controversies conference and a literature review. Semi-structured interviews were analyzed for characterizations of symptoms. FINDINGS: Fifty participants (48% female; 42% Hispanic; 30% American Indian; 14% Black; 12% non-Hispanic White) were recruited from six outpatient dialysis centers (four urban, two rural) in the southwestern United States. Median HD duration was 4 years. Of 13 symptoms assessed, nearly all participants reported difficulties with muscle cramping, fatigue, or both. Negotiating fluid removal with dialysis personnel helped to manage cramping. Some participants tried to adjust dialysis days and shift to mitigate fatigue. Most participants reported having experienced depression early in the course of dialysis; for some, it was a persistent or recurrent problem. Relatively few participants reported using antidepressants or counseling to cope with depression. Itching was highly distressing for those who experienced it frequently. Topical treatments, antihistamines, dietary modifications, and phosphate binders were identified as potentially helpful by some participants. DISCUSSION: The major symptoms attributed to HD treatment by participants were cramping, fatigue, depression, and itching. Greater attention by health care providers to the most common and bothersome symptoms could positively impact daily life for HD patients.

Provider Knowledge, Attitudes, and Practices Surrounding Conservative Management for Patients with Advanced CKD.

BACKGROUND AND OBJECTIVES: Despite the potential benefits of conservative management, providers rarely discuss it as a viable treatment option for patients with advanced CKD. This survey was to describe the knowledge, attitudes, and practices of nephrologists and primary care providers regarding conservative management for patients with advanced CKD in the United States. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We developed a questionnaire on the basis of a literature review to include items assessing knowledge, attitudes, and self-reported practices of conservative management for patients with advanced CKD. Potential participants were identified using the American Medical Association Physician Masterfile. We then conducted a web-based survey between April and May of 2015. RESULTS: In total, 431 (67.6% nephrologists and 32.4% primary care providers) providers completed the survey for a crude response rate of 2.7%. The respondents were generally white, men, and in their 30s and 40s. Most primary care provider (83.5%) and nephrology (78.2%) respondents reported that they were likely to discuss conservative management with their older patients with advanced CKD. Self-reported number of patients managed conservatively was >11 patients for 30.6% of nephrologists and 49.2% of primary care providers. Nephrologists were more likely to endorse difficulty determining whether a patient with CKD would benefit from conservative management (52.8% versus 36.2% of primary care providers), whereas primary care providers were more likely to endorse limited information on effectiveness (49.6% versus 24.5% of nephrologists) and difficulty determining eligibility for conservative management (42.5% versus 14.3% of nephrologists). There were also significant differences in knowledge between the groups, with primary care providers reporting more uncertainty about relative survival rates with conservative management compared with different patient groups. CONCLUSIONS: Both nephrologists and primary care providers reported being comfortable with discussing conservative management with their patients. However, both provider groups identified lack of United States data on outcomes of conservative management and characteristics of patients who would benefit from conservative management as barriers to recommending conservative management in practice.

Conveying uncertainty in prognosis to patients with ESRD.

BACKGROUND: Prognosis is a component of medical practice imbued with uncertainty. In nephrology, where mortality rates of elderly patients on dialysis are comparable to those of cancer patients, the implications of prognosis are unavoidable. Yet while most patients with end-stage renal disease (ESRD) desire to hear their prognosis, many nephrologists balk at this prospect in part owing to the uncertainty inherent in prognostic estimates. SUMMARY: In this review, the concept of 'uncertainty' in clinical practice is considered from physician and patient perspectives. From the training perspective, providers learn that uncertainty is inescapable in medicine and develop strategies to manage its presence, including the avoidance of communicating uncertainty to their patients. This presages infrequent discussions of prognosis, which in turn influence patient preferences for treatments that have little therapeutic benefits. A general approach to conveying prognostic uncertainty to ESRD patients includes confronting our own emotional reaction to uncertainty, learning how to effectively communicate uncertainty to our patients, and using an effective interdisciplinary team approach to demonstrate an ongoing commitment to our patients despite the presence of prognostic uncertainty. KEY MESSAGES: Uncertainty in prognosis is inevitable. Once providers learn to incorporate it into their discussions of prognosis and collaborate with their ESRD patients, such discussions can foster trust and reduce anxiety for both sides.

Liposuction for superficialization of deep veins after creation of arteriovenous fistulas.

PURPOSE: Many individuals with end-stage renal disease (ESRD) have adequate arteries and veins for construction of an arteriovenous fistula (AVF) but the fistula may be too deep to cannulate because of overlying adipose tissue. This study evaluated the safety and efficacy of liposuction to superficialize deep AVFs. METHODS: Between September 2009 and January 2011, 13 patients participated in the study. Mean body mass index (BMI) was 39.1 kg/m2. The study was limited to brachiocephalic and radiocephalic fistulas. Mean fistula depth was 8.1 mm. The primary endpoint was the date of the first successful cannulation with two 17-gauge needles. Patients were followed for 12 mo. RESULTS: Eleven subjects (85%) underwent successful two-needle cannulation a mean of 33.7 days after the procedure. One patient died of endocarditis and one developed a hematoma and wound necrosis that required surgical elevation to enable cannulation. Projection and palpability of the fistulas tended to increase over time. Mean tissue removed was 243 mL and correlated positively with the number of days to cannulation (r=0.74, p=0.01). Greater BMI correlated positively with more surgical site complications and delays in cannulation. At 12 mo, primary patency after liposuction was 50% and secondary patency was 83%. CONCLUSIONS: Most subjects had prompt, uncomplicated cannulation but a few had wound necrosis, large hematomas and prolonged time until cannulation. Liposuction is effective in enabling cannulation of deep vein fistulas but because of the substantial risk of serious surgical site complications, it may not be the ideal method.