Relative and absolute reliability of physical function measures in people with end-stage renal disease.

PURPOSE: End-stage renal disease (ESRD) is a condition affecting multiple physiological systems, leading to a decline in physical function. Effectiveness of therapeutic interventions in people with ESRD has been assessed using various functional and activity outcome measures. The purpose of this study was to determine the relative and absolute reliability of the 6-minute walk test (6MWT), timed sit-to-stand in 30 seconds (TSS30), and maximal and adjusted activity scores (MAS-HAP, AAS-HAP) of the Human Activity Profile (HAP) in people with ESRD. METHOD: A convenience sample of 25 participants (67.2±14.2 years) was recruited from an outpatient dialysis unit. Relative reliability was determined using the intraclass correlation coefficient (ICC(2,1)), and absolute test-retest reliability with the standard error of measurement (SEM) and minimal detectable change at the 95% confidence interval (MDC(95)) statistics, respectively. The test-retest interval was 1 week. RESULTS: Relative reliability (ICC(2,1)) was 0.93 for both the 6MWT and the TSS30, 0.92 for the AAS-HAP, and 0.76 for the MAS-HAP. Absolute reliability (SEM and MDC(95)) values for the 6MWT, AAS-HAP, and TSS30 were 28 m and 77 m, 4.1 and 11.4, and 0.9 and 2.6 repetitions, respectively. CONCLUSIONS: Our results suggest that the 6MWT, TSS30, and AAS-HAP are reliable physical function and activity outcome measures in people with ESRD. However, the magnitude of the absolute reliability statistics suggests significant within-participant variability on repeat testing in this population.

Stressors and coping in individuals with chronic kidney disease.

The purpose of this study was to develop a valid and reliable instrument to measure stressors of patients with chronic kidney disease (CKD), identify those stressors, and determine which coping strategies were used and effective. The participants reported fatigue, sleep problems, and peripheral neuropathy as the most frequently experienced stressors. Optimism as a coping style was most commonly used and was also the most effective. Stress was inversely associated with age and CKD stage, and positively associated with coping. Knowledge from this study can be used to further patient education and supportive interventions for patients with CKD.

Optimal timing of initiation of chronic hemodialysis?

Despite the availability of clinical guidelines for the timing of dialysis initiation in both the United States and Canada, patients continue to start dialysis at very low levels of predicted glomerular filtration rate (GFR). A cross-sectional study was performed to determine the demographic and clinical characteristics of patients who started hemodialysis, their level of GFR, and mortality at 1 and 2 years following the initiation of dialysis. Retrospective data were collected on all eligible patients who commenced chronic hemodialysis in 1 tertiary care center in Canada from March 2001 to February 2005. Only those patients who had been followed by a nephrologist in the chronic kidney disease clinic before dialysis initiation were included (n=271). Seventeen percent of patients started hemodialysis late (GFR<5 mL/min/1.73 m(2)). Compared with the group of patients who started dialysis earlier, the late start group were significantly younger (p=0.008), had more females (p=0.013), more employed (p=0.051), less cardiac (p<0.001), and peripheral vascular disease (p=0.031), and were taking medication for hypertension (p=0.041). Serum albumin was lower in the late start group (p=0.023). At year 1, there was no difference in mortality rate while at year 2, the earlier the dialysis, the greater the mortality rate (p=0.022). After adjustment for demographic variables and comorbidities, only antihypertensive use had an independent but weak association with the 2 year mortality. Adjustment for all these variables eliminated the significant association noted for the 2 year mortality in the early versus late dialysis start. The survival benefit for late versus early dialysis start appears to be multifactorial and relates to a preponderance of clinical and demographic factors favoring a lengthened survival occurring in the late dialysis group. Our survival benefit findings suggest the premorbid health condition is a more important determinant of 2 year survival than the timing of dialysis initiation.

Prevalence of risk factors predisposing to foot problems in patients on hemodialysis.

A disturbingly high prevalence of single or bilateral lower extremity amputations in our program prompted us to conduct a study to identify the prevalence of risk factors that predispose patients on hemodialysis (HD) to foot problems. The study consisted of a one-time assessment of subjects' risk for and actual prevalence of amputation. The sample consisted of 232 subjects--56% male, 44% female. Ages ranged from 21-91 years, mean age 65.1 and median age 69 years. The most common comorbidities were hypertension (75%), coronary artery disease (50%), diabetes (42.2%), hyperlipidemia (34.9%), and peripheral vascular disease (27.2%), which are all established risk factors for peripheral arterial occlusive disease. Twenty-one percent of subjects were current smokers; 28% were former smokers. Nearly 13.4% of subjects had undergone amputations ranging from single toes to bilateral above knee amputations. Only 31% of subjects had both bilateral palpable pedal pulses present. Neuropathy, as evidenced by the inability to feel the application of monofilaments to 10 sites on each foot or the presence of symptoms, was present in 74.6% of subjects. Only 2.6% of subjects demonstrated comprehensive self-care behaviors (SCBs). With respect to subjects' ability for self-care, 75% of subjects had adequate vision, 60% adequate dexterity, and 55% adequate flexibility to perform self-care. Study findings confirmed impressions that patients are at considerable risk for foot complications. Implications for nursing practice include regular foot assessment, education for self-care, and referral to specialists when required.

Preparing for hemodialysis: patient stressors and responses.

This qualitative study explored stressors experienced by individuals with chronic kidney disease (CKD). Individuals on hemodialysis were asked to share their recollections regarding stressors they experienced as they approached dialysis. Content analysis was used and the following themes emerged: (a) stressors; (b) emotional responses; (c) learning, preparation, and acceptance; and (d) regret and dissatisfaction. The results of this study have important implications for patient education and support in the care of patients with CKD.

Caregiving by family and friends of adults receiving dialysis.

This study examined the activities of caregivers of adults on dialysis and explored how these behaviors evolved over time. Using a grounded theory methodology, interviews were conducted with 37 caregivers. Caregivers shared a rich repertoire of caregiving abilities and activities that were often supported by a strong knowledge base. Caregiving activities fell into in five interdependent dimensions: appraising, advocating, juggling, routinizing, and coaching. Caregivers also described specific caregiving tasks, including dialysis- related activities, management of diet, medications and symptoms, and personal care. These findings have important implications for nephrology nurses in planning care that acknowledges and supports the contributions of "lay" caregivers.

Thirst distress and interdialytic weight gain: how do they relate?

Thirst is a frequent and stressful symptom experienced by hemodialysis patients. Several studies have noted a positive relationship between thirst and interdialytic weight gain (IDWG). These factors prompted us to consider ways that we could intervene to reduce thirst and IDWG through an educative, supportive nursing intervention. This paper presents the results of a pilot research project, the purpose of which was to: examine the relationship between thirst distress (the negative symptoms associated with thirst) and IDWG in a sample of our patients, describe patients' strategies for management of thirst, and establish the necessary sample size for the planned intervention study. The pilot research project results showed that in a small sample of 20, there was a mildly positive, though not statistically significant, correlation between thirst distress and IDWG (r = 0.117). Subjects shared a wide variety of thirst management strategies including: limiting salt intake, using ice chips, measuring daily allotment, performing mouth care, eating raw fruits and vegetables, sucking on hard candy and chewing gum. This pilot research project showed that given an alpha of 0.05 and a power of 80%, we will require a sample of 39 subjects to detect a 20% change in IDWG. We will employ these results to plan our intervention study, first by establishing the appropriate sample size and second by incorporating identified patient strategies into an educational pamphlet that will form the basis of our intervention.

Hemodialysis adequacy and quality of life: how do they relate?

There is clear evidence of a link between dialysis adequacy (as measured by urea kinetic modelling or urea reduction ratio) and such important clinical outcomes as morbidity and mortality. Evidence regarding the relationship between dialysis adequacy and quality of life outcomes is less clear. This paper reports the results of a study designed to answer the following research question: What is the impact of changing dialysis adequacy on functional status and well-being in a sample of new hemodialysis patients? The study employed a convenience sampling technique enrolling all willing new patients who started hemodialysis for a four-year period. The final sample size was 69. The adequacy of each new patient's dialysis prescription was determined by calculating Kt/V at one and three months following the start of dialysis. Changes to dialysis prescriptions were made, as necessary, to achieve a minimum Kt/V of 1.2. Each subject's quality of life was measured at the same time intervals, using two instruments. The first instrument, the SF-36, is a generic 36-item instrument designed to measure a range of functioning and well-being. The second instrument, the Kidney Disease Questionnaire (KDQ), is a disease-specific quality of life instrument designed for use with chronic hemodialysis patients. The results of this study demonstrated a significant positive relationship (p < .05) between Kt/V and four of five variables in the KDQ, and two of eight variables in the SF-36. These variables were predominantly in the social/emotional well-being domain.