• A narrative systematic review of randomised controlled trials that compare cannulation techniques for haemodialysis

      Fielding, Catherine; Hadfield, Amanda; White, Kelly; Waters, Dan; James, Cathryn; Fluck, Richard; Selby, Nicholas (2021-01)
      Background: Cannulation of arteriovenous access for haemodialysis affects longevity of the access, associates with complications and affects patients’ experiences of haemodialysis. Buttonhole and rope ladder techniques were developed to reduce complications. However, studies that compare these two techniques report disparate results. This systematic review performs an in-depth exploration of RCTs, with a specific focus on cannulation as a complex intervention. Methods: A PICO question and protocol was developed as per PRISMA-P guidance and registered on PROSPERO (CRD42018094656 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=112895). The systematic review included any RCT performed on adult patients with end-stage kidney disease undergoing cannulation of arteriovenous fistulae or grafts for in-centre haemodialysis, as performed by healthcare staff. Assessment of quality of RCTs and data extraction were performed by two co-authors independently. Data were extracted on the study design, intervention and comparator and outcomes, including patency, infection and patients’ experiences. Results: The literature search identified 241 records. Ten records met inclusion criteria, which described five different RCTs that compared buttonhole to either rope ladder or usual practice. Results were disparate, with patency and infection results varying. Pain Visual Analogue scores were the only measure used to capture patients’ experiences and results were inconclusive. All RCTs had differences and limitations in study design that could explain the disparity in results. Conclusion: Current evidence does not allow definitive conclusions as to whether buttonhole or rope ladder needling technique is superior. Future RCTs should describe interventions and comparators with adequate detail, embed process evaluation, use standardised outcome measures and build on feasibility studies to produce definitive results.
    • National survey of vascular access services for haemodialysis patients

      Fielding, Catherine (2017-11)
      There is much variation in the provision of dialysis access in the UK. To address this, a multiprofessional vascular access special interest group was formed to raise awareness and encourage implementation of clinical guidelines, and share good practice. Mick Kumwenda, Catherine Fielding and Alayne Gagen discuss the findings of the group's survey of haemodialysis vascular access services. vascular access, renal dialysis, surveys and questionnaires, arteriovenous fistula
    • National trends in acute kidney injury requiring dialysis in England between 1998 and 2013.

      Kolhe, Nitin; Fluck, Richard; Taal, Maarten (2015-11)
      Acute kidney injury (AKI) severe enough to require dialysis is increasing and associated with high mortality, yet robust information about temporal epidemiology of AKI requiring dialysis in England is lacking. In this retrospective observational study of the Hospital Episode Statistics (HES) data set covering the entire English National Health Service, we identified all patients with a diagnosis of AKI requiring dialysis between 1998 and 2013. This incidence increased from 774 cases (15.9 per million people) in 1998-1999 to 11,164 cases (208.7 per million people) in 2012-2013. The unadjusted in-hospital case-fatality was 30.3% in 1998-2003 and 30.2% in 2003-2008, but significantly increased to 41.1% in 2008-2013. Compared with 2003-2008, the multivariable adjusted odds ratio for death was higher in 1998-2003 at 1.20 (95% CI: 1.10-1.30) and in 2008-2013 at 1.13 (1.07-1.18). Charlson comorbidity scores of more than five (odds ratio 2.35; 95% CI: 2.20-2.51) and emergency admissions (2.46 (2.32-2.61) had higher odds for death. The odds for death decreased in patients over 85 years from 4.83 (3.04-7.67) in 1998-2003 to 2.19 (1.99-2.41) in 2008-2013. AKI in secondary diagnosis and in other diagnoses codes had higher odds for death compared with AKI in primary diagnosis code in all three periods. Thus, the incidence of AKI requiring dialysis has increased progressively over 15 years in England. Improvement in case-fatality in 2003-2008 has not been sustained in the last 5 years.
    • A national UK audit of suprapubic catheter insertion practice and rate of bowel injury with comparison to a systematic review and meta-analysis of available research.

      Ahmed, Shakeel (2019-09)
      OBJECTIVES: Limited data exist on the risks of complications associated with a suprapubic catheter (SPC) insertion. Bowel injury (BI) is a well-recognized albeit uncommon complication. Guidelines on the insertion of SPC have been developed by the British Association of Urological Surgeons, but there remains little evidence regarding the incidence of this complication. This study uses contemporary UK data to assess the incidence of SPC insertion and the rate of BI and compares to a meta-analysis of available papers. METHODS: National Hospital Episodes Statistics data were searched on all SPC insertions over an 18-month period for operating procedure codes, Code M38.2 (cystostomy and insertion of a suprapubic tube into bladder). Patients age, 30-day readmission rates, 30-day mortality rate, and catheter specific complication rate were collected. To estimate the BI rate, we searched patients who had undergone any laparotomy or bowel operation within 30 days of SPC insertion. Trusts were contacted directly and directed to ascertain whether there was SPC-related BI. PubMed search to identify papers reporting on SPC related BI was performed for meta-analysis RESULTS: 11 473 SPC insertions took place in the UK in this time period. One hundred forty-one cases had laparotomy within 30 days. Responses from 114 of these cases reported one BI related to SPC insertion. Meta-analysis showed an overall BI rate of 11/1490 (0.7%). CONCLUSIONS: This is the largest dataset reported on SPC insertions showing a lower than previously reported rate of BI. We recommend clinicians use a risk of BI of less than 0.25% when counseling low-risk patients.
    • A national UK audit of suprapubic catheter insertion practice and rate of bowel injury with comparison to a systematic review and meta-analysis of available research.

      Ahmed, S (2019-11)
      OBJECTIVES: Limited data exist on the risks of complications associated with a suprapubic catheter (SPC) insertion. Bowel injury (BI) is a well-recognized albeit uncommon complication. Guidelines on the insertion of SPC have been developed by the British Association of Urological Surgeons, but there remains little evidence regarding the incidence of this complication. This study uses contemporary UK data to assess the incidence of SPC insertion and the rate of BI and compares to a meta-analysis of available papers. METHODS: National Hospital Episodes Statistics data were searched on all SPC insertions over an 18-month period for operating procedure codes, Code M38.2 (cystostomy and insertion of a suprapubic tube into bladder). Patients age, 30-day readmission rates, 30-day mortality rate, and catheter complication rate were collected. To estimate the BI rate, we searched patients who had undergone any laparotomy or bowel operation within 30 days of SPC insertion. Trusts were contacted directly and directed to ascertain whether there was SPC-related BI. PubMed search to identify papers reporting on SPC related BI was performed for meta-analysis RESULTS: 11 473 SPC insertions took place in the UK in this time period. One hundred forty-one cases had laparotomy within 30 days. Responses from 114 of these cases reported one BI related to SPC insertion. Meta-analysis showed an overall BI rate of 11/1490 (0.7%). CONCLUSIONS: This is the largest dataset reported on SPC insertions showing a lower than previously reported rate of BI. We recommend clinicians use a risk of BI of less than 0.25% when counseling low-risk patients.
    • Natural history of skeletal muscle mass changes in chronic kidney disease stage 4 and 5 patients: an observational study.

      John, Stephen; Sigrist, Mhairi; Taal, Maarten; McIntyre, Christopher (2013-05)
      Cross-sectional studies in dialysis demonstrate muscle wasting associated with loss of function, increased morbidity and mortality. The relative drivers are poorly understood. There is a paucity of data regarding interval change in muscle in pre-dialysis and dialysis-dependant patients. This study aimed to examine muscle and fat mass change and elucidate associations with muscle wasting in advanced CKD. 134 patients were studied (60 HD, 28 PD, 46 CKD 4-5) and followed up for two years. Groups were similar in age, sex and diabetes prevalence. Soft tissue cross-sectional area (CSA) was measured annually on 3 occasions by a standardised multi-slice CT thigh. Potential determinants of muscle and fat CSA were assessed. Functional ability was assessed by sit-to-stand testing. 88 patients completed follow-up (40 HD, 16 PD, 32 CKD). There was a significant difference in percentage change in muscle CSA (MCSA) over year 1, dependant on treatment modality (χ(2) = 6.46; p = 0.039). Muscle loss was most pronounced in pre-dialysis patients. Muscle loss during year 1 was partially reversed in year 2 in 39%. Incident dialysis patients significantly lost MCSA during the year which they commenced dialysis, but not the subsequent year. Baseline MCSA, change in MCSA during year 1 and dialysis modality predicted year 2 change in MCSA (adjusted R(2) = 0.77, p<0.001). There was no correlation between muscle or fat CSA change and any other factors. MCSA correlated with functional testing, although MCSA change correlated poorly with change in functional ability. These data demonstrate marked variability in MCSA over 2 years. Loss of MCSA in both pre-dialysis and established dialysis patients is reversible. Factors previously cross-sectionally shown to correlate with MCSA did not correlate with wasting progression. The higher rate of muscle loss in undialysed CKD patients, and its reversal after dialysis commencement, suggests that conventional indicators may not result in optimal timing of dialysis initiation.
    • Nephrologists' perspectives on dialysis treatment: results of an international survey.

      Fluck, Richard (2014-01)
      BACKGROUND: In-centre haemodialysis (ICHD) is the most common dialysis method used by patients worldwide. However, quality of life and clinical outcomes in patients treated via ICHD have not improved for some time. 'High-dose' haemodialysis (HD) regimens--which are longer and/or more frequent than conventional regimens and are particularly suitable to delivery in the home--may offer a route to improved outcomes and quality of life. This survey aimed to determine nephrologists' views on the validity of alternatives to ICHD, particularly home HD and high-dose HD. METHODS: A total of 1,500 nephrologists from Europe, Canada and the United States were asked to respond to an online questionnaire that was designed following previous qualitative research. Certified nephrologists in practice for 2-35 years who managed >25 adult dialysis patients were eligible to take part. RESULTS: A total of 324 nephrologists completed the survey. ICHD was the most common type of dialysis used by respondents' current patients (90%), followed by peritoneal dialysis (8%) and home HD (2%). The majority of respondents believed that: home HD provides better quality of life; increasing the frequency of dialysis beyond three times per week significantly improves clinical outcomes; and longer dialysis sessions performed nocturnally would result in significantly better clinical outcomes than traditional ICHD. CONCLUSIONS: Survey results indicated that many nephrologists believe that home HD and high-dose HD are better for the patient. However, the majority of their patients were using ICHD. Education, training and support on alternative dialysis regimens are needed.
    • New horizons in the understanding of the causes and management of diabetic foot disease: report from the 2017 Diabetes UK Annual Professional Conference Symposium.

      Game, Frances (2016-12)
      Diabetes-related foot disease remains a common problem. For wounds, classic teaching recommends the treatment of any infection, offloading the wound and ensuring a good blood supply, as well as ensuring that the other modifiable risk factors are addressed and optimized. There remain, however, several questions about these and other aspects of the care of diabetes-related foot disease. Some of these questions are addressed in the present report; in particular, the impact of newer technologies in the identification of any organisms present in a wound, as well as the use of novel approaches to treat infections. The use of new remote sensing technology to identify people at risk of developing foot ulceration is also considered, in an attempt to allow early intervention and prevention of foot ulcers. The psychological impact of foot disease is often overlooked, but with an increasing number of publications on the subject, the cause-and-effect role that psychology plays in foot disease, such as ulcers and Charcot neuroarthropathy, is considered. Finally, because of heterogeneity in diabetic foot studies, comparing results is difficult. A recently published document focusing on ensuring a standardized way of reporting foot disease trials is discussed.
    • Non coeliac gluten sensitivity.

      Holmes, Geoffrey (2013-07)
    • Non-invasive Diagnosis of Oesophageal Varices Using Systemic Haemodynamic Measurements by Finometry: Comparison with Other Non-invasive Predictive Scores.

      Rye, Kara; Mortimore, Gerri; Austin, Andrew; Freeman, Jan (2016-09)
      BACKGROUND/AIMS: Cirrhosis and portal hypertension are characterised by a hyperdynamic circulation, which is independently associated with variceal size. Non-invasive techniques for measurement of systemic haemodynamics are now available. The aim of the study was to prospectively assess the accuracy of systemic haemodynamics measured non-invasively for the detection of oesophageal varices in cirrhotic patients as compared to other currently available non-invasive methods. METHODS: In a study of 29 cirrhotic patients, systemic haemodynamics were studied non-invasively using the Finometer(®) (mean arterial pressure (MAP), cardiac output (CO)/index, heart rate (HR), peripheral vascular resistance) and portal pressure was assessed by hepatic venous pressure gradient. Sensitivity, specificity, predictive values and area under the receiver operating characteristic (ROC) curves were assessed for predicting presence of varices and large oesophageal varices. Results were compared to child's classification, platelet/spleen ratio and ALT/AST ratios as predictors of the presence of large varices. RESULTS: Using finometry large oesophageal varices were correctly predicted in 83% of patients compared to other non-invasive techniques (range 66-76%). CONCLUSIONS: Non-invasive assessment of systemic haemodynamics using finometry could aid the identification of patients who do not immediately require variceal surveillance reducing the numbers of endoscopies and ensuring services are provided to those most likely to benefit.
    • Nutritional status assessment: a neglected biomarker in persons with end-stage kidney disease

      Taal, Maarten (2020-11)
      Purpose of review: Malnutrition is a frequent complication and risk factor for adverse outcomes in the dialysis population that is often underrecognized and neglected. This article reviews published literature on the associations between malnutrition, mortality, quality of life and hospitalizations in persons on dialysis in order to raise awareness of the importance of preventing and treating it. Recent findings: All methods of nutritional assessment namely serum biochemistry, body composition, dietary intake, handgrip strength and nutritional scoring tools are independently associated with increased mortality in dialysis populations. Malnutrition severely affects physical and mental measures of quality of life and increases the number and length of hospitalizations in persons receiving dialysis, resulting in increased healthcare costs. Worsening of nutritional status is also associated with poor survival and higher rates of hospitalizations in this patient population. Summary: Malnutrition is an unacceptably common complication in dialysis patients that is substantially associated with adverse outcomes and higher hospital costs. Further interventional studies assessing the impact of preventing and treating malnutrition on clinical outcomes are warranted and should be considered a priority.
    • Obesity and recovery from acute kidney injury (Ob AKI): a prospective cohort feasibility study.

      Selby, Nicholas (2019-03)
      OBJECTIVES: To test the methodology of recruitment, retention and data completeness in a prospective cohort recruited after a hospitalised episode of acute kidney injury (AKI), to inform a future prospective cohort study examining the effect of obesity on AKI outcomes. DESIGN: Feasibility study. SETTING: Single centre, multi-site UK tertiary hospital. PARTICIPANTS: 101 participants (67M; 34F) with a median age of 64 (IQR 53-73) years, with and without obesity, recruited within 3 months of a hospitalised episode of AKI. OUTCOME MEASURES: Feasibility outcomes were recruitment (>15% meeting inclusion criteria recruited), participant retention at 6 and 12 months (≥80%) and completeness of data collection. Exploratory measures included recovery from AKI (regaining >75% of pre-AKI estimated glomerular filtration rate [eGFR]) at 6 months, development or progression of chronic kidney disease (CKD) (kidney function decrease of ≥25% +  rise in CKD category) at 12 months, and associations with poorer kidney outcomes. RESULTS: 41% of eligible patients consented to take part, exceeding the target recruitment uptake rate of 15%. Retention was 86% at 6 months and 78% at 12 months; 10 patients died and three commenced dialysis during the study. Data were 90%-100% complete. Median BMI was 27.9 kg/m2 (range 18.1 kg/m2-54.3 kg/m2). 50% of the cohort had stage 3 AKI and 49% had pre-existing CKD. 46% of the cohort met the AKI recovery definition at 6 months. At 12 months, 20/51 patients developed CKD (39%) and CKD progression occurred in 11/49 patients (22%). Post-AKI interleukin-6 and cystatin-C were associated with 12 months decline in eGFR. CONCLUSIONS: Feasibility to conduct a long-term observational study addressing AKI outcomes associated with obesity was demonstrated. A fully powered prospective cohort study to examine the relationships between obesity and outcomes of AKI is warranted.
    • Oesophageal Doppler guided optimization of cardiac output does not increase visceral microvascular blood flow in healthy volunteers.

      Heinink, Thomas; Read, David; Mitchell, William K; Bhalla, Ashish; Lund, Jonathan; Phillips, Bethan; Williams, John P (2017-02)
      BACKGROUND: Oesophageal Doppler monitoring (ODM) is used clinically to optimize cardiac output (CO) and guide fluid therapy. Despite limited experimental evidence, it is assumed that increasing CO increases visceral microvascular blood flow (MBF). We used contrast-enhanced ultrasound (CEUS) to assess whether ODM-guided optimization of CO altered MBF. METHODS: Sixteen healthy male volunteers (62 ± 3·4 years) were studied. Baseline measurements of CO were recorded via ODM. Hepatic and renal MBF was assessed via CEUS. Saline 0·9% was administered to optimize CO according to a standard protocol and repeat CEUS performed. Time-intensity curves were constructed, allowing organ perfusion calculation via time to 5% perfusion (TT5). MBF was assessed via organ perfusion rise time (RT) (5-95%). RESULTS: CO increased (4535 ± 241 ml/min versus 5442 ± 329 ml/min, P<0·0001) following fluid administration, whilst time to renal (22·48 ± 1·19 s versus 20·79 ± 1·31 s; P = 0·03), but not hepatic (28·13 ± 4·48 s versus 26·83 ± 1·53 s; P = 0·15) perfusion decreased. Time to renal perfusion was related to CO (renal: r = -0·43, P = 0·01). Hepatic nor renal RT altered following fluid administration (renal: 9·03 ± 0·86 versus 8·93 ± 0·85 s P = 0·86; hepatic: 27·86 ± 1·60 s versus 30·71 ± 2·19 s, P = 0·13). No relationship was observed between changes in CO and MBF in either organ (renal: r = -0·17, P = 0·54; hepatic: r = -0·07, P = 0·80). CONCLUSIONS: ODM-optimized CO reduces time to renal perfusion but does not alter renal or hepatic MBF. A lack of relationship between microvascular visceral perfusion and CO following ODM-guided optimization may explain the absence of improved clinical outcome with ODM monitoring.
    • Operating during the COVID-19 pandemic: How to reduce medical error.

      Ellis, R (2020-06)
      Our professional and private lives changed on March 11 2020 when the coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO. By March 16, surgical training was suspended, MRCS and FRCS examinations cancelled and all courses postponed. In theory, essential cancer surgery, emergency and trauma operating will continue. All elective, non-essential cases are currently cancelled. While we adapt to our new ways of working, we remind ourselves that surgeons are flexible, resilient and, ultimately, we are doctors in the first instance. We present a short article on operating during the COVID-19 pandemic.
    • Operative and one year outcomes of the custom-made fenestrated Anaconda® aortic stent graft - a UK multicentre study.

      Bungay, Peter (2017-06)
      OBJECTIVES: Early and one year outcomes are presented for fenestrated endovascular aneurysm repair (FEVAR) of complex aortic aneurysmal disease with the custom-made Anaconda fenestrated stent graft in 101 patients. METHODS: Retrospective site-reported data from the first 101 elective cases (2010 to 2014) from four UK centres was studied to evaluate patient demographics, aneurysm morphology, clinical success and one year outcomes in patients undergoing fenestrated aneurysm repair with the custom-made Anaconda device. RESULTS: 101 fenestrated grafts (median age 76, 85% male) were implanted with a total of 255 fenestrations (196 renal arteries, 48 SMA, 11 coeliac arteries) with 3% mortality, 98.4% target vessel patency at 30 day follow-up. Although 15 type I or III endoleaks were demonstrated at completion angiography all 10 type 1a endoleaks resolved spontaneously. Survival by Kaplan-Meier analysis was 97% and 91% at one month and one year respectively; with 75.8% showing reduction in AAA diameter and only one patient with sac expansion. Freedom from loss of target vessel patency (TVP) was 97.6%. CONCLUSIONS: Custom-made fenestrated Anaconda devices demonstrate low procedural mortality and a high rate of technical and clinical success at 30 days and one year.
    • Optimising prescription and titration of oxygen for adult inpatients using novel silicone wristbands: results of a pilot project at three centres.

      Lowrey, Gillian; Forster, Sarah; Smith, S (2016-08)
      Oxygen is the most commonly used drug in the acute hospital setting. Oxygen can be lifesaving but there is increasing evidence that it can cause harm if it is not given correctly. Prescription of oxygen, according to target saturations, has been advocated since 2008 but compliance remains at low levels. This paper describes a novel approach to improve oxygen prescription and titration in three acute hospital trusts using a colour-coded silicone wristband. The project ran for 3 months and covered more than 2,000 emergency admissions to hospital. Data was collected for oxygen prescription and titration rates for 270 patients during the project period. The wristbands showed an improvement in prescription and titration of oxygen in two out of three sites. The results support a wider controlled study of colour-coded wristbands to improve oxygen safety in secondary care.
    • Oral propranolol in the treatment of proliferating infantile haemangiomas: British Society for Paediatric Dermatology consensus guidelines

      Shahidullah, Hossain (2018-09)
      Background Infantile haemangiomas (IH) are the most common vascular tumours of infancy. Despite their frequency and potential complications, there are currently no unified U.K. guidelines for the treatment of IH with propranolol. There are still uncertainties and diverse opinions regarding indications, pretreatment investigations, its use in PHACES (posterior fossa malformations–haemangiomas–arterial anomalies–cardiac defects–eye abnormalities–sternal cleft and supraumbilical raphe) syndrome and cessation of treatment. Objectives To provide unified guidelines for the treatment of IH with propranolol. Methods This study used a modified Delphi technique, which involved an international treatment survey, a systematic evidence review of the literature, a face‐to‐face multidisciplinary panel meeting and anonymous voting. Results The expert panel achieved consensus on 47 statements in eight categories, including indications and contraindications for starting propranolol, pretreatment investigations, starting and target dose, monitoring of adverse effects, the use of propranolol in PHACES syndrome and how to stop treatment. Conclusions These consensus guidelines will help to standardize and simplify the treatment of IH with oral propranolol across the U.K. and assist in clinical decision‐making.
    • Patient Perspectives on the Meaning and Impact of Fatigue in Hemodialysis: A Systematic Review and Thematic Analysis of Qualitative Studies.

      Fluck, Richard (2019-08)
      RATIONALE & OBJECTIVE: Fatigue is a highly prevalent and debilitating symptom in patients on hemodialysis therapy due to the uremic milieu, the hemodialysis treatment itself, and other comorbid conditions. However, fatigue remains underrecognized and the consequences are underappreciated because it may not be visible in clinical settings. This study aims to describe the experience that patients undergoing maintenance hemodialysis have with fatigue. STUDY DESIGN: Systematic review and thematic synthesis of qualitative studies. SETTING & STUDY POPULATIONS: Patients undergoing hemodialysis. SEARCH STRATEGY & SOURCES: MEDLINE, Embase, PsycINFO, CINAHL, reference lists, and PhD dissertations were searched from inception to October 2018. DATA EXTRACTION: All text from the results/conclusion of the primary studies. ANALYTICAL APPROACH: Thematic synthesis. RESULTS: 65 studies involving 1,713 participants undergoing hemodialysis were included. We identified 4 themes related to fatigue: debilitating and exhausting burden of dialysis (bodily depletion, trapped in a vicious cycle of postdialysis exhaustion, vigilance and worry inhibiting rest, tiresome and agonizing regimen, and without remedy and relief), restricted life participation (deprived of time, managing energy reserves, frustrating need to rest, and joys foregone), diminishing capacities to fulfil relationship roles (losing ability to work and provide for family, failing as a parent, lacking stamina for sexual intimacy, and relying on others), and vulnerable to misunderstanding (being criticized for the need to rest and failing to meet expectations). LIMITATIONS: Non-English articles were excluded and most studies were conducted in high-income countries. CONCLUSIONS: For patients undergoing hemodialysis who experience fatigue, fatigue is a profound and relentless exhaustion that pervades the entire body and encompasses weakness. The fatigue drains vitality in patients and constrains their ability to do usual activities and fulfill their roles and meet personal aspirations. Explicit recognition of the impact of fatigue and establishing additional effective interventions to improve fatigue are needed.
    • Patient-Reported Outcome Measures for Fatigue in Patients on Hemodialysis: A Systematic Review.

      Fluck, Richard (2017-11)
      BACKGROUND: Fatigue is a prevalent and debilitating symptom in patients receiving hemodialysis. We aimed to identify and evaluate the characteristics and psychometric properties of patient-reported outcome measures for fatigue in patients receiving hemodialysis, to inform the selection of a robust and feasible measure for use in randomized trials in hemodialysis. STUDY DESIGN: Systematic review of outcome measures for fatigue. SETTING & POPULATION: Patients receiving hemodialysis. SEARCH STRATEGY & SOURCES: MEDLINE, Embase, PsycINFO, and CINAHL from inception to April 2017 were searched for all studies that reported fatigue in patients receiving hemodialysis. ANALYTICAL APPROACH: With a focus on addressing methods, items (individual questions) from all measures were categorized into content and measurement dimensions of fatigue. We assessed the general characteristics (eg, number of items and cost) and psychometric properties of all measures. RESULTS: From 123 studies, we identified 43 different measures: 24 (55%) were developed specifically for the hemodialysis population (of which 18 were nonvalidated author-developed measures for use in their study only), 17 (40%) for other populations, and 2 (5%) for chronic kidney disease (all stages). The measures assessed 11 content dimensions of fatigue, the 3 most frequent being level of energy (19 [44%]), tiredness (15 [35%]), and life participation (14 [33%]); and 4 measurement dimensions: severity (34 [79%]), frequency (10 [23%]), duration (4 [9%]), and change (1 [2%]). The vitality subscale of the 36-Item Short Form Health Survey (SF-36) was the most frequently used (19 [15%] studies), but has only been tested for reliability in hemodialysis. Of the fatigue-specific measures, the Chalder Fatigue Scale was the only one evaluated in hemodialysis, but the full psychometric robustness remains uncertain. LIMITATIONS: For feasibility, we searched for validation studies in the hemodialysis population using the names of measures identified in the primary search strategy. CONCLUSIONS: A very wide range of measures have been used to assess fatigue in patients receiving hemodialysis, each varying in content and length. Many have limited validation data available in this population. A standardized and psychometrically robust measure that captures dimensions of fatigue that are important to patients is needed to estimate and improve this disabling complication of hemodialysis.
    • Patients with CKD have abnormal upper gastro-intestinal tract digestive function: a study of uremic enteropathy.

      Harrison, Laura (2016-05)
      INTRODUCTION: Chronic kidney disease (CKD) affects gastrointestinal function and results in numerous adaptive and maladaptive responses. Disruption of the colonic microbiome and its attendant consequences - the loss of gut barrier integrity and increased generation of uremic toxins - has become well-recognized. However, less attention has been paid to characterizing the mechanisms behind dysfunction of the upper gastrointestinal (GI) tract, largely owing to the difficulty of studying small bowel function in vivo. This present study was designed to comprehensively describe upper GI function in those with advanced renal impairment. METHODS: 35 non-diabetic subjects (12 CKD stage 4/5 patients, 23 healthy controls) underwent detailed gastrointestinal magnetic resonance imaging (MRI) in both fasted and fed states. Upper gastrointestinal function was assessed by quantification of gastric emptying and intra-luminal small bowel water. Characterization of hydration and cardiovascular status was performed at baseline. Gut barrier integrity was assessed using serum endotoxin level. RESULTS: CKD was associated with dysmotility (gastric half-emptying time 96 ± 32 vs. 74 ± 27mins, p = 0.04) and reduced fasting and post-prandial small bowel water (36 ± 22 mL vs. 78 ± 42 mL, p < 0.001), reflecting abnormal digestive secretion and absorption. This was related to the degree of endotoxemia (r = -0.60, p = 0.04) and poorer symptom scores, but not to disease severity, arterial stiffness or hydration status. CONCLUSION: CKD adversely affects digestive function. Abnormalities in digestive secretion and absorption may potentially have a broad impact in the prevention and treatment of both CKD and its complications. Further study is required to assess the factors that contribute to this dysfunction in a wider CKD population.