My patients may ask, at times, then: What does it [fluid management graph] look like? Some nurses expressed frustration because physicians did not trust or follow up results. Use of bioimpedance thus felt meaningless. So we [the nurses] do measurements, but nothing changes and then it feels meaningless. The entire team should be involved, including the physicians, those who It should not depend on the interest of a few professionals; it's supposed to be the same for all patients, an opportunity to get the best care possible — if you believe this is an improvement.
Nurses were often prime initiators of measurement, and physicians appreciated it when nurses had performed measurements before discussing dry weight with them. In some units, nurses would adjust dry weight independently with guidance from bioimpedance, while in other units; the physician only performed dry weight determinations. So we know when to expect errors too, and that helps a lot. In our unit, it is usually the nurses who measure on their own initiative.
They are quite independent, determine dry weights and such, they consult us, the physicians only if they feel uncertain. And if they are uncertain, they usually run a BCM and then discuss with us, so it's usually their initiative. Usually, we the nurses initiate measurements. Confidence among physicians varies, of course. We always consult the physician and tell what it [the bioimpedance device] has shown, and then you can see how the patient […], what the other parameters for the assessment of dry weight, you can discuss it.
It is not always that we determine dry weight after what the BCM shows, but it may indicate that it should be higher and then the physician may increase it. One frequently mentioned barrier to use of bioimpedance was lack of structure. There were large variations in routines regarding when to use it, how to interpret results and how to follow up. Some units had guidelines for utilization, but due to high workloads and a shortage of trained staff, bioimpedance measurement was not a priority.
Having to wait for the device if someone else was currently using it could interrupt workflow, but this barrier did not have a high impact on use. To prevent the spread of infection, one patient with a multi-drug resistant infection had been isolated. Equipment brought to the room had been kept to a minimum; consequently, bioimpedance measurement had not been performed preventively, and the patient gradually developed pulmonary edema. We [the nurses] may have different ways of doing it. The problem is when nurses quit and are replaced; there will be new nurses.
To do measurements, it takes some commitment and motivation, for it to be of any benefit. Some people prioritize other things. Going and getting a machine to measure might sometimes be met with resistance. So it's always in another room, and sometimes you may not want to wait the extra five minutes, so you start the treatment and you'll do the measurement the next time.
That may be a reason why you skip it. A patient was kept isolated due to a multi-drug resistant infection. He - without any known new infarction or so - began to develop pulmonary edema. It has been ten to twenty years since I experienced dialysis patients in that situation, but he had not been measured then.
Small units had higher capacity for organizational change. For example, participants from a satellite clinic described successful implementation of bioimpedance in clinical practice despite absence of written guidelines. I'm in a small unit [PD-unit]. It's easier for us to standardize than it is in the blood dialysis unit.
Considering those [patients] who are very stressed and want their dialysis treatment to get started. If we absolutely want to measure bioimpedance, we usually ask them to come a little earlier, then they can start their dialysis session at the same time as usual, and that usually works. The importance of adequate fluid volume management in hemodialysis patients is well established, and a number of technologies are now available to aid assessment of fluid status of which bioimpedance spectroscopy has been most extensively studied [ 8 — 20 ].
However, many dialysis centers lack an agreed fluid management policy, and studies show access to bioimpedance devices in the clinics may not have impact on practice patterns [ 21 , 22 ]. However, all methods for assessment of hydration status perform best when measured serially and when performed in conjunction with other methods of volume assessment [ 7 , 12 — 14 , 33 ], but not all study participants were aware of the importance of serial bioimpedance measurements.
In some clinics, use of bioimpedance in daily practice depended on individual initiatives. Bioimpedance had not been introduced strategically, but through passive dissemination of information, which is generally ineffective [ 24 , 25 , 37 ].
Thus, awareness of the potential benefits of bioimpedance [ 10 , 11 , 16 , 18 , 19 ] was insufficient. Recommendations for use of bioimpedance have changed over time [ 38 ], but there were diverse opinions on how to use bioimpedance, e. These findings indicate the necessity of channels to provide new and updated research recommendations [ 24 , 39 , 40 ]. Lack of collaboration between different types of professionals and deficient congruency in recommendations were perceived as barriers.
Some nurses reported limited self-efficacy in using bioimpedance and interpreting the results due to lack of preexisting knowledge, but in units where dieticians contributed knowledge, participants expressed a higher degree of self-efficacy. Inter-professional collaboration may be critical to the provision of efficient health care and has the potential to increase self-efficacy [ 41 ]. However, as other participants denied that this was a barrier, professionals may also have misconceptions about patient values [ 30 ].
Software for visualization of bioimpedance results was found helpful in interactions with patients, and motivation and curiosity among well-informed patients were an incentive for use of bioimpedance [ 42 , 43 ]. Several participants in the focus groups, the physicians in particular, found the device attractive, as it had contributed to increased knowledge about hydration status and put the subject of dry weight on the agenda. Attractiveness and experience of advantages in practice are characteristics considered crucial for successful implementation of an innovation [ 26 ].
Hence, implementation of bioimpedance in clinical practice has theoretically a good chance for success. Although some units had developed routines for use of bioimpedance, measurement would not be a priority in periods of high workload and shortage of trained staff. This may indicate that many professionals do not consider bioimpedance a facilitator in daily practice, and inter-professional consensus is missing.
Contextual factors, such as hospital size, may also influence successful implementation [ 44 ], as the use of bioimpedance had been implemented successfully without systematic implementation strategies in small units. Due to the qualitative approach, we gained insight into perceived barriers and facilitators, although we cannot appraise the frequency of the identified determinants or their impact on the use of bioimpedance.
In order to develop an implementation strategy on a national level or in other countries, a quantitative study on the frequency and impact of identified themes and concepts in this study, could contribute to increased transferability. To prevent inaccuracy in the results, we pilot-tested the questioning route, and used the same moderator in all interviews and for improved confirmability [ 45 ], study reporting is based on a rich representation of quotations.
A limitation of the study is that a selection bias might be inherent due to the strategy to recruit volunteer participants who can best supply information i. That is, professionals with unusual experiences and other perceptions might have been missed. The choice to conduct interviews via equipment for telemedicine may have affected dependability, as some users were unaccustomed to the setting.
On the other hand, use of telemedicine allowed for interviews with nationwide representatives. A multidisciplinary perspective, including a wide variety of professionals and different types of clinics enhanced credibility, but input from physicians and dieticians was limited due to the small number of participants. We therefore cannot fully assure that we reached saturation on all themes [ 27 , 29 ] or that all potential perceptions from physicians and dieticians was materialized. However, our aim was not to compare and contrast differences between different professionals perception, and in order to enhance feasibility it is an accepted rule of thumb to plan for three or four interviews when using focus groups for data collection, since the analyst looks for patterns and themes across groups [ 27 ].
Moreover, the relative proportions of dieticians, nephrologists and nurses in the study sample do reflect the actuality of the study population well. Bioimpedance may contribute valuable support to clinical assessment of hydration status in hemodialysis patients. In this qualitative study content analysis of focus groups interviews with renal care professionals was used to identify perceived barriers and facilitators for use of bioimpedance in clinical practice. A multilevel approach to examining barriers and incentives for change was found to be applicable to the ideas and categories that arose from the data, and determinants, either facilitating or preventing use of bioimpedance, were identified on five levels: Barriers for use were found in the areas of insufficient credibility, lack of awareness, insufficient knowledge, limited self-efficacy, lack of structure and contradictory regulations.
Moreover, in units with inter-professional collaboration, participants expressed higher levels of knowledge and self-efficacy, which contributed to motivation to change practice. The funding sources were not involved in the study design; the collection, analysis, and interpretation of data; the writing process; or the decision to submit the article for publication. All authors contributed to the study conception and study design and were responsible for ethical approval. CH conducted the focus groups and interviews, and JS was present for all sessions as assisting moderator taking notes.
The final version of the manuscript was read and approved by all authors. The study was performed in accordance with the ethical standards laid down in the Declaration of Helsinki, and the Regional Ethical Review Board in Uppsala favorably reviewed the research plan.
Written consent was obtained from all focus group participants prior to the data collection. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. National Center for Biotechnology Information , U. Published online May Author information Article notes Copyright and License information Disclaimer.
Received Feb 7; Accepted Apr Associated Data Supplementary Materials Additional file 1: Abstract Background Inadequate volume control may be a main contributor to poor survival and high mortality in hemodialysis patients. Methods Qualitative data were collected through four focus group interviews with 24 renal care professionals: Results Several barriers and facilitators to the use of bioimpedance in clinical practice were identified, and a multilevel approach to examining barriers and incentives for change was found to be applicable to the ideas and categories that arose from the data.
Conclusions Determinants for use of bioimpedance were identified on five levels: Electronic supplementary material The online version of this article Background Assessing hydration status and achieving an adequate dry weight in dialysis patients is a delicate task; morbidity and mortality, primarily due to cardiovascular disease, remain unacceptably high, and emerging evidence suggests inadequate volume control as a main contributor [ 1 — 3 ]. Methods Study design The study has a qualitative explorative design.
Participants and setting We planned for four focus groups with approximately six to eight participants in each group. Data collection A semi-structured questioning route was developed [ 27 , 29 , 30 ]. The definitive main questions were: Analysis The transcripts were read through several times and coded for thematic content analysis in order to inductively derive concepts and core themes from the data.
Open in a separate window. Table 1 Overview of barriers and facilitators on five levels. Table 2 Participant characteristics stratified by profession. Innovation Barriers Several users had been enthusiastic about bioimpedance initially, but expressed declining confidence in the method.
Facilitators Use of bioimpedance was associated with feelings of curiosity and excitement; it put dry weight determination on the agenda and provided new insights. Individual professional Barriers In several units, bioimpedance had not been introduced systematically or strategically, and the continual education was insufficient, lacking, or dependent on the interest or commitment of certain individuals. Facilitators Study participants felt ownership over the initiative to use bioimpedance and were motivated to develop strategies for use, not least to assess nutritional status objectively, which was considered impossible to do otherwise.
Social context Barriers Some nurses expressed frustration because physicians did not trust or follow up results. Organizational context Barriers One frequently mentioned barrier to use of bioimpedance was lack of structure. Facilitators Small units had higher capacity for organizational change. Discussion The importance of adequate fluid volume management in hemodialysis patients is well established, and a number of technologies are now available to aid assessment of fluid status of which bioimpedance spectroscopy has been most extensively studied [ 8 — 20 ].
Limitations Due to the qualitative approach, we gained insight into perceived barriers and facilitators, although we cannot appraise the frequency of the identified determinants or their impact on the use of bioimpedance. Conclusion Bioimpedance may contribute valuable support to clinical assessment of hydration status in hemodialysis patients. Additional file Additional file 1: Acknowledgements We would like to thank all focus group participants for their valuable contributions. Availability of data and materials The data in Swedish analyzed during the current study are available from the corresponding author on reasonable request.
Notes Ethics approval and consent to participate The study was performed in accordance with the ethical standards laid down in the Declaration of Helsinki, and the Regional Ethical Review Board in Uppsala favorably reviewed the research plan. Competing interests The authors declare that they have no competing interests. Footnotes Electronic supplementary material The online version of this article Contributor Information Jenny Stenberg, Phone: Magnitude of end-dialysis overweight is associated with all-cause and cardiovascular mortality: The mortality risk of overhydration in haemodialysis patients.
Importance of normohydration for the long-term survival of haemodialysis patients. KDOQI clinical practice guideline for hemodialysis adequacy: Am J Kidney Dis.
Associated Data
Improving clinical outcomes among hemodialysis patients: Hemodialysis for chronic renal failure. Agarwal R, Weir MR. Clin J Am Soc Nephrol. Importance of whole-body bioimpedance spectroscopy for the Management of Fluid Balance. A whole-body model to distinguish excess fluid from the hydration of major body tissues. Am J Clin Nutr. Effect of fluid management guided by bioimpedance spectroscopy on cardiovascular parameters in hemodialysis patients: Bioimpedance-guided fluid Management in Maintenance Hemodialysis: Covic A, Onofriescu M. Time to improve fluid management in hemodialysis: This level of reinjection requires a perfect conjunction of HD parameters to be obtained in routine practice; the vascular access needs to deliver sufficient blood flow, the hydraulic permeability of the dialysis membrane needs to be adapted for high convective volumes and the session to have few interruptions.
However, most of the HDF-ready centres deal with frail and elderly patients with catheters as vascular access, and the target volume is difficult to reach. HDx can be a valuable option for patients who are not reaching systematically the target volume in HDF because of their vascular access.
These patients could thus benefit from a treatment as effective as HDF for toxin removal [ 2 ]. Pruritus is one of the most tenacious and disabling symptoms in patients with HD [ 3 ]; most suffer from a sine materia pruritus that resists intervention during HD, and this remains an unsolvable problem [ 4 ]. Pruritus among patients with HD results from an interaction of many factors: With a potential for better removal of large middle molecules, HDx may improve pruritus in some patients with HD. Nevertheless, because of the wide range of causes leading to pruritus, this potential benefit could remain insufficient.
He was healthy and had nocturnal HD in our centre. He suffered from a tenacious pruritus that would start during the HD session and last until a few hours before the following session. Many interventions were tried to avoid itching, such as membrane switch and various medications. None of these was effective; intravenous antihistamine therapy before each session mitigated slightly the pruritus.
HDx treatment was initiated and resulted in a significant reduction of the symptoms and the discontinuation of the intravenous antihistamine medication. Pathogenesis is unclear but uraemic toxicity and ESRD-induced disorders seem to play an important role as its occurrence is significantly lowered by transplantation [ 6 ].
Many treatments have been tested but their effectiveness remains partial [ 7 ]. HDx could be an interesting option for these patients, but as RLS remains poorly understood it is not possible to predict its effects. This describes an year-old patient who was suffering from a persistent RLS during and after each HD session despite a maximal neurologist-guided drug therapy. HDx was started and led to slight lowering of the doses of drugs and the RLS intensity. Among all the burdens of routine HD, the length of time recovery after a session was frequently reported by patients to be the most disabling.
This persistent asthenia heavily impacted the quality of life of patients with HD, rendering their free-from-dialysis time difficult to enjoy. Based on our observations, HDx seems to shorten this in some patients. Nevertheless, rendering the effects of HDx is hard to extrapolate in all the HD patients. We report here the cases of two patients receiving HDF treatment but suffering from a persistent and disabling asthenia after the session.
Despite many interventions, such as isonatric dialysis, tight adaptation of their dry weight or prescription cleaning, the asthenia remained. HDx was tried in these two patients and dramatically improved the recovery after the HD session. Albumin leak with HDx has been raised as a potential limitation for its widespread use, especially among malnourished patients.
Nevertheless, many patients receiving HDx therapy in our centre reported a better appetite after switching to this therapy. Many uraemic compounds can be linked to a reduced appetite in HD. For instance, leptin, pro-inflammatory cytokines such as IL-6, or more recently obestatin and acyl-ghrelin, have been associated with diminished appetite among patients with HD [ 8 , 9 ], and a wide range of accumulated middle molecules inhibited the ingestive behaviour in rats [ 10 ].
Thus, a better appetite associated with HDx may be in relation to more effective removal of these molecules when a medium cut-off membrane is used. Further studies are needed to explore the effect of HDx on the appetite and nutritional status of patients with HD. Moreover, albumin leak could be considered as positive as it could enhance protein-bound uraemic toxin removal and clearance of toxic modified forms of albumin [ 11 , 12 ].
Recent data suggest that free light chains FLC removal in patients suffering from cast nephropathy could be an interesting therapy to improve renal injury and mortality. However, these membranes were expensive and cumbersome. Adsorptive membrane, such as polymethylmethacrylate-based BK However, despite a lower cost with respect to HCO membranes, this membrane remains expensive. As HDx improved the clearance of FLC, it could be an interesting and cost-effective therapy among patients with a cast nephropathy. Thus, further studies need to investigate the potential effects of HDx on FLC removal in multiple myeloma.
Similarly, the clearance of myoglobin during acute kidney injury AKI due to rhabdomyolysis highlighted the potential value of HCO membranes [ 15 , 16 ]. However, despite this theoretical advantage, HCO membrane still suffers from a high albumin and protein leakage and a prohibitive cost. Potential development paths and clinical applications of HDx therapy. Thanks to an overall increase in toxin removal, the impact of HDx on cardiovascular diseases, anaemia and calcium-phosphate balance needs to be tested.
Certain reflux and ulcer medications linked with bone fractures in dialysis patients
HDx could be also beneficial for healthy patients receiving HD via autonomous techniques. Then, its effects on long-term outcomes such as success of transplantation or occurrence of cardiovascular diseases need to be investigated. Among patients who underwent HDx therapy in various clinical situations, most reported an increase in appetite, which could be interesting in malnourished patients.
We saw a potential interest in patients with pruritus or RLS. Moreover, HDx therapy seemed to reduce the recovery time of inter-dialytic asthenia. Nevertheless, interventional studies are required to confirm or overturn these statements. Despite continuous improvements in HD procedures, cardiovascular mortality and morbidity remain a concerning issue among patients with HD. Many intertwined factors lead to this higher risk, including accumulation of uraemic toxins, anaemia, phospho-calcic disorders, inflammation and bio-incompatibility.
Expanded haemodialysis: news from the field | Nephrology Dialysis Transplantation | Oxford Academic
HDF emerged as an interesting approach to enhance removal of middle molecules, whose benefits were expected on cardiovascular morbidity. In addition to HDF-removed toxins, larger ones might be removed by HDx therapy, and this could tip the balance; medium cut-off membranes could enhance the removal of middle molecules, such as FLC, pentraxin 3 or chitinaselike protein 1, which are involved in cardiovascular diseases among patients with HD [ 17 ].
Furthermore, improvement of toxin removal could also improve anaemia and calcium-phosphate balance. Autonomous dialysis is dedicated to healthy and young patients because it is suited to their lifestyle, and therefore is associated with better survival than in-centre HD [ 18 ]. Due to logistical reasons, self-care and home dialysis cannot offer HDF and despite a better survival because of younger age and healthier condition, long-term development of vascular calcifications and cardiovascular morbidity remain high. Moreover, such patients are often on transplant waiting lists and better dialysis could improve transplantation outcomes.
First, despite the potential applications of HDx, future studies need to take into account the complexity of patients with HD. Little is really known about the real pathogenesis of almost all the symptoms experienced by patients with HD. For instance, the improvement of asthenia or dietary intake observed in our patients treated by HDx cannot be fully explained by conventional evaluation of dialysis performance. Consequently, it remains difficult to understand positive or negative results arising from dialysis studies.
The use of sensitive and exhaustive techniques, such as proteomics, could be of interest to identify the spectrum of toxins that are involved. This would lead to a better understanding of the uraemic milieu, which is urgently required to evaluate the benefits of HDx.
INTRODUCTION
Second, the benefit of an enhanced toxin removal could be mitigated by the leak of important solutes. HDx may suffer from the same limitations as HDF, and efforts need to be made to describe the real effect of dialysis on non-toxic solutes. Again, high sensitivity of the proteomic approach could be valuable to understand the balance between the solutes removed that are beneficial and those that are toxic. However, enhancement of removal of a wide spectrum of uraemic toxins could already be beneficial for patients with HD.
Furthermore, an acceptable but greater albumin leak could improve the removal of some PBTs. Large uraemic toxins could be targeted in selected patients with emerging techniques such as rheopheresis, in particular in situations such as peripheral artery disease or calciphylaxis. HDx could be an interesting solution in several clinical situations.
The first feedback from the battlefront is promising but the evidence is still incomplete. Future studies should focus on the potential benefits for pruritus, asthenia or cardiovascular disease. Simultaneously, we urgently need to better understand the removal pattern of our devices membrane and dialysate evaluated through sensitive technologies such as proteomics. Logistical issues single-needle puncture and other temporary vascular access malfunction, water loop maintenance ….
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