Background: Depression is a pervasive psychological issue facing hemodialysis (HD) patients. Novel technology-based treatment strategies that deploy psychology-based interventions have not been the focus for therapy and few published studies exist. The aim of the current trial was to determine the feasibility and acceptability of an Internet-based positive psychological intervention in HD patients with comorbid depressive symptoms.Methods: HD patients (n=14) with elevated symptoms of depression were enrolled in a singlearm pre-post trial with clinical assessments at baseline and immediately post intervention. Chairside during regularly scheduled HD treatment, patients utilized a web browser to completed on-line modules promoting skills for increasing positive emotion over a 5-week period using Apple IPads. Targeted skills included noting of daily positive events, gratitude, positive reappraisal, acts of kindness, and mindfulness/meditation. Results:Twelve of 14 patients completed the program for an 85.7% retention rate. Participants felt satisfied with each session and offered consistently positive feedback. On average, participants visited the website 3.5 times per week. Significant improvements were evident for depressive symptoms (15.3 vs. 10.9; p=0.04), as per the Center for Epidemiological Studies Depression Scale.Conclusions: An innovative Internet-based positive psychological intervention represents a feasible and useful therapeutic option for HD patients with depressive symptoms.

Background: Physical inactivity is prevalent and linked with a variety of unfavorable clinical outcomes in hemodialysis patients. To increase physical activity (PA) and improve quality of life in this population, intradialytic and out-of-clinic exercise interventions have been implemented in many studies. However, there is still a lack of consensus in the literature on which type of exercise intervention is more feasible and effective. Summary: This review provides a brief overview of intradialytic and out-of-clinic exercise protocols utilized in previous studies. We also examine data related to the feasibility of each approach, and their efficacy for improving cardiovascular health, muscle mass, strength, and physical function. Key Messages: The benefits from most intradialytic and out-of-center exercise training interventions published to date have been modest or inconsistent. Furthermore, neither appears to provide a significant advantage over the other in terms of benefits for cardiovascular health, muscle mass, strength, and physical function. A significant concern is that most intradialytic and out-of-center exercise interventions are mandated exercise prescriptions that include either endurance or resistance training exercises, performed at low-moderate intensities, for a total of 60–135 min of exercise/week. This volume, intensity, and variety of exercise are far less than what is recommended in most PA guidelines. This type of structured activity is also boring for most patients. To enhance the effectiveness of exercise interventions, we suggest using the intradialytic period to provide patients guidance on how they can best incorporate more activity into their lives, based on their individual needs and barriers.

Background: Virtual reality (VR) is an evolving technology that is becoming a common treatment for pain management and psychological phobias. While non-immersive devices (i.e., the Nintendo Wii) have been previously tested with hemodialysis patients, no studies to date have used fully-immersive VR as a tool for intervention delivery. The current pilot trial tests the initial safety, acceptability, and utility of VR during maintenance hemodialysis treatment sessions-particularly, whether VR triggers motion sickness that mimics or negatively impact treatment related symptoms (e.g., nausea). Methods: Hemodialysis patients (n=20) were enrolled in a Phase I single-arm proof-of-concept trial. While undergoing hemodialysis, participants were exposed to our new JovialityTM VR program. This 25-minute program delivers mindfulness training and guided meditation using the Oculus Rift head-mounted display. Participants experienced the program on two separate occasions. Prior and immediately following exposure, participants recorded motion-related symptoms and related discomfort on the Simulator Sickness Questionnaire. Utility measures included end-user's ability to be fully immersed in the virtual space, interact with virtual objects, find hardware user-friendly, and easily navigate the JovialityTM program with the System Usability Score scale. Results: Mean age was 55.3 (+/-13.1) years; 80% male; 60% African American; and mean dialysis vintage was 3.56 (+/-3.75) years. At the first session, there were significant decreases in treatment and/or motion-related symptoms following VR exposure (22.6 vs. 11.2; p=0.03); scores >20 indicate problematic immersion. HD end-users reported high levels of immersion in the VR environment and rated the software easy to operate, with average System Usability Scores of 82.8/100. Conclusions: Hemodialysis patients routinely suffer from fatigue, nausea, lightheadedness, and headaches that often manifest during their dialysis sessions. Our JovialityTM VR program decreased symptom severity without adverse effects. VR programs may be a safe platform to improve the dialysis patient experience.

Introduction: Patients with kidney failure undergoing maintenance hemodialysis (HD) therapy are routinely counseled to reduce dietary sodium intake to ameliorate sodium retention, volume overload, and hypertension. However, low-sodium diet trials in HD are sparse and indicate that dietary education and behavioral counseling are ineffective in reducing sodium intake. This study aimed to determine whether 4 weeks of low-sodium, home-delivered meals in HD patients reduces interdialytic weight gain (IDWG). Secondary outcomes included changes in dietary sodium intake, thirst, xerostomia, blood pressure, volume overload, and muscle sodium concentration.Methods: Twenty HD patients (55 AE 12 years, body mass index [BMI] 40.7 AE 16.6 kg/m 2 ) were enrolled in this study. Participants followed a usual (control) diet for the first 4 weeks followed by 4 weeks of three low-sodium, home-delivered meals per day. We measured IDWG, hydration status (bioimpedance), standardized blood pressure (BP), food intake (3-day dietary recall), and muscle sodium (magnetic resonance imaging) at baseline (0 M), after the 4-week period of usual diet (1 M), and after the meal intervention (2 M). Findings:The low-sodium meal intervention significantly reduced IDWG when compared to the control period (−0.82 AE 0.14 kg; 95% confidence interval, −0.55 to −1.08 kg; P < 0.001). There were also 1 month (1 M) to 2 month (2 M) reductions in dietary sodium intake (−1687 AE 297 mg; P < 0.001); thirst score (−4.4 AE 1.3; P = 0.003), xerostomia score (−6.7 AE 1.9; P = 0.002), SBP (−18.0 AE 3.6 mmHg; P < 0.001), DBP (−5.9 AE 2.0 mmHg; P = 0.008), and plasma phosphorus −1.55 AE 0.21 mg/dL; P = 0.005), as well as a 0 M to 2 M reduction in absolute volume overload (−1.08 AE 0.33 L; P = 0.025). However, there were no significant changes in serum or tissue sodium (all P > 0.05).Discussion: Low-sodium, home-meal delivery appears to be an effective method for improving volume control and blood pressure in HD patients. Future studies with larger sample sizes are needed to examine the long-term effects of home-delivered meals on these outcomes and to assess cost-effectiveness.

Introduction Chronic volume overload is a persistent problem in hemodialysis (HD) patients. The purpose of this study was to investigate the impacts of comprehensive volume reduction protocol on HD patient's hydration status and blood pressure (BP). Methods Twenty‐three HD patients (age = 55.7 ± 13.3 years) completed a 6‐month comprehensive volume control protocol consisting of: reducing postdialysis weight; reducing BP medication prescriptions; and weekly intradialytic counseling to reduce dietary sodium intake and interdialytic weight gain (IDWG). The primary outcome was volume overload (VO) measured by bioelectrical impedance spectroscopy. Secondary outcomes included: IDWG, postdialysis weight, estimated dry weight (EDW), dietary sodium intake, BP and BP medication prescriptions. Findings From baseline (0M) to 6 months (6M), significant improvements were noted in: VO (0M 3.9 ± 3.9 L vs. 6M 2.6 ± 3.4 L, P = 0.003), postdialysis weight (0M 89.4 ± 23.1 kg vs. 6M 87.6 ± 22.2 kg; P = 0.012), and EDW (0M 89.0 ± 23.2 vs. 6M 86.7 ± 22.5 kg., P = 0.009). There was also a trend for a reduction in monthly averaged IDWG (P = 0.053), and sodium intake (0M 2.9 ± 1.6 vs. 6M 2.3 ± 1.1 g/d, P = 0.125). Neither systolic BP (0M 162 ± 27 vs. 6M 157 ± 23 mmHg, P = 0.405) nor diastolic BP (0M 82 ± 21 vs. 6M 82 ± 19 mmHg, P = 0.960) changed, though there was a significant reduction in the total number of BP medications prescribed (0M 3.0 ± 1.0 vs. 6M 1.5 ± 1.0 BP meds; P = 0.004). Discussion Our volume reduction protocol significantly improved HD patient's hydration status. While BP did not change, the reduction in prescribed BP medication number suggests improved BP control. Despite these overall positive findings, the magnitude of change in most variables was modest. Comprehensive changes in HD clinics may be necessary to realize more clinically significant results.

Older Hispanics routinely exhibit unhealthy beliefs about “normal” aging trajectories, particularly related to exercise and physical function. We evaluated the prospective effects of age reattribution on physical function in older Hispanics. Participants ( n = 565, ≥60 years) were randomly assigned into (a) treatment group—attribution-retraining, or (b) control group—health education. Each group separately engaged in four weekly 1-hr group discussions and 1-hr exercise classes, followed by monthly maintenance sessions. The Short Physical Performance Battery (SPPB) measured physical function throughout the 24-month intervention. No significant difference in physical function between intervention arms was evident over time. However, both groups experienced significant improvements in physical function at 24 months (β = 0.43, 95% confidence interval [CI] = [0.16, 0.70]). Participating in the exercise intervention was associated with improvements in physical function, although no additional gains were apparent for age attribution-retraining. Future research should consider strengthening or modifying intervention content for age reattribution or dosage received.

The beneficial influence of positive affect (e.g., joy) remains unexplored in relation to heart health in adults with chronic kidney disease (CKD)—a population at increased risk for poor cardiovascular health (CVH). Therefore, we evaluated the association of positive affect and CVH in a diverse U.S. population of Hispanics/Latinos with CKD. We analyzed cross-sectional data of adults ages 18–74 enrolled between 2008 and 2011 in the Hispanic Community Health Study/Study of Latinos with prevalent CKD (N = 1712). Positively worded items from the Center for Epidemiologic Studies Depression Scale were used to create a composite positive affect score (0–6; higher scores indicate greater positive affect). Prevalent CKD was defined as estimated glomerular filtration <60 ml/min/1.73 m 2 or urine albumin-to-creatinine ratio ≥30 mg/g. A composite CVH score was calculated using diet, body mass index, physical activity, cholesterol, blood pressure, fasting glucose, and smoking status. Each metric was defined as ideal, intermediate, or poor to compute an additive score. Linear regression was used for continuous scores of CVH and logistic regression for binary treatment (e.g., ≥4 Ideal). In participants with CKD, each unit increase in the positive affect score was associated with higher CVH scores when modeling CVH as a continuous outcome (β = 0.06, 95% CI = 0.01, 0.11). Similarly, a 1-unit increase in positive affect was associated with 1.15 times the odds of having >4 (vs. <4) ideal CVH indicators. Positive affect is associated with favorable CVH profiles in Hispanics/Latinos with CKD. Replication and prospective studies are needed to elucidate whether emotional well-being is a potential therapeutic target for intervention.

Previous studies have demonstrated a positive correlation between dietary sodium intake and blood pressure (BP) in hemodialysis (HD) patients. High BP is linked to increased cardiovascular (CV) mortality, and CV disease contributes to 41% of deaths among HD patients. To reduce these risks, HD patients are often counseled to restrict their dietary sodium intake, but few studies have examined the efficacy of this strategy.In this study, we aimed to assess the impacts of individualized low sodium dietary counseling in conjunction with a liberalized diet approach on sodium intake and BP. Liberalized dietary guidelines include more whole food consumption, decreasing foods eaten outside the home, and increased food label reading.32 patients (age = 53.8 ± 13.5y, 44% female) enrolled in the study and underwent baseline testing, including three 24‐hour recalls, and standardized BP measurement. Dietary recalls were analyzed using the Nutrition Data System for Research. During the 6‐month intervention, participants received weekly one‐on‐one dietary counseling to reduce sodium intake, address a liberalized diet, and set individual goals. Study coordinators performed counseling, supervised by both research and clinical dietitians. Baseline testing measures were repeated at the end of the 6‐month intervention period.Comparing baseline (BL) measurements to those post‐intervention (6m), average kilocalorie (kcal) intake was not significantly different (BL 1489 ± 968 vs. 6m 1445 ± 484 kcal, p= 0.876). Daily protein intake did not change over 6 months (BL 55.16 ± 21.62 vs. 6m 59.63 ± 21.15 grams, p=0.605). Total sodium intake numerically decreased (BL 2780.4 ± 1112.6 vs 6m 2482.5 ± 1147.6 mg, p=0.297), as did milligrams of sodium normalized per kcal (BL 2.07 ± 0.87 vs 1.68 ± 0.54 mg/kcal, p=0.08). Systolic BP (BL 154.71 ± 26.89 vs. 6m 157.57 ± 25.07 mmHg, p=0.674) and diastolic BP (BL 77.78 ± 20.54 vs 6m 77.85 ± 16.17 mmHg, p= 0.991) showed no significant changes, but total number of BP medications prescribed to patients (BL 2.93 ± 1.26 vs 6m 1.5 ± 1.09 medications) were significantly reduced (p=0.004).Maintenance of energy and protein intake is important for HD patients to preserve their lean mass and serum protein values, a potential challenge during sodium restrictions. Notably, this six‐month dietary intervention was not associated with decreases in kcal and protein intake, although patients remain below recommendations. Though not statistically significant, the modestly reduced sodium intake that was found may suggest developing changes in consumption due to our intervention. Minimal changes in sodium intake had no significant effects on systolic and diastolic BP values, but may have played a role in the significant decrease in number of BP medications. This indicates that a six‐month dietary intervention may be meaningful for both systolic and diastolic BP maintenance with decreased BP medication usage.