Zafar W, Hu Y, Brubaker L
… +3 more, Harshaw N, Green J, Chang AR
Am J Kidney Dis
· 2026 Mar · PMID 41360254
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RATIONALE & OBJECTIVE: Early detection of albuminuria can enable administration of therapeutic interventions that improve clinical outcomes in patients at elevated risk for chronic kidney disease (CKD). We investigated t...RATIONALE & OBJECTIVE: Early detection of albuminuria can enable administration of therapeutic interventions that improve clinical outcomes in patients at elevated risk for chronic kidney disease (CKD). We investigated the impact of smartphone-enabled home urinary albumin-creatinine ratio (UACR) testing on albuminuria screening and clinical management of these patients. STUDY DESIGN: Nonrandomized clinical trial. SETTING & PARTICIPANTS: Active intervention group comprised 3,998 randomly selected adults (50% with hypertension but no diabetes; 50% with diabetes) receiving primary care at a large, regional health system compared with 3,998 propensity score-matched controls who were receiving usual care. INTERVENTIONS: Minuteful Kidney, a smartphone-enabled home UACR test kit cleared by the US Food and Drug Administration. OUTCOME: The primary outcome was completion of UACR testing (either laboratory-based or home testing) within 100 days of program start. ANALYTICAL APPROACH: Covariate balance between matched groups was evaluated using the standardized mean difference (SMD). Outcomes were compared between the 2 matched groups using McNemar's test. RESULTS: Overall, completion of any UACR test was higher in the intervention program than in the control group for the hypertension subgroup (53% vs 13%) and the diabetes subgroup (53% vs 30%). Greater UACR testing with Minuteful Kidney was consistent across age, sex, race, and ethnicity subgroups, though lower in nonusers of the patient portal. The Minuteful Kidney UACR results were abnormal (≥30 mg/g) in 38% (330 of 872) in the hypertension subgroup and in 45% (306 of 682) in the diabetes subgroup. Among the Minuteful Kidney-tested individuals, those with abnormal UACR were more likely to have follow-up primary care and nephrology visits and new prescriptions of renin-angiotensin-aldosterone system inhibitors than those with normal UACR. LIMITATIONS: Despite random assignment to intervention, this was not a randomized study; intervention was limited to 1 large rural health system; use of glucagon-like peptide-1 receptor agonists in CKD was not assessed. CONCLUSIONS: A convenient smartphone-enabled home albuminuria test is effective in increasing albuminuria screening among high-risk individuals. PLAIN LANGUAGE SUMMARY: This study evaluated whether a smartphone-enabled home albuminuria test could improve chronic kidney disease (CKD) screening among adults with hypertension or diabetes. We found that home testing increased albuminuria test completion 2.5-fold in the intervention group compared with the control group (53% vs 21%). The impact was larger in the hypertension-only subgroup (53% vs 13%) than in the diabetes subgroup (53% vs 30%). Among those tested at home, 38% (hypertension subgroup) and 45% (diabetes subgroup) had abnormal albuminuria levels. These individuals were more likely to have follow-up care and new prescriptions for certain kidney-protective medications. These findings support the use of home albuminuria testing as an effective strategy to increase screening and early intervention for kidney disease in high-risk populations.
Driehuis E, Peters SCE, Roeterdink AJ
… +8 more, Vogels TJFM, Goto NA, Broese van Groenou MI, de Wildt R, Dekker FW, van Jaarsveld BC, Abrahams AC, DOMESTICO Study Group
RATIONALE & OBJECTIVE: Starting dialysis is challenging for both patients and their informal caregivers. Caregivers help patients adapt and adhere to treatment by providing practical and emotional support, but these resp...RATIONALE & OBJECTIVE: Starting dialysis is challenging for both patients and their informal caregivers. Caregivers help patients adapt and adhere to treatment by providing practical and emotional support, but these responsibilities can take a considerable toll on them. Because little is known about how caregiver experiences evolve after dialysis initiation, we (1) assessed the trajectory of experiences and health-related quality of life (HRQoL) of caregivers of patients on dialysis during the first year of dialysis, (2) assessed whether differences in these trajectories exist between caregivers of home dialysis patients and those of in-center hemodialysis (ICHD) patients, and (3) explored in which domains caregivers desire support over time. STUDY DESIGN: Multicenter, longitudinal cohort study. SETTING & PARTICIPANTS: 202 dyads of incident dialysis patients and their adult informal caregivers. EXPOSURE: Home dialysis and ICHD. OUTCOME: Positive experiences, caregiver burden, depressive symptoms, and HRQoL. ANALYTICAL APPROACH: Descriptive analyses of desired support and linear mixed models to assess and compare trajectories. RESULTS: All but 2 of the caregiver outcomes deteriorated over the first year of dialysis. The change over time was significant for positive experiences (β, -1.44 [95% CI, -2.36 to -0.51]), depressive symptoms (β, 5.20 [95% CI, 3.15-7.25]), physical HRQoL (β, -5.73 [95% CI, -9.20 to -2.26]), general HRQoL (β, -0.13 [95% CI, -0.17 to -0.07]), and perceived health status (β, -9.40 [95% CI, -15.12 to -3.67]), but not for caregiver burden (β, 0.85 [95% CI, -0.02 to 1.72]) or mental HRQoL (β, -2.99, [95% CI, -6.93 to 0.94]). No differences in the trajectories were found between caregivers of patients receiving home dialysis and ICHD, but these groups did differ in desired support. LIMITATIONS: Small sample size of subgroups. CONCLUSIONS: Informal caregivers experience significant challenges during the first year of dialysis, marked by a notable decline in positive experiences, physical and general HRQoL, and perceived health status, alongside an increase in depressive symptoms, regardless of dialysis location. These findings underscore the need for targeted support for informal caregivers in dialysis care. PLAIN-LANGUAGE SUMMARY: The initiation of maintenance dialysis treatments presents notable challenges not only to patients but also to their informal caregivers, such as spouses, other family members, or friends. However, there is limited understanding of how these caregivers are affected over time. Therefore, we studied caregivers' experiences and health-related quality of life (HRQoL) during the first year of dialysis treatments received by the individual for whom they provide care. We found that caregivers reported a decline in positive experiences, worse physical and general HRQoL, and more depressive symptoms over time, whether dialysis was implemented in the home or a dialysis center. However, the types of support needed by caregivers of home and in-center dialysis patients differed. These findings underscore the need for targeted support for informal caregivers in dialysis care.
Wong-Mersereau C, El Wazze S, Gaudio K
… +2 more, Loban K, Sandal S
Am J Kidney Dis
· 2026 Mar · PMID 41354317
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RATIONALE & OBJECTIVE: Living kidney donors (LKDs) perceive gaps in care along their donation journeys, such as poor coordination and communication between providers. Better integration of their primary care providers (P...RATIONALE & OBJECTIVE: Living kidney donors (LKDs) perceive gaps in care along their donation journeys, such as poor coordination and communication between providers. Better integration of their primary care providers (PCPs) in their donation journey can help address these gaps. We captured the perspectives of Canadian PCPs to understand the challenges they perceive when caring for LKDs and their recommendations to address them. STUDY DESIGN: Qualitative descriptive design. SETTING & PARTICIPANTS: Semistructured in-depth interviews with 19 family physicians conducted until data saturation. ANALYTICAL APPROACH: Thematic analysis. RESULTS: Participants highlighted several challenges with the current living kidney donation processes: (1) limited scope of LKD care in primary practice; (2) poor clarity surrounding roles and responsibilities before donation (perceived as a facilitator) and after donation (perceived as low-barrier and high-access resource, and providing soft psychosocial support); (3) variable understanding of the living kidney donation process; and 4) lack of support and resources (patient accessibility to primary care, communication challenges between providers, poor health record transmission, limited availability of mental health services, limited financial support for patients and providers). The participants had 3 key recommendations: (1) support PCPs with pragmatic approaches and on-demand resources; (2) empower LKDs to be active participants in their care; and (3) implement strategies to address LKD care provision deficiencies (primary care accessibility, developing a collaborative care model, improving communication between all stakeholders, dedicated and prolonged psychosocial support, and governmental prioritization). LIMITATIONS: About half the sample had limited experience with LKD care; inability to recruit some PCPs such as nurse practitioners. CONCLUSIONS: As co-providers of patient care during the predonation phase and the primary drivers of care in the postdonation period, PCPs are positioned to deliver high-quality care to LKDs, contribute to long-term data collection, and potentially improve LKD outcomes. This study outlines challenges PCPs perceive and possible approaches to address them. PLAIN-LANGUAGE SUMMARY: Living kidney donors (LKDs) have reported gaps in their care, such as poor communication and a lack of coordination between doctors. Because family physicians play a key role in supporting donors before and after surgery, we interviewed 19 Canadian family doctors to hear their perspectives. Participants reported challenges such as unclear roles, limited scope of seeing LKDs in their practices, poor communication with transplant centers, and a lack of mental health and financial services. They suggested multiple ways to improve LKD care, such as giving family doctors better resources, empowering LKDs to be active partners in their care, and several other systems-level approaches. These findings suggest that greater connections among primary care providers may improve donor well-being and outcomes.
van Doorn DPC, Al-Nasiry S, Spaanderman MEA
… +3 more, Damoiseaux JGMC, van Paassen P, Timmermans SAMEG
Am J Kidney Dis
· 2026 Feb · PMID 41352724
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Thrombotic microangiopathies (TMAs) are severe endotheliopathies that can arise in pregnancy and require early recognition. Complement-mediated (C-)TMA should be differentiated from other endotheliopathies of pregnancy b...Thrombotic microangiopathies (TMAs) are severe endotheliopathies that can arise in pregnancy and require early recognition. Complement-mediated (C-)TMA should be differentiated from other endotheliopathies of pregnancy because the treatment differs. Here, we report a case of a pregnant woman with acute kidney injury requiring hemodialysis due to C-TMA on the background of a pathogenic C3 variant at 28+5 weeks of gestation. The low soluble Fms-like tyrosine kinase-1 to placental growth factor (sFlt1/PlGF) ratio excluded pre-eclampsia. Eculizumab was started, and therapeutic drug monitoring was applied for optimal dosing. Despite prolonged hemodialysis, fetal well-being was preserved, and delivery was safely postponed till 34+3 weeks of gestation, resulting in a healthy neonate. We also separately report on sFlt1/PlGF ratios measured in a cohort of 11 patients with TMA and coexisting pregnancy. Ten of 11 patients (91%) had low sFlt1/PlGF ratios, excluding pre-eclampsia. Thus, successful pregnancy in women with C-TMA can occur, and sFlt1/PlGF ratios may aid in clarifying the diagnosis and appropriate treatment.
Winkelmayer WC, Erickson KF, Khairallah P
… +4 more, He M, Montez-Rath ME, Chang TI, Niu J
Am J Kidney Dis
· 2026 Mar · PMID 41352721
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RATIONALE & OBJECTIVE: Atrial fibrillation (AF) is common among patients with kidney failure treated with hemodialysis. We studied the outcomes of apixaban initiation compared with no initiation of any oral anticoagulati...RATIONALE & OBJECTIVE: Atrial fibrillation (AF) is common among patients with kidney failure treated with hemodialysis. We studied the outcomes of apixaban initiation compared with no initiation of any oral anticoagulation among patients with hemodialysis-treated kidney failure and newly diagnosed AF. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Medicare-insured patients with hemodialysis-treated kidney failure with newly diagnosed AF and without recent oral anticoagulant (OAC) use (2014-2019). EXPOSURE: Initiation of apixaban treatment versus no OAC initiation within 30 days of an AF diagnosis. OUTCOMES: Thromboembolic and bleeding events and death within 365 days of follow-up. ANALYTICAL APPROACH: Propensity-matched comparison of new apixaban users and OAC nonusers implemented using Cox proportional hazards models while accounting for competing risks. RESULTS: Within 30 days of the new diagnosis of AF among 63,300 previously OAC-naïve patients, 4,010 initiated apixaban and 59,290 did not initiate any OAC. After propensity matching, 3,985 apixaban users were well matched to 3,985 OAC nonusers on all measured characteristics. Median CHADS-VASc, a multidimensional stroke risk score, was 4 (interquartile range [IQR], 3-5). Apixaban was initiated a median of 5 (IQR, 2-12) days after AF and used for a median of 59 (IQR, 37-135) days. In intention-to-treat analyses, rates of ischemic stroke were 25% lower (HR, 0.75; 95% CI, 0.57-0.97) and those of a composite outcome of thromboembolic events and cardiovascular death were 24% lower (HR, 0.76; 95% CI, 0.70-0.83) among apixaban users. Conversely, apixaban users had a 55% higher rate of hemorrhagic stroke (HR, 1.55; 95% CI, 1.03-2.33) and a 29% increased rate of clinically important bleeding (HR, 1.29; 95% CI, 1.14-1.45). The HR for all-cause mortality was 0.61 (95% CI, 0.56-0.67). Results from as-treated analyses were qualitatively consistent with intent-to-treat analyses but generally larger in magnitude. LIMITATIONS: Potential for residual confounding from unobserved characteristics or informative censoring unaccounted for by competing risk models. CONCLUSIONS: Among patients with hemodialysis-treated kidney failure, compared with no anticoagulation, initiation of apixaban soon after newly diagnosed AF was associated with lower risks of ischemic stroke, a composite thromboembolic end point, and all-cause mortality but higher rates of clinically meaningful bleeding. PLAIN-LANGUAGE SUMMARY: In this study of existing data of patients with kidney failure receiving dialysis who were newly diagnosed with atrial fibrillation, the most common heart rhythm disorder, we found that initiating a newer blood thinner, apixaban, was associated with fewer strokes, other clotting-related cardiovascular events, and deaths compared with what was observed in patients who did not initiate any blood-thinner treatment after their atrial fibrillation diagnosis. However, patients initiating apixaban did have higher rates of bleeding events that required hospitalization or, rarely, led to death. The information presented in this study can be used to inform shared decision-making between patients and their physicians.
Glennon CM, Nigwekar SU, Kroshinsky D
… +1 more, Tucker JK
Am J Kidney Dis
· 2026 Jan · PMID 41251635
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Skin disorders occur commonly in patients with chronic kidney disease (CKD) and may greatly impact their quality of life. These skin disorders have varying underlying pathophysiologies, but there are a few common mechani...Skin disorders occur commonly in patients with chronic kidney disease (CKD) and may greatly impact their quality of life. These skin disorders have varying underlying pathophysiologies, but there are a few common mechanisms including the accumulation of uremic solutes, metabolic disturbances, and inflammation. Pruritus in the setting of CKD (CKD-associated pruritus or CKD-aP), acquired perforating disorder (APD), calcinosis cutis, calciphylaxis, cutaneous lupus, and vasculitis are skin disorders often occurring in association with kidney disease and with which clinicians should be familiar. CKD-aP is reported to have a prevalence of 40% among patients receiving dialysis and 20% with earlier stages of CKD. Acquired perforating disorder (APD) is a skin disorder seen commonly in patients with diabetes mellitus and kidney failure that presents typically with crater-shaped nodular eruptions with a central hyperkeratosis. Calcinosis cutis is a skin disorder that occurs when calcium salts deposit into skin and subcutaneous tissues. Calciphylaxis is a rare cutaneous vasculopathy characterized by microvascular calcium deposition and thrombosis leading to tissue ischemia and subsequent skin necrosis. Lupus erythematosus and the vasculitides are systemic disorders with distinct skin manifestations that may offer clues as to the underlying disorder.
Am J Kidney Dis
· 2026 Feb · PMID 41241128
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The detection and management of depression have special considerations in people with kidney disease. Screening should be performed every 6-12 months using a self-reported questionnaire. Clinicians should rule out sympto...The detection and management of depression have special considerations in people with kidney disease. Screening should be performed every 6-12 months using a self-reported questionnaire. Clinicians should rule out symptoms from medical conditions such as dialysis inadequacy or hypothyroidism and confirm the presence of sadness or anhedonia. Sertraline has shown limited efficacy and an increased risk for adverse effects such as gastrointestinal symptoms, so cautious, gradual dose titration is warranted. Cognitive behavioral therapy has potential benefit for depressive symptoms in people with kidney disease. Current trials are evaluating behavioral activation therapy. Physical activity has many benefits and likely improves depression.
Am J Kidney Dis
· 2026 Feb · PMID 41238167
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Medicare Advantage (MA) enrollment among patients receiving dialysis has surged following the passage of the 21st Century Cures Act, which lifted prior restrictions on enrollment. As MA becomes the plurality payer for di...Medicare Advantage (MA) enrollment among patients receiving dialysis has surged following the passage of the 21st Century Cures Act, which lifted prior restrictions on enrollment. As MA becomes the plurality payer for dialysis, understanding its implications for patients, providers, and policymakers is critical. MA offers out-of-pocket spending caps and additional services not covered under fee-for-service (FFS) Medicare. Some plans also prioritize care coordination, which may improve patient outcomes. However, concerns remain regarding limited provider networks, prior authorization barriers, and disparities in access to medications and transplants. The increasing shift to MA also challenges value-based care models, as most quality measures and payment models for patients receiving dialysis are limited to FFS Medicare. Although research examining the benefits and downsides of MA is paramount, a comparison of MA versus FFS Medicare is complicated by selection bias and incomplete or inaccessible data. To ensure that increasing enrollment into MA has not harmed patients, policymakers must enhance data fidelity and transparency, strengthen regulatory oversight, and align financial incentives across populations to safeguard access to high-quality care for patients receiving dialysis.
Yau K, Ray JG, Jeyakumar N
… +15 more, Luo B, Abdullah S, Dixon SN, Wing S, Clemens KK, Castrillon-Ramirez F, Udell JA, Meraz-Munoz A, Young A, Harel Z, Perl J, Leiter LA, Garg AX, Cherney DZI, Wald R
Am J Kidney Dis
· 2026 Feb · PMID 41238166
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RATIONALE & OBJECTIVE: There are limited real-world data describing the cardiovascular benefits of glucagon-like peptide-1 receptor agonists (GLP1-RAs) across the spectrum of chronic kidney disease (CKD) severity. This s...RATIONALE & OBJECTIVE: There are limited real-world data describing the cardiovascular benefits of glucagon-like peptide-1 receptor agonists (GLP1-RAs) across the spectrum of chronic kidney disease (CKD) severity. This study evaluated the association of GLP1-RAs with major adverse cardiovascular events (MACE) in comparison with dipeptidyl peptidase-4 (DPP-4) inhibitors in the setting of CKD. STUDY DESIGN: Retrospective observational cohort study. SETTING & PARTICIPANTS: 24,576 new users of GLP1-RA and 44,367 new users of DPP-4 inhibitors with estimated glomerular filtration rate (eGFR) < 90 mL/min/1.73 m in Ontario, Canada. EXPOSURE: New use of GLP1-RAs versus DPP-4 inhibitors. OUTCOME: The primary outcome was MACE, comprising nonfatal myocardial infarction, unstable angina, nonfatal ischemic stroke or transient ischemic attack, coronary revascularization, and cardiovascular death. Secondary outcomes included individual components of the composite outcome, hospitalization or emergency department visits for congestive heart failure, peripheral vascular disease revascularization, lower limb amputation, and all-cause mortality. ANALYTICAL APPROACH: Inverse probability of treatment weighting using propensity scores was used to minimize confounding. Multivariable Fine-Gray subdistribution hazard models stratified by eGFR subgroup were fit to evaluate the primary outcome. FINDINGS: Mean age of study participants was 69 years, 50% were female, 92% had type 2 diabetes mellitus, 40% were taking a sodium/glucose cotransporter 2 (SGLT2) inhibitor, and 41% had CKD stages 3-5. MACE occurred among 1,296 (31.6 per 1,000 person-years) GLP1-RA users versus 1,374 (36.5 per 1,000 person-years) DPP-4 inhibitor users (subdistribution hazard ratio [SHR], 0.88 [95% CI, 0.80-0.97]). The lower rate of MACE among GLP1-RA users was largely related to a lower rate of cardiovascular death (SHR, 0.72 [95% CI, 0.62-0.85]). In subgroup analyses, there was no effect modification between the association of GLP1-RA initiation and lower rates of MACE by CKD stages, degree of albuminuria, or concomitant use of SGLT2 inhibitors. LIMITATIONS: Retrospective design. A substantial amount of missing information on albuminuria. CONCLUSIONS: In a population-based study of individuals across the spectrum of kidney disease, GLP1-RA initiation was associated with a lower rate of MACE than initiation of DPP-4 inhibitors. PLAIN-LANGUAGE SUMMARY: A class of medications called glucagon-like peptide-1 receptor agonists (GLP1-RA) is now used for the treatment of diabetes. This study explored the association of GLP1-RA administration with cardiac health in people with kidney disease compared with another common class of diabetes medication, dipeptidyl peptidase-4 (DPP-4) inhibitors. In this study of nearly 69,000 individuals in Ontario, Canada, with a wide range of kidney function, people taking GLP1-RA experienced a lower rate of heart disease than those taking DPP-4 inhibitors. The lower rate was mainly related to fewer deaths from heart disease. Differences were consistent across different levels of kidney disease and regardless of whether people were also taking other medications that protect the heart.
Am J Kidney Dis
· 2026 Feb · PMID 41238165
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RATIONALE & OBJECTIVE: Adults receiving maintenance hemodialysis (HD) frequently report pain, yet detailed descriptions of pain in this population are lacking. This study examines pain locations, characteristics, and ass...RATIONALE & OBJECTIVE: Adults receiving maintenance hemodialysis (HD) frequently report pain, yet detailed descriptions of pain in this population are lacking. This study examines pain locations, characteristics, and associations with other symptoms in adults receiving HD. STUDY DESIGN: Cross-sectional analysis. SETTING & PARTICIPANTS: Adults with moderate to severe chronic pain receiving maintenance HD enrolled in the multicenter HOPE Consortium Trial from 2021 to 2023. EXPOSURE: Sociodemographic, pain treatment, dialysis, medical comorbidity, and psychological and behavioral characteristics. Other patient-reported symptoms. OUTCOME: Pain interference and severity as assessed by the Brief Pain Inventory (BPI) Interference and Severity subscales (range, 0-10). ANALYTICAL APPROACH: Multivariable regression with least absolute shrinkage and selection operator (LASSO) to examine associations between participant characteristics and pain interference/severity, and Spearman's correlation to examine relationships between other symptoms and pain interference/severity at baseline. RESULTS: Among 643 participants, the median BPI interference was 6.6 (IQR, 5.1-7.9) and severity was 6.0 (IQR, 4.5-7.5). Among the participants, 84% of participants reported pain >1 year, and 75% had daily pain; 89% and 66% of participants endorsed musculoskeletal and neuropathic pain, respectively. Of 32 body regions, the median number of painful regions was 8 (IQR, 4-14). Common regions in females were lower back (72%), knees (64%), legs (60%), and upper back (59%), and a similar pattern existed for males. In LASSO analyses, cardiovascular disease and depression were associated with significantly higher pain interference whereas White race (reference, Black race) and non-Hispanic ethnicity were associated with significantly lower pain interference. Similar findings were noted for pain severity. Pain catastrophizing and symptoms of fatigue, depression, and anxiety were moderately correlated with pain interference (r > 0.4). LIMITATIONS: Neither relationship directionality nor causality can be inferred. CONCLUSIONS: Among adults treated with HD who have chronic pain, pain locations were numerous and diverse, with substantial musculoskeletal and neuropathic characteristics. Factors associated with pain interference were predominantly sociodemographic and psychological rather than those related to comorbid diseases and dialysis. PLAIN-LANGUAGE SUMMARY: Adults receiving maintenance hemodialysis (HD) frequently experience chronic pain, but it remains poorly understood. We examined pain locations, characteristics, and relationships with other symptoms among 643 adults with moderate to severe chronic pain receiving maintenance HD enrolled in the multicenter HOPE Consortium Trial from 2021 to 2023. We found that pain locations were numerous and diverse, with substantial musculoskeletal and neuropathic pain characteristics. The factors associated with pain interference were predominantly sociodemographic and psychological rather than related to comorbid diseases and dialysis. Given these findings, routine pain assessments and treatment plans tailored to the specific needs and symptoms of the individual patient seem warranted for this patient population.