The prevalence of symptoms in end-stage renal disease: a systematic review

Daily symptom burden in end-stage chronic organ failure: a systematic review

Chronic diseases are nowadays the major cause of morbidity and mortality worldwide. Patients with end-stage chronic organ failure may suffer daily from distressful physical and psychological symptoms. The objective of the present study is to systematically review studies that examined daily symptom prevalence in patients with end-stage chronic organ failure, with attention to those that included patients with either congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) or chronic renal failure (CRF). Thirty-nine articles (8 CHF, 7 COPD, 2 CHF and COPD, 22 CRF) have been included. The included studies used various study designs. There was a wide range of daily symptom prevalence that may be due to the heterogeneity in methodology used. Nevertheless, findings suggest significant symptom burden in these patients. This review highlights the need for further prospective and longitudinal research on symptom prevalence in patients with end-stage CHF, COPD and CRF to facilitate the development of patient-centred palliative care programs.

Symptom clusters in incident dialysis patients: associations with clinical variables and quality of life

BACKGROUND

To date, the pathophysiology underlying symptoms in renal patients is still unclear. Symptom management research suggests that identification of related clusters of symptoms could provide insight into underlying determinants associated with multiple symptom experience. Theoretically, symptoms within a cluster could have a synergistic relationship. We aimed to identify symptom clusters in incident dialysis patients, and investigated associations between symptom clusters, clinical variables, functional status as measured by the Karnofsky Index and quality of life.

METHODS

1553 haemodialysis (HD) and peritoneal dialysis (PD) patients completed the Kidney Disease Quality of Life Short Form symptom/problem list at 3 months after the start of dialysis. Principal component analysis using varimax rotation was used to identify symptom clusters.

RESULTS

Patients were bothered by an average of 2.8 (+/-2.4) symptoms of 'moderate bother' or more. Three clusters were identified, explaining 49% of the total variance. All clusters showed strong negative associations with the SF-36 quality of life dimensions (-0.142 to -0.593) and with functional status (-0.130 to -0.332) in HD and PD patients. In contrast, only the clinical variables serum albumin (-0.084 to -0.232) and haemoglobin (-0.068 to -0.126) were associated with all clusters in HD patients, and Kt/V(urea) (-0.089 to -0.125) in PD patients.

CONCLUSIONS

Symptom clustering does not explain the lack of meaningful associations between symptoms and clinical variables. Strong associations of symptom clusters with quality of life dimensions suggest that psychological factors could better explain symptom burden. Patients' perceptions of symptoms should be routinely assessed as part of clinical care to improve self-management strategies.

Effect of social support on psychological-stress-induced anxiety and depressive symptoms in patients receiving peritoneal dialysis

OBJECTIVE

The objective of this study was to assess the association of psychological stress and social support with anxiety and depressive symptoms in peritoneal dialysis (PD) patients with end-stage renal disease (ESRD).

METHODS

Eighty-one patients receiving PD were recruited. Their demographic characteristics, psychological stress, and social support were determined with a structured questionnaire, and their anxiety and depressive symptoms were assessed with the Hospital Anxiety and Depression Scale.

RESULTS

Psychological stressors caused by ESRD and PD originated from five major sources, as determined by factor analysis. These included "Job and family crisis," "Worry about health and family being harmed," "Worry about daily life being restricted and physical appearance being altered," "Fear of decline in social ability," and "Fear of decline in physical function." Hierarchical linear regression analysis indicated that, after adjusting for gender, age, marital status, educational level, and duration of illness, solid social support can alleviate such symptoms.

Fatigue in patients receiving maintenance dialysis: a review of definitions, measures, and contributing factors

Fatigue is a debilitating symptom or side effect experienced by many patients on long-term dialysis therapy. Fatigue has a considerable effect on patient health-related quality of life and is viewed as being more important than survival by some patients. Renal providers face many challenges when attempting to reduce fatigue in dialysis patients. The lack of a reliable, valid, and sensitive fatigue scale complicates the accurate identification of this symptom. Symptoms of daytime sleepiness and depression overlap with fatigue, making it difficult to target specific therapies. Moreover, many chronic health conditions common in the long-term dialysis population may lead to the development of fatigue and contribute to the day-to-day and diurnal variation in fatigue in patients. Key to improving the assessment and treatment of fatigue is improving our understanding of potential mediators, as well as potential therapies. Cytokines have emerged as an important mediator of fatigue and have been studied extensively in patients with cancer-related fatigue. In addition, although erythropoietin-stimulating agents have been shown to mitigate fatigue, the recent controversy regarding erythropoietin-stimulating agent dosing in patients with chronic kidney disease suggests that erythropoietin-stimulating agent therapy may not serve as the sole therapy to improve fatigue in this population. In conclusion, fatigue is an important and often underrecognized symptom in the dialysis population. Possible interventions for minimizing fatigue in patients on long-term dialysis therapy should aim at improving health care provider awareness, developing improved methods of measurement, understanding the pathogenesis better, and managing known contributing factors.

Anxiety disorders in adults treated by hemodialysis: a single-center study

BACKGROUND

Anxiety is a complicating comorbid diagnosis in many patients with medical illnesses. In patients with end-stage renal disease (ESRD), anxiety disorders often are perceived to represent symptoms of depression rather than independent conditions and therefore have been relatively understudied in this medical population.

STUDY DESIGN

To evaluate the psychosocial impact of anxiety disorders on patients with ESRD, we sought to identify the rates of these disorders in a sample of patients receiving hemodialysis at a single center by using a structured clinical interview. We also compared a commonly used screening measure, the Hospital Anxiety and Depression Scale (HADS), with these clinical diagnoses to determine the measure's criterion validity or ability to predict a psychiatric diagnosis in ESRD populations. Finally, we examined the relationship between anxiety diagnosis and perceptions of quality of life (QOL) and health status.

SETTING & PARTICIPANTS

A sample of 70 randomly selected hemodialysis patients from an urban metropolitan center.

PREDICTOR

Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis I Diagnosis (SCID-I).

OUTCOMES

HADS and Kidney Disease Quality of Life Short Form.

RESULTS

Using the SCID, 71% of the sample received a DSM-IV Axis I diagnosis, with 45.7% of subjects meeting criteria for an anxiety disorder and 40% meeting criteria for a mood disorder. The concordance between DSM-IV anxiety disorders and anxiety scores acquired by using the HADS was not significant. Thus, although the HADS may provide an acceptable measure of overall "psychic distress" compared against the SCID-I, it has poor predictive power for anxiety diagnoses in patients with ESRD. Additionally, the presence of an anxiety disorder was associated with an overall perceived lower QOL (t = 2.4; P < 0.05).

LIMITATIONS

Single-center study and a population not representative of US demographics.

CONCLUSIONS

A substantial proportion of participating patients met criteria for an anxiety disorder. The utility of the HADS as a screening tool for anxiety in patients with ESRD should be questioned. The finding that anxiety disorders negatively impact on QOL and are not merely manifestations of depression in patients with ESRD emphasizes the importance of accurate diagnosis and effective treatment. Strategic options are necessary to improve the diagnosis of anxiety disorders, potentially enhancing QOL and medical outcome in patients with ESRD.

Maintaining quality of life at the end of life in the end-stage renal disease population

The rapidly advancing age of incident dialysis patient has coincided with a rising mortality rate during the first year of dialysis. This is occurring despite a steady decline in mortality of prevalent patients. These statistics suggest that there is a subset of sick, elderly dialysis patients who will not survive the first 6 months of dialysis. It may be that these patients would be better served with a conservative, palliative approach that does not include initiation of dialysis. Even though hospice care is universally available to the Center for Medicare and Medicaid Services population, dialysis patients encounter many barriers to obtaining this benefit and have a hospice utilization rate only one quarter that of cancer patients. This article discusses the barriers to and goals of palliative care in the chronic kidney disease/end-stage renal disease population.

Symptoms in advanced renal disease: a cross-sectional survey of symptom prevalence in stage 5 chronic kidney disease managed without dialysis

BACKGROUND

Numbers of patients with stage 5 chronic kidney disease (CKD) managed conservatively (without dialysis) are increasing steadily but prevalence and severity of symptoms in this population are not yet known.

AIM

To describe symptom prevalence, symptom severity, and total symptom burden in patients with stage 5 CKD managed conservatively.

METHOD

A cross-sectional survey of patients with stage 5 CKD managed conservatively, in three U.K. renal units. Symptoms were assessed using the patient-completed Memorial Symptom Assessment Scale Short Form (MSAS-SF), with additional renal symptoms.

RESULTS

Sixty-six patients were recruited (response rate, 62%), with mean age 82 years (standard deviation [SD] +/- 6.6), and mean estimated glomerular filtration rate 11.2 mL/min (SD +/- 2.8). Symptoms reported by more than one third or 33% of patients were (95% confidence intervals shown in parentheses): lack of energy, 76% (66%-84%); pruritus, 74% (65%-82%); drowsiness, 65% (54%-74%); dyspnea, 61% (50%-70%); edema, 58% (47%-66%); pain, 53% (42%-63%); dry mouth, 50% (39%-60%); muscle cramps, 50% (39%-60%); restless legs, 48% (38%-58%); lack of appetite, 47% (37%-58%); poor concentration, 44% (34%-54%); dry skin, 42% (32%-53%); sleep disturbance, 41% (32%-51%); and constipation, 35% (26%-45%). Mean number of symptoms reported on MSAS-SF was 11.58 (SD +/- 5.2), with an additional 2.77 (SD +/- 1.7) renal symptoms. Symptoms were also most severe in the more prevalent symptoms. Pain was an exception, with disproportionately greater severity (32% of all patients reported moderate/severe pain).

CONCLUSION

This study demonstrates that patients with stage 5 CKD have considerable symptom control needs, similar to advanced cancer populations, but with different patterns of individual symptoms and severity, particularly pain. Implications for palliative care, hospice, and nephrology services in planning and providing care are discussed.

Dialysis discontinuation: quo vadis?

Approximately 1 in 4 deaths of patients maintained on dialysis in the United States is preceded by a decision to discontinue treatment. Once considered to be a form of suicide, dialysis discontinuation is now increasingly common in most countries that are fortunate enough to offer renal replacement therapies. Given an aging and progressively sicker chronic kidney disease patient population, the rate of terminating dialysis is likely to increase. The literature on dialysis discontinuation includes studies principally from Canada, the United Kingdom, and the United States. The research is reviewed, critiqued, and examined to determine its relevance to practice. Future issues include the need to explore variability in dialysis practice as well as employment of a more patient-centered approach that is consistent with modern palliative medicine.

Withholding and Withdrawal from Dialysis: What We Know About How Our Patients Die

Withholding and withdrawal of dialysis has been a reality since dialysis was invented. Only in the past 20 years has it been formally studied, and we still have a great deal to learn. The nephrology community has slowly come to accept that, for some of our patients, not having dialysis is a better option than continuing or initiating therapy. The principles of palliative care throughout the disease trajectory and hospice care at end of life are germane to this population due to its high symptom burden and mortality rate. We review what is currently known concerning patients who choose to withhold or withdraw from dialysis, and the current barriers (and solutions) to providing them with optimal palliative care.