Quality of life in peritoneal dialysis patients

Nurse-based educational interventions in patients with peritoneal dialysis: A systematic review and meta-analysis

Background

Peritoneal dialysis (PD) is a major renal replacement therapy modality for patients with end-stage kidney disease (ESKD) worldwide. As poor self-care of PD patients could lead to serious complications, including peritonitis, exit-site infection, technique failure, and death; several nurse-based educational interventions have been introduced. However, these interventions varied and have been supported by small-scale studies so the effectiveness of nurse-based educational interventions on clinical outcomes of PD patients has been inconclusive.

Objectives

To evaluate the effectiveness of nurse-based education interventions in PD patients.

Design

A systematic review and meta-analysis of Randomized Controlled Trials (RCTs).

Methods

We performed a systematic search using PubMed, Embase, and CENTRAL up to December 31, 2021. Selection criteria included Randomized Controlled Trials (RCTs) relevant to nurse-based education interventions in ESKD patients with PD in the English language. The meta-analyses were conducted using a random-effects model to evaluate the summary outcomes of peritonitis, PD-related infection, mortality, transfer to hemodialysis, and quality of life (QoL).

Results

From 9,816 potential studies, 71 theme-related abstracts were selected for further full-text articles screening against eligibility criteria. As a result, eleven studies (1,506 PD patients in seven countries) were included in our systematic review. Of eleven studies, eight studies (1,363 PD patients in five countries) were included in the meta-analysis. Sleep QoL in the intervention group was statistically significantly higher than control (mean difference = 12.76, 95% confidence intervals 5.26-20.27). There was no difference between intervention and control groups on peritonitis, PD-related infection, HD transfer, and overall QoL.

Conclusions

Nurse-based educational interventions could help reduce some PD complications, of which only the sleep QoL showed statistically significant improvement. High-quality evidence on the nurse-based educational interventions was limited and more RCTs are needed to provide more robust outcomes.

Tweetable abstract

Nurse-based educational interventions showed promising sleep quality improvement and potential peritonitis risk reduction among PD patients.

Depression is a main determinant of health-related quality of life in patients with diabetic kidney disease

Low health-related quality of life (HRQOL) is associated with adverse outcomes in diabetic kidney disease (DKD) patients. We examined the modifiable factors associated with low HRQOL in these patients. We enrolled 141 DKD patients. HRQOL was assessed with the Short Form 36 (SF-36) questionnaire. Low HRQOL was defined as a score > one standard deviation below the mean. Depression and anxiety were assessed with the Hospital Anxiety and Depression Scale (HADS-D and HDAS-A, respectively). The patients’ median age was 65 years, and 73% were men. The prevalence rates of anxiety and depression were 8% (n = 11) and 17% (n = 24), respectively. Forty (28%) patients were identified as poor sleepers, and 40 (28%) had low physical activity levels. Anxiety, depression, and poor sleep quality were negatively correlated with SF-36 scores. Higher levels of physical activity and the estimated glomerular filtration rate (eGFR) were correlated with higher SF-36 scores, which indicated better health status. Higher depression scores (HADS-D scores) were associated with low HRQOL, independent of factors including age, sex, smoking status, comorbidities, eGFR, anemia, sleep quality, anxiety levels, and physical activity levels (odds ratio, 1.43; 95% confidence interval, 1.17–1.75). Among the clinical and psycho-physical factors, depression was a main determinant of low HRQOL in DKD patients.

Psychometric properties of the Arabic version of the hospital anxiety and depression scale in hemodialysis patients

The literature lacks a rigorous psychometric evaluation of the Arabic version of Hospital Anxiety and Depression Scale (HADS) in hemodialysis (HD) patients. This study aims to evaluate reliability, determine the underlying factor structure of the Arabic version of HADS and assess its suitability as screening tool for depression and anxiety among Arabic HD patients.A sample of 370 HD patients were recruited from all health districts in Kuwait. Reliability for HADS (all items) and its subscales HADS-A (anxiety) and HADS-D (depression) were estimated using Cronbach's alpha and item analysis was conducted. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted to extract and test the factor structure for the Arabic version of HADS. Eight models were tested using CFA to determine goodness-of-fit.The Cronbach α for the Arabic HADS (all items), HADS-A and HADS-D were 0.884, 0.852 and 0.764, respectively. Pearson correlation coefficient between HADS-A and HADS-D subscales indicated significant correlation (r = +0.69, PV < 0.001). EFA indicated two factors with eigenvalues >1, which accounted for 48.5% of the total variance. CFA revealed the one-factor model had the poorest fit, the two-factor models with acceptable fit, and three-factor models showed good fit.The Arabic HADS has good reliability and internal consistency, which warrants its use in screening for anxiety and depression among Arabic HD patients. Furthermore, the three-factor structure has shown a better fit which warrants further exploration in HD patients with the advancement in theory of psychological models for anxiety and depression.

Patient-reported outcome measures for life participation in peritoneal dialysis: a systematic review

BACKGROUND

Patients receiving peritoneal dialysis (PD) endure an ongoing regimen of daily fluid exchanges and are at risk of potentially life-threatening complications and debilitating symptoms that can limit their ability to participate in life activities. The aim of the study was to identify the characteristics, content and psychometric properties of measures for life participation used in research in PD.

METHODS

We searched MEDLINE, Embase, PsychInfo, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Cochrane Central Register of Controlled Trials from inception to May 2020 for all studies that reported life participation in patients on PD. The characteristics, dimensions of life participation and psychometric properties of these measures were extracted and analyzed.

RESULTS

Of the 301 studies included, 17 (6%) were randomized studies and 284 (94%) were nonrandomized studies. Forty-two different measures were used to assess life participation. Of these, 23 (55%) were used in only one study. Fifteen (36%) measures were specifically designed to assess life participation, while 27 (64%) measures assessed broader constructs, such as quality of life, but included questions on life participation. The 36-Item Short Form Health Survey and Kidney Disease Quality of Life Short Form were the most frequently used measures [122 (41%) and 86 (29%) studies, respectively]. Eight (19%) measures had validation data to support their use in patients on PD.

CONCLUSIONS

The many measures currently used to assess life participation in patients receiving PD vary in their characteristics, content and validation. Further work to pilot and validate potential measures is required to establish a core patient-reported outcome measure to assess life participation in patients receiving PD.

Quality of Life of Elderly Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

Objective

The aim of the present study was to evaluate the impact of continuous ambulatory peritoneal dialysis (CAPD) on the lifestyle of elderly patients.

Patients and Methods

Aspects of health-related quality of life (QL) were studied in 48 patients (16 men, 32 women) in end-stage chronic renal failure (ESRF) undergoing CAPD at the Clinic of Nephrology, Clinical Centre of Serbia. The first group comprised 20 adult patients (8 men, 12 women; age range: 35 – 59 years). The second group consisted of 28 older adult patients (8 men, 20 women; age range: 65 – 75 years). Mean length of CAPD treatment was 5.2 years in the first group and 3.67 years in the second group. Fifteen QL variables were investigated: marital status, family relationships, working ability, sleep, tiredness, appetite, wound healing, hobby, sports, friendships, sexual activity, mood, travel, self management, and happiness.

Results

The results showed that, in the examined groups, marital status and relationships with family members weren't influenced at all by dialysis. In both groups, CAPD had a negative influence on ability to bear cold and to travel, but other life functions were not significantly affected. Elderly patients had a significantly worse appetite ( p = 0.03, Fisher test) and mood ( p = 0.045, Fisher test) than did younger adults. In other examined variables, no statistically significant differences were found between the groups.

Conclusions

Lack of large, statistically significant differences between the groups suggests that CAPD has an equal influence on quality of life in younger and older adult patients.

Relationship between Dialysis Adequacy and Quality of Life in Long-Term Peritoneal Dialysis Patients

Objective

The purpose of this study was to compare quality of life (QOL) between peritoneal dialysis (PD) patients with adequate and inadequate total solute clearance (TSC). We also tried to determine the relationship between QOL and TSC.

Design

A cross-sectional study design was used in which QOL was evaluated and compared between PD patients with adequate and inadequate TSC.

Setting

The PD unit of a university teaching hospital.

Patients

Sixty-seven patients were recruited, 38 on continuous ambulatory PD and 29 on continuous cycler-assisted PD.

Methods

Patients were divided into adequate and inadequate groups, based on the results of either total urea clearance (Kt/Vurea) or total creatinine clearance (weekly CCr). The demographic data, dialysis variables, and clinical parameters of these patients were all collected. QOL was evaluated using the SF-36 questionnaire, which contains eight domains and is a comprehensive and validated instrument for QOL evaluation. QOL of patients in adequate and inadequate groups was compared. The relationship between QOL and TSC was also examined.

Results

Among patients grouped by Kt/Vurea, patients in the adequate group had significantly higher scores in two domains of the SF-36, that is, physical and emotional role functioning, than did those in the inadequate group. The total SF-36 scores were positively correlated with Kt/Vureawhen all patients were pooled together. However, among patients grouped by weekly CCr, there was no significant difference in any of the eight domains of the SF-36 between patients in the adequate and inadequate groups. No correlation was found between the total SF-36 scores and weekly CCr.

Conclusion

Our study had two important findings: First, PD patients with adequate total solute clearance, based on Kt/Vureaand not on weekly CCr, had a better QOL. Second, Kt/Vureais better correlated with QOL than weekly CCr. These findings suggest that Kt/Vureais a better parameter for the clinical evaluation of total solute clearance from the viewpoint of QOL.

Psychosocial interventions for preventing and treating depression in dialysis patients

BACKGROUND

People with end-stage kidney disease (ESKD) treated with dialysis are frequently affected by major depression. Dialysis patients have prioritised depression as a critically important clinical outcome in nephrology trials. Psychological and social support are potential treatments for depression, although a Cochrane review in 2005 identified zero eligible studies. This is an update of the Cochrane review first published in 2005.

OBJECTIVES

To assess the effect of using psychosocial interventions versus usual care or a second psychosocial intervention for preventing and treating depression in patients with ESKD treated with dialysis.

SEARCH METHODS

We searched Cochrane Kidney and Transplant's Register of Studies up to 21 June 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of psychosocial interventions for prevention and treatment of depression among adults treated with long-term dialysis. We assessed effects of interventions on changes in mental state (depression, anxiety, cognition), suicide, health-related quality of life (HRQoL), withdrawal from dialysis treatment, withdrawal from intervention, death (any cause), hospitalisation and adverse events.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of Bias' tool and used the GRADE process to assess evidence certainty. We estimated treatment effects using random-effects meta-analysis. Results for continuous outcomes were expressed as a mean difference (MD) or as a standardised mean difference (SMD) when investigators used different scales. Dichotomous outcomes were expressed as risk ratios. All estimates were reported together with 95% confidence intervals (CI).

MAIN RESULTS

We included 33 studies enrolling 2056 participants. Twenty-six new studies were added to this 2019 update. Seven studies originally excluded from the 2005 review were included as they met the updated review eligibility criteria, which have been expanded to include RCTs in which participants did not meet criteria for depression as an inclusion criterion. Psychosocial interventions included acupressure, cognitive-behavioural therapy, counselling, education, exercise, meditation, motivational interviewing, relaxation techniques, social activity, spiritual practices, support groups, telephone support, visualisation, and voice-recording of a psychological intervention. The duration of study follow-up ranged between three weeks and one year. Studies included between nine and 235 participants. The mean study age ranged between 36.1 and 73.9 years. Random sequence generation and allocation concealment were at low risk of bias in eight and one studies respectively. One study reported low risk methods for blinding of participants and investigators, and outcome assessment was blinded in seven studies. Twelve studies were at low risk of attrition bias, eight studies were at low risk of selective reporting bias, and 21 studies were at low risk of other potential sources of bias. Cognitive behavioural therapy probably improves depressive symptoms measured using the Beck Depression Inventory (4 studies, 230 participants: MD -6.10, 95% CI -8.63 to -3.57), based on moderate certainty evidence. Cognitive behavioural therapy compared to usual care probably improves HRQoL measured either with the Kidney Disease Quality of Life Instrument Short Form or the Quality of Life Scale, with a 0.5 standardised mean difference representing a moderate effect size (4 studies, 230 participants: SMD 0.51, 95% CI 0.19 to 0.83) , based on moderate certainty evidence. Cognitive behavioural therapy may reduce major depression symptoms (one study) and anxiety, and increase self-efficacy (one study). Cognitive behavioural therapy studies did not report hospitalisation. We found low-certainty evidence that counselling may slightly reduce depressive symptoms measured with the Beck Depression Inventory (3 studies, 99 participants: MD -3.84, 95% CI -6.14 to -1.53) compared to usual care. Counselling reported no difference in HRQoL (one study). Counselling studies did not measure risk of major depression, suicide, or hospitalisation. Exercise may reduce or prevent major depression (3 studies, 108 participants: RR 0.47, 95% CI 0.27 to 0.81), depression of any severity (3 studies, 108 participants: RR 0.69, 95% CI 0.54 to 0.87) and improve HRQoL measured with Quality of Life Index score (2 studies, 64 participants: MD 3.06, 95% CI 2.29 to 3.83) compared to usual care with low certainty. With moderate certainty, exercise probably improves depression symptoms measured with the Beck Depression Inventory (3 studies, 108 participants: MD -7.61, 95% CI -9.59 to -5.63). Exercise may reduce anxiety (one study). No exercise studies measured suicide risk or withdrawal from dialysis. We found moderate-certainty evidence that relaxation techniques probably reduce depressive symptoms measured with the Beck Depression Inventory (2 studies, 122 participants: MD -5.77, 95% CI -8.76 to -2.78). Relaxation techniques reported no difference in HRQoL (one study). Relaxation studies did not measure risk of major depression or suicide. Spiritual practices have uncertain effects on depressive symptoms measured either with the Beck Depression Inventory or the Brief Symptom Inventory (2 studies, 116 participants: SMD -1.00, 95% CI -3.52 to 1.53; very low certainty evidence). No differences between spiritual practices and usual care were reported on anxiety (one study), and HRQoL (one study). No study of spiritual practices evaluated effects on suicide risk, withdrawal from dialysis or hospitalisation. There were few or no data on acupressure, telephone support, meditation and adverse events related to psychosocial interventions.

AUTHORS' CONCLUSIONS

Cognitive behavioural therapy, exercise or relaxation techniques probably reduce depressive symptoms (moderate-certainty evidence) for adults with ESKD treated with dialysis. Cognitive behavioural therapy probably increases health-related quality of life. Evidence for spiritual practices, acupressure, telephone support, and meditation is of low certainty . Similarly, evidence for effects of psychosocial interventions on suicide risk, major depression, hospitalisation, withdrawal from dialysis, and adverse events is of low or very low certainty.

Needs Around Dialysis Treatment from Different Perspectives (NADIP): Results of the Exploratory German Multicenter Survey

BACKGROUND/AIMS

In 2015, approximately 70,000 patients with end-stage renal disease were treated chronically with dialysis in Germany. However, there is only sparse information regarding subjective appreciation of the different aspects of extracorporeal renal replacement therapies. This study was performed to gain insight into the needs and appreciation of services in dialysis centers in Germany including the views not only of the patients but also of the caregivers, physicians, and nurses.

METHODS

A cross-sectional written voluntary questionnaire survey based on the international RAND Kidney Disease Quality of Life Short Form (version 1.3) comprising 510 adult dialysis patients, 274 caregivers, 29 physicians, and 60 nurses in 30 dialysis centers across Germany.

RESULTS

Although patients were mostly satisfied with present treatment options, room for improvement exists. Patients were less critical of services than doctors and nurses. Factors such as trustworthy contact with staff at the centers as well as information exchange with other patients and among caregivers play a significant role in the patients' perception of a high-quality dialysis treatment facility. Therefore, continued cost saving, in particular regarding personnel, may subjectively counteract the objective technical improvements of dialysis.

CONCLUSIONS

High-quality technical standards are essential for successful dialysis therapy; however, additionally, we recommend an array of communicative and social tools employed by all stakeholders to convey and exchange information and also support subjective well-being. This survey represents one of the largest evaluations to date. The data are also of potential international relevance for non-German health management systems.

The positive influence of psychological intervention on the level of anxiety and depression in dialysis patients: A pilot study

Medical progress in dialysis therapy made it possible to treat patients with the end-stage renal disease for many years. But at the other side it may lead to profound changes in everyday life and may induce depression and anxiety. The research presented in this article explores the influence of psychological interventions on anxiety and depression levels in patients undergoing dialysis therapy. The experimental design included two experimental groups: cognitive intervention and cognitive/narrative intervention and one control group (standard treatment). In total, 139 participants aged 22–75, including 67 women and 72 men diagnosed with end-stage renal disease and treated with dialysis, were divided into a control group and two experimental groups. Two well-known tools were used in the study: Beck Depression Inventory and State-Trait Anxiety Inventory. It was indicated that cognitive intervention may decrease the level of anxiety as a state, whereas cognitive/narrative intervention may decrease the level of anxiety as a state and the level of depression in dialysis patients. The stronger effect in the case of using narrative therapy may be the consequence of the fact that narrative therapy stimulates deeper analysis of the discussed issues (involving emotional level).

A Longitudinal Study on the Prevalence and Risk Factors for Depression and Anxiety, Quality of Life, and Clinical Outcomes in Incident Peritoneal Dialysis Patients

Background

Starting dialysis is an important life event. The prevalence and evolution of psychological symptoms at commencement of long-term dialysis is unclear. We examined the prevalence of and risk factors for depression and anxiety, and the quality of life (QOL) of incident peritoneal dialysis (PD) patients, and also the change of these parameters in the first year of PD in relation to clinical outcomes under the PD-first policy.

Methods

All patients commencing long-term PD from March 2011 to April 2015 were asked to complete the Hospital Anxiety and Depression Scale (HADS), World Health Organization Quality of Life-BREF and the Kidney Disease Quality of Life Instrument Short Form questionnaire. Patient demographics and the incidence of hospitalization, peritonitis, exit-site infection, and all-cause mortality were studied. The HADS was repeated after 9 – 12 months.

Results

A high depression score was present in 39.6% of 191 patients at commencement of PD and was more common in diabetes patients (odds ratio [OR] 2.03, 95% confidence interval [CI] 1.09 – 3.81). A high anxiety score was present in 23.6%, and the risk factors included younger age (OR 0.96 per year, 95% CI 0.94 – 0.99) and diabetes (OR 2.59, 95% CI 1.20 – 5.57). Both high depression and anxiety scores were associated with an inferior QOL, overall and across most QOL domains. Depression and anxiety symptoms did not change in the first year of PD and were not associated with short-term clinical outcomes.

Conclusions

High depression and anxiety scores were prevalent in incident PD patients where PD-first policy is adopted and were associated with inferior QOL. There was no improvement after 1 year of PD. The impact of strategic interventions targeting patient groups at risk such as those with diabetes or of younger age warrants further investigation.

Antidepressants for treating depression in adults with end-stage kidney disease treated with dialysis

BACKGROUND

Depression affects approximately one-quarter of people treated with dialysis and is considered an important research uncertainty by patients and health professionals. Treatment for depression in dialysis patients may have different benefits and harms compared to the general population due to different clearances of antidepressant medication and the severity of somatic symptoms associated with end-stage kidney disease (ESKD). Guidelines suggest treatment of depression in dialysis patients with pharmacological therapy, preferably a selective serotonin reuptake inhibitor. This is an update of a review first published in 2005.

OBJECTIVES

To evaluate the benefit and harms of antidepressants for treating depression in adults with ESKD treated with dialysis.

SEARCH METHODS

We searched Cochrane Kidney and Transplant's Specialised Register to 20 January 2016 through contact with the Information Specialist using search terms relevant to this review.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing antidepressant treatment with placebo or no treatment, or compared to another antidepressant medication or psychological intervention in adults with ESKD (estimated glomerular filtration rate < 15 mL/min/1.73 m(2)).

DATA COLLECTION AND ANALYSIS

Data were abstracted by two authors independently onto a standard form and subsequently entered into Review Manager. Risk ratios (RR) for dichotomous data and mean differences (MD) for continuous data were calculated with 95% confidence intervals (95% CI).

MAIN RESULTS

Four studies in 170 participants compared antidepressant therapy (fluoxetine, sertraline, citalopram or escitalopram) versus placebo or psychological training for 8 to 12 weeks. In generally very low or ungradeable evidence, compared to placebo, antidepressant therapy had no evidence of benefit on quality of life, had uncertain effects on increasing the risk of hypotension (3 studies, 144 participants: RR 1.72, 95% CI 0.75 to 3.92), headache (2 studies 56 participants: RR 2.91, 95% CI 0.73 to 11.57), and sexual dysfunction (2 studies, 101 participants: RR 3.83, 95% CI 0.63 to 23.34), and increased nausea (3 studies, 114 participants: RR 2.67, 95% CI 1.26 to 5.68). There were few or no data for hospitalisation, suicide or all-cause mortality resulting in inconclusive evidence. Antidepressant therapy may reduce depression scores during treatment compared to placebo (1 study, 43 participants: MD -7.50, 95% CI -11.94 to -3.06). Antidepressant therapy was not statistically different from group psychological therapy for effects on depression scores or withdrawal from treatment and a range of other outcomes were not measured.

AUTHORS' CONCLUSIONS

Despite the high prevalence of depression in dialysis patients and the relative priority that patients place on effective treatments, evidence for antidepressant medication in the dialysis setting is sparse and data are generally inconclusive. The relative benefits and harms of antidepressant therapy in dialysis patients are poorly known and large randomised studies of antidepressants versus placebo are required.

Lack of motivation: a new modifiable risk factor for peritonitis in patients undergoing peritoneal dialysis?

AIM

Can we identify modifiable risk factors for peritonitis in patients undergoing peritoneal dialysis (PD)? We aimed to determine whether housing standard, PD exchange technique or patient motivation might be modifiable risks for peritonitis. We also explored the relationship between lack of motivation and depression.

METHODS

Nurse home visits assessed PD exchange technique, environment and patient motivation. Motivation scores were correlated separately with an Apathy Evaluation Score and a depression score using PHQ-9 questionnaires.

RESULTS

Home hygiene, exchange technique and motivation were above average in 53%, 56% and 60%, respectively in 104 patients undergoing PD. After 15 months, 25.9% patients developed peritonitis but nurses' ratings of homes and exchange techniques were not predictive. Low patient motivation was predictive. Patients rated to have above or below median motivation had significantly different Apathy Scores (p = 0.0002). Unmotivated depressed patients were significantly more likely to develop peritonitis compared to motivated depressed patients.

CONCLUSION

Lack of motivation predicted peritonitis particularly if associated with depression. Further studies are required focusing on specific motivation scoring schemes and the psychosocial support that might lead to better outcomes.

The Choice of Renal Replacement Therapy (CORETH) project: study design and methods

BACKGROUND

To date, research has neglected the patient's psychosocial and cognitive conditions as contributing factors to dialysis modality decision-making. Hence, the Choice of Renal Replacement Therapy (CORETH) study aims to examine these conditions with regard to their impact on the choice. Here we describe the design of the multicentre study, which is supported by a grant from the German Ministry for Education and Research.

METHODS

Two groups of patients will be compared after having chosen peritoneal or haemodialysis as permanent treatment. About 1200 participants from 50 dialysis centres all over Germany will be questioned. The questionnaire addresses social, psychological and shared decision-making aspects. Furthermore, cognitive functioning will be tested. For an economic evaluation direct and indirect costs of treatment will be calculated. Changes will be examined through a one-year follow-up.

CONCLUSIONS

The results will enlighten the treatment choice under the German healthcare system. They will provide further insight regarding the discussion on patient autonomy. From the patients' perspective, the results will help to strengthen their participation in the individual process of health-related decision-making.

Chronic Ischemic Heart Disease Affects Health Related Quality of Life

Background

Chronic diseases endanger not only physical health but also psychological and social health of patient. Thus, evaluation of such patients for psychological treatment decisions is very important.

Method

This is a descriptive study that was performed with 50 chronic patients (ischemic heart disease) selected from Valiasr and Mousavi at cardiac wards in Zanjan Province. They were given three types of questionnaire: demographic, WHOQOL, and Zung depression and anxiety index. The information was statically analyzed by frequency chart, central indexes, dispersion, Chi-Square and t tests, Pearson’s correlation index (P < 0.05).

Results

The average of quality of life in all patients were calculated as was respectively 12.19, 11.98, 12.08, and 12.4 in physical, psychological, social and environmental domains respectively, 68 percent of total number of the patients had various degrees of anxiety and 78 percent of them had various degrees of depression. There was a significant relationship between the life quality average in all domains and anxiety intensity and depression intensity (P < 0.05) and there was a significant relationship between life quality average in all domains and income (P < 0.05).

Conclusion

As the level of depression and anxiety goes up, quality of life decreases pointing out that they have a reverse relationship. Depression and anxiety are one of the most significant factors of quality of life among other variables. Regarding specific conditions of the treatment, it is necessary to pay special attention to psychological aspects.

Daytime sleepiness and quality of life in peritoneal dialysis patients

We aimed to compare automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) therapy with regard to patients' excessive daytime sleepiness (EDS) and quality of life (QOL). EDS was assessed with the Epworth Sleepiness Scale (ESS) and QOL with the Medical Outcomes Study 36-Item Short Form (SF-36) health survey. We included 59 patients (CAPD/APD, 30/29; male/female, 33/26; age, 45.3±15.8 years; dialysis duration, 42.0±33.6 months). The CAPD and APD groups were similar with respect to factors that affected sleep quality (age, sex, duration of PD), smoking, alcohol intake, socioeconomic status, body mass index, comorbid disease, and various laboratory parameters. Although one patient (3.3%) treated with CAPD and four patients (13.8%) treated with APD experienced EDS, there was no significant differences in ESS scores between the CAPD and APD patients. There was no difference in the SF-36 total and subscale scores when APD patients were compared with CAPD patients. The independent predictors of ESS were the serum albumin level (β= -2.04, P<0.01), total SF-36 score (β= 0.08, P=0.02), social functioning score (β= -2.47, P=0.01), and role-emotional subscale score (β= -1.12, P=0.05). The incidence of EDS was slightly higher in APD patients, but it did not negatively affect daily activities or QOL.

Psychiatric disorders in patients with end-stage renal disease

Psychiatric disorders in patients with end-stage renal disease are associated with poor prognosis and quality of life. The goal of this study is to investigate the association between psychiatric disorders and renal disease in patients undergoing dialysis treatment, compared with other chronic diseases, appreciating the demographic status of these patients. Sixty-nine patients participated in a diagnostic interview and gave socio-demographic data. The population was composed of 55% men aged 19-77 years with an average age of 50 years (95% CI = 47-54 years). The prevalence of psychiatric disorders found in this study (46.6%) was compared with that found in patients with asthma, polycystic ovary syndrome and HIV-positive. Moreover, the prevalence of the four most common psychiatric disorders which were identified among patients on dialysis were also the subject of comparison between them and others. These results demonstrate the relationship between the various psychiatric disorders and are compatible with other research studies.

Major depressive disorders in chronic hemodialysis patients in Nazareth: identification and assessment

OBJECTIVE

Depression illnesses are commonly observed in hemodialysis (HD) patients, which can influence the quality of life of end-stage renal disease patients. We evaluate the prevalence and predictive risk factors of depression in the Arab population undergoing HD in Nazareth, Israel.

METHODS

We conducted a prospective study that included 71 patients in the HD unit with a mean age of 61.9 ± 14.13 years who had undergone HD and 26 healthy control subjects with a mean age of 59.3 ± 7.3. Beck's Depression Inventory and Hamilton Depression Scale assessments were administered. Blood analysis for hematological and biochemical parameters was obtained. Diagnosis was made using the Diagnostic and Statistical Manual of Mental Disorders scale to correlate psychological variables with clinical, hematological, and biochemical parameters. Statistical analysis was carried out using analysis of variance followed by Tukey post-hoc multiple comparison tests.

RESULTS

The prevalence of depression was 43.7% in HD patients. Between HD patients and controls, cortisol values were 16.96 ± 0.5476 and 11.96 ± 1.116, respectively (P < 0.0001; 95% confidence intervals [CI]: 2.416-6.825). Between depressed HD patients versus control subjects, cortisol values were 16.48 ± 0.72 and 11.96 ± 1.116, respectively (P = 0.0013; 95% CI: 1.878-7.184). Hematological and biochemical parameters were compared between depressed HD and nondepressed patients, but differences between the two groups were found to be insignificant (P > 0.05).

CONCLUSION

Our HD patients were severely depressed. Studies of glucocorticoid turnover activity such as cortisol, a potent chemical stress hormone, may be used as a model and marker for early diagnosis of depression among HD patients. The strong familial support system in Arabic traditions has failed to decrease depression among these patients.

Assessment of the relationship between quality of life and stress in the hemodialysis patients in 2008

The aim of this study was to determine the relationship between quality of life with stress in the haemodialysis patients. This descriptive correlation study was done on 100 haemodialysis patients selected by consent method from Imam Khomeini and Fatemeh Zahra Hospitals in Sari/Iran from March 2008 to February 2009. Data were collected in questionnaire consisting of 3 sections (demographic feature, quality of life and stress) in three months. In the questionnaire, first, quality of life then stress in the patients was studied and the variables described. Then the relation between them was determined by statistical analysis. From the total number of 100 patients (53 men and 47 women) under study, 42% with partial comfortable life had moderate tension. Pearson correlation coefficient showed that there is a significant linear relationship with quality of life and degree of tension, (r = 0.802). That is with increase of tension, quality of life declines (p < 0.001). Also Pearson correlation coefficient indicated that there is positive correlation between the number of hemodialysis per week and the history of dialysis (p = 0.001). History of dialysis in 69% of the patients was 1-5 years and 74% of them were dialyzed in the morning trice a week. Findings showed that, with increase of stress, quality of such patients' life decreases. Therefore, the nurses and the other members of medication team should know to reduce the patient's stress using the supportive procedures and adaptation techniques, help improve quality of life by proper intervention method.

Depression as a determinant of quality of life in patients with chronic disease: data from Brazil

BACKGROUND

Depressive symptoms are associated with impaired quality of life (QOL). However, there are scarce data comparing the magnitude of depression on QOL among persons with different chronic diseases in developing countries. This study aimed to evaluate the impact of depression on QOL in patients with ischemic heart disease (IHD) and end-stage renal disease (ESRD) in hemodialysis.

METHODS

Cross-sectional survey conducted in 173 patients: 103 with IHD and 70 in hemodialysis. Depression was diagnosed by the Mini International Neuropsychiatric Interview-5.0 and depressive symptoms measured by Beck Depression Inventory. QOL was assessed through the Short-Form-36 (SF-36) and World Health Organization Quality of Life Instrument-brief (WHOQOL-brief). Multivariate analyses were performed to assess the association between variables and QOL.

RESULTS

Depression prevalence was 14.3% among IHD patients and 9.9% in the hemodialysis group, and depressive symptoms were present in 39 and 36%, respectively. Regardless of the chronic condition, depressed patients presented lower QOL scores than non-depressed ones in all domains, and the most affected were role emotional, mental health and social functioning of SF-36, and psychological domain of WHOQOL-brief. In linear regression analysis, depressive symptoms were predictive for lower QOL in all domains, with the highest standardized beta coefficients (ranging from -0.26 to -0.64).

CONCLUSION

Depression is an independent factor associated with worse QOL in IHD and ESRD patients. Among the priorities aiming at improving QOL must be evaluation and management of depressive symptoms.

Sertraline treatment is associated with an improvement in depression and health-related quality of life in chronic peritoneal dialysis patients

OBJECTIVES

There is scarce data about effects of treatment of clinical depression in peritoneal dialysis (PD) population. We aimed to determine prevalence of depression, its association with health-related quality of life (HRQoL) and effects of sertraline treatment in PD patients.

MATERIALS AND METHODS

We included 124 PD patients who had been on PD at least for 6 months. Short Form of Medical Outcomes Study was used to evaluate HRQoL. Depression was screened by Beck Depression Inventory (BDI). Patients with a BDI score > or = 17 were deemed to have depression and were referred to a psychiatrist for evaluation via Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) of diagnosis of clinical depression. About 25 patients diagnosed with clinical depression agreed to receive antidepressant treatment (Sertraline hydrochloride, 50 mg/day) for a 12-week period. After the treatment, biochemical analyses and questionnaires were repeated.

RESULTS

Thirty-two patients (25.8%) had depression. BDI score of patients were lower compared to those without depressive symptoms (23 + or - 6.7 and 9.8 + or - 3.0, respectively P < 0.001). Physical component scale (PCS) and mental component scale (MCS) domains of HRQoL were significantly decreased in patients with depression than in patients without depression (P < 0.001 for PCS and MCS). In bivariate analysis the BDI score was correlated inversely with the PCS and MCS (P < 0.001). Sertraline treatment improved BDI score of patients with depression (P < 0.001). HRQoL parameters also improved. No adverse effects requiring drug cessation was seen in the study group.

CONCLUSIONS

Treatment of depression with sertraline is associated with improvement of the HRQoL and symptoms related to depression.

The effects of kidney-disease-related loss on long-term dialysis patients' depression and quality of life: positive affect as a mediator

BACKGROUND AND OBJECTIVES

In kidney disease, the concept of loss is widely discussed but minimally researched. It appears that dialysis patients who grieve a range of losses suffer increased depression and reduced quality of life (QoL). Limited research is partly due to the lack of a relevant loss measure. The study presented here developed a measure and tested the criterion validity of loss in relation to depression and QoL.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In a cross-sectional observational study, 151 long-term dialysis patients were interviewed using standardized psychometric measures and the Kidney Disease Loss Scale (KDLS), developed for the study. Factor, path and multigroup analyses were conducted.

RESULTS

The factor structure and reliability of KDLS were supported. The path analyses supported the criterion validity of loss. It was a stronger contributor to depression than other clinical variables. Its effect on QoL was fully mediated by depression and positive affect (coping). The magnitude of the paths from loss to QoL through depression and positive affect was larger in home-based dialysis patients than in hospital-based patients.

CONCLUSIONS

KDLS is a promising measure of loss. Patient-defined losses may contribute to the high level of depression and in turn a reduction in patients' coping and QoL. These findings suggest several points of intervention to improve long-term dialysis patients' QoL.

PSYCHOSOCIAL FACTORS IN PATIENTS WITH CHRONIC KIDNEY DISEASE: Quality of Life and Psychological Issues in Peritoneal Dialysis Patients

Both peritoneal dialysis (PD) and hemodialysis (HD) patients have diminished quality of life (QOL) scores compared to healthy patients. QOL tends to decline over time, with the perception of the quality of physical health deteriorating more than mental health. However, many patients continue to feel hopeless, anxious, and worry about finances, loss of sexual function, family burden, and loss of independence. Depression is the most widely acknowledged psychosocial factor seen in patients with chronic kidney disease. Major depression occurs in 25% of patients facing impending dialysis. Once on PD, the proportion with major depression sharply declines to approximately 6%. This may be due to adjustment to dialysis, but may also be because depressive symptoms are associated with an increased risk of death. A low QOL score and depression are associated with higher comorbidity, poorer nutritional status, anemia, lower residual renal function, and increased hospitalization rates. Increased depressive scores are independently predictive of an elevated peritonitis risk, perhaps due to inattentiveness, or alternatively from a decrease in immune defenses. Small molecule clearances appear to have little to do with depressive symptoms. Depression is a significant problem in PD and other dialysis patients. There is an interrelationship between psychosocial factors, perception of illness, and clinical outcome that requires further study. Serial and simple measures of both depression and QOL should be obtained routinely in all PD patients. This permits rapid recognition of problems and may enhance patients' education on the importance of depression. Further research on interventions is urgently needed.

PSYCHOSOCIAL FACTORS IN PATIENTS WITH CHRONIC KIDNEY DISEASE: The Identification and Treatment of Depression in Patients Maintained on Dialysis

The high incidence of depression in end-stage renal disease (ESRD) patients is well documented. Our group and others have estimated that 20-30% of ESRD patients experience major depression. Several recent studies have emphasized the relationship between depressive symptoms and mortality and morbidity in both hemodialysis (HD) and peritoneal dialysis (PD) patients. We screened 380 PD patients for depression using the Beck Depression Inventory (BDI). The mean patient age was 59.9 +/- 14.1 (SD) years, 55% were Caucasian, 51% were male, and 39% had diabetes. The mean BDI score was 12.1 +/- 7.7; 49% had a score of 11 or greater. Fifty-five percent refused further assessment to confirm the diagnosis of major depression, while 45% of patients eligible for treatment agreed to further assessment. Their mean BDI was 18.8 +/- 6.2. Eighty-four percent were diagnosed with major depression on direct interviews and offered pharmacologic treatment, 16% did not meet the criteria for a diagnosis of depression, and 50% successfully completed 12 weeks of pharmacologic treatment. The BDI score of these patients at the start of treatment was 17.4 +/- 6.6, and at completion of treatment it was 8.4 +/- 3.0. Thirty-eight percent of treatment failures were in those who were also diagnosed with a DSM-IV personality disorder. Major depression is common in PD patients, and is potentially treatable with pharmacologic therapy. However, there are major problems providing a depression assessment and treatment program to such patients. Problems include refusal to complete depression assessment and patients with axis 2 personality disorders who have difficulty complying with treatment. Although depression treatment can improve depressive symptoms, it is unclear whether such therapy will improve medical outcomes.

Quality of life in hemodialysis, peritoneal dialysis, and transplantation patients

Quality of life (QOL) has recently been explored as one of the main outcomes of renal replacement therapy. In this study, we sought to compare three groups of patients-hemodialysis, peritoneal dialysis, and transplantation-with regard to QOL.

METHODS

Seventy-five hemodialysis, 41 peritoneal dialysis and 20 transplant patients were given Patient Information Form, Short Form Health Survey 36, Beck Depression Inventory, and State-Trait Anxiety Inventory.

RESULTS

The QOL scores of the three groups were similar and lower than the normal Turkish population. Depression and anxiety levels had significant and negative effects on QOL of hemodialysis and peritoneal dialysis, but not transplant patients. In a multiple regression analysis, being male, being older than 46 years, living with family, having middle-higher income, having renal disease for a longer time, having a longer period of dialysis treatment, having comorbid illness, having not enough illness knowledge, and having higher levels of depression and of anxiety significantly correlated with a worse quality of life.

CONCLUSIONS

The three forms of renal replacement therapy did not differ with regard to QOL. Among the factors that seem to affect QOL, psychological status and treatment/illness knowledge had the most significant correlation. The underlying mechanisms need to be clarified.

Assessment of health-related quality of life among patients with chronic kidney disease

The health-related quality of life (HRQOL) of patients with chronic kidney disease influences the timing of the initiation of dialysis, whether they continue to work with progressive kidney failure and whether they maintain an active role in the home and community. The importance of HRQOL to the goals of therapy has been widely documented for dialysis patients who chose not to receive a kidney transplant and those with substantial comorbidities who are not candidates for kidney transplantation, patients who are confined to the chronic rigors of maintenance dialysis. The usual conceptualization of HRQOL has been based on the World Health Organization's definition of QOL as a complete state of physical, mental, and social well-being and not merely an absence of disease in infirmity. This conceptual model has limitations because few standard HRQOL questionnaires assess satisfaction with family despite being a critical domain to patients. Measuring and monitoring HRQOL in CKD patients can be achieved with the widespread implementation of facile HRQOL assessment. The importance of HRQOL has been increasingly recognized by health care payers, health care providers, regulatory agencies, and researchers, both within and outside the renal community. Despite the apparent need and potential benefits of HRQOL assessments in dialysis patients, there are limitations to the translation of such assessments from the research domain into the clinical arena such as the length of questionnaires and display of the information at the point of care. These limitations can be addressed through the development of computer-adaptive testing (CAT). CAT permits the response of the patient to inform the selection of the next question. In this way, the length of HRQOL questionnaires may be dramatically shortened while not sacrificing the sensitivity or reliability of a longer instrument. The routine use of HRQOL assessments in the care of patients with CKD represents an important opportunity for the nephrologist to better incorporate the values and concerns of the patient into their care.

Psychosocial assessment of the patient on chronic peritoneal dialysis: an overview

The psychosocial assessment of the patient with end-stage renal disease is critically important because (1) there is growing evidence that the psychosocial status of the patient impacts medical outcomes and (2) the objective of therapy is to maximize a patient's sense of well-being and quality of life. This is particularly true for patients receiving a home-based therapy such as chronic peritoneal dialysis. The present review outlines a possible structure and format for performing psychosocial evaluations for patients maintained on chronic peritoneal dialysis. But, each facility must design its own format, making sure that the critical domains discussed in this review are addressed.

Why do patients sleep on dialysis?

Sleep-associated symptoms and excessive daytime sleepiness are felt to be more common in dialysis patients. Several surveys conducted in this patient population have identified a prevalence of sleep disturbances in up to 80% of patients. This review article summarizes common disorders associated with sleep disturbances in dialysis patients, including sleep-disordered breathing, restless legs syndrome, and major depression. Special attention is given to pathophysiological processes and effective approaches for the prevention and timely treatment of these conditions, which in turn reduces the substantial morbidity associated with sleep disturbances.

Outcome of patients with reactive amyloidosis associated with rheumatoid arthritis in dialysis treatment

The aim was to analyze the clinical outcome of a group of 51 patients diagnosed with systemic amyloidosis associated with rheumatoid arthritis who received hemodialysis (HD) as renal replacement therapy. We monitored the clinical course of the disease and factors that could influence survival. Determination of the onset of the underlying disorder was made retrospectively by reviewing the patient's chart when a diagnosis of amyloid was confirmed. During a 96.9 person-year follow-up, 42 patients died. Survival of these 51 patients from the initiation of HD at 251 days was 50%. Poor prognosis in amyloid patients was mainly due to a large number of sudden deaths immediately following HD therapy. Out of 51 patients 21 needed unplanned initiation of HD. The unplanned initiation was significantly associated with poor survival. Seventy-five percentile of creatinine clearance (Ccr) was 9.7 ml/min, and 75% of these patients who initiated HD had highly impaired renal functional states. These data indicated that amyloidotic patients with HD showed a high mortality rate; therefore, planned initiation of HD was highly recommended to improve the patient's survival. Particular attention was given to the Ccr levels, because the levels of serum creatinine may not be a useful marker for some patients with amyloidosis.

Diagnosis and Treatment of Depression in Dialysis Patients

A high prevalence of depressive disorder, between 33% and 50%, has been reported in dialysis patients, although it is difficult to distinguish the physical symptoms like general fatigue, insomnia, and loss of appetite which are common among dialysis patients, from the psychiatric symptoms seen in depressive patients. Furthermore, co-occurrence of depression has been shown to be one of the risk factors of poor prognosis in dialysis patients, partly because depressed patients are less likely to adhere to their medication regimen and modify their lifestyle appropriately. The efficacy of psychiatric interventions, including pharmacotherapy and psychotherapy, has been examined for dialysis patients with co-occurrence of depression. Randomized controlled trials of psychiatric interventions for depression in dialysis patients are needed to investigate the impact of such interventions on depression, quality of life, and mortality.

Characteristics of depression in hemodialysis patients: symptoms, quality of life and mortality risk

BACKGROUND

Depression is often underrecognized in patients with end-stage renal disease. We interviewed outpatients at an urban dialysis facility using a criterion-based case-finding instrument to assess the rates, clinical correlates and outcomes of depression.

METHODS

The Primary Care Evaluation of Mental Disorders Mood Module and the nine-item Patient Health Questionnaire were used to assess depression. We measured health-related quality of life using the Kidney Disease and Quality of Life Short Form, and medical comorbidities were measured using the Charlson Comorbidity Index. We compared the sociodemographic and clinical characteristics and health-related quality of life of depressed and nondepressed patients using t tests and the chi-square test, and we used a Cox regression model to test the relationship between depression and mortality.

RESULTS

We interviewed 62 patients and followed them for a mean of 29 months (range, 0.1-36). Seventeen (28%) had major or minor depression. Depressed patients were younger and had lower health-related quality of life than did nondepressed patients. Depression predicted mortality (HR=4.1, 95% CI=1.5-32.2, P<.05) after adjusting for age, gender, race, medical comorbidities, albumin, kt/V and/or the presence of diabetes.

CONCLUSIONS

Depression is common and associated with decreased health-related quality of life and increased mortality in hemodialysis patients. Clinical trials are necessary to examine whether treatment of depression can improve these outcomes.

Quality of Life and Psychosocial Factors in Renal Transplant Recipients

An ideal method for quality of life (QOL) assessment in renal transplant recipients (RTR) has not yet been determined. Present assessments of QOL in RTR are lengthy, cumbersome to administer, and difficult to interpret. We used a previously validated single question QOL scale score (QLS) that directly asks about the patients' overall assessment of their QOL; "Considering all parts of my life-physical, emotional, social, spiritual, and financial--over the past 2 days the quality of my life has been ... ". The QLS ranges from 0 ("very bad") to 10 ("excellent"). Patients were contacted prior to their routine office visit when they were free of acute medical problems. Fifty RTR participated. Psychosocial and medical variables included the Beck Depression Inventory, Illness Effects Questionnaire, Multidimensional Scale of Perceived Social Support, time since transplant, age, creatinine, hemoglobin, and albumin levels. Of the patients, 64% were African-American and 48% were women; 94% of patients had a score>5. Mean QLS was 7.5+/-2.3. Perception of a better QOL correlated with less perception of depression and illness effects and with perception of greater social support and satisfaction with life (all P<.05). Perception of QOL did not correlate with age, time since transplantation, creatinine, hemoglobin or albumin levels. We concluded that QLS is a quick tool to measure subjective QOL in RTR for correlation with psychosocial factors of interest in this group. These studies should be replicated in larger multiethnic populations.

The predictive value of self-report scales compared with physician diagnosis of depression in hemodialysis patients

The prevalence of depression in end-stage renal disease (ESRD) patients on hemodialysis has not been definitively determined. We examined the prevalence of depression and the sensitivity, specificity, positive, and negative likelihood ratios (+LR and -LR) of self-report scales using the physician-administered Structured Clinical Interview for Depression (SCID) as the comparison. Ninety-eight consecutive patients completed the Beck Depression Inventory (BDI) and the Center for Epidemiological Study of Depression (CESD) scales. A physician blinded to BDI and CESD scores administered the SCID. Receiver/responder operating characteristic curves determined the best BDI and CESD cutoffs for depression. Depressed patients had more co-morbidities and lower quality of life, P<0.05. The prevalence of depression by SCID was 26.5% and of major depression was 17.3%. The CESD cutoff with the best diagnostic accuracy was 18, with sensitivity 69% (95% confidence interval (CI) (51%, 87%)), specificity 83% (95% CI (74%, 92%)), positive predictive value (PPV) 60%, negative predictive value (NPV) 88%, +LR 4.14, and -LR 0.37. The best BDI cutoff was 14, with sensitivity 62% (95% CI (43%, 81%)), specificity 81% (95% CI (72%, 90%)), PPV 53%, NPV 85%, +LR 3.26, and -LR 0.47. Self-report scales have high +LR but low -LR for diagnosis of depression. When used for screening, the threshold for depression should be higher for ESRD compared with non-ESRD patients. Identifying depression using physician interview is important, given the low -LR of self-report scales.

Health-related quality of life in nephrology research and clinical practice

Physical, psychosocial, and lifestyle disturbances, along with physical and emotional symptoms, have been shown to impact the health-related quality of life (HRQOL) of those dependent on renal replacement therapy. The value of HRQOL measurement as a tool to improve clinical care has been recognized by patients, clinical investigators, and health care providers. The potential importance of HRQOL assessment lies in the additional information it provides and the impact it has on the clinical decision-making process between a patient and a physician. There remain a multitude of challenges facing renal providers who wish to incorporate HRQOL measurement to improve patient care. These challenges include the clinician's understanding of the conceptual model of HRQOL, the quality of the scientific process that contributed to the current literature on HRQOL, a willingness of the clinician to incorporate HRQOL information into clinical practice, and the logistic difficulties of collecting and applying HRQOL data in a busy practice setting. Arguably, optimizing HRQOL may be the most substantial impact the health care team will have on the person with kidney failure. In order to implement HRQOL assessment at the point of care, providers may consider using computer adaptive testing and scoring algorithms using item response theory, which will allow adequate reliability for interpretation of change among individuals. Moreover, the effective assessment and interpretation of HRQOL will be aided by continued publication of norms, outcomes of randomized controlled trials, and continued experience of investigators and clinicians.

Psychosocial interventions for depression in dialysis patients

BACKGROUND

Depression is the most common psychological problem in the dialysis population. The diagnosis of depression in dialysis patients is confounded by the fact that several symptoms of uraemia mimic the somatic components of depression. It affects the physical, psychological and social well being of the dialysis population in several ways.

OBJECTIVES

The aim of this systematic review was to assess the effectiveness of psychosocial interventions in the treatment of depression in patients who are dialysed for end-stage renal disease.

SEARCH STRATEGY

A comprehensive search strategy was employed to identify all randomised controlled trials (RCTs) relevant to the treatment of depression in dialysis patients. The following databases were searched - MEDLINE (1966 - October 2003), EMBASE (1980 - October 2003), PsycINFO (1872 - October 2003) and The Cochrane Library (issue 3, 2003). Authors of potential studies were contacted, reference lists of identified RCTs and relevant narrative reviews were screened.

SELECTION CRITERIA

RCTs comparing any psychosocial intervention with control intervention or no intervention in depressed dialysis patients.

DATA COLLECTION AND ANALYSIS

Data were to be abstracted by two investigators independently onto a standard form and entered into Review Manager 4.2. Relative risk (RR) for dichotomous data and a (weighted) mean difference (MD) for continuous data were to be calculated with 95% confidence intervals (CI).

MAIN RESULTS

Despite extensive searching, no RCTs were identified.

AUTHORS' CONCLUSIONS

Data were not available to draw conclusions about the effectiveness of psychosocial interventions in the treatment of depression in the chronic dialysis population, as we did not find any RCTs of psychosocial interventions to treat depression in dialysis patients. This review highlights the need for commencing and completing adequately powered RCTs to address the issue of psychosocial interventions for depression in dialysis patients.

Health-related quality of life predicts outcomes but is not affected by peritoneal clearance: The ADEMEX trial

BACKGROUND

We hypothesized that increasing small solute clearance in peritoneal dialysis (PD) would lead to improvements in patient health-related quality of life (HRQOL).

METHODS

Patients were randomized to a control group [standard 4 x 2 L continuous ambulatory peritoneal dialysis (CAPD)] and an intervention group (CAPD with a target creatinine clearance >/=60 L/week/1.73 m(2)). The Kidney Disease Quality of Life Short Form was obtained at baseline and at 6, 12, and 24 months. Physical (PCS), mental (MCS), and kidney disease component summary (KDCS) scores were computed.

RESULTS

The two groups were comparable at baseline with respect to HRQOL. Baseline variables highly predictive of better QOL included absence of diabetes, younger age, higher starting GFR, and serum albumin. Baseline values of QOL were highly predictive of survival and hospitalizations. An unadjusted comparison revealed that patients in the intervention group had significantly higher PCS and KDCS scores at six months. However, there were no significant differences between the intervention and control patients at 12 or 24 months. When similar analyses were carried out adjusting for different patterns of patient dropout, there were no significant differences between the two groups at any time point in terms of PCS, MCS, and KDCS scores.

CONCLUSION

We found no evidence of a long-term benefit in HRQOL of CAPD patients by increasing peritoneal small-solute clearances when HRQOL parameters were adjusted for patient dropout. Measures of HRQOL have a significant predictive value for patient survival and hospitalizations.

Physical measures for treating depression in dialysis patients

BACKGROUND

Depression is the most common psychological problem in the chronic dialysis population. The diagnosis of depression in patients on chronic dialysis is confounded by the fact that several symptoms of uraemia mimic the somatic components of depression. It affects their physical, psychological and social well-being. Furthermore, the frequent occurrence of cardiovascular problems and the pharmacokinetic consequences of renal impairment may make drug treatment of depression difficult.

OBJECTIVES

The aim of this systematic review was to assess the efficacy and safety of physical measures in the treatment of depression in patients who are dialysed for end-stage renal disease.

SEARCH STRATEGY

A comprehensive search strategy was employed to identify all Randomised Controlled Trials (RCTs) relevant to the treatment of depression in patients on chronic dialysis. The following database were searched - MEDLINE (1966-March 2004), EMBASE (1980-March 2004), PSYCHINFO (1872-March 2004), The Cochrane Library (Issue 1, 2004). Authors of included studies were contacted, reference lists of identified RCTs and relevant narrative reviews were screened.

SELECTION CRITERIA

RCTs comparing drugs with placebo or no treatment, or a comparison of drugs against a combination of electroconvulsive therapy and drugs.

DATA COLLECTION AND ANALYSIS

Data were abstracted by two investigators independently onto a standard form and subsequently entered into Review Manager 4.2. Relative risk (RR) for dichotomous data and a (weighted) mean difference (WMD) for continuous data were calculated with 95% confidence intervals (95% CI).

MAIN RESULTS

Only one trial, with a total of 12 patients and of eight weeks duration was identified. The trial compared fluoxetine against placebo in depressed patients on chronic dialysis. This study did not show any significant difference in depression scores between the treatment and control groups or safety.

AUTHORS' CONCLUSIONS

Firm conclusions on the efficacy of physical methods of treatment cannot be made as we identified only one small RCT that was of short duration. More larger and longer term RCTs are needed in this area. Current screening tools for depression are recognised to have poor specificity in the medically ill due to overlap of somatic symptoms of the medical illness. The development of a valid diagnostic tool would be helpful.

Effects of an adaptation training programme for patients with end-stage renal disease

AIMS

This paper reports a study investigating the effectiveness of an adaptation training programme (ATP) to help patients with end-stage renal disease (ESRD) to cope with illness-related stresses and, thus, to alleviate depression and improve quality of life.

BACKGROUND

Patients with ESRD who receive dialysis must confront the burdens of long-term illness and numerous treatment-associated stressors. The ability of these patients to cope with and adapt to these stresses, whether related to their medical regimen or to the demands of daily life, has an important influence on physical and psychological well-being.

METHODS

The study was a randomized controlled trial using a convenience sample of 57 eligible, fully informed and consenting patients with ESRD who were assigned to experimental (ATP plus usual care) or control (usual care) groups. Participants in the ATP took part in weekly small group sessions over an 8-week period and monthly follow-up to help them to cope with stressors. A clinical nurse specialist and an experienced psychotherapist led them in three small groups (8-10 per group). Participants in the usual care group received routine care. Instruments comprised the Haemodialysis Stressor Scale, Beck Depression Inventory and Medical Outcomes Study SF-36. Data were collected at baseline and at three months following the intervention.

RESULTS

The major stressors for these patients were limitations on time and place related to employment, limitations on fluid intake, transport difficulties, loss of bodily function, length of dialysis treatment, and limitation of physical activities. The ATP had a beneficial effect on perceived stress (P = 0.005), depression (P = 0.001) and quality of life (P = 0.02) 3 months after the intervention.

CONCLUSIONS

This study supports the effectiveness of an ATP to decrease stress and depression levels, and to improve the quality of life of ATP patients receiving haemodialysis.

Depression and its 6-month course in untreated hemodialysis patients: A preliminary prospective follow-up study in turkey

The major goal of this study is to assess the frequency of psychiatric disorders in end-stage renal disease (ESRD) patients, who were on hemodialysis (HD) treatment in Turkey. Additionally, it aims to determine whether depression, anxiety, and functional and occupational levels of patients who did not receive any psychiatric treatments change at the end of 6 months. We conducted Structured Clinical Interview for the DSM-IV, Clinical Version on 50 HD patients, and 16 (32%) fulfilled the criteria for a psychiatric disorder. Depressive disorder, not otherwise specified, was observed in 12 (24%) patients. Adjustment disorder with depressed mood and dysthymic disorder were observed in 8% of our population. Fourteen patients were followed up for 6 months. All patients were assessed with Hamilton Depression (HDRS), Anxiety Rating Scale (HARS), and Global Assessment of Functioning (GAF) at baseline and at 6 months. The comparisons of baseline and 6 months HDRS, HARS, and GAF scale scores did not reveal any statistically significant differences in 14 depressed patients. The level of depression, anxiety, and functional and occupational impairment did not remit spontaneously in our untreated depressed HD patients. We believe that further studies regarding categorization, prognosis, and treatment of these patients are needed to better understand what to do when we encounter depressive ESRD patients.

A one-year trial of in-center daily hemodialysis with an emphasis on quality of life

BACKGROUND/AIMS

Hemodialysis is associated with acute changes in several physiologic factors. Previous studies have suggested significant clinical and quality of life (QOL) benefits of daily hemodialysis (DHD) compared with 3 times weekly hemodialysis (CHD). We conducted a prospective trial to evaluate the effects of switching chronic hemodialysis patients to in-center DHD for a 12-month period.

METHODS

There were no exclusion criteria. Patients received hemodialysis 6 times per week. The study set a standardized weekly Kt/V (stdKt/V) goal of 3.0. A broad array of clinical parameters was determined. QOL was assessed with multiple instruments.

RESULTS

Eleven subjects completed 12 months and 12 completed 6 months on DHD. Significant changes relative to baseline at 12 months of DHD included decreased BP and improvements in QOL parameters by multiple techniques. 100% of patients at 12 months wished to continue DHD.

CONCLUSIONS

DHD offers advantages over CHD with respect to improved QOL and BP control.

ESRD patient quality of life: symptoms, spiritual beliefs, psychosocial factors, and ethnicity

BACKGROUND

Recent research suggests that patients' perceptions may be more important than objective clinical assessments in determining quality of life (QOL) for patients with end-stage renal disease (ESRD).

METHODS

We interviewed 165 hemodialysis patients from 3 sites using a QOL questionnaire that included the Satisfaction With Life Scale (SWLS) and the McGill QOL (MQOL) scale, which includes a single-item global measure of QOL (Single-Item QOL Scale [SIS]). The MQOL scale asks patients to report their most troublesome symptoms. We also initiated the use of a Support Network Scale and a Spiritual Beliefs Scale.

RESULTS

Mean patient age was 60.9 years, 52% were men, 63% were white, and 33% were African American. Patients had a mean treatment time for ESRD of 44 months, mean hemoglobin level of 11.8 g/dL (118 g/L), mean albumin level of 3.7 g/dL (37 g/L), and mean Kt/V of 1.6. Forty-five percent of patients reported symptoms. Pain was the most common symptom (21% of patients). There was an inverse relationship between reported number of symptoms and SWLS (P < 0.01), MQOL scale score (P < 0.001), and SIS (P < 0.001). The Spiritual Beliefs Scale correlated with the MQOL scale score, SWLS (both P < 0.01), and SIS (P < 0.05). The Support Network Scale score correlated with the MQOL Existential (P = 0.01) and MQOL Support (P < 0.01) subscales. No clinical parameter correlated with any measure of QOL, spiritual beliefs, or social support.

CONCLUSION

Symptoms, especially pain, along with psychosocial and spiritual factors, are important determinants of QOL of patients with ESRD. Additional studies, particularly a longitudinal trial, are needed to determine the reproducibility and utility of these QOL measures in assessing patient long-term outcome and their association with other QOL indices in larger and more diverse patient populations.

New trends on health related quality of life assessment in end-stage renal disease patients

Health related quality of life (HRQOL) is a useful measure in the analysis of the output of medical interventions in groups of chronic patients like end-stage renal disease (ESRD) patients. From the 1980s to the present day, the interest in evaluating the HRQOL of ESRD patients has been continually growing. A review of published studies shows the existence of important differences in the applied conceptual model of HRQOL, in the assessment instruments used, in the methods of data collection recording, and in the results and conclusions. In this paper we tried to answer some of the main questions which could appear when nephrologists begin to use the HRQOL measures with renal patients: we clearly define the concept of HRQOL; we made recommendations about the instruments to evaluate HRQOL (generic vs specific instruments); and we show how to refine a HRQOL score to make it practical and comprehensible (the standardization of the scores by age and gender).