Screening for depression in hemodialysis patients: Associations with diagnosis, treatment, and outcomes in the DOPPS

Comparison of the pre-dilution and post-dilution methods for online hemodiafiltration

Online hemodiafiltration (OL-HDF) is a treatment modality using diffusion and ultrafiltration. There are two types of dilution methods in OL-HDF: pre-dilution, which is commonly provided in Japan, and post-dilution, which is commonly provided in Europe. The optimal OL-HDF method for individual patients is not well studied. In this study, we compared the clinical symptoms, laboratory data, spent dialysate, and adverse events of pre- and post-dilution OL-HDF. We conducted a prospective study of 20 patients who underwent OL-HDF between January 1, 2019 and October 30, 2019. Their clinical symptoms and dialysis efficacy were evaluated. All patients underwent OL-HDF every 3 months in the following sequence: first pre-dilution, post-dilution, and second pre-dilution. We evaluated 18 patients for the clinical study and 6 for the spent dialysate study. No significant differences in spent dialysates regarding small and large solutes, blood pressure, recovery time, and clinical symptoms were observed between the pre- and post-dilution methods. However, the serum α1-microglobulin level in post-dilution OL-HDF was lower than that in pre-dilution OL-HDF (first pre-dilution: 124.8 ± 14.3 mg/L; post-dilution: 116.6 ± 13.9 mg/L; second pre-dilution: 125.8 ± 13.0 mg/L; first pre-dilution vs. post-dilution, post-dilution vs. second pre-dilution, and first pre-dilution vs. second pre-dilution: p = 0.001, p < 0.001, and p = 1.000, respectively). The most common adverse event was an increase in transmembrane pressure in the post-dilution period. Compared to pre-dilution, the post-dilution method decreased the α1-microglobulin level; however, there were no significant differences in clinical symptoms or laboratory data.

Prevalence, overlap, and prognostic impact of multiple frailty domains in older patients on hemodialysis

BACKGROUND

Frailty is a state of increased vulnerability owing to adverse health outcomes and is recognized as a multidimensional construct. There is limited evidence on the association between multiple domains of frailty and the risk of adverse events in patients undergoing hemodialysis. We aimed to report on the prevalence, degree of overlap, and prognostic impact of multiple frailty domains in older patients undergoing hemodialysis.

METHODS

We retrospectively enrolled outpatients (aged ≥60 years) undergoing hemodialysis at two dialysis centers in Japan. The physical domain of frailty was defined as slow gait speed and low handgrip strength. The psychological and social domains of frailty were defined using a questionnaire to assess depressive symptoms and define social frailty status. The outcomes were all-cause mortality, all-cause hospitalization, and cardiovascular hospitalization. Cox proportional hazard and negative binomial models were used to examine these associations.

RESULTS

Among the 344 older patients (mean age, 72 years; male, 61%), 15.4% had an overlap in all three domains. Patients with a higher number of frailty domains had a higher risk of all-cause mortality, all-cause hospitalization, and cardiovascular hospitalization (P for trend = 0.001, 0.001, and 0.08, respectively).

CONCLUSIONS

These results suggest that multiple-domain assessment of frailty is an important strategy to prevent adverse events in patients requiring hemodialysis.

Decreased Intracellular to Total Body Water Ratio and Depressive Symptoms in Patients with Maintenance Hemodialysis

Objective

Depression is a common psychiatric disorder and related to poor outcomes in patients undergoing maintenance hemodialysis (MHD). Previous studies have reported some associations between sarcopenia and depressive symptoms. Recently, intracellular water (ICW) and total body water (TBW) have been found to reflect muscle function and muscle mass. ICW/TBW ratio is a marker of sarcopenia that is simple to assess. However, the relationship between ICW/TBW ratio and depression has not been explored in MHD patients.

Methods

In our cross-sectional and multi-center study, 3300 adult MHD patients were included from June 1, 2021, to August 30, 2021. Depressive symptoms were evaluated using the Beck Depression Inventory-II (BDI-II). TBW and ICW were measured by Body Composition Monitor (BCM). Multivariable logistic regression, stratified analyses, and interactive analyses were conducted to assess the relationship between ICW/TBW ratio and depression.

Results

About 16.5% of the 3300 MHD patients were found to have depressive symptoms. The prevalence of depression increased with decreasing quartiles of ICW/TBW ratios, and decreased ICW/TBW ratio was independently associated with depression after adjusting for potential confounders. Patients in Quartile 1 of ICW/TBW ratios were more likely to have depressive symptoms (odds ratio 1.55, 95% confidence interval 1.07-2.22; p=0.002) than those in Quartile 4. History of diabetes and education status had interactive roles in the relationship between depression and ICW/TBW ratios (p < 0.05). The association of ICW/TBW ratios and depression existed in patients of both genders and different education levels, but only in non-diabetic patients.

Conclusion

In MHD patients, the decreased ratio of ICW/TBW was independently related to high depression rates.

Mortality, health-related quality of life, and depression symptoms in younger and older men and women undergoing hemodialysis

BACKGROUND AND OBJECTIVE

Some studies on maintenance hemodialysis (MHD) patients report a longer survival, albeit with poorer health-related quality of life (HRQoL), and more depression symptoms in women than in men. Whether these gender differences vary with age is uncertain. We tested the associations of gender with mortality, depression symptoms, and HRQoL in MHD patients of different age groups.

METHODS

We used data from 1504 adult MHD patients enrolled in the PROHEMO, a prospective cohort in Salvador, Brazil. The KDQOL-SF was used for the component summaries of the mental (MCS) and physical (PCS) HRQoL scales. Depression symptoms were assessed by the complete version of the Center for Epidemiological Studies Depression Screening Index (CES-D). To test for gender differences, extensively adjusted linear models were used for depression and HRQoL scores, and Cox models for death hazard ratio (HR).

RESULTS

Women reported worse HRQoL than men, particularly for ages ⩾60 years. In the age group ⩾60 years, the adjusted difference (AD) in score was -3.45; 95% CI: -6.81, -0.70 for MCS -3.16; -5.72, -0.60 for PCS. Older (⩾60 years) women also had more depression symptoms (AD 4.98; 2.33, 7.64). Mortality was slightly lower in women than in men with an adjusted HR of 0.89 (0.71, 1.11) and consistent across age categories.

CONCLUSIONS

In a sample of Brazilian MHD patients, women had a slightly lower mortality, albeit with more depression symptoms and poorer HRQoL than men, particularly among older patients. This study highlights the need to investigate gender inequalities for MHD patients across different cultures and populations.

Managing the symptom burden associated with maintenance dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Individuals with kidney failure undergoing maintenance dialysis frequently report a high symptom burden that can interfere with functioning and diminish life satisfaction. Until recently, the focus of nephrology care for dialysis patients has been related primarily to numerical targets for laboratory measures, and outcomes such as cardiovascular disease and mortality. Routine symptom assessment is not universal or standardized in dialysis care. Even when symptoms are identified, treatment options are limited and are initiated infrequently, in part because of a paucity of evidence in the dialysis population and the complexities of medication interactions in kidney failure. In May of 2022, Kidney Disease: Improving Global Outcomes (KDIGO) held a Controversies Conference-Symptom-Based Complications in Dialysis-to identify the optimal means for diagnosing and managing symptom-based complications in patients undergoing maintenance dialysis. Participants included patients, physicians, behavioral therapists, nurses, pharmacists, and clinical researchers. They outlined foundational principles and consensus points related to identifying and addressing symptoms experienced by patients undergoing dialysis and described gaps in the knowledge base and priorities for research. Healthcare delivery and education systems have a responsibility to provide individualized symptom assessment and management. Nephrology teams should take the lead in symptom management, although this does not necessarily mean taking ownership of all aspects of care. Even when options for clinical response are limited, clinicians should focus on acknowledging, prioritizing, and managing symptoms that are most important to individual patients. A recognized factor in the initiation and implementation of improvements in symptom assessment and management is that they will be based on locally existing needs and resources.

Global research trends and mapping knowledge structure of depression in dialysis patients

BACKGROUND

Depression is one of the most common and important psychological issues faced by dialysis patients. It can make it more difficult for them to adhere to their treatment regimen, which, in turn, can worsen their physical symptoms and lead to poorer health outcomes.

AIM

To examine the evolution and growth of publications related to dialysis and depression. The objectives were to identify the number of publications, the top active countries, the contributed institutions, funding agencies and journals, as well as to perform citation and research theme analysis.

METHODS

The search was conducted using the Scopus database for publications related to dialysis and depression between 1970 and 2022. Subsequently, bibliometric analysis was carried out on the data obtained using VOSviewer software, version 1.6.9. This analysis included visualization analysis, co-occurrence analysis and examination of publication trends in dialysis and depression.

RESULTS

We identified 800 publications that met the search criteria. The number of publications related to dialysis and depression has increased significantly in the past two decades. The USA led the way with 144 publications, which is 18% of all publications on this topic. Turkey came second with 88 publications (11%), followed by China with 55 publications (6.88%) and Iran with 52 publications (6.5%). Analysis of the research theme identified three main clusters related to gender differences in prevalence, identification of depression as a risk factor, and effective interventions to relieve depression. Future research direction analysis shows a shift toward effective interventions to relieve depression in dialysis patients.

CONCLUSION

This study provides a comprehensive overview of growth, trends and research themes related to dialysis and depression that could help researchers identify gaps in the literature and develop future research.

Evaluation of factors related to depression in peritoneal dialysis patients: a multicenter cross-sectional study

Background

End-stage renal disease (ESRD) is serious global public health challenge in many developing countries. Treatment of ESRD is carried out through renal replacement therapy like peritoneal dialysis (PD). Depression is the most common mood disorder which has a strong impact on the quality of life in patients with ESRD. Little is known about the prevalence and risk factors of depression in peritoneal dialysis patients.

Method and materials

A multicenter cross-sectional study was conducted on 164 adult ESRD patients undergoing peritoneal dialysis for at least three months who referred to the peritoneal dialysis centers of Al-Zahra, Noor & Ali Asghar hospitals, Isfahan, Iran from May to August 2019. Beck Depression Inventory Second Edition questionnaire was used to measure the symptoms of depression and its severity.

Results

43.5% of patients had some levels of depression. Assessing the association of depression with demographic and PD-related factors showed that there was no significant difference regarding age, BMI, dialysis adequacy and residual kidney function, dialysis frequency, type of dialysis solution used, disease duration, and age at the start of dialysis. Ordinal logistics regression analysis showed significant association between depression severity categories and gender (OR = 0.397, CI: 0.160–0.985, p = 0.046), marital status (OR = 2.983, CI: 1.180–7.541, p = 0.021), having a separate room for dialysis (OR = 2.511, CI: 1.108–5.692, p = 0.027).

Conclusion

As our findings have revealed 43.5% of our participants suffered from mild-to-severe depression, we suggest careful attention and routine evaluation for depression in PD patients, especially women and single patients and those who have low socioeconomic status.

Comparison of the association between six different frailty scales and clinical events in patients on hemodialysis

BACKGROUND

Frailty is associated with adverse outcomes in patients undergoing hemodialysis (HD). However, no study has used various frailty assessments in patients on HD to examine their association with clinical events. In this study, we investigated the association between clinical events and six frailty scales.

METHODS

Outpatients who underwent HD between 2018 and 2020 were retrospectively enrolled. Frailty was defined using the Fried Frailty Phenotype, Study of Osteoporotic Fractures (SOF) Index, Short Physical Performance Battery (SPPB), Frail Screening Index, FRAIL scale and Clinical Frailty Scale. Outcomes were clinical events, including a composite of multiple (i.e. recurrent) all-cause hospitalizations, fractures and/or all-cause mortality. The association of clinical events and the frailty scales were investigated using negative binomial regression analysis.

RESULTS

Fried Frailty Phenotype [incident rate ratio (IRR), 1.62; 95% confidence interval (CI), 1.49-1.76], SOF Index (IRR, 1.42; 95% CI, 1.10-1.83), SPPB (IRR, 1.79; 95% CI, 1.11-2.88) and Clinical Frailty Scale (IRR, 1.65; 95% CI, 1.04-2.61) were significantly associated with clinical events. However, Frail Screening Index (IRR, 1.38; 95% CI, 0.60-3.18) and FRAIL scale (IRR, 1.30; 95% CI, 0.88-1.92) showed no significant association with clinical events.

CONCLUSIONS

Objective frailty assessments (SPPB) and medical staff impression-based frailty (Clinical Frailty Scale) may be useful prognostic predictors for patients on HD. Questionnaire-based frailty assessment should be carefully considered when used as a measurement of frailty.

Relationship between psychiatric symptoms and activities of daily living in patients undergoing hemodialysis

Background

Accurately identifying the factors contributing to decline in activities of daily living (ADL) is important for preventing such decline in patients undergoing hemodialysis (HD). We studied the prevalence and number of overlapping psychiatric symptoms (depressive symptoms, apathy, and sleep disturbance) in patients undergoing HD and examined the relationship between psychiatric symptoms and ADL.

Methods

The study utilized a cross-sectional research design. The sample included 203 outpatients (median age: 69 years) undergoing stable HD treatment three times a week. Patient characteristics, including age, sex, body composition, dialysis vintage, primary kidney disease, comorbidity, and nutritional status, were collected from patients’ medical records. Functional status was assessed based on the self-reported questionnaire that combined five basic and eight instrumental ADL items. Usual walking speed was used as an index of physical function. Additionally, the short version of the Center for Epidemiologic Studies Depression Scale was used to assess depressive symptoms. Further, apathy and sleep disturbance were assessed using the Motivation Score and the Athens Insomnia Scale, respectively.

Results

Overall, 59 (29.1%) patients demonstrated depressive symptoms, 100 (49.3%) reported apathy, 83 (40.9%) had sleep disturbance, 31 (15.3%) had three overlapping psychiatric symptoms, 43 (21.2%) had two overlapping psychiatric symptoms, 63 (31.0%) had only one symptom, and 66 (32.5%) had no psychiatric symptoms. Multiple logistic regression analysis showed that having two or three overlapping psychiatric symptoms was independently and significantly associated with ADL (functional status of 13 points for the ADL maintenance group, and of < 13 points for the ADL decline group, respectively), even after adjusting for patient characteristics and walking speed (odds ratio: 2.74, 95% confidence interval: 1.12–6.69, reference; no psychiatric symptoms).

Conclusion

The present study clarified that the overlapping symptoms, including depressive symptoms, apathy, and sleep disturbance, were independently associated with ADL decline in patients undergoing HD. It is useful to examine not only depressive symptoms but also other symptoms such as apathy and sleep disturbance to elucidate factors associated with deteriorated ADL in chronic patients. Our findings provide a strong basis for targeted interventions to prevent functional dependence in the HD population.

Depressive Symptoms at Kidney Transplant Evaluation and Access to the Kidney Transplant Waitlist

Introduction

Depressive symptoms, even without a clinical diagnosis of depression, are common in kidney failure patients and may be a barrier to completing the complex process of kidney transplant (KT) evaluation. We assessed depressive symptom burden and association between depressive symptoms and access to KT waitlist by age.

Methods

In a prospective cohort of 3728 KT patients (aged 18–88 years), the Center for Epidemiologic Studies—Depression (CES-D) scale was used to measure depressive symptoms at evaluation. Depressive symptom severity was defined as follows: none: 0; minimal: 1 to 15; mild: 16 to 20; moderate: 21 to 25; severe: 26 to 60. Hazard ratios (HRs) of active listing within 1 year after evaluation were estimated using Cox proportional hazards models, adjusted for clinical and social factors.

Results

At evaluation, 85.8% of the patients reported at least minimal depressive symptoms; the proportion was lower among older patients: 18 to 29 years = 92.0%; 30 to 39 years = 88.3%; 40 to 49 years = 87.2%; 50 to 59 years = 87.0%; 60 to 69 years = 83.4%; and ≥70 years = 82.0%. Chance of active listing decreased with more severe depressive symptoms (log-rank, P < 0.001). After adjustment, every 5-point higher CES-D score (more depressive symptoms) was associated with a 13% lower chance of listing (HR = 0.87, 95% CI: 0.85–0.90); the strongest association was found among patients aged ≥70 years (adjusted HR [aHR] = 0.73, 95% CI: 0.62–0.86). Furthermore, minimal (HR = 0.69, 95% CI: 0.60–0.79), mild (HR = 0.57, 95% CI: 0.44–0.72), moderate (HR = 0.53, 95% CI: 0.39–0.71), and severe (HR = 0.44, 95% CI: 0.34–0.57) depressive symptoms were all associated with a lower chance of listing.

Conclusion

Older candidates were less likely to report depressive symptoms at KT evaluation. Regardless of age, candidates who did report depressive symptoms, and even minimal symptoms, had a lower chance of listing. Transplant centers should routinely screen patients for depressive symptoms and refer the affected patients to mental health services to improve access to KT.

Epidemiology of haemodialysis outcomes

Haemodialysis (HD) is the commonest form of kidney replacement therapy in the world, accounting for approximately 69% of all kidney replacement therapy and 89% of all dialysis. Over the last six decades since the inception of HD, dialysis technology and patient access to the therapy have advanced considerably, particularly in high-income countries. However, HD availability, accessibility, cost and outcomes vary widely across the world and, overall, the rates of impaired quality of life, morbidity and mortality are high. Cardiovascular disease affects more than two-thirds of people receiving HD, is the major cause of morbidity and accounts for almost 50% of mortality. In addition, patients on HD have high symptom loads and are often under considerable financial strain. Despite the many advances in HD technology and delivery systems that have been achieved since the treatment was first developed, poor outcomes among patients receiving HD remain a major public health concern. Understanding the epidemiology of HD outcomes, why they might vary across different populations and how they might be improved is therefore crucial, although this goal is hampered by the considerable heterogeneity in the monitoring and reporting of these outcomes across settings.

This Review examines the epidemiology of haemodialysis outcomes — clinical, patient-reported and surrogate outcomes — across world regions and populations, including vulnerable individuals. The authors also discuss the current status of monitoring and reporting of haemodialysis outcomes and potential strategies for improvement.

Nearly 4 million people in the world are living on kidney replacement therapy (KRT), and haemodialysis (HD) remains the commonest form of KRT, accounting for approximately 69% of all KRT and 89% of all dialysis.

Dialysis technology and patient access to KRT have advanced substantially since the 1960s, particularly in high-income countries. However, HD availability, accessibility, cost and outcomes continue to vary widely across countries, particularly among disadvantaged populations (including Indigenous peoples, women and people at the extremes of age).

Cardiovascular disease affects over two-thirds of people receiving HD, is the major cause of morbidity and accounts for almost 50% of mortality; mortality among patients on HD is significantly higher than that of their counterparts in the general population, and treated kidney failure has a higher mortality than many types of cancer. Patients on HD also experience high burdens of symptoms, poor quality of life and financial difficulties.

Careful monitoring of the outcomes of patients on HD is essential to develop effective strategies for risk reduction. Outcome measures are highly variable across regions, countries, centres and segments of the population. Establishing kidney registries that collect a variety of clinical and patient-reported outcomes using harmonized definitions is therefore crucial.

Evaluation of HD outcomes should include the impact on family and friends, and personal finances, and should examine inequities in disadvantaged populations, who comprise a large proportion of the HD population.

Diagnosis and Management of Depression in Patients With Kidney Disease

Depression disproportionately affects patients with kidney disease, including those with nondialysis chronic kidney disease, end-stage kidney disease requiring dialysis, and kidney transplant recipients. Patients across the spectrum of kidney disease should be screened for depression every 6 to 12 months using self-report questionnaires, followed by an interview with a clinician to confirm the presence of sadness or anhedonia when depressive symptoms are identified. Pharmacologic treatment with selective serotonin reuptake inhibitors has not consistently shown benefit compared with placebo and may be associated with serious adverse outcomes including cardiovascular events, bleeding, and fractures. However, based on the availability of alternative therapies, a watchful trial with close monitoring for therapeutic and adverse effects is reasonable. Several clinical trials have suggested that cognitive behavioral therapy and physical activity improve depressive symptoms when compared with a control group. Given the low risk associated with these therapies, they should be recommended to patients who have access and are amenable to such interventions. Future trials are needed to study therapeutic options for depression in nondialysis chronic kidney disease, peritoneal dialysis, or kidney transplant recipients, as well as alternative pharmacologic therapy and combination therapies. Given improvement in depressive symptoms with placebo in existing trials, inclusion of a control group is paramount.

Mediating Effects of Malnutrition on the Relationship between Depressive Symptoms Clusters and Muscle Function Rather than Muscle Mass in Older Hemodialysis Patients

OBJECTIVES

The purpose of this study was to investigate the association and mediation pathways among muscle mass, muscle function (muscle strength and physical performance), and malnutrition with depressive symptoms clusters in the older hemodialysis patients.

DESIGN

A multi-center cross-sectional study.

SETTING AND PARTICIPANTS

A total of 499 patients aged ≥ 60 on hemodialysis from seven facilities in Shanghai of China from 2020 to 2021.

MEASUREMENTS

Muscle mass was assessed by skeletal muscle index(SMI). Muscle strength was measured by handgrip strength, and physical performance was measured via gait speed and Timed Up and Go Test (TUGT). Nutritional status was assessed by Malnutrition Inflammation Score (MIS). Depressive symptoms were evaluated by the Patient Health Questionnaire-9 (PHQ-9). Logistic regression and mediation analyses fully adjusted for all potential confounding factors.

RESULTS

Among 499 participants (312 men, mean age 69.2±6.6 years), 108 (21.6%) had depressive symptoms. The muscle strength, physical performance and malnutrition were associated with depressive symptoms. Furthermore, malnutrition significantly mediated the association of muscle function with total, cognitive-affective symptoms. The association of the muscle function with somatic symptoms were mediated by the nutritional status. The mediated proportions of malnutrition in the relationship between physical performance and depressive symptoms clusters were stronger in somatic symptoms than in cognitive-affective symptoms.

CONCLUSIONS

Our findings suggest that muscle function rather than muscle mass may contribute substantially to the development of depressive symptoms clusters in the hemodialysis via malnutrition. The malnutrition mediated stronger in the association of muscle function with somatic symptoms. These findings may help guide clinicians to better diagnose and manage depression in the context of concomitant muscle function and malnutrition.

Mental illness in patients with end-stage kidney disease in South Korea: a nationwide cohort study

Background

The limited literature on mental illness in end-stage kidney disease (ESKD) patients suggests that this disease is common and burdensome but underrecognized in clinical practice. This study aimed to analyze the prevalence of mental illness in ESKD patients.

Methods

We assessed the prevalence and patterns of mental illnesses in a nationwide cohort of patients diagnosed with ESKD between January 1, 2008, and December 31, 2017. The risk of mental illness was evaluated using a multivariable Cox proportional hazards model.

Results

A total of 70,079 patients met all study inclusion criteria. A total of 28.3% of patients had mental illness, and the specific distribution was as follows: depression, 16.8%; anxiety, 20.0%; somatoform/conversion disorder, 0.9%; stress reaction/adjustment disorder, 2.5%; and substance abuse disorder, 0.6%. The frequency of mental illness was highest in patients on hemodialysis (HD), followed by patients on peritoneal dialysis (PD) and kidney transplant (KT) patients. The peak rate of mental illness in HD and PD patients was reached 1 to 2 years after renal replacement therapy initiation, but the peak rate of most mental illnesses in KT patients occurred before surgery. The prevalence of depression was 2.19 times higher in HD patients and 1.97 times higher in PD patients than in KT patients.

Conclusion

ESKD patients are at high risk of mental illness, and the prevalence of mental illness is highest in HD patients. Since the onset of mental illness occurs around the initiation of renal replacement therapy, clinicians need to pay attention to mental illness when treating ESKD patients.

Chronic prescription of antidepressant medication in patients with chronic kidney disease with and without kidney replacement therapy compared with matched controls in the Dutch general population

Background

Chronic kidney disease (CKD) is associated with a higher prevalence of depression, neuropathic pain and insomnia. These conditions are often treated pharmaceutically. In this study we aimed to determine the prevalence of chronic antidepressant use among CKD patients with and without kidney replacement therapy (KRT).

Methods

By using the Dutch health claims database, we were able to determine the prevalence, type and dosage of chronic antidepressant prescriptions in patients with CKD Stage G4/G5 without KRT (n = 14 905), patients on dialysis (n = 3872) and patients living on a functioning graft (n = 8796) and compared these to age-, sex- and socio-economic status (SES)-matched controls from the general population.

Results

Our data show that the prevalence of chronic antidepressant prescription is 5.6%, 5.3% and 4.2% in CKD Stage G4/G5, dialysis and kidney transplant patients, respectively, which is significantly higher than in matched controls. Although our data revealed more prescriptions in female patients and in the age category 45–64 years, our data did not show any association between antidepressant prescriptions and SES. Selective serotonin reuptake inhibitors were the most prescribed drugs in all patient groups and controls. Tricyclic antidepressants were more often used in patients compared with controls.

Conclusion

This nationwide analysis revealed that chronic antidepressant prescription in the Netherlands is higher in CKD patients with and without KRT than in controls, higher in middle-aged patients and women, unrelated to socio-economic status and lower than chronic use reported in other countries.

Psychosocial characteristics of patients evaluated for kidney transplant and associations with functional and frailty metrics at a veterans affairs hospital

BACKGROUND

The effect of psychosocial problems on listing outcomes and potential interactions with functional metrics is not well-characterized among Veteran transplant candidates.

METHODS

The results from psychosocial evaluations, frailty metrics, and biochemical markers were collected on 375 consecutive Veteran kidney transplant candidates. Psychosocial diagnoses were compared between patients listed or denied for transplant. Functional abilities were compared among patients with or without psychosocial diagnoses and then evaluated based on reason for denial.

RESULTS

Eighty-four percent of patients had a psychosocial diagnosis. Common issues included substance or alcohol abuse (62%), psychiatric diagnoses (50%), and poor adherence (25%). Patients with psychiatric diagnoses, cognitive impairments, and poor adherence were more likely to be denied for transplant (P < .05). Patients with depression, PTSD, and anxiety did not have worse functional ability, but experienced more exhaustion than patients without these problems. Patients denied for medical but not purely psychosocial reasons had worse troponin and functional metrics compared with listed patients.

CONCLUSION

Over 80% of patients with a psychosocial diagnosis were listed; however, poor adherence was a particularly important reason for denial for purely psychosocial reasons. Patients with psychosocial diagnoses generally were not more functionally limited than their counterparts without psychosocial diagnoses or those listed for transplant.

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.

Depression in dialysis

PURPOSE OF REVIEW

The aim of this study was to examine updated prevalence rates, risk factors and the prognosis, diagnosis and treatments for depression among dialysis patients.

RECENT FINDINGS

Depression influences prognosis, complications, quality of life (QOL), treatment and costs for dialysis patients worldwide. Reported prevalence of depression is 13.1-76.3%; it is higher for dialysis than transplant and higher post than predialysis. Reported depression rates with peritoneal dialysis (PD) compared with in-centre haemodialysis (HD) are inconsistent. Related medical factors are known, but suspected associated patient characteristics including gender and race remain unexplored. Associations between depression in dialysis and QOL, mortality, pathophysiological mechanisms of increased mortality, infection and pathways of inflammation-mediated and psychosocial factors require clarification. Several depression screening instruments are validated for dialysis patients - the Structured Clinical Interview for DSM disorders (SCID) remains the gold standard - but authors suggest the diagnostic standard should be higher than for the general population. Short-term studies indicate nonpharmacological therapy achieves clinical effects for depression in dialysis patients, but research on long-term effects is needed.

SUMMARY

Depression management through early screening and continuous care models emphasizing dynamic relationships between healthcare teams, patients and families should be encouraged. Large-scale studies of short-term and long-term benefits of pharmacological and nonpharmacological depression management are warranted.

Limitations of SARC-F as a Screening Tool for Sarcopenia in Patients on Hemodialysis

INTRODUCTION

There are limited screening tools for sarcopenia in patients undergoing hemodialysis. This study aimed to investigate the reliability and validity of the SARC-F (Strength, Assistance in walking, Rise from a chair, Climb stairs, and Falls) questionnaire as a screening tool for sarcopenia (defined by the Asian Working Group for Sarcopenia [AWGS2019]) in patients undergoing hemodialysis.

METHODS

This cross-sectional study enrolled 179 patients (mean age: 66.5 ± 12 years, 58% men) undergoing maintenance hemodialysis 3 times per week at a hemodialysis center in Japan. The SARC-F score, handgrip strength, usual gait speed, sit-to-stand test time, short physical performance battery (SPPB), and appendicular skeletal muscle mass were evaluated. The reliability and validity of the SARC-F were analyzed using receiver-operating characteristic curve, area under the curve (AUC), and sensitivity/specificity analyses.

RESULTS

There were 49 (27.4%) patients with sarcopenia. Patients with SARC-F ≥4 (59 patients, 33.0%) had poorer grip strength, lower SPPB score, and slower gait speed than those with SARC-F <4, while the skeletal muscle mass index did not differ significantly between the two groups. The sensitivity and specificity values of the SARC-F for identifying sarcopenia were 42.9% and 70.8%, respectively, while those for identifying severe sarcopenia were 66.7% and 72.3%, respectively. The AUCs of SARC-F were 0.57 for sarcopenia and 0.70 for severe sarcopenia.

DISCUSSION/CONCLUSION

The SARC-F alone is an inadequate screening tool for sarcopenia in patients undergoing hemodialysis. It should be used in combination with objective assessment measures, rather than as a first-step screening tool, to diagnose sarcopenia.

The FRAILMar Study Protocol: Frailty in Patients With Advanced Chronic Kidney Disease Awaiting Kidney Transplantation. A Randomized Clinical Trial of Multimodal Prehabilitation

Introduction: Frailty is very frequent among patients with chronic kidney disease (CKD) who are awaiting deceased donor kidney transplantation (KT), and transplant outcomes are worsened in those frail recipients. Frailty and poor fitness powerfully predict mortality, kidney graft survival, and healthcare utilization after KT. Intervention is essential to improve survival and quality of life for frail CKD patients, regardless of their age. Studies of post-transplant physical therapy intervention have been met with limited success, in large part due to high dropout rates. A pre-transplant clinical framework for multimodal prehabilitation interventions including physical therapy, nutritional measures, and psychological support scheduled during the KT waiting list period may improve patient retention and compliance, better mitigate the effects of frailty and poor fitness after KT, and improve main outcomes in frail CKD patients.

Main Objective: To study the effectiveness, feasibility, and safety of multimodal prehabilitation (exercise, nutritional plans, psychological advice) in KT candidates.

Methods: Randomized controlled clinical trial in 38 frail and 76 non-frail KT candidates. The prehabilitation program will consist of physical exercise (24 sessions, 8 weeks), nutritional supplementation, and psychological advice. The primary endpoint will be a composite achievement of clinical and functional main outcomes in frail and non-frail KT candidates at 90 days post-transplantation. Secondary outcomes include changes in exercise capacity, physical activity, gait speed, respiratory and peripheral muscle strength, muscle size, body composition, performance in activities of daily living (basic and instrumental), anxiety and depression symptoms, and health-related quality of life. Feasibility of the intervention will be also analyzed.

Expected Results: Multimodal prehabilitation is a feasible and effective intervention to decrease bad outcomes at 90 days post-KT by 25 and 12.5% in frail and non-frail patients, respectively.

Clinical Trial Registration:clinicaltrials.gov (NCT04701398), date: 2021, January 8th (Protocol version: Frailmar_vers2).

Depression symptoms and quality of life in patients receiving renal replacement therapy in Jordan: A cross-sectional study

Patients with chronic illnesses, such as those with chronic kidney disease (CKD) that are undergoing renal replacement therapy (RRT), face significant psychological changes. This descriptive cross-sectional research was carried out to investigate the factors that influence depressive symptoms and quality of life (QoL) in patients with end-stage renal disease. Data were collected from 70 participants undergoing RRT using a self-reported questionnaire that included sociodemographic information, depressive symptoms, disease status, and QoL. The Beck Depression Inventory-II (BDI-II) screening scale was used to measure depressive symptoms and the SF-36 (Medical Outcome Survey-Short Form 36) was used to assess QoL. Participants in the study rated their depressive symptoms as 'minimum (44.3%), 'mild' (20%), 'moderate' (21.4%), and 'severe (14.3%). Furthermore, a shorter duration of dialysis and comorbid conditions were significantly associated with the development of depressive symptoms. Patients on RRT for a longer period of time had lower physical activity scores than patients on dialysis for a shorter period of time. Male participants have a higher mental QoL than female participants, suggesting that the mental aspect of renal disease is less impaired than the physical aspect. The findings of this study are expected to increase awareness of RRT therapy targets and enhance patient outcomes.

Burden of Kidney Disease, Health-Related Quality of Life, and Employment Among Patients Receiving Peritoneal Dialysis and In-Center Hemodialysis: Findings From the DOPPS Program

RATIONALE & OBJECTIVE

Individuals faced with decisions regarding kidney replacement therapy options need information on how dialysis treatments might affect daily activities and quality of life, and what factors might influence the evolution over time of the impact of dialysis on daily activities and quality of life.

STUDY DESIGN

Observational cohort study.

SETTING & PARTICIPANTS

7,771 hemodialysis (HD) and peritoneal dialysis (PD) participants from 6 countries participating in the Peritoneal and Dialysis Outcomes and Practice Patterns Studies (PDOPPS/DOPPS).

PREDICTORS

Patient-reported functional status (based on daily living activities), country, demographic and clinical characteristics, and comorbidities.

OUTCOME

Employment status and patient-reported outcomes (PROs) including Kidney Disease Quality of Life (KDQOL) instrument physical and mental component summary scores (PCS, MCS), kidney disease burden score, and depression symptoms (Center for Epidemiologic Studies Depression Scale [CES-D] score > 10).

ANALYTICAL APPROACH

Linear regression (PCS, MCS, kidney disease burden score), logistic regression (depression symptoms), adjusted for predictors plus 12 additional comorbidities.

RESULTS

In both dialysis modalities, patients in Japan had the highest PCS and employment (55% for HD and 68% for PD), whereas those in the United States had the highest MCS score, lowest kidney disease burden, and lowest employment (20% in HD and 42% in PD). After covariate adjustment, the association of age, sex, dialysis vintage, diabetes, and functional status with PROs was similar in both modalities, with women having lower PCS and kidney disease burden scores. Lower functional status (score <11) was strongly associated with lower PCS and MCS scores, a much greater burden of kidney disease, and greater likelihood of depression symptoms (CES-D, >10). The median change in KDQOL-based PROs was negligible over 1 year in participants who completed at least 2 annual questionnaires.

LIMITATIONS

Selection bias due to incomplete survey responses. Generalizability was limited to the dialysis populations of the included countries.

CONCLUSIONS

Variation exists in quality of life, burden of kidney disease, and depression across countries but did not appreciably change over time. Functional status remained one of the strongest predictors of all PROs. Routine assessment of functional status may provide valuable insights for patients and providers in anticipating outcomes and support needs for patients receiving either PD or HD.

Comparisons of fatigue between dialysis modalities: A cross-sectional study

Background

Fatigue is one of the most frequent complications in dialyzed patients and is associated with poorer patient outcomes. Multiple factors are reported to be associated with fatigue development. Of them, the impacts of dialysis modalities remain unknown.

Methods

A total of 194 dialysis patients (mean age, 61±11 years; 134 males; modalities included hemodialysis (HD) in 26, online hemodiafiltration (HDF) in 74, peritoneal dialysis (PD) in 68, and combined therapy with PD and HD in 26 cases) were recruited for this cross-sectional study. Fatigue was assessed using the Profile of Mood States (POMS), a Visual Analogue Scale (VAS), and our original scale of fatigue, and depression was assessed by the Beck Depression Inventory-second edition (BDI-II). Our original scale of fatigue was administered both on dialysis and dialysis-free days to patients on HD and online HDF.

Results

The scores of the POMS, VAS, and our original scale were weakly but significantly inter-related (rho = 0.58, P<0.01; rho = 0.47, P<0.01, and rho = 0.42, P<0.01 between POMS and VAS, POMS and our original scale for fatigue, and VAS and our original scale for fatigue, respectively). The scores of these 3 tests showed no significant differences among the 4 modalities. On multivariate analysis, age, body mass index, creatinine, and employment status were associated with the presence or severity of fatigue, whereas dialysis modality was not. A similar result was obtained in 122 patients without depression. The prevalence of fatigue by our original scale was significantly lower on dialysis-free days than on dialysis days in patients on HD and online HDF.

Conclusions

The results suggest that there is no significant association between different dialysis modalities including HD, online HDF, PD and combined therapy with PD and HD and the prevalence or severity of fatigue.

Psychological Flexibility and Depression in Advanced CKD and Dialysis

Rationale & Objective

Depression is prevalent and highly associated with mortality among patients with chronic kidney disease (CKD). Psychological flexibility can be captured as acceptance in psychology, and its improvement by behavioral therapy is associated with reduced depression in some clinical settings. However, no study has been reported on patients with CKD. This study aimed to examine the association between psychological flexibility and depression in patients with CKD.

Study Design

Cohort study.

Setting & Participants

This multicenter study of 5 hospitals in Japan included patients with nondialysis stage 3-5 CKD or stage 5D CKD receiving hemodialysis or peritoneal dialysis.

Predictor

Psychological flexibility measured using the 7-item Acceptance and Action Questionnaire (AAQ-II).

Outcomes

The prevalence and incidence of depression after 1 year, which was defined by a score ≥ 16 points on the Center for Epidemiologic Studies Depression (CES-D) questionnaire.

Analytical Approach

Gamma regression was used in the examination of correlates of the psychological flexibility value. Modified Poisson regression models were fit for the prevalence and incidence of depression.

Results

The cross-sectional and longitudinal analyses included 433 and 191 patients, respectively. Lower (ie, worse) psychological flexibility levels were associated with hemodialysis and peritoneal dialysis. Higher (ie, better) psychological flexibility levels were associated with lower prevalence of depression (per 5-point increase; adjusted prevalence ratio, 0.75; 95% CI, 0.70-0.80) and lower incidence of depression (per 5-point increase; adjusted risk ratio, 0.72; 95% CI, 0.61-0.85).

Limitations

Depression was assessed using the CES-D questionnaire. Cultural differences may exist in the interpretation of AAQ-II scores.

Conclusions

Better psychological flexibility was associated with lower prevalence and incidence of depression in patients with CKD. Further studies are warranted to determine the possible prevention and treatment of depression by the development of behavioral interventions to improve psychological flexibility.

Evolving Landscape of New Drug Approval in Japan and Lags from International Birth Dates: Retrospective Regulatory Analysis

The Pharmaceuticals and Medical Devices Agency (PMDA) has approved hundreds of new drugs in recent years. We retrospectively analyzed the new drugs approved in Japan from 2008 to 2019, and identify the first-in-world approvals and clarify the current drug lag. The new drug and the drug lag were defined as a drug with a new active substance and a difference between the approval date in Japan and the international birth date, respectively. Among 400 new drugs approved in Japan during the last 12 years, 80 (20.0%) were first approved in Japan, and 320 were outside Japan (the United States: 202, 50.5%; Europe: 82, 20.5%; other regions: 36, 9.0%). Of these, 45 new drugs have not yet been approved outside Japan, and the remaining 355 have been globally approved in Japan and overseas. The number of new drug approvals were the largest in oncology followed by metabolic/endocrine and infectious diseases. The median drug lags (year) among all 400 new drugs and 355 new drugs with global approvals were 4.3 and 4.7 in the first tertile (2008-2011), 1.5 and 2.6 in the second tertile (2012-2015), and reduced to 1.3 and 2.2 in the third tertile (2016-2019), respectively. Substantial drug lag remains in neurology, psychiatry, and therapeutic areas where the number of new drug approvals was relatively small. Collectively, one-fifth of the new drugs approved in Japan are first-in-world approvals. Drug lag has been greatly decreased, although it still exists.

Frailty measures can be used to predict the outcome of kidney transplant evaluation

BACKGROUND

Experience incorporating frailty and functional metrics in the transplant evaluation process is limited. We hypothesized that simple tests correlate with kidney transplant listing outcomes.

METHODS

Frailty metrics, treadmill ability, pedometer data, troponin T, and brain natriuretic peptide were collected on 375 consecutive kidney transplant evaluations between July 2015 and December 2018. Patients initially denied were compared with those listed or deferred. Frailty metrics included handgrip, chair sit-stand, up-and-go, chair sit-reach, and questions related to exhaustion.

RESULTS

A total of 95 (25%) patients were initially denied. Those denied were older, diabetic, or had higher body mass indexes. Frailty metrics including chair sit-stand, up-and-go, chair sit-reach, grip strength, and exhaustion; biochemical markers troponin and brain natriuretic peptide; and pedometer and treadmill ability were all significantly associated with denial (P < .001). The best order three model combining parsimony and predictiveness included treadmill ability, exhaustion, and troponin. The most predictive pedometer model also included exhaustion and up-and-go. The best order three model excluding biochemical markers, pedometer, and treadmill results included up-and-go, exhaustion, and chair sit-reach.

CONCLUSION

Outcomes after on-site kidney transplant evaluation strongly correlated with the results of common clinical and functional frailty metrics.

Functional dependence and the mental dimension of quality of life in Hemodialysis patients: the PROHEMO study

Background

Functional dependence is highly prevalent in maintenance hemodialysis (MHD) settings. Also, poor health-related quality of life (HRQoL) and high levels of depressive symptoms have been reported by MHD patients. We investigated associations between functional status and mental aspects of quality of life in Brazilian MHD patients.

Methods

Cross sectional study of 235 patients enrolled in two of the four participating MHD clinics of the Prospective Study of the Prognosis of Chronic Hemodialysis Patients (PROHEMO) in Salvador, BA, Brazil. Data were collected from September 2016 to August 2017. The Katz’s questionnaire was used for basic activities of daily living (ADL) and the Lawton-Brody’s questionnaire for instrumental activities of daily living (IADL). ADL and IADL scores were combined to create 3 functional status groups: highly dependent (n = 47), moderately dependent (n = 109) and independent (n = 82). The validated Brazilian version of the Kidney Disease Quality of Life Short Form (KDQOL-SF) was used for scores of two distinct HRQoL measures, i.e., the mental component summary (MCS) and the 5-item mental health inventory (MHI-5). We used linear regression to estimate differences in scores with adjustment for possible confounders: months of dialysis, age, gender, other sociodemographic variables, body mass index, type of vascular access, dialysis dose by Kt/V, laboratory variables (albumin, blood hemoglobin, calcium, phosphorus, urea, creatinine and parathyroid hormone) and nine comorbid conditions.

Results

Mean age was 51.2 ± 12.4 yr (median age = 51.0 yr), 59.1% were male, 93.2% were non-White. The prevalence of self-reported functional status differed by age: 54.4% for age < 45 yr, 67.8% for age 45–60 yr and 73.9% for age ≥ 60 yr. Using functionally independent as reference, lower scores were observed for highly dependent patients in MCS (difference: -4.69, 95% CI: -8.09, -0.29) and MHI-5 (difference: -5.97, 95% CI: -8.09, -1.29) patients. These differences changed slightly with extensive adjustments for covariates.

Conclusions

Our results call attention to a high prevalence of functional dependence in younger and older MHD patients. The results suggest that the lower self-reported mental quality of life in functionally dependent MHD patients cannot be explained by differences in age and comorbidities.

Pain Assessment in Hemodialysis Patients

Background

Pain is a common complaint among hemodialysis (HD) patients; however, most patients are not assessed for this aspect and are not sufficiently treated. In these patients, pain is reported to be associated with a range of parameters like increased depression and disrupted quality of life (QOL). Previously residual renal function (RRF) was not assessed for associations with pain. The primary aim of the study is to evaluate the pain frequency in the Turkish HD patient population. In addition, the type, origin, and severity of chronic pain, the pain treatment ratio, and the relationship between pain, QOL, and RRF were investigated during the study.

Methods

This study included 328 HD patients. Pain assessment used the McGill Pain Questionnaire and neuropathic pain assessment used the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scale. The correlation of pain and quality of life was evaluated with the Short Form 36 (SF-36) quality of life scale.

Results

Of patients, 244 experienced pain (74.4%), and this pain had a neuropathic character in 61.8% of these patients. Patients with pain had a longer dialysis duration than those without pain (4.00 (2.00-8.00), 3.00 (2.00-4.75), p=0.01). The most common site of pain was the lower extremities. Pain was observed more often among females and with increasing age. Only 36.4% of patients used analgesics. The quality of life of patients with pain was found to be lower. The incidence of pain was higher among patients without RRF and had more neuropathic character.

Conclusions

Pain is a significant problem for the majority of HD patients and is not effectively managed. To increase the quality of life of patients, the care team should regularly question pain symptoms, and it should be treated effectively. In this context, RRF should be regularly monitored and efforts should be made to preserve it.

Health-related quality of life and adequacy of dialysis for the individual maintained on peritoneal dialysis

The goal of care of the peritoneal dialysis (PD) patient should be directed at adjusting therapy to maximize the patient's health-related quality of life (HRQOL). Incorporating the routine assessments of HRQOL into the care of PD patients is important and should serve as an essential marker of the adequacy of dialysis and help the dialysis staff design the optimal treatment regimen for each patient. HRQOL is best assessed with patient-reported outcome measures (PROMs). How best to incorporate these PROMs into the routine care of the PD patient is not clear in terms of the best instruments to use, frequency of measurements, patient acceptability, and how to translate these assessments into improvements in patient care. Nevertheless, incorporating routine assessments of HRQOL into the care of PD patients is essential if the dialysis team is to provide optimal care; it is an area that is receiving increasing attention and is ripe for further study and investigation.

Prevalence and associated factors of depressive symptoms among chronic kidney disease patients in China: Results from the Chinese Cohort Study of Chronic Kidney Disease (C-STRIDE)

OBJECTIVE

Depression is the most common mental disorder in patients with chronic kidney disease (CKD), and previous studies have found that: (a) depression can accelerate the progression of CKD; and (b) depression is an independent risk factor for hospitalization and death among patients with CKD. Therefore, the objective of the current study was to investigate the prevalence of depression in Chinese patients with CKD, and to identify variables associated with depression.

METHODS

The study analyzed baseline data from a multicenter prospective cohort study of Chinese patients with chronic kidney disease (the C-STRIDE study). In all, 2995 participants in CKD stages 1 to 4 who completed a survey of depressive symptoms were included in the analyses. Depressive symptoms were assessed by the Zung Self-Rating Depression Scale (ZSDS). A ZSDS ≥50 was used as the cut-off score for the presence of depressive symptoms. Multivariable logistic regression was used to identify variables associated with depression.

RESULTS

The mean estimated glomerular filtration rate (eGFR) in the study sample was 51.59±29.49 ml/min/1.73 m². The prevalence of depressive symptoms was 37.8% and increased significantly with CKD stage. Being female, a higher level of education, a low income, a larger economic impact of disease cost, comorbid cardiovascular disease, anemia, and impaired physical ability were independently associated with depressive symptoms.

CONCLUSION

Our study revealed that depressive symptoms were common among patients with CKD in China. Sociodemographic variables and the clinical characteristics of disease severity were strongly associated with depressive symptoms.

Patient-Reported Outcome Measures for Adults With Kidney Disease: Current Measures, Ongoing Initiatives, and Future Opportunities for Incorporation Into Patient-Centered Kidney Care

Tools that measure patients' experiences and perceptions of disease are increasingly being recognized as important components of a multidisciplinary personalized approach to care. These patient-reported outcome measures (PROMs) have the ability to provide clinicians, researchers, and policymakers with valuable insights into patients' symptoms and experiences that are unable to be ascertained by laboratory markers alone. If developed rigorously, studied systematically, and used judiciously, PROMs can effectively incorporate the patient voice into clinical care, clinical trials, and health care policy. PROMs have continued to gain attention and interest within the nephrology community, but key challenges and opportunities for their seamless uptake and integration remain. In this narrative overview, we provide nephrologists with a comprehensive list of existing PROMs developed for adults with kidney disease with information on their gaps and limitations; a rationale to support the continued incorporation of PROMs into nephrology clinical trials, clinical care, and health care policy; and a summary of ongoing initiatives and future opportunities to do so.

Depressive symptoms and dietary non-adherence among end stage renal disease patients undergoing hemodialysis therapy: systematic review

Background

Research suggests that patients with end stage renal disease undergoing hemodialysis have a higher rate of depression and dietary non adherence leading to hospitalization and mortality. The purpose of this review was to synthesize the quantitative evidence on the relationship between depressive symptoms and dietary non adherence among end stage renal disease (ESRD) patients receiving hemodialysis.

Methods

A systematic review was undertaken. Three electronic databases were searched including PubMed, CINHAL and Web of Science. Only quantitative studies published between 2001 and 2016 were included in the review.

Result

A total of 141 publications were reviewed during the search process and 28 articles that fulfilled the inclusion criteria were included in the review. Eleven studies (39.3%) reported on the prevalence of depressive symptoms or depression and its effect on patient outcomes. Ten studies (35.7%) focused on dietary adherence/non adherence in patients with ESRD and the remaining seven (25%) articles were descriptive studies on the relationship between depressive symptoms and dietary non adherence in patients with ESRD receiving hemodialysis. The prevalence of depressive symptoms and dietary non adherence ranged as 6–83.49% and from 41.1–98.3% respectively. Decreased quality of life & increased morbidity and mortality were positively associated with depressive symptoms. Other factors including urea, hemoglobin, creatinine and serum albumin had also association with depressive symptoms. Regarding dietary non adherence, age, social support, educational status, behavioral control and positive attitudes are important factors in ESRD patients receiving hemodialysis. Having depressive symptoms is more likely to increase dietary non adherence.

Conclusion

Depressive symptoms and dietary non adherence were highly prevalent in patients with end stage renal disease receiving hemodialysis therapy. Nearly all of the articles that examined the relationship between depressive symptoms and dietary non adherence found a significant association. Future research using experimental or longitudinal design and gold standard measures with established cut-points is needed to further explain the relationship.

Prevalence, detection and associations of depression in Australian dialysis patients

OBJECTIVE

Depression in dialysis patients is often undetected despite associations with poor outcomes. The aim was to determine the prevalence and associations of depressive symptoms and physician recognition of depression within a typical Australian dialysis population.

METHOD

A cross-sectional study examined haemodialysis and peritoneal dialysis patients of two hospitals in Sydney. Participants were screened for depression using the Hospital Anxiety and Depression Scale (HADS).

RESULTS

One hundred and ten patients completed the HADS. Subjects had a mean age of 63.7 years, 37% from a culturally and linguistically diverse background, and median dialysis duration of 2 years. Forty-one per cent of participants had significant depressive symptoms, of whom 42% had been diagnosed with depression by their clinicians. After adjustment for sociodemographic factors, having >10 medications prescribed, >3 hospitalisations in the last 12 months, and a history of depression were associated with depression.

CONCLUSION

Depressive symptoms are prevalent in Australian dialysis patients. Robust evidence is needed on the effectiveness of treatments for depression in changing outcomes in chronic kidney disease.

Dimensions of Depressive Symptoms and Their Association With Mortality, Hospitalization, and Quality of Life in Dialysis Patients: A Cohort Study

OBJECTIVE

Unraveling specific dimensions of depressive symptoms may help to improve screening and treatment in dialysis patients. We aimed to identify the best-fitting factorial structure for the Beck Depression Inventory-II (BDI) in dialysis patients and to assess the relation of these structure dimensions with quality of life (QoL), hospitalization, and mortality.

METHODS

This prospective study included chronic dialysis patients from 10 dialysis centers in five hospitals between 2012 and 2017. Dimensions of depressive symptoms within the BDI were analyzed using confirmatory factor analysis. To investigate the clinical impact of these dimensions, the associations between symptom dimensions and QoL, hospitalization rate, and mortality were investigated using logistic, Poisson, and Cox proportional hazard regression models. Multivariable regression models included demographic, social, and clinical variables.

RESULTS

In total, 687 dialysis patients were included. The factor model that included a general and a somatic factor provided the best-fitting structure of the BDI-II. Only the somatic dimension scores were associated with all-cause mortality (hazard ratio of 1.7 [1.2-2.5], p < .007) in the multivariable model. All dimensions were associated with increased hospitalization rate and reduced QoL.

CONCLUSIONS

The somatic dimension of the BDI-II in dialysis patients was associated with all-cause mortality, increased hospitalization rate, and reduced QoL. Other dimensions were associated with hospitalization rate and decreased QoL. These findings show that symptom dimensions of depression have differential association with adverse clinical outcomes. Future studies should take symptom dimensions into account when investigating depression-related pathways, screening, and treatment effects in dialysis patients.

Health Care Utilization Among Adults With CKD and Psychological Distress

Rationale & Objective

Despite extensive research on health care access for individuals with chronic kidney disease (CKD), there is little research on the relationship between health care access barriers and psychological distress.

Study Design

An observational study based on the publicly available 2013 to 2017 US National Health Interview Survey data.

Setting & Participants

3,923 respondents 18 years or older who self-reported a diagnosis of CKD in the preceding 12 months.

Predictor(s) and Outcome(s)

Psychological distress was measured using the Kessler Psychological Distress Scale (K6). Barriers to health care access included lack of health insurance coverage, lack of a usual source of health care, and financial barriers to accessing/obtaining health care, including medical specialist services, prescription drugs, mental health counseling, and dental care.

Analytical Approach

Multinomial logistic regression with 3 levels of K6 scores (no distress, mild to moderate distress, and serious distress) as the dependent variable.

Results

15% of respondents reported mild to moderate and 11% reported serious psychological distress. Compared with those with no distress, those with mild to moderate and serious distress were younger but less likely to have worked in the preceding year, had more chronic medical conditions, and visited an emergency department more frequently. Multivariable regression models show that each financial barrier to health care access (likely due to lack of health insurance) was significantly associated with mild to moderate and serious distress.

Limitations

CKD diagnosis was self-reported and CKD stage was unknown. Because this is a cross-sectional study, associations cannot be assumed to imply causal relationships.

Conclusions

Access to sick and preventive/routine care should be improved. People with CKD should be assessed for psychological distress, treated as needed, and offered case management and social services to help them navigate the health care system and alleviate personal stressors.

Posttraumatic Embitterment Disorder in Patients with Chronic Kidney Disease

Objective

Posttraumatic embitterment disorder (PTED), a subgroup of an adjustment disorder, is a feeling with anger and helplessness. Hemodialysis may be a trigger event leading to PTED. We investigated the prevalence of PTED in patients with each categorized stages of chronic kidney disease (CKD) and the association between PTED and depression and functional impairment.

Methods

Patients were categorized into three groups according to the stages of CKD (stage I–II, III–IV, and V). CKD (I–II) group was defined as estimated glomerular filtration rate (eGFR) >60 ml/min/1.73 m², CKD (III–IV) group as eGFR <60 ml/min/1.73 m², and CKD (V) group as CKD stage V including patients ongoing hemodialysis. Patients were assessed for the prevalence of PTED, depression, and decreased quality of life by using the scale of PTED, Patient Health Questionnaire-9 (PHQ-9), and EuroQol Five Dimensional Questionnaires, Visual Analogue Scale (EQ-5D-VAS), respectively.

Results

A total of 445 patients were analyzed. The number of patients in CKD (I–II) was 166, CKD (III–IV) was 172, and CKD (V) was 107. Multivariate analysis by binomial logistic regression demonstrated that CKD (V) was significantly associated with the prevalence of PTED (odds ratio, 4.13; 95% confidence interval, 1.56–15.6; p=0.006) after adjustment for age, gender, and diabetes mellitus. Also, a significant correlation existed between PTED and EQ-5D-VAS in all stages, but the correlation was nonsignificant between PTED and PHQ-9 score in group CKD (V).

Conclusion

The findings suggest that PTED is underdiagnosed in CKD patients. Acknowledgment and diagnosis of PTED in CKD patients may lead to a better quality of life.

Effects of electrical muscle stimulation in frail elderly patients during haemodialysis (DIAL): rationale and protocol for a crossover randomised controlled trial

INTRODUCTION

The phenomenon of population ageing is accompanied by increases in the number of elderly haemodialysis patients worldwide. The incidence of frailty is high in the haemodialysis population and is associated with poor clinical outcome. Although several interventions have been developed for use in general haemodialysis patients, the efficacy of such rehabilitation programmes in frail elderly patients on haemodialysis has not been elucidated. Here, we examined whether electrical muscle stimulation (EMS) would show beneficial effects in frail elderly patients on haemodialysis.

METHODS AND ANALYSIS

This is a randomised, two-period, controlled crossover trial, which will enrol 20 patients. Haemodialysis patients aged ≥65 years and defined as frail (ie, Short Physical Performance Battery score 4-9), will be randomly assigned to either group 1 (EMS intervention beginning in treatment period I, followed by reallocation as controls in treatment period II after a 5-week washout period) or group 2 (opposite schedule) in a 1:1 ratio. The two intervention periods will last 5 weeks each with an intervening washout period of 5 weeks. In the EMS intervention group, the treatment will be applied to the skeletal muscle of the entire lower extremity for 5 weeks, three times/week for 30-40 min during haemodialysis. The primary outcome of this study is the change in quadriceps isometric strength after the interventions. The secondary outcomes are the changes in physical function, physical activity, difficulty in activities of daily living, body composition, cognitive function, depressive symptoms, quality of life, blood test results and the clinical safety and feasibility of EMS therapy.

ETHICS AND DISSEMINATION

This study has been approved by the institutional review board/ethics committee of Kitasato University Allied Health Sciences. This study will be reported in peer reviewed publications and at conference presentations.

TRIAL REGISTRATION NUMBER

UMIN000032501.

Prevalence and predictors of depression among hemodialysis patients: a prospective follow-up study

BACKGROUND

Even though depression is one of the most common psychiatric disorders, it is under-recognized in hemodialysis (HD) patients. Existing literature does not provide enough information on evaluation of predictors of depression among HD patients. The objective of the current study was to determine the prevalence and predictors of depression among HD patients.

METHODS

A multicenter prospective follow-up study. All eligible confirmed hypertensive HD patients who were consecutively enrolled for treatment at the study sites were included in the current study. HADS questionnaire was used to assess the depression level among study participants. Patients with physical and/or cognitive limitations that prevent them from being able to answer questions were excluded.

RESULTS

Two hundred twenty patients were judged eligible and completed questionnaire at the baseline visit. Subsequently, 216 and 213 patients completed questionnaire on second and final follow up respectively. The prevalence of depression among patients at baseline, 2nd visit and final visit was 71.3, 78.2 and 84.9% respectively. The results of regression analysis showed that treatment given to patients at non-governmental organizations (NGO's) running HD centers (OR = 0.347, p-value = 0.039) had statistically significant association with prevalence of depression at final visit.

CONCLUSIONS

Depression was prevalent in the current study participants. Negative association observed between depression and hemodialysis therapy at NGO's running centers signifies patients' satisfaction and better depression management practices at these centers.

The effects of intradialytic resistance training on muscle strength, psychological well-being, clinical outcomes and circulatory micro-ribonucleic acid profiles in haemodialysis patients: Protocol for a quasi-experimental study

BACKGROUND

Intradialytic resistance training (IRT) protects patients' muscle mass and functions against protein-energy wasting, malnutrition and cachexia. However, the evidence of the effects of such an intervention in haemodialysis patients is limited and not conclusive. To improve the applicability of such interventions, we need a better understanding of molecular, functional and psycho-social adaptation in dialysed patients following a physical training. Therefore, the aim of this study is to investigate the effects of IRT on lower extremity muscle functions, quality of life, and anxiety and depression, clinical outcomes and circulatory micro-ribonucleic acid (miRNA) profiles in patients on chronic haemodialysis therapy.

METHODS

We will perform a quasi-experimental study in 3 dialysis centres. Patients will be recruited via their nephrologists and will be allocated to an experimental and a control group based on the location of the patients' dialysis centre. Patients allocated to the experimental group will undergo a 12-week IRT, while the control group will remain physically inactive during dialysis. The primary outcome is the change in the maximal force produced during an isometric contraction of lower extremity muscles. Secondary outcomes regard quality of life, anxiety and depression, clinical outcomes and circulatory miRNA profiles. Patients' level of health literacy defined as the ability to get and understand health information will be also measured in the study as a potential modifier of effects.

DISCUSSION

This quasi-experimental study can add in an important way to our understanding of the effects of resistance training on dialysis patients' muscle strength, quality of life and disease-specific outcomes.

Sleep disturbance among Malaysian patients with end-stage renal disease with pruritus

Background

Chronic kidney disease-associated pruritus (CKD-aP) is a well-recognized, frequent and compromising complication among patients on hemodialysis. Despite advancement in basic medical sciences, CKD-aP is still a major complication and a challenge for both physicians and patients to manage. The aim of this study was to estimate the prevalence of CKD-aP among hemodialysis patients in Malaysia, to determine the impact of CKD-aP on sleep quality and any factors associated with CKD-aP.

Method

A multi-centered, cross-sectional study design was conducted from February 2017 to September 2017 at a tertiary hospital and its affiliated dialysis centers, in Kuala Lumpur, Malaysia. Included were patients > 18 years of age who were undergoing hemodialysis and could understand Malay. Participants were asked to fill the Malay 5D-itch scale and the Malay Pittsburgh sleep quality index (PSQI) upon recruitment.

Results

A total of 334/334 patients were recruited (response rate = 100%). The majority were male (59.6%) and Chinese (61.7%). A total of 61.3% had pruritus, of which most patients (63.4%) reported that their pruritus was mild. More than half (54.1%) reported that they slept > 6 h, and 93.2% experienced no sleep disturbances during the night. However; the overall PSQI median score [IQR] was 6.0 [5.0–9.0]. No significant association was found between demographic and clinical characteristics of patients with the severity of pruritus. Patients with moderate to severe pruritus were found to be 5.47 times more likely to experience poor sleep quality as compared to patients with mild or no pruritus.

Conclusion

In Malaysia, the prevalence of CKD-aP was 61.3%, of which the majority reported that their pruritus was mild. Patients with moderate to severe pruritus were found to be 5.47 times more likely to experience poor sleep quality as compared to patients with mild or no pruritus.

Pharmacokinetics of antidepressants in patients undergoing hemodialysis: a narrative literature review

We conducted a narrative literature review on studies that specifically addressed the pharmacokinetics of antidepressants in patients on hemodialysis. The search included the MEDLINE, LILACS, and Web of Knowledge databases and combined Medical Subject Headings and free-text search terms for chronic kidney disease, end-stage renal disease, renal replacement therapy, depression, and antidepressants; it was limited to studies conducted in humans, with no language or time constraints. The search yielded 212 studies. After screening titles and abstracts, 32 studies were read in full and 11 ultimately met the inclusion criteria and were included in the review. Most of the studies showed no difference in the pharmacokinetics of antidepressant drugs between patients with normal renal function and patients undergoing hemodialysis. However, studies with fluvoxamine and amitriptyline showed that variations in albumin levels might affect serum concentrations of these agents. The included studies have several limitations, and there are many obstacles to the adequate treatment of depression in patients undergoing hemodialysis. Further studies on this topic are needed to support proper treatment of these patients, improving their quality of life and reducing mortality.

SARC-F Questionnaire: Rapid and Easy Tool for Identifying Physical Limitations in Hemodialysis Patients

Background:SARC-F is a simple questionnaire for rapidly assessing physical function and screening for sarcopenia. This study aimed to determine whether the SARC-F questionnaire is useful for identifying impaired physical function and the risk of physical limitations in hemodialysis patients.Methods:This cross-sectional study included 281 patients undergoing hemodialysis at two dialysis units.SARC-F, handgrip strength, leg strength, one-leg standing time, usual gait speed, and short physical performance battery (SPPB) score were measured. Patients were classified according to the SARC-F score (SARC-F <4 and SARC-F ≥4), indicating the risk of sarcopenia. Furthermore, we defined physical limitations as handgrip strength of <26 kg for men and <18 kg for women, leg strength of <40%, usual gait speed of ≤0.8 m/s, and SPPB score of ≤8 points. To calculate the areas under the curves (AUCs) of the SARC-F score for physical limitations, receiver-operating characteristic curve analysis was performed.Results:SARC-F ≥4 was observed in 75 (26.7 %) hemodialysis patients. The SARC-F ≥4 group had a significantly lower handgrip and leg strength, shorter one-leg standing time, slower usual gait speed, and lower SPPB score than the SARC-F <4 group, even after adjusting for potential confounders (all P<0.001). Further, SARC-F demonstrated good accuracy in identifying the risk of physical limitations (all AUCs > 0.75).Conclusions:The SARC-F questionnaire is useful for screening impaired physical function and for identifying the risk of physical limitations in hemodialysis patients and can be easily and rapidly administered to this patient group in clinical practice.

Depressive symptoms, frailty, and mortality among dialysis patients

INTRODUCTION

Frailty and depression are highly prevalent in the dialysis population, but the association between them, the risk factors for their development, and their independent associations with mortality have not been studied.

METHODS

We examined 771 patients enrolled in the ACTIVE/ADIPOSE prevalent dialysis cohort study. Fried's frailty phenotype and the Center for Epidemiologic Studies Depression score were used to determine frailty and presence of depressive symptoms, respectively. We assessed the baseline association between frailty and depressive symptoms, whether one entity is a risk factor for development of the other, and associations between frailty and depressive symptoms with mortality.

FINDINGS

At baseline, 13.1% of our population screened positive for depressive symptoms, 21.8% met criteria for frailty, and 10.0% met criteria for both. During follow-up, 26.6% of our population developed frailty and 12.7% developed depressive symptoms. Using multivariable logistic regression, baseline depressive symptoms were associated with 2.14-fold higher odds of being frail at baseline (95% confidence interval [CI] 1.45-3.17) and with a 2.16-fold higher odds of incident frailty during follow-up (95% CI 1.22-3.82). However, baseline frailty was not associated with incident depressive symptoms. Frailty and depressive symptoms were independent predictors of mortality in time-varying survival analysis (meeting frailty criteria: hazard ratio [HR] 1.53, 95% CI 1.05-2.23; depressive symptoms: HR 2.21, 95% CI 1.50-3.25).

DISCUSSION

Frailty and depressive symptoms remained highly prevalent over time and were strongly associated with one another and independently associated with mortality among dialysis patients. Future studies should investigate whether interventions for depression could potentially mitigate the appearance of frailty and its associated poor outcomes.

Psychosocial Health and Lifestyle Behaviors in Young Adults Receiving Renal Replacement Therapy Compared to the General Population: Findings From the SPEAK Study

RATIONALE & OBJECTIVE

Patients in late adolescence and early adulthood receiving renal replacement therapy (RRT) face disruption to normal activities, which affects well-being. We aimed to define psychosocial and lifestyle outcomes for young adults on RRT compared to the general population.

STUDY DESIGN

We undertook a cross-sectional survey (the SPEAK [Surveying Patients Experiencing Young Adult Kidney Failure] Study) using validated measures and general population comparator data from the Health Survey for England and Avon Longitudinal Study of Parents and Children. Additional clinical information was obtained from the UK Renal Registry.

SETTING & PARTICIPANTS

16- to 30-year-olds receiving RRT.

OUTCOMES

Psychosocial health and lifestyle behaviors.

ANALYTICAL APPROACH

We compared outcomes between populations using age- and sex-adjusted regression models, weighted to account for response bias by sex, ethnicity, and socioeconomic status. Our findings were used to update recent meta-analyses.

RESULTS

We recruited 976 young adults and 64% responded to the survey: 417 (71%) with kidney transplants and 173 (29%) on dialysis therapy. Compared to the general population, young adults on RRT were less likely to be in a relationship and have children and more likely to live in the family home, receive no income, and be unable to work due to health. They had poorer quality of life, worse well-being, and twice the likelihood of a psychological disturbance (OR, 2.7; 95% CI, 2.0-3.7; P<0.001). They reported less smoking, alcohol and drug abuse, and crime. In a meta-analysis, our study showed the greatest differences in quality of life compared to the general population.

LIMITATIONS

Cross-sectional study design, meaning that we could not track the impact of treatment changes on the outcomes.

CONCLUSIONS

This study involving a large cohort of young adult transplant recipients and dialysis patients provides evidence of worse psychosocial outcomes but more positive lifestyle behaviors in young adults on RRT compared to the age-matched general population.

Single Questions for the Screening of Anxiety and Depression in Hemodialysis

Background:

Depression and anxiety are common and underrecognized in end-stage renal disease (ESRD), are associated with poor outcomes and reduced health-related quality of life, and are potentially treatable. Simple, accurate screening tools are needed.

Objective:

We examined the operating characteristics of single questions for anxiety and depression from the Edmonton Symptom Assessment System (ESAS) in hemodialysis.

Design:

Cross-sectional study.

Setting:

Two outpatient hemodialysis units (1 tertiary, 1 community) in Hamilton, Canada.

Patients:

Adult prevalent hemodialysis patients.

Measurements:

ESAS and Hospital Anxiety and Depression Scale (HADS).

Methods:

Participants were asked the degree to which they experienced anxiety and depression using the ESAS. ESAS single questions for anxiety and depression were compared with the reference standard of the HADS using dialysis population specific cutoffs (HADS anxiety subscale ≥6 and HADS depression subscale ≥7). Logistic regression was used to create receiver operating characteristics (ROC) curves.

Results:

We recruited 50 participants with a mean age of 64 (SD = 12.4) years, of whom 52% were male and 96% were on ≥3× weekly hemodialysis. Using the reference standards, 28 (56%) had a diagnosis of anxiety and 27 (54%) had a diagnosis of depression. Areas under the ROC curves were 0.83 for anxiety and 0.81 for depression using ESAS scores of ≥2.

Limitations:

Sample size and the lack of a reference gold standard.

Conclusions:

The ESAS single questions for anxiety and depression have reasonable discrimination in a hemodialysis population. The use of more complex and time-consuming screening instruments could be reduced by adopting the ESAS questions for anxiety and depression in hemodialysis.

Relationship Between Stress Coping Mechanisms and Depression in Kidney Transplant Recipients

BACKGROUND

It has been reported that transplant recipients are exposed to physical and psychosocial stresses even after transplant surgery and exhibit psychological disorders such as depression.

PURPOSE

In this study, we extracted trends concerning how recipients of kidney transplants cope with stress, and we also examined how they cope with depression and its countermeasures.

METHOD

We administered questionnaire surveys to 109 kidney transplant recipients. These included items on personal attributes, medical information, depression, and stress-coping type scales. Statistical analysis was performed using factor analysis and multiple regression analysis.

RESULTS

Fifteen out of 109 (13.8%) were found to be high-risk patients for depression based on responses to the questionnaire using the depression scale. We extracted 2 factors of stress-coping type, namely Factor 1, "Directly coping with the problem," of patients who try to directly resolve the problem in a positive manner and Factor 2, "Stress-release while avoiding the problem," for those who relieve their feelings in response to the stress without resolving the problem itself. When multiple regression analysis was conducted with the depression scale as the dependent variable and the stress-coping factor as the independent variable, Factor 1 tended to be associated with reduced depression and Factor 2 with increased depression.

CONCLUSIONS

Results showed that to improve the mental health of those who receive kidney transplants, it is necessary to examine the depression and stress-coping types of such patients at an early stage and carry out education on stress-coping, focusing on resolving the actual problem.