Psychosocial intervention improves depression, quality of life, and fluid adherence in hemodialysis

Pharmacologic and psychological interventions for depression treatment in patients with kidney disease

PURPOSE OF REVIEW

It remains controversial whether existing therapies, including pharmacologic and psychological interventions, are effective for treatment of depression in patients with chronic kidney disease (CKD) and end-stage kidney disease.

RECENT FINDINGS

Most studies of depression treatment were underpowered or uncontrolled. The CKD Antidepressant Sertraline Trial showed no benefit of a serotonin-selective reuptake inhibitor (SSRI), sertraline, over double-blind matched placebo for the treatment of depressive symptoms in patients with nondialysis CKD. A Trial of Sertraline vs. Cognitive Behavioral Therapy (CBT) for End-stage Renal Disease Patients with Depression showed improvement in depressive symptoms from baseline in both groups and a marginal benefit of sertraline over CBT that was of unclear clinical significance, given the lack of an active control group. SSRIs are associated with poor tolerability in clinical trials and serious adverse outcomes in large retrospective studies.

SUMMARY

Although the data do not support unlimited use of SSRIs in patients with CKD or end-stage kidney disease, it is reasonable to initiate a cautious trial of sertraline while closely monitoring for depressive symptom improvement and adverse effects. CBT is a low-risk, possibly effective intervention to treat major depressive disorder in patients with kidney disease who have access to such treatments.

A conceptual framework of quality of life in chronic kidney disease in Turkey: A patient-focused approach

This study aimed to determine the quality of life of patients with chronic kidney disease who were receiving dialysis treatment. It also aimed to identify the factors affecting the quality of life of these patients. The independent variables analyzed were: patients' sociodemographic characteristics, organizational characteristics, adherence to treatment, patient-physician relationship, and patient activation level. The sample consisted of 328 patients with chronic kidney disease who received services from dialysis units of two university hospitals and two private dialysis centers. Data analysis was performed through multivariate regression. Results showed that receiving treatment from a hospital-based dialysis unit may have a positive effect in patients' quality of life; and patient-physician relationship, patient activity, and adherence to treatment may positively affect quality of life. Thus, planning of health service delivery that focus on improving the quality of life of patients who are more active by allowing them to establish positive relationships with their physicians and to have a better adherence to treatment should be adopted. These findings may provide health managers, health professionals, and individual patients with evidence-based information about treatment management and health service planning processes related to chronic kidney disease.

The current and future landscape of dialysis

The development of dialysis by early pioneers such as Willem Kolff and Belding Scribner set in motion several dramatic changes in the epidemiology, economics and ethical frameworks for the treatment of kidney failure. However, despite a rapid expansion in the provision of dialysis — particularly haemodialysis and most notably in high-income countries (HICs) — the rate of true patient-centred innovation has slowed. Current trends are particularly concerning from a global perspective: current costs are not sustainable, even for HICs, and globally, most people who develop kidney failure forego treatment, resulting in millions of deaths every year. Thus, there is an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible and offer improved patient outcomes. Nephrology researchers are increasingly engaging with patients to determine their priorities for meaningful outcomes that should be used to measure progress. The overarching message from this engagement is that while patients value longevity, reducing symptom burden and achieving maximal functional and social rehabilitation are prioritized more highly. In response, patients, payors, regulators and health-care systems are increasingly demanding improved value, which can only come about through true patient-centred innovation that supports high-quality, high-value care. Substantial efforts are now underway to support requisite transformative changes. These efforts need to be catalysed, promoted and fostered through international collaboration and harmonization.

Dialysis is a life-saving therapy; however, costs of dialysis are high, access is inequitable and outcomes are inadequate. This Review describes the current landscape of dialysis therapy from an epidemiological, economic, ethical and patient-centred framework, and describes initiatives that are aimed at stimulating innovations in the field to one that supports high-quality, high-value care.

The global dialysis population is growing rapidly, especially in low-income and middle-income countries; however, worldwide, a substantial number of people lack access to kidney replacement therapy, and millions of people die of kidney failure each year, often without supportive care.

The costs of dialysis care are high and will likely continue to rise as a result of increased life expectancy and improved therapies for causes of kidney failure such as diabetes mellitus and cardiovascular disease.

Patients on dialysis continue to bear a high burden of disease, shortened life expectancy and report a high symptom burden and a low health-related quality of life.

Patient-focused research has identified fatigue, insomnia, cramps, depression, anxiety and frustration as key symptoms contributing to unsatisfactory outcomes for patients on dialysis.

Initiatives to transform dialysis outcomes for patients require both top-down efforts (that is, efforts that promote incentives based on systems level policy, regulations, macroeconomic and organizational changes) and bottom-up efforts (that is, patient-led and patient-centred advocacy efforts as well as efforts led by individual teams of innovators).

Patients, payors, regulators and health-care systems increasingly demand improved value in dialysis care, which can only come about through true patient-centred innovation that supports high-quality, high-value care.

The effects of cognitive behavioural therapy on depression and quality of life in patients with maintenance haemodialysis: a systematic review

BACKGROUND

Depression is highly prevalent among Haemodialysis (HD) patients and is known to results in a series of adverse outcomes and poor quality of life (QoL). Although cognitive behavioural therapy (CBT) has been shown to improve depressive symptoms and QoL in other chronic illness, there is uncertainty in terms of the effectiveness of CBT in HD patients with depression or depressive symptoms.

METHODS

All randomised controlled trials relevant to the topic were retrieved from the following databases: CINHAL, MEDLINE, PubMed, PsycINFO and CENTRAL. The grey literature, specific journals, reference lists of included studies and trials registers website were also searched. Data was extracted or calculated from included studies that had measured depression and quality of life using valid and reliable tools -this included mean differences or standardised mean differences and 95% confidence intervals. The Cochrane risk of bias tool was used to identify the methodological quality of the included studies.

RESULTS

Six RCTs were included with varying methodological quality. Meta-analysis was undertaken for 3 studies that employed the CBT versus usual care. All studies showed that the depressive symptoms significantly improved after the CBT. Furthermore, CBT was more effective than usual care (MD = - 5.28, 95%CI - 7.9 to - 2.65, P = 0.37) and counselling (MD = - 2.39, 95%CI - 3.49 to - 1.29), while less effective than sertraline (MD = 2.2, 95%CI 0.43 to 3.97) in alleviating depressive symptoms. Additionally, the CBT seems to have a beneficial effect in improving QoL when compared with usual care, while no significant difference was found in QoL score when compared CBT with sertraline.

CONCLUSIONS

CBT may improve depressive symptoms and QoL in HD patients with comorbid depressive symptoms. However, more rigorous studies are needed in this field due to the small quantity and varied methodological quality in the identified studies.

Educational or behavioural interventions for symptoms and health-related quality of life in adults receiving haemodialysis: A systematic review

BACKGROUND

People with end-stage kidney disease (ESKD) suffer from multiple symptoms, which have a negative impact on their health-related quality of life (HRQoL). Educational and behavioural interventions are being developed for this population; however, the effect of these interventions is unclear.

AIM

To evaluate the effectiveness of educational or behavioural interventions compared with standard care or alternative strategies on reducing symptoms and improving HRQoL in adults with ESKD receiving haemodialysis (HD).

METHODS

An effectiveness systematic review using Joanna Briggs Institute (JBI) procedures was conducted on experimental studies [randomised controlled trials (RCTs), pseudo-RCTs and quasi-experimental designs] published in English between January 2009 and July 2019. Studies were retrieved from CINAHL, PubMed, MEDLINE, Embase, PsycINFO, Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trial) and JBI databases. Effect size at 95% confidence interval was calculated where possible.

RESULTS

Eighteen studies involving 791 participants were included in this review. All studies involved behavioural interventions with the majority of studies (n = 11) targeting psychological symptoms. Interventions were categorised as either active or passive. Active interventions seemed to improve some physical symptoms, although there was very little evidence of improvements to HRQoL. Passive interventions tended to have a large effect on psychological symptoms and the mental health components of HRQoL.

CONCLUSION

Due to great heterogeneity between studies, meta-analyses could not be conducted further limiting the evidence to inform practice. In addition, further research on educational interventions to teach self-management strategies for symptom management and to improve HRQoL in people with ESKD receiving HD are needed.

Effectiveness of a Multifaceted Educational Intervention to Enhance Therapeutic Regimen Adherence and Quality of Life Amongst Iranian Hemodialysis Patients: A Randomized Controlled Trial (MEITRA Study)

Purpose

A multimodal intervention designed and executed to improve therapeutic regimen adherence and quality of life in a sample of Iranian hemodialysis patients. Its feasibility and impact was assessed post intervention.

Patients and Methods

This randomized controlled trial (RCT) study was conducted at two hemodialysis wards of the Shahrvand hospital located in Sari, the capital city of the Mazandaran province, north of Iran. The study sample included patients with end-stage renal disease (ESRD) receiving outpatient hemodialysis treatment. Considering 10% attrition, 70 registered patients were randomly categorized into intervention and control groups. The proposed intervention included playing of relevant educational video tracks, conducting eight cognitive behavioral therapy (CBT) group sessions, and telephone-based peer support. Data were collected applying a set of questionnaires including sociodemographic, Beck Depression Inventory (BDI-SF), Multidimensional Scale of Perceived Social Support (MSPSS), Patient Satisfaction with Nursing Care Quality Questionnaire (PSNCQQ), End-Stage Renal Disease Adherence Questionnaire (ESRD-AQ) and the World Health Organization Quality of Life (WHOQOL-SF) scale. Sociodemographic and clinical data were collected at baseline in both groups and the postintervention assessment was performed in the intervention and nonintervention groups after one month and three months.

Results

A significant change in the self-reported depression symptoms (P=0.001), mean social support score (P=0.001), nursing care satisfaction score (P=0.001), quality of life score (P=0.001) and interdialytic weight gain (IDWG) (P=0.001) was observed among the participants in the intervention group compared to the baseline measures. The highest rise in the ESRD-AQ scores within the intervention group was observed after one month of intervention (mean difference=131.88) compared to the baseline values. Same pattern of statistically significant changes in mean scores of the intervention group’s attendants in all subscales of the ESRD-AQ were also ascertained.

Conclusion

This interventional study revealed that inaugurating of a feasible low-cost intervention without need to add major logistic or financial inputs into existing health-care systems, especially in resource limited contexts, is achievable. Findings of this study could provide insights into scientific basis of evidence-informed interventions applicable in the realm of health-care delivery.

Antidepressant Usage in Haemodialysis Patients: Evidence of Sub-Optimal Practice Patterns

BACKGROUND

Depression is common in patients on haemodialysis and associated with adverse outcomes. Antidepressant use is widespread though evidence of efficacy is limited.

OBJECTIVES

To study antidepressant management practices in patients on haemodialysis with reference to NICE guidelines on management of depression in adults with chronic physical health problems.

DESIGN

Prospective, multicentre, longitudinal cohort study with 6-15 month follow-up.

PARTICIPANTS

Patients on haemodialysis established on antidepressant medication.

MEASUREMENTS

Baseline assessment of mood was undertaken using Beck Depression Inventory (BDI-II). Demographic, clinical and medication data were also collected. Changes in clinical and life circumstances and medication during follow-up were recorded. At follow-up, BDI-II was reassessed and diagnostic psychiatric assessment undertaken.

RESULTS

Forty-one patients were studied. General practitioners were the main prescribers (68%). Ten agents were in use, the commonest being Citalopram (39%). Doses were often suboptimal. At baseline, 30 patients had high BDI-II scores (≥16) and 22 remained high at follow-up. Eleven had BDI-II < 16 at baseline. In five, this increased on follow-up to ≥16. Sixteen patients (39%) had no medication review during follow-up, 14 (34%) had a dose review, and 11 (27%) a medication change. On psychiatric assessment at follow-up, eight patients had current major depressive disorder (MDD), seven recurrent and 20 evidence of past MDD. Six displayed no evidence of ever having MDD.

CONCLUSIONS

Antidepressant management in patients on haemodialysis reflected poor drug selection, overprescription, under-dosing and inadequate follow-up suggesting sub-optimal adherence to NICE guidelines. Most patients had high depression scores at follow-up. Antidepressant use in haemodialysis requires reappraisal.

The influence of cognitive-behavioral therapy on depression in dialysis patients - meta-analysis

INTRODUCTION

Depressive disorders are the most common mental health problem among patients undergoing dialysis. Furthermore, depression is an independent factor increasing the mortality and frequency of hospitalization in this group of patients, yet psychological intervention programs aimed at improving the mental health of dialysis patients have still not been developed. This meta-analysis aimed to assess the effects of cognitive-behavioral therapy on depressive symptoms in dialysis patients. The main hypothesis of this study is that cognitive-behavioral therapy is an effective psychological method of reducing the severity of depression symptoms among patients undergoing dialysis.

MATERIAL AND METHODS

A systematic search was conducted using Medline, PubMed, Web of Science, Scopus and Google Scholar. Data extraction was carried out by two independent researchers. The severity of depression symptoms in the included studies was measured by the Beck Depression Inventory. A random-effects model was used to estimate the pooled mean difference of these values between patients undergoing CBT and the controls.

RESULTS

Four of the 1841 search results met the inclusion criteria with data from 226 patients who had undergone dialysis therapy due to renal disorders and psychological intervention based on cognitive-behavioral therapy. This therapy significantly reduced the level of depression symptoms in all studies included in the meta-analysis (mean difference = -5.3, p = 0.001; 95% CI: -7.95 to -2.66).

CONCLUSIONS

The study showed that the use of psychological intervention based on cognitive- behavioral therapy was an effective method of decreasing the severity of depressive symptoms in hemodialyzed patients. For the sake of patient well-being, it seems reasonable to extend renal replacement therapy with psychological intervention such as cognitive-behavioral therapy.

Patients' experiences of transitioning between different renal replacement therapy modalities: A qualitative study

BACKGROUND

Different kidney replacement therapy modalities are available to manage end-stage kidney disease, such as home-based dialysis, in-center hemodialysis, and kidney transplantation. Although transitioning between modalities is common, data on how patients experience these transitions are scarce. This study explores patients' perspectives of transitioning from a home-based to an in-center modality.

METHODS

Patients transitioning from peritoneal dialysis to in-center hemodialysis were purposively selected. Semi-structured interviews were performed, digitally recorded, and transcribed verbatim. Data analysis, consistent with Charmaz' constructivist approach of grounded theory was performed.

RESULTS

Fifteen patients (10 males; mean age 62 years) participated. The conditions of the transitioning process impacted the participants' experiences, resulting in divergent experiences and associated emotions. Some participants experienced a loss of control due to the therapy-related changes. Some felt tied down and having lost independence, whereas others stated they regained control as they felt relieved from responsibility. This paradox of control was related to the patient having or not having (1) experienced a fit of hemodialysis with their personal lifestyle, (2) a frame of reference, (3) higher care requirements, (4) insight into the underlying reasons for transitioning, and (5) trust in the healthcare providers.

CONCLUSIONS

Care teams need to offer opportunities to elicit patients' knowledge and fears, dispel myths, forge connections with other patients, and visit the dialysis unit before transition to alleviate anxiety. Interventions that facilitate a sense of control should be grounded in the meaning that the disorder has for the person and how it impacts their sense of self.

Asociación de estrategias de afrontamiento y calidad de vida relacionada con la salud en pacientes en diálisis peritoneal

Objetivo: Evaluar la relación entre estrategias de afrontamiento y calidad de vida relacionada con la salud en pacientes incidentes en diálisis peritoneal. Métodos: Estudio transversal en 106 pacientes incidentes en diálisis peritoneal, en cuatro centros de Ciudad de México. Se usaron los instrumentos Kidney Disease Quality of Life Short Form (KDQOL-SF36) y Coping Strategies Inventory para evaluar la calidad de vida relacionada con la salud y las estrategias de afrontamiento, respectivamente. Se evaluó la correlación de puntuaciones de estrategias de afrontamiento y calidad de vida. Se comparó la calidad de vida relacionada con la salud entre los pacientes con estrategia de afrontamiento activa y pasiva. Resultados: La estrategia de afrontamiento activa mostró correlación positiva con componentes físico y mental, efectos de la enfermedad renal y carga de la enfermedad renal del KDQOL-SF36, en tanto que el puntaje de estrategia pasiva correlacionó negativamente con componente mental y carga de la enfermedad renal en el KDQOL-SF36. Los puntajes de componentes físico y mental, efectos de enfermedad renal, carga de enfermedad renal y problemas por síntomas del KDQOL-SF36 fueron significativamente más altos en pacientes con estrategia de afrontamiento activa que en los que presentaron estrategia pasiva. Conclusiones: A partir de los resultados encontrados podemos concluir que los pacientes con estrategia de afrontamiento activa presentan mejor calidad de vida relacionada con la salud, tanto en las dimensiones del cuestionario específico de las alteraciones renales como en el genérico de calidad de vida, en comparación con los pacientes con estrategia de afrontamiento pasiva.

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.

The (cost) effectiveness of guided internet-based self-help CBT for dialysis patients with symptoms of depression: study protocol of a randomised controlled trial

BACKGROUND

Only a minority of dialysis patients with depressive symptoms are diagnosed and receive treatment. Depressive symptoms are highly prevalent in this population and are associated with adverse clinical outcomes. Underlying factors for this undertreatment may be the lack of evidence for the safety and effectivity of antidepressant medication, the reluctance of patients to adhere to antidepressant medication, the lack of mental healthcare provision in somatic healthcare environments and end-stage renal disease (ESRD) related physical limitations that complicate face-to-face psychotherapy. Guided Internet-based self-help treatment has demonstrated to be effective for depressive symptoms in other chronic patient populations and may overcome these barriers. The aim of this study is to investigate the (cost) effectiveness of a guided Internet-based self-help intervention for symptoms of depression in dialysis patients.

METHODS

This study is a cluster randomized controlled trial (RCT) that investigates the effectiveness of a 5-week Internet-based self-help Problem Solving Therapy (PST) for depressive symptoms in dialysis patients. Depressive symptoms will be measured using the Beck Depression Inventory - second edition (BDI-II), with a cut-off score of ≥10. We aim to include 206 dialysis patients with depressive symptoms who will be cluster randomized to the intervention or the Care as Usual (CAU) control group. Secondary outcomes will include anxiety symptoms, quality of life, economic costs and clinical outcomes, such as inflammatory factors and hair cortisol levels. Assessments will take place at baseline (T0), 2 weeks after intervention (T1) and 6 months (T2), 12 months (T3) and 18 months (T4) after intervention. The control group will be measured at the same time points. Analysis will be based on the intention-to-treat principle. Mixed models will be used to assess the changes within each condition between pre-treatment and post-treatment.

DISCUSSION

If demonstrated to be (cost) effective, Internet-based PST will offer new possibilities to treat dialysis patients with depressive symptoms and to improve their quality of care.

TRIAL REGISTRATION

Dutch Trial Register: Trial NL6648 (NTR6834) (prospectively registered 13th November 2017).

A systematic review and meta-analysis of randomized controlled trials of cognitive behavioral therapy for hemodialysis patients with depression

OBJECTIVE

The aim of this meta-analysis was to examine the efficacy of cognitive behavioral therapy (CBT) for hemodialysis patients with comorbid depression and to identify which other aspects, including anxiety and quality of life, can be improved through intervention.

METHODS

A systematic literature review was performed using multiple databases (PubMed, EMBase, PsycINFO, CENTRAL). The inclusion criteria included randomized controlled trials (RCTs) of CBT conducted in hemodialysis patients with depression. Study reporting quality was assessed with the Cochrane tool and Review Manager version 5.3 was used to obtain pooled results.

RESULTS

Eight RCTs, with a total sample size of 540 participants, met the inclusion criteria. Compared with control groups, the CBT groups had statistically significant improvements in depression (standardized mean differences [SMD] = -0.68, 95% confidence interval [CI] (-0.94 to -0.42), P < .001), anxiety (SMD = -0.99, 95%CI (-1.99 to 0.00), P = .05) and quality of life (SMD = 0.34, 95%CI (0.13 to 0.54), P < .001).

CONCLUSIONS

The results of this meta-analysis showed that CBT could have an effective role in reducing symptoms of depression and anxiety as well as improving quality of life in hemodialysis patients with comorbid depression.

Selective Serotonin Reuptake Inhibitor Use and Hip Fracture Risk Among Patients on Hemodialysis

RATIONALE & OBJECTIVE

Use of selective serotonin reuptake inhibitors (SSRIs) has been associated with hip fracture risk in the general population. This study examined this relationship among patients with kidney failure treated by hemodialysis, a unique high-risk subpopulation, within which the impact of SSRIs on hip fracture risk remains unexplored.

STUDY DESIGN

Case-control study.

SETTINGS & PARTICIPANTS

Eligible cases of hip fracture among maintenance hemodialysis patients between January 1, 2009, and September 30, 2015, were identified using the US Renal Data System. Each case was matched on index date with 10 eligible controls. To be eligible, study participants needed to have more than 1 year of Medicare Parts A and B coverage and more than 3 years of Part D coverage. For a separate examination of new short-term SSRI exposure, we selected cases and controls with more than 18 months of Part D coverage and no prior antidepressant use for 1 year.

EXPOSURE

During the 3-year Part D coverage period, use of SSRIs characterized as any (≥1 prescription filled), low, moderate, and high use (<20%, 20%-<80%, and≥80% of days covered by filled prescriptions, respectively).

OUTCOME

We selected cases using International Classification of Diseases, Ninth Revision codes 820.xx and 821.xx. In addition to 1 of these codes tied to a hospitalization, we required a corresponding surgical procedural code within 7 days of diagnosis.

ANALYTIC APPROACH

Conditional logistic regression to estimate unadjusted and multivariable-adjusted ORs and 95% CIs.

RESULTS

We identified 4,912 cases and 49,120 controls. SSRI use was associated with increased hip fracture risk (adjusted OR, 1.25; 95% CI, 1.17-1.35). Risk for fracture was estimated for any, low, moderate, and high SSRI use: adjusted conditional ORs were 1.25 (95% CI, 1.17-1.35), 1.20 (95% CI, 1.08-1.32), 1.31 (95% CI, 1.18-1.43), and 1.26 (95% CI, 1.12-1.41), respectively. The association between hip fracture events and SSRI use was also seen in the examination of new short-term use (adjusted OR, 1.43; 95% CI, 1.23-1.67).

LIMITATIONS

Biomarkers of mineral bone disorder were not captured and accounted for in this analysis.

CONCLUSIONS

We demonstrated an association between increased hip fracture risk and both long- and new short-term SSRI use. The stronger association with new short-term use may suggest an acute mechanism potentially related to falls.

A Qualitative Study on Factors Affecting Adherence Among Indian Haemodialysis Patients at a Tertiary Teaching Hospital of Southern India

Non-adherence to treatment regimen can have a detrimental effect on the heath of dialysis patients, increase mortality, morbidity and increase in healthcare service utilization and cost of hospitalization. This qualitative study explores the factors affecting adherence among the dialysis population visiting a tertiary care teaching hospital in southern India by conducting one-to-one in-depth interviews with the patients as well as key informant interview with the caregivers at the outpatient dialysis facility of a tertiary care teaching hospital. Interview transcripts were thematically analyzed using ATLAS.ti. Patient factors, health financing, cultural beliefs, caregivers’ burden and health systems factors were identified. Understanding the factors affecting adherence can help the healthcare providers and the government to devise strategies to promote adherence and improved well-being among dialysis patients. Universal health coverage for dialysis, regulations to safeguard employment, creating awareness about opting for critical illness policies through private insurance companies when the disease is not pre-existing can reduce the out-of-pocket expenditure; these are some of the important areas for consideration to promote adherence.

Nonpharmacological Interventions for Depressive Symptoms in End-Stage Renal Disease: A Systematic Review

Depressive symptoms are common in patients with end-stage renal disease, which can affect treatment and prognosis. We aimed to evaluate the effects of nonpharmacological interventions for depressive symptoms in end-stage renal disease. Eligible studies were identified using PubMed, Web of Science, the Cochrane Library, Embase, and PsycNET (up to March 2019). We identified 24 studies including 1,376 patients. We found that psychological intervention (-0.60, 95% confidence interval [CI] = [-0.87, -0.33]), exercise (-1.13, 95% CI = [-1.56, -0.69]), and manual acupressure (-0.26, 95% CI = [-0.50, 0.03]) were associated with a significant effect on depressive symptoms. However, few studies reported adverse events, and conclusions about safety should be drawn cautiously. While the available data show that nonpharmacological interventions are potential strategies to alleviate depressive symptoms of patients with end-stage renal disease, recommendation of the most efficacious interventions for this population will require future randomized controlled trials with large-scale, long-term intervention.

The prevalence of depression and the association between depression and kidney function and health-related quality of life in elderly patients with chronic kidney disease: a multicenter cross-sectional study

Purpose: The prevalence of depression and the relationship between depression and kidney function and health-related quality of life (HRQOL) are not well understood in elderly patients with predialysis chronic kidney disease (CKD). This study aimed to evaluate the prevalence of depression and the association between depression and kidney function and HRQOL. Patients and methods: In this cross-sectional study, 1079 elderly participants with CKD were recruited at 32 clinical centers located within 26 cities throughout 24 provinces in China. Demographic information and laboratory analyses were collected. Symptoms of depression were assessed using the 15-item Geriatric Depression Scale (GDS-15). HRQOL was evaluated using the Kidney Disease Quality of Life-36 (KDQOL-36) instrument. Results: The prevalence of depression was 23.0%. The estimated glomerular filtration rate (eGFR) was negatively correlated with the GDS score whether it was treated as a categorical variable (r=-0.097, P=0.001) or as a continuous variable (r=-0.100, P=0.001). Marital status, education level, history of CVD and diabetes, CKD stage and proteinuria confirmed to be independent and significant predictors of depression in patients with CKD. Compared with CKD 1-2 patients, we observed an increase of 0.541 and 4.171 in the odds for developing depression in patients CKD 4 (odds ratio [OR] =1.541; P=0.031) and CKD 5 (odds ratio [OR] =5.171; P<0.001), respectively. We observed negative and significant correlations with the GDS score for the following components: PCS (r=-0.370, P<0.001), MCS (r=-0.412, P<0.001), burden of kidney disease (r=-0.403, P<0.001), symptoms and problems of kidney disease (r=-0.360, P<0.001) and effects of kidney disease (r=-0.355, P<0.001). Depression was an independent and significant predictor of all the subcomponents of the HRQOL. Conclusions: The prevalence of depression in elderly patients with CKD was high and was negatively correlated with kidney function. Depression had a major negative impact on HRQOL.

Prevalence of mental health problems among medical students in China: A meta-analysis

BACKGROUND

The prevalence of mental health problems in medical students has continuously increased and is higher than the prevalence of mental health problems in students with other majors, which could lead to undesirable consequences for the students and their future patients. In China, the current states of medical education and healthcare workplaces differ in certain areas from those in Western or other Asian countries. However, the mental health status of Chinese medical students has not been systematically analyzed.

OBJECTIVES

The purpose of this meta-analysis was to summarize the prevalence of mental health problems in Chinese medical students.

METHODS

All cross-sectional studies that investigated the prevalence of any mental health problem among Chinese medical students were retrieved from the following databases: EMBASE, PubMed, PsycINFO, OVID, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials. We accepted each individual trial's inclusion and exclusion criteria for participants. The National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was adopted to appraise the methodological quality of each study. RevMan (version 5.3) was used to analyze the data.

RESULTS

Ten cross-sectional studies involving a total of 30,817 Chinese medical students were included. The prevalence of depression, anxiety, suicidal ideation, and eating disorders were 29%, 21%, 11%, and 2%, respectively. Subgroup analysis revealed no significant differences in the prevalence of depression and suicidal ideation between genders and no significant difference in the prevalence of depression between individuals of different ages (20 years and older or younger than 20 years).

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Chinese medical students have relatively high prevalence of depression, anxiety, and suicidal ideation but a low prevalence of eating disorders. Mental health problems in Chinese medical students should be taken seriously, and timely screening of and proper intervention in these mental health problems are highly recommended.

Repercusiones del tratamiento psicoterapéutico sobre indicadores psicosomáticos en el paciente en hemodiálisis

Introducción: Aunque las relaciones psico-somáticas y los efectos del tratamiento psicológico en el desarrollo de enfermedades ha sido un tema de interés en las últimas décadas, no existen estudios con pacientes renales en hemodiálisis. Objetivo: Evaluar las repercusiones psicológicas y físicas de la aplicación de psicoterapia en el paciente renal en hemodiálisis. Material y Método: Estudio cuasi experimental. 39 personas recibieron atención psicológica entre 3 y 18 meses. Se les aplicaron los cuestionarios de depresión de Beck y Ansiedad-Rasgo antes y después del tratamiento con psicoterapia, y mientras duró dicho tratamiento también se registraron los valores de frecuencia cardiaca, tensión arterial, peso seco y ganancia hídrica inter-sesiones. Resultados: Tras el tratamiento psicológico los niveles de depresión descendieron en todos los pacientes excepto en aquellos con depresión leve, y en el caso de la ansiedad, tan sólo descendió en los pacientes con ansiedad elevada. La única variable fisiológica que mostró variaciones durante el tratamiento psicológico fue la ganancia hídrica inter-diálisis, que describió una tendencia lineal descendiente en 24 casos. Conclusiones: Las repercusiones del tratamiento psicológico pueden verse reflejadas en una variación de los niveles de ansiedad y depresión, así como en una disminución de las ganancias de líquido interdiálisis.

Comparative Efficacy of Therapies for Treatment of Depression for Patients Undergoing Maintenance Hemodialysis: A Randomized Clinical Trial

BACKGROUND

Although depression is common among patients receiving maintenance hemodialysis, data on their acceptance of treatment and on the comparative efficacy of various therapies are limited.

OBJECTIVE

To determine the effect of an engagement interview on treatment acceptance (phase 1) and to compare the efficacy of cognitive behavioral therapy (CBT) versus sertraline (phase 2) for treating depression in patients receiving hemodialysis.

DESIGN

Multicenter, parallel-group, open-label, randomized controlled trial. (ClinicalTrials.gov: NCT02358343).

SETTING

41 dialysis facilities in 3 U.S. metropolitan areas.

PARTICIPANTS

Patients who had been receiving hemodialysis for at least 3 months and had a Beck Depression Inventory-II score of 15 or greater; 184 patients participated in phase 1, and 120 subsequently participated in phase 2.

INTERVENTION

Engagement interview versus control visit (phase 1) and 12 weeks of CBT delivered in the dialysis facility versus sertraline treatment (phase 2).

MEASUREMENTS

The primary outcome for phase 1 was the proportion of participants who started depression treatment within 28 days. For phase 2, the primary outcome was depressive symptoms measured by the Quick Inventory of Depressive Symptoms-Clinician-Rated (QIDS-C) at 12 weeks.

RESULTS

The proportion of participants who initiated treatment after the engagement or control visit did not differ (66% vs. 64%, respectively; P = 0.77; estimated risk difference, 2.1 [95% CI, -12.1 to 16.4]). Compared with CBT, sertraline treatment resulted in lower QIDS-C depression scores at 12 weeks (effect estimate, -1.84 [CI, -3.54 to -0.13]; P = 0.035). Adverse events were more frequent in the sertraline than the CBT group.

LIMITATION

No randomized comparison was made with no treatment, and persistence of treatment effect was not assessed.

CONCLUSION

An engagement interview with patients receiving maintenance hemodialysis had no effect on their acceptance of treatment for depression. After 12 weeks of treatment, depression scores were modestly better with sertraline treatment than with CBT.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute, Dialysis Clinic, Kidney Research Institute, and National Institute of Diabetes and Digestive and Kidney Diseases.

A Conceptual Framework of Palliative Care across the Continuum of Advanced Kidney Disease

Kidney palliative care is a growing discipline within nephrology. Kidney palliative care specifically addresses the stress and burden of advanced kidney disease through the provision of expert symptom management, caregiver support, and advance care planning with the goal of optimizing quality of life for patients and families. The integration of palliative care principles is necessary to address the multidimensional impact of advanced kidney disease on patients. In particular, patients with advanced kidney disease have a high symptom burden and experience greater intensity of care at the end of life compared with other chronic serious illnesses. Currently, access to kidney palliative care is lacking, whether delivered by trained kidney care professionals or by palliative care clinicians. These barriers include a gap in training and workforce, policies limiting access to hospice and outpatient palliative care services for patients with ESKD, resistance to integrating palliative care within the nephrology community, and the misconception that palliative care is synonymous with end-of-life care. As such, addressing kidney palliative care needs on a population level will require not only access to specialized kidney palliative care initiatives, but also equipping kidney care professionals with the skills to address basic kidney palliative care needs. This article will address the role of kidney palliative care for patients with advanced kidney disease, describe models of care including primary and specialty kidney palliative care, and outline strategies to improve kidney palliative care on a provider and system level.

Depressive Symptoms Associate With Race and All-Cause Mortality in Patients With CKD

INTRODUCTION

Depression is common but underrecognized in patients with chronic kidney disease (CKD), especially among racial/ethnic minorities. We examined the association between depressive symptoms and all-cause mortality (including deaths before and after end-stage renal disease [ESRD]) and whether antidepressant use impacts this association, overall, and by race/ethnicity.

METHODS

We ascertained whether the presence of depressive symptoms, defined by a Beck Depression Inventory II (BDI) score of >14 at cohort enrollment, was associated with all-cause mortality (before or after ESRD) among study participants of the Chronic Renal Insufficient Cohort (CRIC) overall and by race/ethnicity. Models were adjusted for socioeconomic factors, baseline CKD severity, time-updated comorbid conditions, and time-updated antidepressant use. Confirmatory analyses were performed among African American Study of Kidney Disease and Hypertension (AASK) participants.

RESULTS

Among 3739 CRIC participants, 16.3% had a baseline BDI of >14; 18.2% reported antidepressant use. Crude mortality rate was 3.16 per 100 person-years during 6.8 years of median follow-up. Baseline BDI >14 was independently associated with higher risk of all-cause mortality (adjusted hazard ratio [aHR]: 1.27; 95% confidence interval: 1.07-1.52) without attenuation by antidepressant use. Differences among white and black individuals were noted (Pinteraction= 0.02) but not among white versus Hispanic individuals (Pinteraction = 0.43) or black versus Hispanic individuals (Pinteraction = 0.22). Depressive symptoms were associated with higher mortality among white individuals (aHR: 1.66; 1.21-2.28), but not Hispanic individuals (aHR: 1.47; 0.95-2.28) or black individuals (aHR: 1.06; 0.82-1.37). Similar results were noted among 611 AASK participants (aHR: 0.99; 0.69-1.42).

CONCLUSIONS

The presence of depressive symptoms is a risk factor for all-cause mortality among patients with mild-moderate CKD, particularly among white individuals. Further studies are needed to understand the heterogeneity in the response to the presence of depressive symptoms by race.

Peer Navigator Intervention for Latinos on Hemodialysis: A Single-Arm Clinical Trial

Background: Latinos with end-stage renal disease (ESRD) have worse mental and kidney composite health-related quality of life (HRQOL) scores compared to non-Latino ESRD patients. Latino ESRD patients uniquely report that social factors (e.g., lack of care coordination, food insecurity, and low health literacy) and mental health influence their HRQOL. We developed a culturally tailored peer navigator (PN) intervention to improve the HRQOL of Latinos on hemodialysis. Objective: To determine the feasibility of the PN intervention. Design: Single-arm prospective study. The PN provided individualized support with advance care planning, care coordination, and counseling about the importance of diet and mental health. Setting and Participants: Latino with ESRD receiving scheduled outpatient thrice-weekly hemodialysis or reliant on emergency-only hemodialysis in Denver. Main measures: Recruitment, retention rates, data completeness, intervention dose, patient- and staff-reported satisfaction with the intervention. Results: Of 49 eligible patients, 40 (82%) agreed to participate. The majority of participants received scheduled outpatient hemodialysis (75%), 20 were women (50%), with a mean (standard deviation [SD]) age of 56 (13) years. No participants withdrew from the intervention. One participant died. The mean (SD) number of PN visits per participant was 7 (2) and the mean (SD) length of the visits was 97 minutes (49). The majority of visits took place at the hemodialysis facility (59%) and home (27%). The vast majority of participants reported that the PN improved their quality of life as a patient on hemodialysis (95%). Conclusions: The PN intervention achieved feasibility goals and was well received by participants.

Strategies to improve dietary, fluid, dialysis or medication adherence in patients with end stage kidney disease on dialysis: A systematic review and meta-analysis of randomized intervention trials

Background

In patients with end stage kidney disease (ESKD) on dialysis, treatment non-adherence is common and results in poor health outcomes. However, the clinical benefits of interventions to improve adherence in dialysis patients are difficult to evaluate since trialled interventions and reported outcomes are highly diverse/ heterogeneous. This review summarizes existing literature on randomized controlled trials (RCTs) evaluating adherence interventions in ESKD patients focusing on the intervention category, outcome efficacy and persistence of benefit beyond the intervention.

Methods

We performed electronic database searches in Medline, Embase & Cochrane CENTRAL upto 1^st July 2018 for RCTs evaluating interventions to improve diet, fluid, medication or dialysis adherence in ESKD patients. Study characteristics including category of interventions, outcomes, efficacy and follow-up were assessed. Meta-analysis was used to compute pooled estimates of the effects on the commonest reported outcome measures.

Results

From 1311 citations, we included 36 RCTs (13 cluster-randomized trials), recruiting a total of 3510 dialysis patients (mean age 55.1 ± 5.8 years, males 58.1%). Overall risk of bias was ‘high’ for 24 and of ‘some concern’ for 12 studies. Most interventions (33 trials, 92%) addressed patient related factors, and included educational/cognitive (N = 11), behavioural / counselling (N = 4), psychological/affective (N = 4) interventions or a combination (N = 14) of the above. A majority of (28/36) RCTs showed improvement in some reported outcomes. Surrogate measures like changes in phosphate (N = 19) and inter-dialytic weight gain (N = 15) were the most common reported outcomes and both showed significant improvement in the meta-analysis. Sixteen trials reported follow-up (1–12 months) beyond intervention and the benefits waned or were absent in nine trials within 12 months post-intervention.

Conclusions

Interventions to improve treatment adherence result in modest short-term benefits in surrogate outcome measures in dialysis patients, but significant improvements in trial design and outcome reporting are warranted to identify strategies that would achieve meaningful and sustainable clinical benefits.

Limitations

Poor methodological quality of trials. Frequent use of surrogate outcomes measures. Low certainly of evidence.

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.

Health-related quality of life in peritoneal dialysis patients: A narrative review

Health-related quality of life (HRQOL) is an important aspect of patients´ health that should be an integral part of the evaluation of patient-centered outcomes, not least because HRQOL associates with patients´ morbidity and mortality. This applies also to chronic kidney disease patients, including those dependent on renal replacement therapies, the type of which may influence patients´ perception of HRQOL. Several studies have addressed HRQOL in chronic kidney disease patients undergoing renal replacement therapies, especially transplanted patients and hemodialysis patients, while publications concerning peritoneal dialysis (PD) patients are scarcer. This review describes some of the methods used to assess HRQOL, factors influencing HRQOL in PD patients, HRQOL in PD vs hemodialysis, and the relation between HRQOL and patient outcomes. We conclude that assessment of HRQOL-often neglected at present-should be included as a standard measure of patient-centered outcomes and when monitoring the quality and effectiveness of renal care including PD treatment.

Is successful treatment of depression in dialysis patients an achievable goal?

Depression is undisputedly common among individuals with End-Stage Kidney Failure and associated with adverse outcomes. It is well recognized that effective treatments for depression are needed within routine dialysis care. But, are we any closer to successfully treating depression in dialysis patients? We consider this question here with respect to two common treatments, antidepressant medication and cognitive behavioural therapy (CBT). Currently, there are limited data from randomized placebo-controlled trials regarding the acceptability and efficacy of antidepressants. CBT trials appear to show more consistent treatment effects, albeit the feasibility of routine delivery remains unknown. No studies in dialysis patients has evaluated the combined effects of CBT with antidepressants. There is a need to consider pragmatic depression treatment trials in dialysis patients in order to increase study recruitment in order to have more reliable data from which to evaluate the evidence base. Furthermore, we need to understand why treatments work, and for whom do they work? Lastly, addressing issues surrounding treatment acceptability and implementation as part of regular care remain as key challenges that require attention if we are to improve the mental health of individuals on dialysis.

Fostering Innovation in Symptom Management among Hemodialysis Patients: Paths Forward for Insomnia, Muscle Cramps, and Fatigue

Individuals receiving in-center maintenance hemodialysis bear a high burden of both physical and mood symptoms. More than half of patients on hemodialysis report sleep disturbance, muscle cramps, and fatigue. Patients describe symptoms as having a deleterious effect on their quality of life, suggesting that symptom alleviation may meaningfully improve patient-reported outcomes. Moreover, patients on hemodialysis have identified symptom management as a key area for research and innovation, prioritizing symptom alleviation over other health outcomes such as mortality and biochemical indices. Despite the importance of symptoms to patients, there has been little research explicitly geared toward improving patient symptoms, and therefore minimal innovation in symptom management. In general, the physiologic underpinnings of symptoms are poorly understood, hampering the development of targeted therapies. In fact, there have been few drugs or devices approved by the US Food and Drug Administration for the indication of improving any patient-reported outcomes for patients on hemodialysis. Recognizing this gap in innovation, the Kidney Health Initiative, a public-private partnership between the American Society of Nephrology and US Food and Drug Administration, convened a workgroup to first prioritize symptoms for the development of therapeutic interventions, and then identify near-term actionable research goals for the prioritized physical symptoms of insomnia, muscle cramps, and fatigue. This paper summarizes the pathophysiology of the three prioritized symptoms, identifies key knowledge gaps, acknowledges factors that challenge development of new therapies, and offers the nephrology community actionable research goals for insomnia, muscle cramps, and fatigue.

The effect of brief self-management intervention for hemodialysis patients (HED-SMART) on trajectories of depressive and anxious symptoms

OBJECTIVE

Depression is often comorbid with End-Stage Renal Disease, and associated with poor adherence and clinical outcomes but course of symptoms is variable. This study sought to describe the long-term trajectories of anxiety and depression in hemodialysis patients, to identify predictors of these trajectories over 12 months and to evaluate the effectiveness of the HEmoDialysis Self-Management Randomized Trial (HED SMART) against usual care on symptoms of anxiety and depression.

METHODS

A secondary analysis of data from a randomized controlled trial that contrasted HED SMART (n = 101) against usual care (n = 134). Depressive and anxious symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS) at baseline, 1 week and at 3 and 9 months post-intervention. Latent class growth analysis identified trajectories of depression and anxiety, and their sociodemographic and clinical predictors.

RESULTS

Symptoms of depression and anxiety over 12 months were characterized by two trajectories: low stable (depression: 55%; anxiety: 59%) with non-clinical levels of distress, and high stable (depression: 45%; anxiety: 41%) with clinical levels of distress. HED SMART predicted significant reductions in depression relative to usual care. A similar trend was noted for anxiety. Younger age, Chinese ethnicity, and more comorbidities were associated with persistent high depression. Younger age and shorter dialysis vintage was associated with persistent high anxiety.

CONCLUSION

A brief self-management intervention designed to support behavioral change can also lead to significant reductions in symptoms of depression and may be of great value for younger HD patients shown to be at greater risk for persistent distress.

TRIAL REGISTRATION

ISRTN31434033.

A protocol for a pilot randomized controlled trial to assess the feasibility and effect of a cognitive behavioral intervention on quality of life for patients on hemodialysis

INTRODUCTION

Poor health-related quality of life (HrQOL) is highly prevalent in patients on hemodialysis (HD), and is associated with increased hospitalizations and mortality. Cognitive behavioral (CB) techniques have improved HrQOL in HD patients but have not been routinely translated into clinical practice. The investigators present the rationale, study design and protocol of a randomized controlled trial to pilot the feasibility and effect of a translatable, behavioral-education intervention using CB techniques to improve poor HrQOL and self-management in hemodialysis patients.

METHODS

Forty-eight HD patients will be randomly assigned to either the study intervention which includes 8-12 behavioral-education sessions with incorporated CB techniques delivered over 12 weeks or a control group of dialysis education without incorporated CB techniques. Subjects will be followed for 16 weeks and the primary outcome, change in kidney disease quality of life (KDQOL)-36 scores, will be measured at 0, 8, and 16 weeks. The study will have 85% power to detect an 8-point change in KDQOL-36 scores. At the end of the study, qualitative data will be gathered through end-of-study focus groups, and semi-structured interviews. These data will be used to refine the intervention and help translate it into clinical practice.

DISCUSSION

There is promising evidence in support of CB-based interventions to improve HrQOL for patients on HD. Despite this, these interventions have not been routinely incorporated into clinical practice. The proposed intervention has the potential to improve both HrQOL and self-management, while also being easily translatable to other HD units.

Rationale and design of technology assisted stepped collaborative care intervention to improve patient-centered outcomes in hemodialysis patients (TĀCcare trial)

Most hemodialysis (HD) patients experience symptoms of depression, pain and fatigue that impair their health-related quality of life (HRQOL) significantly. These symptoms are associated with increased hospitalization and mortality, mediated by behavioral factors (e.g. non-adherence to medication and dialysis) and biological factors (e.g. inflammatory cytokines). Prior interventions to alleviate symptoms and improve HRQOL showed limited effectiveness in HD patients and their effect on bio-behavioral mediators is lacking evidence. It is imperative to improve patient-centered dialysis care and to address call from Kidney Disease Improving Global Outcomes (KDIGO) guidelines for integration of symptom assessment and management in routine HD-care. Technology-Assisted stepped Collaborative Care (TĀCcare) is a multi-center randomized controlled trial (RCT) of 150 diverse HD patients from Pennsylvania and New Mexico, designed to compare the effectiveness of a 12-week stepped collaborative care intervention (cognitive behavioral therapy, CBT) with an attention control arm of technology-delivered health education. Collaborative care provides an integrated multi-disciplinary structured management plan. Furthermore, a stepped approach to pharmacotherapy and/or CBT allows for individualization of treatment according to patients' clinical status, preferences and treatment response. To simplify the delivery of CBT and to minimize patient and provider burden, we will use live video-conferencing with patients in dialysis units. We will examine the effect of these interventions on patient symptoms, HRQOL, treatment adherence and inflammatory biomarkers. This RCT tests a readily implementable intervention that can be integrated in routine HD-care and will generate novel and meaningful insights on strategies to alleviate common symptoms and improve HRQOL in HD.

Comparison of Incidence and Risk of Depression in Recipients of Renal Transplantation and Patients Undergoing Hemodialysis in China

AIM

To investigate depressive symptoms in recipients of renal transplantation (RTx) compared with patients undergoing hemodialysis (HD) in China.

METHODS

Forty-two Chinese recipients of transplant and 42 Chinese patients on hemodialysis were randomly selected from 2011 to 2012. These 2 groups were assessed with the validated Chinese versions of Hospital Anxiety Depression Scales and Structured Clinical Interview for the Diagnostic and Statistical Manual, fourth edition-after matching by sex, age, marital status, educational background, and somatic comorbidities-for investigation of the relationships of depressive symptoms with sex and family income.

RESULTS

Irritability was common among both groups, but no significant difference was found. Patients undergoing RTx were less likely than patients of HD to report depressive mood (26.1% vs 38.1%; P < .05), diminished interest or pleasure (14.3% vs 31.0%; P < .05), and suicidal ideation including recurrent thoughts of death (33.3% vs 54.8%; P < .05).

CONCLUSIONS

Among Chinese patients with end-stage renal disease, improved renal health after RTx reduced the incidence and risk of depression compared with HD. The effective profiling of patients with end-stage renal disease, treated with both RTx and HD, should be more extensive, including examination of all facets of their mental and emotional well-being, to accurately screen for depression.

Opioid Prescription, Morbidity, and Mortality in US Transplant Recipients

BACKGROUND

Centers for Disease Control and Prevention guidelines recommend caution in prescribing opioids for chronic pain. The characteristics of opioid prescription (OpRx) among kidney transplant (KTx) recipients have not been described in a national population.

METHODS

We assessed OpRx prevalence among prevalent KTx recipients, and associated duration (long-term, defined as ≥90 days in a year) and dosing (in morphine milligram equivalents per day of <50, 50-89, and ≥90) with outcomes, death and graft loss, among incident KTx recipients using 2006-2010 US Renal Data System files, including Medicare Part D for medication ascertainment. Cox models controlled for recipient factors.

RESULTS

Of 36,486 KTx recipients in the 2010 prevalent cohort, approximately 14.6% had long-term OpRx. The strongest association with long-term OpRx after KTx was long-term OpRx before KTx (64%; adjusted odds ratio, 95% confidence interval, 95.2, 74.2-122.1). Incident KTx recipients with long-term OpRx had increased risk of mortality and graft loss compared with those without OpRx or short-term OpRx after KTx. This risk was highest among recipients with long-term OpRx doses of ≥90 morphine milligram equivalents or higher per day (adjusted hazard ratio, 95% confidence interval, 1.61, 1.24-2.10 for death, and 1.33, 1.05-1.67 for graft loss, respectively).

CONCLUSIONS

In contrast to either no or short-term OpRx, long-term, and especially long-term high-dose OpRx, is associated with increased risk of death and graft loss in US KTx recipients. Causal relationships cannot be inferred, and OpRx may be an illness marker. Nevertheless, efforts to treat pain effectively in KTx recipients with less toxic interventions and decrease OpRx deserve consideration.

The Effectiveness of Cognitive Behavioral Therapy versus Psychoeducation in the Management of Depression among Patients Undergoing Haemodialysis

The aim of this randomized controlled trial was to compare the effectiveness of psychoeducation versus cognitive behavioral therapy (CBT) in the management of depression among renal dialysis patients. A sample of 130 dialysis patients participated in the study and they were assigned at random to one of two therapies: psychoeducation (N = 65) or CBT (N = 65). Hamilton depression rating scale was completed by the participants in both groups prior to the therapies and after completion. Both therapies were effective in the management of depression, although psychoeducation was superior. Psychoeducation is recommended over CBT in the management of depression among renal dialysis patients.

Exploring the relationship between illness perceptions and depression in patients with chronic kidney disease: A systematic literature review

BACKGROUND

The prevalence of depression is found to increase from early stages to later stages of chronic kidney disease. Research on illness perceptions in patients undergoing dialysis has confirmed that patients' beliefs are associated with important outcomes; one of the most significant being depression. However, the association between illness perceptions and depression in patients in pre-dialysis care remains unclear.

OBJECTIVE

The main objective of this systematic review was to explore the associative relationship between illness perceptions and depression in patients with CKD prior to the commencement of dialysis.

METHODS

The inclusion criteria for papers in this review were studies investigating illness perceptions and depression in patients diagnosed with CKD. Eligible studies were identified by searching the following electronic databases; Medline, CENTRAL, Embase, Psych INFO, Web of Science and Scopus. Data on the participants and the severity of kidney disease, illness perceptions and depression were extracted.

RESULTS

Sixty-four studies met the criteria for full text review and of these, only four studies met the inclusion criteria following data extraction and quality assessment. Consistent with the common sense model, disease severity was found to be significantly associated with illness perceptions, and both were found to be associated with depression CONCLUSIONS: The results from this review provide further evidence that the illness perceptions and disease severity play a crucial role in the adaption to CKD. This review highlights the lack of research in this area and concludes that more studies are needed to determine the nature and impact of illness perceptions in relation to depression in pre-dialysis CKD.

Effectiveness of group cognitive behavioral therapy with mindfulness in end-stage renal disease hemodialysis patients

Background

Many patients with end-stage renal disease (ESRD) undergoing hemodialysis (HD) experience depression. Depression influences patient quality of life (QOL), dialysis compliance, and medical comorbidity. We developed and applied a group cognitive behavioral therapy (CBT) program including mindfulness meditation for ESRD patients undergoing HD, and measured changes in QOL, mood, anxiety, perceived stress, and biochemical markers.

Methods

We conducted group CBT over a 12-week period with seven ESRD patients undergoing HD and suffering from depression. QOL, mood, anxiety, and perceived stress were measured at baseline and at weeks 8 and 12 using the World Health Organization Quality of Life scale, abbreviated version (WHOQOL-BREF), the Beck Depression Inventory II (BDI-II), the Hamilton Rating Scale for Depression (HAM-D), the Beck Anxiety Inventory (BAI), and the Perceived Stress Scale (PSS). Biochemical markers were measured at baseline and after 12 weeks. The Temperament and Character Inventory was performed to assess patient characteristics before starting group CBT.

Results

The seven patients showed significant improvement in QOL, mood, anxiety, and perceived stress after 12 weeks of group CBT. WHOQOL-BREF and the self-rating scales, BDI-II and BAI, showed continuous improvement across the 12-week period. HAM-D scores showed significant improvement by week 8; PSS showed significant improvement after week 8. Serum creatinine levels also improved significantly following the 12 week period.

Conclusion

In this pilot study, a CBT program which included mindfulness meditation enhanced overall mental health and biochemical marker levels in ESRD patients undergoing HD.

Palliative Care Disincentives in CKD: Changing Policy to Improve CKD Care

The dominant health delivery model for advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the United States, which focuses on provision of dialysis, is ill-equipped to address many of the needs of seriously ill patients. Although palliative care may address some of these gaps in care, its integration into advanced CKD care has been suboptimal due to several health system barriers. These barriers include uneven access to specialty palliative care services, underdeveloped models of care for seriously ill patients with advanced CKD, and misaligned policy incentives. This article reviews policies that affect the delivery of palliative care for this population, discusses reforms that could address disincentives to palliative care, identifies quality measurement issues for palliative care for individuals with advanced CKD and ESRD, and considers potential pitfalls in the implementation of new models of integrated palliative care. Reforming health care delivery in ways that remove policy disincentives to palliative care for patients with advanced CKD and ESRD will fill a critical gap in care.