Promoting functioning and well-being in older CKD patients: review of recent evidence

Frailty as a dynamic process in a diverse cohort of older persons with dialysis-dependent CKD

This study examines frailty status evolution observed in a two-year follow-up of a cohort of older persons (age ≥65) with chronic kidney disease (CKD) undergoing maintenance hemodialysis (HD) treatment. Frailty, a geriatric syndrome that connotes a state of low physiologic reserve and vulnerability to stressors, is associated with increased risk for multiple adverse health outcomes in studies of persons with CKD as well as older persons in the general population. The Fried frailty index defines frailty as the presence of 3 or more of 5 indicators-recent unintentional weight loss, slowed gait speed, decreased muscle strength, self-reported exhaustion, and low physical activity. In the seminal work by Fried and colleagues, persons who were characterized by 1-2 of the Fried index criteria were termed "pre-frail" and considered at risk for subsequently becoming frail, potentially providing insight regarding intervention targets that might slow or prevent individuals' transition from pre-frail to frail status. Other less frequently studied types of transitions may also be informative, including "recovery or reversion" (improvement) by people whose longitudinal assessments indicate movement from frailty to prefrailty or robust, or from prefrailty to robust. These status changes are also a potential source of insights relevant for prevention or remediation of frailty, but research focusing on the various ways that individuals may transition between frailty states over time remains limited, and no previous research has examined varying patterns of frailty status evolution in an older cohort of persons with dialysis-dependent CKD. In a study cohort of dialysis-dependent older persons, we characterized patterns of frailty status evolution by age, sex, race/ethnicity, and treatment vintage; by longitudinal profiles of non-sedentary behavior; and by self-report indicators relevant for dimensions emphasized in the Age-Friendly 4Ms Health System (What Matters, Mobility, Mentation). Our study suggests that strategies to promote resiliency among older persons with dialysis-dependent CKD can be informed not only by frailty status transition that indicates improvement over time but also by older adults' maintenance of (stable) robust status over time, and we concur that inclusion of both frailty and resilience measures is needed in future longitudinal studies and clinical trials.

Cognition in chronic kidney disease patients: Evaluation with the Beijing version of the Montreal Cognitive Assessment

Patients with chronic kidney disease (CKD) may undergo cognitive impairment. We aimed to explore the cognition of patients with cognitive impairment (CI) and no cognitive impairment (NCI) respectively and the effect of demographics, estimated glomerular filtration rate (eGFR), number of comorbidities (NCD), and hemoglobin on CI in Chinese patients with CKD at stage 3-5 treated by nondialysis by using the Beijing version of the Montreal Cognitive Assessment (MoCA-BJ). A total of 120 patients with CKD were recruited from the Department of Nephrology at the Affiliated Hospital of Nanjing University of Chinese Medicine at in-patient and out-patient follow up. A logistic regression model was performed to assess the effect of these variables on CI of CKD patients. The results indicated that the CI group was mainly in the decline of visuospatial and executive function, abstraction, and memory, compared with the NCI group. In addition, years of education, eGFR and NCD were found as predictors of CI of CKD patients at stage 3-5. Specifically, lower eGFR, less years of education and more comorbidities were risk predictors of CI.

Health related quality of life in chronic kidney disease; a descriptive study in a rural Sri Lankan community affected by chronic kidney disease

INTRODUCTION

The current epidemic of chronic kidney disease (CKD) in Sri Lanka is ascribed to the exponential increase in the number of CKD patients, which cannot be attributed to any known etiology (CKDu). The aim of this study is to describe the health related quality of life (HRQOL) and the associated factors among CKD/CKDu patients in a rural district in Sri Lanka.

METHODS

A community based cross-sectional study included 1174 CKD/CKDu patients. Kidney Disease Quality of Life-Short Form was used to assess the HRQOL, while Centre for Epidemiologic Studies Depression Scale, General Health Questionnaire (GHQ) 12 and CKD Symptom Index - Sri Lanka were used to assess presence of depression, psychological distress and symptom burden respectively. Three summary scores; kidney disease (KDSC), physical (PCS) and mental (MCS) are derived from Kidney Disease Quality of Life-Short Form (KDQOL-SF™).

RESULTS

Mean age of the study population was 58.3 years (standard deviation (SD) 10.7). Median KDSC (58.4; inter-quartile range (IQR) 54.2-63.4), was higher than the median scores of PCS (35.0; IQR 26.2-41.9) and MCS (58.4; IQR 54.2-63.4). Multiple linear regression revealed low income, advanced stages of CKD, symptom burden, being positive for depression and psychological distress were significantly associated with low HRQOL.

CONCLUSION

The HRQOL of the CKD patients in this rural Sri Lankan population was found to be poor. Superior socio-economic status, less physical and psychological symptom burden were found to be independently associated with better HRQOL. Periodical screening of the CKD patients for depression and psychological distress and measures to alleviate symptom burden seem to be important to improve the HRQOL of these patients.

End-Stage Kidney Disease in the Elderly: Approach to Dialysis Initiation, Choosing Modality, and Predicting Outcomes

The number of patients with end-stage kidney disease 65 years and older is growing, and this growth is expected to continue. The presence of medical comorbidities, limited life expectancy, frailty, and poor functional status in these patients poses substantial challenges in clinical decision-making and provision of optimal care. Frailty is more common in elderly patients with CKD than without and is associated with poor outcomes. Several prognostic tools were developed to estimate the rate of CKD progression among elderly, and risk of mortality after dialysis initiation. Risk factors for CKD progression among elderly include low estimated glomerular filtration rate, high baseline proteinuria, acute kidney injury, low serum albumin, and presence of congestive heart failure. The decision to initiate dialysis in the elderly should take into consideration life expectancy, risks and benefits of each dialysis modality, quality of life, and patient and caregiver preferences. This article discusses common issues in the elderly with end-stage kidney disease, with particular emphasis on the impact of frailty and functional status, choice of dialysis modality and vascular access, and prognosis after dialysis initiation, to assist the nephrologist in making decisions regarding optimal care for this complex group of patients.

Relationship between symptom clusters and quality of life in patients at stages 2 to 4 chronic kidney disease in Korea

PURPOSE

This study was conducted to identify the relationship between symptom clusters and quality of life (QOL) in patients with stages 2 to 4 chronic kidney disease (CKD) in Korea.

METHODS

Using self-reported questionnaires, data were collected from 143 patients who underwent treatment for CKD at one hospital in Korea. The 17-item Patient Outcome Scale was used to measure symptoms, and the 36-item Short Form Health Survey Instrument Version 2 (SF-36v2) was used to measure the QOL. Data were analyzed using factor analysis to draw symptom clusters.

RESULTS

Among five symptom clusters, the energy insufficiency and pain cluster was found to have the highest prevalence and greatest severity. The severity of symptom clusters showed negative correlations with both physical and mental component summary (PCS and MCS) scores. Elderly patients scored low on PCS, whereas younger patients in their 30s and 40s scored low on MCS. Negative correlations were found between symptom clusters and PCS as well as MCS. The severity of symptoms and QOL had stronger relationships with subjective perception of symptoms and psychological factors than with objective clinical indicators.

CONCLUSION

As the effects of physical and psychological symptoms on the QOL in patients with stages 2 to 4 CKD were identified in this study, nurses should develop strategic nursing plans focused on symptom clusters and patients' subjective perception of symptoms rather than objective clinical indicators in order to improve the QOL in patients with CKD.

Dialysis therapies in older patients with end-stage renal disease

Each year a large number of older individuals with advanced renal disease are started on chronic dialysis therapy. Life expectancy is estimated at between 2 and 4 years depending on age, comorbidity, and intensity of medical care required in the weeks around the dialysis start time. Survivors remain at high risk of ongoing morbidity. Regarding quality of life, many older patients express regret over having opted for chronic dialysis therapy and subsequently choose to withdraw from treatment, whereas many others maintain a quality of life similar to that of age-matched peers. Early assessment and ongoing comprehensive geriatric assessment is recommended.

The perception of sleep quality in kidney transplant patients during the first year of transplantation

OBJECTIVE

Poor sleep quality is one of the factors that adversely affects patient quality of life after kidney transplantation, and sleep disorders represent a significant cardiovascular risk factor. The objective of this study was to investigate the prevalence of changes in sleep quality and their outcomes in kidney transplant recipients and analyze the variables affecting sleep quality in the first years after renal transplantation.

METHODS

Kidney transplant recipients were evaluated at two time points after a successful transplantation: between three and six months (Phase 1) and between 12 and 15 months (Phase 2). The following tools were used for assessment: the Pittsburgh Sleep Quality Index; the quality of life questionnaire Short-Form-36; the Hospital Anxiety and Depression scale; the Karnofsky scale; and assessments of social and demographic data. The prevalence of poor sleep was 36.7% in Phase 1 and 38.3% in Phase 2 of the study.

RESULTS

There were no significant differences between patients with and without changes in sleep quality between the two phases. We found no changes in sleep patterns throughout the study. Both the physical and mental health scores worsened from Phase 1 to Phase 2.

CONCLUSION

Sleep quality in kidney transplant recipients did not change during the first year after a successful renal transplantation.

Factors associated with health-related quality of life in elderly patients on hemodialysis

OBJECTIVE

To identify factors associated with health-related quality of life in elderly patients on hemodialysis.

METHODS

Cross-sectional study including 223 patients aged > 60 years on hemodialysis conducted in dialysis centers in the city of Belo Horizonte, southeastern Brazil, in 2008. Health-related quality of life was measured with the Kidney Disease Quality of Life Short Form (KDQOL-SF) and the Medical Outcomes Study 36-Item Short-Form Health Survey (MOS SF-36). The three KDQOL-SF component scores measured were: kidney disease component summary (11 subscales), physical component summary (four subscales) and mental component summary (four subscales).

RESULTS

Significant independent negative associations were found between the kidney disease and mental components and number of chronic diseases and treatment duration. A lower physical component was seen among women, those with more advanced age, more hospital admissions, and three or more chronic diseases.

CONCLUSIONS

The finding that health-related quality of life was consistently associated with chronic diseases points to the importance of the morbidity profile in elderly patients on hemodialysis. The associated factors identified including advanced age, female gender, number of hospital admissions and treatment duration can provide input for planning health actions that can more adequately meet this populations' needs.

Renal replacement therapy in the elderly population

ESRD has become an important problem for elderly patients. The segment of the ESRD population age 65 years or older has grown considerably, and this growth is expected to accelerate in coming years. Nephrologists caring for the elderly with advanced kidney disease will encounter patients with comorbid conditions common in younger patients, as well as physical, psychological, and social challenges that occur with increased frequency in the aging population. These challenging factors must be addressed to help inform decisions regarding the option to initiate dialysis, the choice of dialysis modality, whether to pursue kidney transplantation, and end-of-life care. This article will highlight some common problems encountered by elderly patients with ESRD and review data on the clinical outcomes of elderly patients treated with different modalities of dialysis, outcomes of kidney transplantation in the elderly, and nondialytic management of CKD stage 5.

A practical approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease

Depression is a common, under-recognized, and under-treated problem that is independently associated with increased morbidity and mortality in CKD patients. However, only a minority of CKD patients with depression are treated with antidepressant medications or nonpharmacologic therapy. Reasons for low treatment rates include a lack of properly controlled trials that support or refute efficacy and safety of various treatment regimens in CKD patients. The aim of this manuscript is to provide a comprehensive review of studies exploring depression treatment options in CKD. Observational studies as well as small trials suggest that certain serotonin-selective reuptake inhibitors may be safe to use in patients with advanced CKD and ESRD. These studies were limited by small sample sizes, lack of placebo control, and lack of formal assessment for depression diagnosis. Nonpharmacologic treatments were explored in selected ESRD samples. The most promising data were reported for frequent hemodialysis and cognitive behavioral therapy. Alternative proposed therapies include exercise training regimens, treatment of anxiety, and music therapy. Given the association of depression with cardiovascular events and mortality, and the excessive rates of cardiovascular death in CKD, it becomes imperative to not only investigate whether treatment of depression is efficacious, but also whether it would result in a reduction in morbidity and mortality in this patient population.

Depressive symptoms and chronic kidney disease: results from the National Health and Nutrition Examination Survey (NHANES) 2005-2006

BACKGROUND AND OBJECTIVE

Depression is common in individuals with end-stage renal disease. However, its relationship with earlier stages of chronic kidney disease (CKD) is less well known. In this study, we examined the association between depressive symptoms and CKD.

METHODS

Cross-sectional analysis of the prevalence and correlates of depressive symptoms were measured by the Patient Health Questionnaire (PHQ-9) among adult participants with CKD in the National Health and Nutrition Examination Survey 2005-2006. CKD was defined according to estimated glomerular filtration rate by Modification of Diet in Renal Disease Study equation of <60 ml/min/1.73 m(2) or the presence of microalbuminuria (≥ 30 mg/g creatinine), using the Kidney Disease Outcomes Quality Initiative classification. A PHQ-9 score ≥ 10 was considered to be indicative of depressive symptoms.

RESULTS

Among 3653 subjects in our study sample, 683 (15.2%) met laboratory criteria for CKD. The prevalence of depressive symptoms was 7% (95% confidence interval [CI] 3.2-10.8%) in subjects with CKD and 6% (95% CI 4.6-7.4%) in subjects without CKD (P = 0.6). In regression analysis, the presence of CKD was not significantly associated with depressive symptoms (adjusted odds ratio = 0.96 [95% CI 0.51, 1.78], P = 0.9).

CONCLUSIONS

We found no difference in the prevalence of depressive symptoms among individuals with or without CKD.

Health-related quality of life outcomes in chronic kidney disease

PURPOSE OF REVIEW

Patients with chronic kidney disease (CKD) endure compromised health-related quality of life (HRQOL). Although the link between HRQOL and increased mortality in patients with end-stage renal disease (ESRD) is well documented, less is known about the relationship between CKD and HRQOL. This article reviews the recent evidence on HRQOL, its correlates and proposed intervention strategies to improve HRQOL in CKD.

RECENT FINDINGS

A growing body of literature indicates that various comorbid conditions related to CKD play a substantial role in impaired HRQOL in CKD. Hypertension, both a cause and complication of CKD, negatively affects HRQOL due to associated comorbidities, side effects from antihypertensive medications and awareness of the diagnosis. Anemia has been associated with HRQOL, but concerns about the safety of erythropoietin-stimulating agents (ESAs) have led to more conservative anemia treatment. Frailty, symptom burden and depression are also major contributory factors to HRQOL in CKD.

SUMMARY

Certain determinants of HRQOL in CKD, namely anemia and depression, are treatable. Early identification and correction may improve overall well being of patients. Clinical trials are required to demonstrate whether treatment interventions benefit HRQOL in this high-risk population. Furthermore, whether integration of HRQOL assessment into routine clinical practice will improve HRQOL outcomes remains to be determined.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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