Anxiety Presentations and Treatments in Populations With Kidney Disease

Examining the acceptability and feasibility of the Compassionate Mindful Resilience (CMR) programme in adults living with chronic kidney disease: the COSMIC study findings

BACKGROUND

Individuals with chronic kidney disease experience difficult physical and psychological symptoms, that impact quality of life, and are at increased risk of anxiety and depression. Access to specialist psychological support is limited. This study aimed to support a new service development project, in collaboration with Kidney Care UK, to implement the Compassionate Mindful Resilience (CMR) programme, developed by MindfulnessUK, which provides accessible mindfulness techniques and practices to enhance compassion and resilience, and explore its feasibility for people living with stage 4 or 5 kidney disease and transplant.

METHODS

A multi-method feasibility design was utilised. Participants over 18 years, from the UK, with stage 4 or 5 kidney disease or post-transplant, and who were not currently undergoing psychotherapy, were recruited to the four-week CMR programme. Data was collected at baseline, post-intervention and three-months post to measure anxiety, depression, self-compassion, mental wellbeing, resilience, and mindfulness. The acceptability of the intervention for a kidney disease population was explored through qualitative interviews with participants, and the Mindfulness Teacher.

RESULTS

In total, 75 participants were recruited to the study, with 65 completing the CMR programme. The majority were female (66.2%) and post-transplant (63.1%). Analysis of completed outcome measures at baseline and post-intervention timepoints (n = 61), and three-months post intervention (n = 45) revealed significant improvements in participant's levels of anxiety (p < .001) and depression (p < .001), self-compassion (p = .005), mental wellbeing (p < .001), resilience (p.001), and mindfulness (p < .001). Thematic analysis of interviews with participants (n = 19) and Mindfulness Teacher (n = 1) generated three themes (and nine-subthemes); experiences of the CMR programme that facilitated subjective benefit, participants lived and shared experiences, and practicalities of programme participation. All participants interviewed reported that they found programme participation to be beneficial.

CONCLUSION

The findings suggest that the CMR programme has the potential to improve psychological outcomes among people with chronic kidney disease. Future randomized controlled trials are required to further test its effectiveness.

Experiences of People with Kidney Disease Following the Implementation of the Compassionate Mindful Resilience Programme: Qualitative Findings from the COSMIC Study

BACKGROUND

Kidney disease is a progressive, debilitating condition. Patients experience challenging physical and psychological symptoms and are at increased risk of anxiety, depression, and poor mental wellbeing. Access to specialist psychological or social support is limited, with inadequate provision of psychosocial support available across UK renal units. The COSMIC study (examining the acceptability and feasibility of the Compassionate Mindful Resilience programme for adult patients with chronic kidney disease) aimed to support a new service development project, in partnership with Kidney Care UK, by implementing the Compassionate Mindful Resilience (CMR) programme, developed by MindfulnessUK, and explore its feasibility for patients with stage 4 or 5 kidney disease and kidney transplant recipients. This paper reports on the qualitative exploratory work which examined the experiences of study participants, their adherence to practice, and the acceptability of the intervention.

METHOD

Participants (n = 19) took part in semi-structured interviews, which were transcribed, coded, and thematically analysed.

RESULTS

Three themes (and nine subthemes) were reported: experiences of the CMR programme that facilitated subjective benefit, participants' lived and shared experiences, and the practicalities of CMR programme participation. All participants reported that they found taking part in the CMR programme to be a beneficial experience.

CONCLUSION

The CMR programme was found to be an acceptable intervention for people living with kidney disease and provided tools and techniques that support the mental health and wellbeing of this patient group. Further qualitative exploration into participant experience should be integrated within future trials of this intervention.

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

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

Comparison of quality of life in patients with advanced chronic kidney disease undergoing haemodialysis, peritoneal dialysis and conservative management in Johannesburg, South Africa: a cross-sectional, descriptive study

INTRODUCTION

Mental health and quality of life are under-appreciated clinical targets which affect patient and modality survival. Lack of dialysis availability in the resource-constrained public health sector in South Africa results in assignment to treatment modalities without regard to effects on these parameters. We assessed the effect of dialysis modality, demographic and laboratory parameters on mental health and quality of life measurements.

METHODS

Size-matched cohorts were recruited from patients on haemodialysis (HD), peritoneal dialysis (PD), and patients on conservative management (CM) between September 2020 and March 2021. Responses to the Hospital Anxiety and Depression Scale (HADS) and Kidney Disease Quality of Life Short Form 36 (KDQOL-SF36) questionnaires and demographic and baseline laboratory parameters were compared between modalities. Multivariate linear regression was used to evaluate independent effect of baseline characteristics on HADS and KDQOL-SF36 scores between treatment groups where significant difference was observed.

RESULTS

Anxiety, depression, and reduced KDQOL measures were widespread amongst respondents. Dialyzed patients reported higher anxiety and depression scores than those on CM (p = 0.040 and p = 0.028). Physical composite (PCS), role-physical (RP), vitality (VS), and emotional well-being (EWB) KDQOL-SF36 scores were poorer in dialyzed patients (p < 0.001 for all). PCS (p = 0.005), pain (p = 0.030), vitality (p = 0.005), and social functioning KDQOL scores were poorer in PD compared to HD; HADS anxiety (p < 0.001) and KDQOL-SF36 EWB scores (p < 0.001) were better in PD. PD patients were more likely to be employed (p = 0.008). Increasing haemoglobin concentration reduced anxiety (p < 0.001) and depression scores (p = 0.004), and improved PCS (p < 0.001), and pain scores (p < 0.001). Higher serum albumin improved PCS (p < 0.001) and vitality (p < 0.001) scores.

CONCLUSION

Advanced chronic kidney disease increases anxiety and depression and limits quality of life. PD improves mental health and emotional wellbeing and preserves the ability to undertake economic activity but limits social functioning and causes greater physical discomfort. Targeting haemoglobin may ameliorate modality effects on mental health and quality of life.

How Are Albertans "Adjusting to and Coping With" Dialysis? A Cross-Sectional Survey

Background:

Depression and anxiety are commonly reported (40% and 11%-52%) among adults receiving dialysis, compared with ~10% among all Canadians. Mental health in dialysis care is underrecognized and undertreated.

Objective:

(1) To describe preferences for mental health support reported by Albertans receiving dialysis; (2) to compare depression, anxiety, and quality-of-life (QOL) domains for people who would or would not engage in support for mental health; and (3) to explore sociodemographic, mental health, and QOL domains that explain whether people would or would not engage in support for mental health.

Design:

A cross-sectional survey.

Setting:

Alberta, Canada.

Patients:

Adults receiving all modalities of dialysis (N = 2972).

Measurements:

An online survey with questions about preferences for mental health support and patient-reported outcome measures (Patient Health Questionnaire–9 [PHQ-9], Generalized Anxiety Disorder–7 [GAD-7], and Kidney Disease QOL Instrument–36 [KDQOL-36]).

Methods:

To address objectives 1 and 2, we conducted chi-square tests (for discrete variables) and t tests (for continuous variables) to compare the distributions of the above measures for two groups: Albertans receiving dialysis who would engage or would not engage in support for mental health. We subsequently conducted a series of binary logistic regressions guided by the purposeful variable selection approach to identify a subset of the most relevant explanatory variables for determining whether or not people are more likely to engage in support for mental health (objective 3). To further explain differences between the two groups, we analyzed open-text comments following a summative content analysis approach.

Results:

Among 384 respondents, 72 did not provide a dialysis modality or answer the PHQ-9. The final data set included responses from 312 participants. Of these, 59.6% would consider engaging in support, including discussing medication with a family doctor (72.1%) or nephrologist (62.9%), peer support groups (64.9%), and talk therapy (60%). Phone was slightly favored (73%) over in person at dialysis (67.6%), outpatient (67.2%), or video (59.4%). Moderate to severe depressive symptoms (PHQ-9 score ≥10) was reported by 33.4%, and most respondents (63.9%) reported minimal anxiety symptoms; 36.1% reported mild to severe anxiety symptoms (GAD-7 score ≥5). The mean (SD) PHQ-9 score was 8.9 (6.4) for those who would engage in support, and lower at 5.8 (4.8) for those who would not. The mean (SD) GAD-7 score was 5.2 (5.6) for those who would engage in support and 2.8 (4.1) for those who would not. In the final logistic regression model, people who were unable to work had 2 times the odds of engaging in support than people who are able to work. People were also more likely to engage in support if they had been on dialysis for fewer years and had lower (worse) mental health scores (odds ratios = 1.06 and 1.38, respectively). The final model explained 15.5% (Nagelkerke R²) of the variance and with 66.6% correct classification. We analyzed 146 comments in response to the question, “Is there anything else you like to tell us.” The top 2 categories for both groups were QOL and impact of dialysis environment. The third category differed: those who would engage wrote about support, whereas those who would not engage wrote about “dialysis is the least of my worries.”

Limitations:

A low response rate of 12.9% limits representativeness; people who chose not to participate may have different experiences of mental health.

Conclusions:

Incorporating patients’ preferences and willingness to engage in support for mental health will inform future visioning for person-centered mental health care in dialysis.