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Abstract
As chronic renal failure (CRF) worsens, the nutritional balance is disrupt ed at several different levels that are normally responsible for maintaining metabolic homeostasis (1–3). These abnormalities may remain constant, improve, or worsen once dialysis is initiated. The success of dialytic intervention in correcting these abnormalities depends not only on the actual dose of delivered therapy, but also on the availability of nutrient substrate and the ease of modulating body composition. In the general population body composition has long been used as a predictor for mortality (4). Several different approaches have been taken to identify individuals at risk for a poor outcome (5). These techniques may examine specific serological parameters or actual components of body composition thought to more precisely depict nutritional balance. Historically, many reports have stressed the link between serum albumin levels and patient survival for both hemodialysis and peritoneal dialysis (6–11). However, some authors have questioned the usefulness of this marker (12–14). Based on these concerns, defining nutritional status through body composition measurements may offer a more meaningful assessment than standard serological parameters. Furthermore, in the setting of uremia the ability to successfully modulate body composition may denote the essence of what aptimal dialysis should signify. Conceptually, optimal dialysis represents the therapeutic return of an individual to nutritional balance, with an expected survival comparable to that of age, gender, and disease-matched nonuremic individuals. Because of the complexity of maintaining nutrient balance, the definition of adequate dialysis should be re-evaluated. Contemporary dialysis practice should extend beyond solely quantitating dialysis to include an understanding of nutrient balance, regulation of food intake, and the application of surveillance tools for identifying abnormalities in body composition. Only through expanding the end points of adequate dialysis can we move closer to optimal dialysis synonymous with long-term treatment survival.
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Affiliation(s)
- Martin J. Schreiber
- Department of Nephrology and Hypertension, Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A
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Kimmel PL, Fwu CW, Abbott KC, Moxey-Mims MM, Mendley S, Norton JM, Eggers PW. Psychiatric Illness and Mortality in Hospitalized ESKD Dialysis Patients. Clin J Am Soc Nephrol 2019; 14:1363-1371. [PMID: 31439538 PMCID: PMC6730507 DOI: 10.2215/cjn.14191218] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 06/24/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Limited existing data on psychiatric illness in ESKD patients suggest these diseases are common and burdensome, but under-recognized in clinical practice. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We examined hospitalizations with psychiatric diagnoses using inpatient claims from the first year of ESKD in adult and pediatric Medicare recipients who initiated treatment from 1996 to 2013. We assessed associations between hospitalizations with psychiatric diagnoses and all-cause death after discharge in adult dialysis patients using multivariable-adjusted Cox proportional hazards regression models. RESULTS In the first ESKD year, 72% of elderly adults, 66% of adults and 64% of children had at least one hospitalization. Approximately 2% of adults and 1% of children were hospitalized with a primary psychiatric diagnosis. The most common primary psychiatric diagnoses were depression/affective disorder in adults and children, and organic disorders/dementias in elderly adults. Prevalence of hospitalizations with psychiatric diagnoses increased over time across groups, primarily from secondary diagnoses. 19% of elderly adults, 25% of adults and 15% of children were hospitalized with a secondary psychiatric diagnosis. Hazards ratios of all-cause death were higher in all dialysis adults hospitalized with either primary (1.29; 1.26 to 1.32) or secondary (1.11; 1.10 to 1.12) psychiatric diagnoses than in those hospitalized without psychiatric diagnoses. CONCLUSIONS Hospitalizations with psychiatric diagnoses are common in pediatric and adult ESKD patients, and are associated with subsequent higher mortality, compared with hospitalizations without psychiatric diagnoses. The prevalence of hospitalizations with psychiatric diagnoses likely underestimates the burden of mental illness in the population.
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Affiliation(s)
- Paul L. Kimmel
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Chyng-Wen Fwu
- Department of Public Health Sciences, Social & Scientific Systems, Inc., Silver Spring, Maryland; and
| | - Kevin C. Abbott
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | | | - Susan Mendley
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Jenna M. Norton
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Paul W. Eggers
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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Gant CM, Minovic I, Binnenmars H, de Vries L, Kema I, van Beek A, Navis G, Bakker S, Laverman GD. Lower Renal Function Is Associated With Derangement of 11- β Hydroxysteroid Dehydrogenase in Type 2 Diabetes. J Endocr Soc 2018; 2:609-620. [PMID: 29942925 PMCID: PMC6007243 DOI: 10.1210/js.2018-00088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 05/17/2018] [Indexed: 02/08/2023] Open
Abstract
Context Derangement of 11-β hydroxysteroid dehydrogenase type 1 and type 2 (11β-HSD1 and 11β-HSD2), which regulate intracellular cortisol production, has been suggested in both type 2 diabetes (T2D) and chronic kidney disease (CKD). However, activity of 11β-HSD enzymes in patients with T2D and CKD has never been assessed. Objectives To compare 11β-HSD activities between patients with T2D and healthy controls, and assess whether in T2D, renal function is associated with 11β-HSD activities. Design Cross-sectional analysis in the Diabetes and Lifestyle Cohort Twente (DIALECT-1). Setting Referral center for T2D. Patients Patient with T2D [n = 373, age 64 ± 9 years, 58% men, 26% of patients estimated glomerular filtration rate (eGFR) <60 mL/min·1.73 m2] and healthy controls (n = 275, age 53 ± 11 years, 48% men). Mean Outcome Measure We measured cortisol, cortisone, and metabolites [tetrahydrocortisol (THF), allo-THF (aTHF), and tetrahydrocortisone (THE)] in 24-hour urine samples. Whole body 11β-HSD and 11β-HSD2 activities were calculated as the urinary (THF + aTHF)/THE and cortisol/cortisone ratios, respectively. Results Patients with T2D had a higher (THF + aTHF)/THE ratio [1.02 (0.84 to 1.27) vs 0.94 (0.79 to 1.0), P < 0.001] and cortisol/cortisone ratio [0.70 (0.58 to 0.83) vs 0.63 (0.54 to 0.74), P < 0.001] than healthy controls. In T2D, lower eGFR was associated with a higher (THF + aTHF)/THE ratio (β = −0.35, P < 0.001), and a higher cortisol/cortisone ratio (β = −0.16, P = 0.001). Conclusions In this real-life secondary care setting of patients with T2D, 11β-HSD enzymes activities were shifted to higher intracellular cortisol production in T2D, which was further aggravated in patients with CKD. Prospective analyses are warranted to investigate causality of these associations.
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Affiliation(s)
- Christina Maria Gant
- Department of Internal Medicine/Nephrology, Ziekenhuisgroep Twente Hospital, PP Almelo and Hengelo, Netherlands.,Department of Nephrology, University of Groningen, University Medical Centre Groningen, EZ Groningen, Netherlands
| | - Isidor Minovic
- Department of Nephrology, University of Groningen, University Medical Centre Groningen, EZ Groningen, Netherlands
| | - Heleen Binnenmars
- Department of Nephrology, University of Groningen, University Medical Centre Groningen, EZ Groningen, Netherlands
| | - Laura de Vries
- Department of Nephrology, University of Groningen, University Medical Centre Groningen, EZ Groningen, Netherlands
| | - Ido Kema
- Department of Laboratory Medicine, University of Groningen, University Medical Centre Groningen, EZ Groningen, Netherlands
| | - André van Beek
- Department of Endocrinology, University of Groningen, University Medical Centre Groningen, EZ Groningen, Netherlands
| | - Gerjan Navis
- Department of Nephrology, University of Groningen, University Medical Centre Groningen, EZ Groningen, Netherlands
| | - Stephan Bakker
- Department of Nephrology, University of Groningen, University Medical Centre Groningen, EZ Groningen, Netherlands
| | - Gozewijn Dirk Laverman
- Department of Internal Medicine/Nephrology, Ziekenhuisgroep Twente Hospital, PP Almelo and Hengelo, Netherlands
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Norton JM, Moxey-Mims MM, Eggers PW, Narva AS, Star RA, Kimmel PL, Rodgers GP. Social Determinants of Racial Disparities in CKD. J Am Soc Nephrol 2016; 27:2576-95. [PMID: 27178804 PMCID: PMC5004663 DOI: 10.1681/asn.2016010027] [Citation(s) in RCA: 194] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Significant disparities in CKD rates and outcomes exist between black and white Americans. Health disparities are defined as health differences that adversely affect disadvantaged populations, on the basis of one or more health outcomes. CKD is the complex result of genetic and environmental factors, reflecting the balance of nature and nurture. Social determinants of health have an important role as environmental components, especially for black populations, who are disproportionately disadvantaged. Understanding the social determinants of health and appreciating the underlying differences associated with meaningful clinical outcomes may help nephrologists treat all their patients with CKD in an optimal manner. Altering the social determinants of health, although difficult, may embody important policy and research efforts, with the ultimate goal of improving outcomes for patients with kidney diseases, and minimizing the disparities between groups.
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Affiliation(s)
- Jenna M Norton
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Marva M Moxey-Mims
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Paul W Eggers
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Andrew S Narva
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Robert A Star
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Paul L Kimmel
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Griffin P Rodgers
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland Office of the Director and
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Niculescu DA, Ismail G, Poiana C. Plasma free metanephrine and normetanephrine levels are increased in patients with chronic kidney disease. Endocr Pract 2016; 20:139-44. [PMID: 24014007 DOI: 10.4158/ep13251.or] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Patients with impaired renal function, particularly those on dialysis, frequently exhibit high blood pressure and hemodynamic instability, which often lead to pheochromocytoma assessment. Our objective was to assess plasma free metanephrine (MN) and normetanephrine (NMN) in chronic kidney disease patients (CKD) with or without dialysis. METHODS In this prospective observational study we performed enzyme-linked immunosorbent assays (ELISAs) to evaluate plasma free MN and NMN in 48 CKD patients (15 with stage 3-5 CKD without dialysis, 26 on hemodialysis [HD], and 7 continuous ambulatory peritoneal dialysis [CAPD]), 30 patients with histologically proven pheochromocytoma, and 43 hypertensive patients. Adrenal masses were ruled out by abdominal computed tomography (CT) scans in all CKD and control hypertensive patients. RESULTS All 3 CKD groups (HD, CAPD, and CKD without dialysis) had significantly higher plasma free MN and NMN levels than the control hypertensive group (P<.0055). HD and CAPD patients had significantly lower plasma free NMN (P<.0055), but free MN levels were not significantly different than those observed in pheochromocytoma patients. In patients with HD, CAPD, and CKD without dialysis, plasma free MN and NMN were higher than manufacturer's upper limits of normal in 57.7% and 28.5%, 13.3% and 61.5%, and 85.7% and 26.6%, respectively. Regression models showed that the number of dialysis years was significantly correlated with plasma free MN (r = 0.615, P<.001) but not free NMN. CONCLUSION Plasma free MN and NMN levels are frequently elevated in CKD patients, particularly in those on dialysis. Plasma free MN levels significantly overlap with the range in pheochromocytoma patients and correlate with the number of years on dialysis.
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Affiliation(s)
- Dan A Niculescu
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Gener Ismail
- Department of Nephrology and Internal Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Catalina Poiana
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Nilsson E, Carrero JJ, Heimbürger O, Hellberg O, Lindholm B, Stenvinkel P. A cohort study of insulin-like growth factor 1 and mortality in haemodialysis patients. Clin Kidney J 2015; 9:148-52. [PMID: 26798476 PMCID: PMC4720197 DOI: 10.1093/ckj/sfv118] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 09/22/2015] [Accepted: 10/19/2015] [Indexed: 01/29/2023] Open
Abstract
Background Protein-energy wasting (PEW) is highly prevalent in haemodialysis (HD) patients and associated with increased mortality and cardiovascular disease (CVD). Insulin-like growth factor 1 (IGF-1) correlates to markers of PEW and CVD. Disturbances in the growth hormone axis in end-stage renal disease (ESRD) could have an impact on survival through increased PEW and CVD. Methods A cohort of 265 incident HD patients (median age 68 years, 59% males) was followed for 3 years. Subjects were categorized according to IGF-1 levels at dialysis initiation. Outcome and comorbidity data were retrieved from national registers. The Kaplan–Meier diagram and Cox proportional hazards model were used for the analysis of survival. Results Patients with IGF-1 levels in the lowest tertile were characterized by female sex, low creatinine, hypoalbuminemia and high C-reactive protein (CRP) levels. IGF-1 levels within the lowest tertile were associated with increased mortality [hazard ratio (HR) 2.4, 95% confidence interval (CI) 1.7–3.4]. This association persisted when corrected for demographic factors (age, sex) and comorbidities (diabetes mellitus, CVD, heart failure) in multivariable analysis. Including high-sensitivity C-reactive protein (hs-CRP) and serum creatinine in the model had a small effect on the magnitude of the hazard. When serum albumin was added to the model, the HR declined from 2.2 to 1.6, but remained significant (P = 0.02). Conclusion Low IGF-1 levels associate with increased mortality in HD, independent of biomarkers of inflammation (hs-CRP) and PEW (creatinine, albumin). Serum albumin modulates the relationship between IGF-1 levels and mortality, indicating shared pathophysiological pathways with IGF-1.
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Affiliation(s)
- Erik Nilsson
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Huddinge, Sweden; Division of Nephrology, Department of Medicine, School of Medicine, Örebro University, Örebro, Sweden
| | - Juan Jesus Carrero
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science , Intervention and Technology, Karolinska Institutet , Huddinge , Sweden
| | - Olof Heimbürger
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science , Intervention and Technology, Karolinska Institutet , Huddinge , Sweden
| | - Olof Hellberg
- Division of Nephrology, Department of Medicine , School of Medicine, Örebro University , Örebro , Sweden
| | - Bengt Lindholm
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science , Intervention and Technology, Karolinska Institutet , Huddinge , Sweden
| | - Peter Stenvinkel
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science , Intervention and Technology, Karolinska Institutet , Huddinge , Sweden
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Beberashvili I, Sinuani I, Azar A, Kadoshi H, Shapiro G, Feldman L, Sandbank J, Averbukh Z. Decreased IGF-1 levels potentiate association of inflammation with all-cause and cardiovascular mortality in prevalent hemodialysis patients. Growth Horm IGF Res 2013; 23:209-214. [PMID: 23958273 DOI: 10.1016/j.ghir.2013.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 07/20/2013] [Accepted: 07/21/2013] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Insulin-like growth factor-1 (IGF-1) and inflammation have both been linked to high cardiovascular risk and mortality in the general population, as well as in hemodialysis (HD) patients. We hypothesized that the association of low IGF-1 with chronic inflammation may increase the mortality risk in HD patients. DESIGN We investigated the interactions between inflammatory biomarkers (IL-6 and TNF-α) and IGF-1 as predictors of death over a 4 years of follow-up (median--47 months, interquartile range--17.5-75 months) in 96 prevalent HD patients (35% women, mean age of 64.9 ± 11.6 years). RESULTS A significant interaction effect of low IGF-1 (defined as a level less than median) and high IL-6 (defined as a level higher than median) on all-cause and cardiovascular mortality was found: crude Cox hazard ratios (HR) for the product termed IGF-1 × IL-6 were 4.27, with a 95% confidence interval (CI): 2.10 to 8.68 (P<0.001) and 7.49, with a 95% CI: 2.40-24.1 (P=0.001), respectively. Across the four IGF-1-IL-6 categories, the group with low IGF-1 and high IL-6 exhibited the worse outcome in both all-cause and cardiovascular mortality (multivariable adjusted hazard ratios were 4.92, 95% CI 1.86 to 13.03, and 14.34, 95% CI 1.49 to 137.8, respectively). The main clinical characteristics of patients in the low-IGF-1-high IL-6 group didn't differ from other IGF-1-IL-6 categorized groups besides gender that consequently was inserted in all multivariable models together with the other potential confounders. CONCLUSIONS An increase in mortality risk was observed in HD patients with low IGF-1 and high IL-6 levels, especially cardiovascular causes.
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Affiliation(s)
- Ilia Beberashvili
- Nephrology Division, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler Faculty of Medicine Tel Aviv University, Israel.
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Zalai D, Szeifert L, Novak M. Psychological Distress and Depression in Patients with Chronic Kidney Disease. Semin Dial 2012; 25:428-38. [DOI: 10.1111/j.1525-139x.2012.01100.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Halen NV, Cukor D, Constantiner M, Kimmel PL. Depression and mortality in end-stage renal disease. Curr Psychiatry Rep 2012; 14:36-44. [PMID: 22105534 DOI: 10.1007/s11920-011-0248-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
End-stage renal disease is growing in prevalence and incidence. With technical advancements, patients are living longer on hemodialysis. Depression is the most prevalent comorbid psychiatric condition, estimated at about 25% of end-stage renal disease samples. The identification and assessment of depression are confounded by the overlap between depression symptomatology and uremia. Several recent studies have employed time-varying models and identified a significant association between depression and mortality. Due to the high prevalence of depression and the potential impact on survival, well-constructed investigations are warranted.
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Affiliation(s)
- Nisha Ver Halen
- SUNY Downstate Medical Center, 450 Clarkson Avenue, Box 1203, Brooklyn, NY 11203, USA.
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Leal VO, Stockler-Pinto MB, Farage NE, Aranha LN, Fouque D, Anjos LA, Mafra D. Handgrip strength and its dialysis determinants in hemodialysis patients. Nutrition 2011; 27:1125-9. [DOI: 10.1016/j.nut.2010.12.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Revised: 11/25/2010] [Accepted: 12/13/2010] [Indexed: 01/04/2023]
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DESAI AA, NISSENSON A, CHERTOW GM, FARID M, SINGH I, VAN OIJEN MGH, ESRAILIAN E, SOLOMON MD, SPIEGEL BMR. The relationship between laboratory-based outcome measures and mortality in end-stage renal disease: A systematic review. Hemodial Int 2009; 13:347-59. [DOI: 10.1111/j.1542-4758.2009.00377.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Cukor D, Coplan J, Brown C, Peterson RA, Kimmel PL. Course of depression and anxiety diagnosis in patients treated with hemodialysis: a 16-month follow-up. Clin J Am Soc Nephrol 2008; 3:1752-8. [PMID: 18684897 PMCID: PMC2572273 DOI: 10.2215/cjn.01120308] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Accepted: 06/27/2008] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES There is growing identification of the need to seriously study the psychiatric presentations of end-stage renal disease patients treated with hemodialysis. This study reports on the course of depression and anxiety diagnoses and their impact on quality of life and health status. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The 16-mo course of psychiatric diagnoses in 50 end-stage renal disease patients treated with hemodialysis was measured by structured clinical interview. RESULTS Three different pathways were identified: one subset of patients not having a psychiatric diagnosis at either baseline or 16-mo follow-up (68% for depression, 51% for anxiety), one group having an intermittent course (21% for depression, 34% for anxiety), and one group having a persistent course (11% for depression, 15% for anxiety), with diagnoses at both time 1 and time 2. For depression, the people with the persistent course showed marked decreases in quality of life and self-reported health status compared with the nondepressed and intermittently depressed cohorts. The most powerful predictor of depression at time 2 is degree of depressive affect at time 1(P < 0.05). CONCLUSIONS Patients at risk for short- and long-term complications of depression can be potentially identified by high levels of depressive affect even at a single time point. As nearly 20% of the sample had chronic depression or anxiety, identifying a psychiatric diagnosis in hemodialysis patients and then offering treatment are important because, in the absence of intervention, psychiatric disorders are likely to persist in a substantial proportion of patients.
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Affiliation(s)
- Daniel Cukor
- Department of Psychiatry, SUNY Downstate Medical Center, Brooklyn, NY 11203-2098, USA.
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Ramirez G, Bittle P, Matfin G. Commentary. Semin Dial 2008. [DOI: 10.1111/j.1525-139x.1997.tb00453.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cukor D, Cohen SD, Peterson RA, Kimmel PL. Psychosocial Aspects of Chronic Disease: ESRD as a Paradigmatic Illness. J Am Soc Nephrol 2007; 18:3042-55. [DOI: 10.1681/asn.2007030345] [Citation(s) in RCA: 248] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Cukor D, Peterson RA, Cohen SD, Kimmel PL. Depression in end-stage renal disease hemodialysis patients. ACTA ACUST UNITED AC 2007; 2:678-87. [PMID: 17124525 DOI: 10.1038/ncpneph0359] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2006] [Accepted: 10/06/2006] [Indexed: 11/09/2022]
Abstract
Depression has been identified as a complicating comorbid diagnosis in a variety of medical conditions, including end-stage renal disease (ESRD). Despite this, the psychological health of hemodialysis patients is understudied. The purpose of this paper is to review the research and issues involved in the assessment of depression and its sequelae in ESRD. Accurate estimation of the prevalence of depression in the ESRD population has been difficult due to the use of different definitions of depression and varied assessment techniques, the overlap of depressive symptomatology with symptoms of uremia, and the confounding effects of medications. We suggest that depressive affect is a more important construct to study than diagnosis of depression syndromes per se in patients with chronic kidney disease. The Beck Depression Inventory is a reasonable measure of depressive affect in the ESRD population, if a higher than usual cutoff score is used or if its somatic components are omitted. Several pathways link depression and ESRD, and are probably bidirectional. As such, treatment of depressive affect could impact medical as well as psychological outcomes. The need for treatment intervention trials is great. Limited evidence regarding the safety and efficacy of treatment of hemodialysis patients with selective serotonin reuptake inhibitors is available, and cognitive behavioral therapy holds promise as an intervention for depression in this complex medical population.
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Affiliation(s)
- Daniel Cukor
- Department of Psychiatry, SUNY Downstate Medical Center, Brooklyn, NY, USA
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Abstract
Even apparently healthy patients on dialysis have significant loss of lean body mass. Patients with chronic renal failure without coexisting metabolic acidosis or inflammation have decreased protein turnover, with balanced reduction in protein synthesis and breakdown. However, regional and whole-body protein kinetic studies indicate that hemodialysis (HD) induces net increase in protein breakdown. Whole-body protein turnover studies show that HD is associated with decreased protein synthesis, but proteolysis is not increased. Muscle protein kinetics studies, however, identify enhanced muscle protein breakdown with inadequate compensatory increases in synthesis as the cause of the catabolism. Transmembrane amino acid-transport kinetics studies show that the outward transport is increased more than the inward transport of amino acids during HD. Altered intracellular amino acid transport kinetics and protein turnover during HD could be caused by the loss of amino acids in the dialysate or cytokine activation. Cytokines may be released from peripheral blood mononuclear cells and skeletal muscle during HD. Preliminary evidence indicates that intradialytic increase in cytokines activates the ubiquitin-proteasome pathway. An intradialytic increase in albumin and fibrinogen synthesis is facilitated by interleukin-6 and the constant supply of amino acids derived from skeletal muscle catabolism. Protein anabolism can be induced in end-stage renal disease patients by repletion of amino acids, and perhaps treatment with recombinant human insulin-like growth factor.
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Affiliation(s)
- Dominic S C Raj
- Division of Nephrology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.
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Bohé J, Joly MO, Arkouche W, Laville M, Fouque D. Haemodialysis with the biocompatible high permeability AN-69 membrane does not alter plasma insulin-like growth factor-I and insulin-like growth factor binding protein-3. Nephrol Dial Transplant 2001; 16:590-4. [PMID: 11239037 DOI: 10.1093/ndt/16.3.590] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Insulin-like growth factor-I (IGF-I) bioactivity has been reported to be decreased in maintenance haemodialysis patients and this may affect their nutritional status. Clearances of IGF-I and its binding proteins (IGFBPs) during haemodialysis sessions using a high permeability biocompatible membrane are unknown. METHODS Five well nourished, non-diabetic adult patients were studied during one 4-h morning haemodialysis treatment using the high permeability biocompatible AN-69 dialyser. Blood was collected at the arterial and venous ports of the dialyser at 0, 1, 2 and 4 h of dialysis for haematocrit, plasma IGF-I, IGFBP-3 and insulin measurements. IGF-I, IGFBP-3 and insulin concentrations were adjusted for haemoconcentration before comparisons were made. RESULTS At the beginning of the dialysis session, plasma IGF-I, IGFBP-3 and insulin levels were within the normal range (297 +/- 47 ng/ml (mean+/-SEM), 4.3 +/- 0.6 microg/ml and 11.8 +/- 3.4 microIU/ml, respectively). During the session, insulin tended to be cleared through the dialyser, whereas plasma IGF-I and IGFBP-3 values did not vary significantly. CONCLUSION Dialysis with the high permeability AN69 membrane did not alter the main blood compounds of the IGF system in well nourished chronic haemodialysis patients, and it is unlikely that the malnutrition frequently observed in such patients would result from alterations of the IGF system during haemodialysis.
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Affiliation(s)
- J Bohé
- Medical Intensive Care Unit, Lyon-Sud Hospital, Pierre-Bénite, E Herriot Hospital, Lyon, France
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Chazot C, Laurent G, Charra B, Blanc C, VoVan C, Jean G, Vanel T, Terrat JC, Ruffet M. Malnutrition in long-term haemodialysis survivors. Nephrol Dial Transplant 2001; 16:61-9. [PMID: 11208995 DOI: 10.1093/ndt/16.1.61] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Long survival is now common in patients with end-stage renal disease owing to improvement in dialysis techniques and kidney transplantation. As malnutrition is commonly reported in dialysis patients, we evaluated the nutritional status of patients treated with haemodialysis (HD) for more than 20 years. METHODS Ten patients (59.5 years old; 4F/6M; HD treatment for 304 months; group A) underwent an extensive nutritional examination and were compared to a control group of 10 patients treated with HD for an average of 51 months and strictly matched for age (58.6 years old), gender, and height (group B). The patients were treated on a similar basis (long-duration HD, cellulosic membranes, Daugirdas index >2). RESULTS The body weight (BW) in group A had decreased gradually from the 11th year of HD treatment, whereas it had increased by an average of 1.9+/-4.4% since the beginning of the HD treatment in group B. The body mass index (BMI) was lower in group A (19.3 +/- 2.3 vs 21.4 +/- 2.8 kg/m(2); P = 0.05). The arm-muscle circumference (AMC), the arm-muscle area (AMA), and triceps skinfold (TSF) were lower in group A than in group B. The fat mass assessed with anthropometry (10.8 +/- 4.0 vs 14.8 +/- 4.2 kg) was significantly lower in group A. The deviation of actual BW from ideal BW (IBW) was significantly lower in group A than in group B (80.6 +/- 10.7% vs 89.6 +/- 9.0%; P = 0.028); The deviations of actual BW, TSF, and AMA from standard values of the NHANES II study were more marked in group A than in group B. On the other hand, daily energy and protein intakes (DEI and DPI) were identical in both groups and met the recommendations for dialysis patients when normalized to the actual BW. When normalized to the IBW, the DEI appeared low. Energy expenditure was not different between groups, and not different from the resting metabolism calculated from the Harris and Benedict formula. Average albumin, prealbumin, and IgF-1 were normal and not different between groups. Branched-chain amino acids (BCAA), and especially leucine, were correlated with BMI in group A but not in group B. Serum total and free carnitine were low in both groups. Three patients had ascorbic acid deficiency in group A but none in group B. CONCLUSIONS Hence, despite adequate dialysis dose and protein intake, patients treated with HD for a long period of time became malnourished, whereas the classical nutritional markers remained in normal ranges. Among the potential causes leading to malnutrition, inadequate energy intake and micronutrient deficiencies were found in these patients.
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Affiliation(s)
- C Chazot
- Centre de Rein Artificiel, Tassin, France
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21
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Kelly MP. Use of dietetic-specific nutritional diagnostic codes in clinical reasoning relevant to the nutritional management of core clinical outcome indicators in hemodialysis patients. ADVANCES IN RENAL REPLACEMENT THERAPY 1997; 4:125-35. [PMID: 9113228 DOI: 10.1016/s1073-4449(97)70039-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The Health Care Financing Agency (HCFA) has recommended conscientious monitoring of four core outcome indicators (anemia, albumin, treatment adequacy, and hypertension) by the end stage renal disease (ESRD) health care team. Dietetic-specific nutritional diagnostic categories (D-S NDCs) can be a powerful tool in guiding renal nutrition specialists through the clinical reasoning required to diagnose and clinically correct nutrition-related problems in hemodialysis (HD) patients. The purpose of this article is to portray one clinician's dual use of D-S NDCs to identify the nutritional problem responsible for poor performance and determine nutritionally treatable causes. Although four indicator-specific sets of D-S NDCs commonly used in the nutritional assessment of anemia, albumin, treatment adequacy and hypertension were identified and referenced, seven codes were consistently repeated. These D-S NDCs were (1) altered nutritional biochemistry integrity; (2) absence of/limited nutritional service; (3) deficit in nutrition knowledge; (4) imbalance of nutrient/fluid; (5) nutrition misinformation; (6) toxicity of nutrient/nutrient end-product; and (7) possibility of developing a specific disease. Thus, in ESRD, use of D-S NDCs shows the implicit role of the registered dietitian in disease prevention, management of altered nutrient disposition, and patient education.
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Affiliation(s)
- M P Kelly
- University of California Renal Center, San Francisco 94110, USA
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Wolfson M, Strong C. Assessment of nutritional status in dialysis patients. ADVANCES IN RENAL REPLACEMENT THERAPY 1996; 3:174-9. [PMID: 8814924 DOI: 10.1016/s1073-4449(96)80058-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Malnutrition is common in patients treated with maintenance dialysis and appears to influence mortality in these patients. Thus, assessment of the nutritional status of dialysis patients is important if one is to make appropriate treatment interventions. This article describes the various parameters used in assessing the nutritional status of patients treated by hemodialysis and continuous ambulatory peritoneal dialysis. The usefulness of these parameters, as well as the pitfalls in their interpretation, are also reviewed.
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Affiliation(s)
- M Wolfson
- Renal Division, Baxter Healthcare Corporation, McGaw Park, IL 60085, USA
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Quillen DA, Gass DM, Brod RD, Gardner TW, Blankenship GW, Gottlieb JL. Central serous chorioretinopathy in women. Ophthalmology 1996; 103:72-9. [PMID: 8628563 DOI: 10.1016/s0161-6420(96)30730-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Central serous chorioretinopathy is a disorder that typically affects young and middle-aged men. Although extensive information is available pertaining to the clinical features of central serous chorioretinopathy in men, little is known about this condition in women. MATERIALS AND METHODS The authors reviewed the medical records and photographic files of women who received a diagnosis of central serous chorioretinopathy. The women were divided into three groups for data analysis: idiopathic, exogenous corticosteroid use, and pregnancy. RESULTS Fifty-one women with active central serous chorioretinopathy were evaluated. These findings in women with idiopathic serous chorioretinopathy were similar to those described in men, with the exception that women tend to be older at the time of onset. Central serous chorioretinopathy in women taking exogenous corticosteroids more likely was characterized by bilateral involvement and subretinal fibrin. Central serous chorioretinopathy in pregnant women typically developed in the third trimester and resolved spontaneously within 1-2 months after delivery. CONCLUSION Idiopathic central serous chorioretinopathy is similar in women and men, with the exception that women tend to be more older at the time of onset. The finding of exogenous corticosteroid use in a significant number of women in our study provides further support that cortisol may play a role in the development of central serous chorioretinopathy. The mechanism by which cortisol influences the development of central serous chorioretinopathy is unclear.
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Affiliation(s)
- D A Quillen
- Department of Ophthalmology, Penn State University, Hershey, Pennsylvania, USA
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