Cross-sectional study of quality of life and symptoms in chronic renal disease patients: the Modification of Diet in Renal Disease Study

Metabolites Associated With Uremic Symptoms in Patients With CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study

RATIONALE & OBJECTIVE

The toxins that contribute to uremic symptoms in patients with chronic kidney disease (CKD) are unknown. We sought to apply complementary statistical modeling approaches to data from untargeted plasma metabolomic profiling to identify solutes associated with uremic symptoms in patients with CKD.

STUDY DESIGN

Cross-sectional.

SETTING & PARTICIPANTS

1,761 Chronic Renal Insufficiency Cohort (CRIC) participants with CKD not treated with dialysis.

PREDICTORS

Measurement of 448 known plasma metabolites.

OUTCOMES

The uremic symptoms of fatigue, anorexia, pruritus, nausea, paresthesia, and pain were assessed by single items on the Kidney Disease Quality of Life-36 instrument.

ANALYTICAL APPROACH

Multivariable adjusted linear regression, least absolute shrinkage and selection operator linear regression, and random forest models were used to identify metabolites associated with symptom severity. After adjustment for multiple comparisons, metabolites selected in at least 2 of the 3 modeling approaches were deemed "overall significant."

RESULTS

Participant mean estimated glomerular filtration rate was 43mL/min/1.73m2, with 44% self-identifying as female and 41% as non-Hispanic Black. The prevalence of uremic symptoms ranged from 22% to 55%. We identified 17 metabolites for which a higher level was associated with greater severity of at least one uremic symptom and 9 metabolites inversely associated with uremic symptom severity. Many of these metabolites exhibited at least a moderate correlation with estimated glomerular filtration rate (Pearson's r≥0.5), and some were also associated with the risk of developing kidney failure or death in multivariable adjusted Cox regression models.

LIMITATIONS

Lack of a second independent cohort for external validation of our findings.

CONCLUSIONS

Metabolomic profiling was used to identify multiple solutes associated with uremic symptoms in adults with CKD, but future validation and mechanistic studies are needed.

PLAIN-LANGUAGE SUMMARY

Individuals living with chronic kidney disease (CKD) often experience symptoms related to CKD, traditionally called uremic symptoms. It is likely that CKD results in alterations in the levels of numerous circulating substances that, in turn, cause uremic symptoms; however, the identity of these solutes is not known. In this study, we used metabolomic profiling in patients with CKD to gain insights into the pathophysiology of uremic symptoms. We identified 26 metabolites whose levels were significantly associated with at least one of the symptoms of fatigue, anorexia, itchiness, nausea, paresthesia, and pain. The results of this study lay the groundwork for future research into the biological causes of symptoms in patients with CKD.

Presence of gastrointestinal symptoms in IgA nephropathy: a cross-sectional study

BACKGROUND

Gastrointestinal (GI) symptoms are common in end-stage kidney disease. Mounting evidence indicates that the intestine plays an important role in the pathogenesis of IgA nephropathy (IgAN). However, no studies have addressed the obvious question; do IgAN patients suffer from GI symptoms?

METHODS

Presence of GI symptoms and health-related quality of life were evaluated using the validated Gastrointestinal Symptom Rating Scale (GSRS) and Psychological General Well-Being (PGWB) questionnaires in 104 patients with kidney biopsy-verified IgAN and in 147 healthy controls. A person was regarded to experience 'increased GI symptoms' if the GSRS score exceeded plus 1 standard deviation of the mean of the corresponding score in the healthy controls.

RESULTS

According to the GSRS total score, the IgAN patients had more GI symptoms than the healthy controls (2.0 vs. 1.7, p < 0.001). Female IgAN patients had higher GSRS total score than male patients (2.2 vs. 1.7, p = 0.001). More IgAN patients with preserved kidney function (eGFR > 60ml/min/1.73m²) suffered from increased symptoms of diarrhoea (76 vs. 25%, p = 0.028), constipation (81 vs. 19%, p = 0.046) and reflux (85 vs. 15%, p = 0.004) than did IgAN patients with reduced kidney function (eGFR < 60ml/min/1.73m²).

CONCLUSIONS

IgAN patients and especially female IgAN patients experienced more GI symptoms than healthy controls. More prevalent GI symptoms were already observed before kidney function was clearly reduced. Systematic enquiry of GI symptoms might increase the standard of care among IgAN patients. Moreover, GI symptoms may provide clues for future studies that examine the pathophysiology of IgAN.

Effect of Structured, Moderate Exercise on Kidney Function Decline in Sedentary Older Adults: An Ancillary Analysis of the LIFE Study Randomized Clinical Trial

Importance

Observational evidence suggests that higher physical activity is associated with slower kidney function decline; however, to our knowledge, no large trial has evaluated whether activity and exercise can ameliorate kidney function decline in older adults.

Objective

To evaluate whether a moderate-intensity exercise intervention can affect the rate of estimated glomerular filtration rate per cystatin C (eGFRCysC) change in older adults.

Design, Setting, and Participants

This ancillary analysis of the Lifestyle Interventions and Independence For Elders randomized clinical trial enrolled 1199 community-dwelling, sedentary adults aged 70 to 89 years with mobility limitations and available blood specimens. The original trial was conducted across 8 academic centers in the US from February 2010 through December 2013. Data for this study were analyzed from March 29, 2021, to February 28, 2022.

Interventions

Structured, 2-year, partially supervised, moderate-intensity physical activity and exercise (strength, flexibility) intervention compared with a health education control intervention with 2-year follow-up. Physical activity was measured by step count and minutes of moderate-intensity activity using accelerometers.

Main Outcomes and Measures

The primary outcome was change in eGFRCysC. Rapid eGFRCysC decline was defined by the high tertile threshold of 6.7%/y.

Results

Among the 1199 participants in the analysis, the mean (SD) age was 78.9 (5.2) years, and 800 (66.7%) were women. At baseline, the 2 groups were well balanced by age, comorbidity, and baseline eGFRCysC. The physical activity and exercise intervention resulted in statistically significantly lower decline in eGFRCysC over 2 years compared with the health education arm (mean difference, 0.96 mL/min/1.73 m2; 95% CI, 0.02-1.91 mL/min/1.73 m2) and lower odds of rapid eGFRCysC decline (odds ratio, 0.79; 95% CI, 0.65-0.97).

Conclusions and Relevance

Results of this ancillary analysis of a randomized clinical trial showed that when compared with health education, a physical activity and exercise intervention slowed the rate of decline in eGFRCysC among community-dwelling sedentary older adults. Clinicians should consider targeted recommendation of physical activity and moderate-intensity exercise for older adults as a treatment to slow decline in eGFRCysC.

Trial Registration

ClinicalTrials.gov Identifier: NCT01072500.

Trajectories of Uremic Symptom Severity and Kidney Function in Patients with Chronic Kidney Disease

BACKGROUND AND OBJECTIVES

Uremic symptoms, including fatigue, anorexia, pruritus, nausea, paresthesia, and pain, are attributed to the accumulation of organic waste products normally cleared by the kidneys, but whether kidney function is the primary driver of changes in symptom severity over time is not known. The goal of our study was to evaluate the association between eGFR and uremic symptom severity score in patients with CKD.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

We identified 3685 participants with CKD not on dialysis in the prospective, observational Chronic Renal Insufficiency Cohort (CRIC) Study with baseline assessment of eGFR and uremic symptom severity. Symptoms were assessed by separate questions on the Kidney Disease Quality of Life-36 instrument (zero- to 100-point scale). The longitudinal association between eGFR and uremic symptom severity score was examined with multivariable adjusted linear mixed-effects models with random intercepts and random slopes.

RESULTS

The mean±SD eGFR at baseline was 44±15 ml/min per 1.73 m2, and participants had a median of six (interquartile range 3-11) simultaneous assessments of eGFR and uremic symptoms over the duration of follow-up. The most prevalent symptoms at baseline were pain (57%), fatigue (52%), paresthesia (45%), and pruritus (42%). In adjusted models, a decrease in eGFR of 5 ml/min per 1.73 m2 was associated with a worsening of the symptom severity score by two points or less for each uremic symptom (P<0.01; zero- to 100-point scale). The association between eGFR and uremic symptom severity score was nonlinear. When starting from a lower initial eGFR, a 5 ml/min per 1.73 m2 decrease in eGFR was associated with a greater magnitude of uremic symptom worsening.

CONCLUSIONS

The prevalence of uremic symptoms in CKD is high, with significant variability in patient symptom change over time. Declines in eGFR were associated with worsening of uremic symptom severity, but the magnitude of these changes is small and of uncertain clinical significance.

A metabolomics approach identified toxins associated with uremic symptoms in advanced chronic kidney disease

Uremic symptoms are common in patients with advanced chronic kidney disease, but the toxins that cause these symptoms are unknown. To evaluate this, we performed a cross-sectional study of the 12 month post-randomization follow-up visit of Modification of Diet in Renal Disease (MDRD) participants reporting uremic symptoms who also had available stored serum. We quantified 1,163 metabolites by liquid chromatography-tandem mass spectrometry. For each uremic symptom, we calculated a score as the severity multiplied by the number of days the symptom was experienced. We analyzed the associations of the individual symptom scores with metabolites using linear models with empirical Bayesian inference, adjusted for multiple comparisons. Among 695 participants, the mean measured glomerular filtration rate (mGFR) was 28 mL/min/1.73 m². Uremic symptoms were more common in the subgroup of 214 patients with an mGFR under 20 mL/min/1.73 m² (mGFR under 20 subgroup) than in the full group. For all metabolites with significant associations, the direction of the association was concordant in the full group and the subgroup. For gastrointestinal symptoms (bad taste, loss of appetite, nausea, and vomiting), eleven metabolites were associated with symptoms. For neurologic symptoms (decreased alertness, falling asleep during the day, forgetfulness, lack of pep and energy, and tiring easily/weakness), seven metabolites were associated with symptoms. Associations were consistent across sensitivity analyses. Thus, our proof-of-principle study demonstrates the potential for metabolomics to understand metabolic pathways associated with uremic symptoms. Larger, prospective studies with external validation are needed.

Health-Related Quality of Life Measurement in Public Health

Patient-reported outcomes are recognized as essential for the evaluation of medical and public health interventions. Over the last 50 years, health-related quality of life (HRQoL) research has grown exponentially from 0 to more than 17,000 papers published annually. We provide an overview of generic HRQoL measures used widely in epidemiological studies, health services research, population studies, and randomized clinical trials [e.g., Medical Outcomes Study SF-36 and the Patient-Reported Outcomes Measurement Information System (PROMIS^®)-29]. In addition, we review methods used for economic analysis and calculation of the quality-adjusted life year (QALY). These include the EQ-5D, the Health Utilities Index (HUI), the self-administered Quality of Well-being Scale (QWB-SA), and the Health and Activities Limitation Index (HALex). Furthermore, we consider hybrid measures such as the SF-6D and the PROMIS-Preference (PROPr). The plethora of HRQoL measures has impeded cumulative science because incomparable measures have been used in different studies. Linking among different measures and consensus on standard HRQoL measurement should now be prioritized. In addition, enabling widespread access to common measures is necessary to accelerate future progress. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Better health-related quality of life in kidney transplant patients compared to chronic kidney disease patients with similar renal function

Renal functional deterioration is associated with physical and mental burdens for kidney transplant (KT) and chronic kidney disease (CKD) patients. However, the change in health-related quality of life (HRQOL) over time in KT patients compared to that of native CKD patients has not been evaluated. We addressed this issue using KT patients registered in the KNOW-KT cohort study and patients at CKD stage 1–3 registered in the KNOW-CKD cohort study. HRQOL scores were assessed using the Kidney Disease Quality of Life Short Form at baseline, 2-, and 4-years follow-up in 842 KT patients and at baseline and 5-year follow-up in 1,355 CKD patients. SF-36 scores declined at the 4-year follow-up, whereas CKD-targeted scores showed no change in the KT group. In contrast, CKD-targeted scores as well as SF-36 scores were decreased at the 5-year follow-up in CKD patients. When prognostic factors were analyzed for longitudinal HRQOL data over time, renal functions, diabetes, cardiovascular and cerebrovascular diseases, hemoglobin level, marital status, income, employment, and health care were significant prognostic factors. Furthermore, KT was an independent prognostic factor for better HRQOL. These results highlight that KT can offer a better HRQOL than that of CKD patients, even when renal function is similar.

Kidney function and symptom development over time in elderly patients with advanced chronic kidney disease: results of the EQUAL cohort study

BACKGROUND

Initiation of renal replacement therapy often results from a combination of kidney function deterioration and symptoms related to chronic kidney disease (CKD) progression. We investigated the association between kidney function decline and symptom development in patients with advanced CKD.

METHODS

In the European Quality study on treatment in advanced CKD (EQUAL study), a European prospective cohort study, patients with advanced CKD aged ≥65 years and a kidney function that dropped <20 mL/min/1.73 m2 were followed for 1 year. Linear mixed-effects models were used to assess the association between kidney function decline and symptom development. The sum score for symptom number ranged from 0 to 33 and for overall symptom severity from 0 to 165, using the Dialysis Symptom Index.

RESULTS

At least one kidney function estimate with symptom number or overall symptom severity was available for 1109 and 1019 patients, respectively. The mean (95% confidence interval) annual kidney function decline was 1.70 (1.32; 2.08) mL/min/1.73 m2. The mean overall increase in symptom number and severity was 0.73 (0.28; 1.19) and 2.93 (1.34; 4.52) per year, respectively. A cross-sectional association between the level of kidney function and symptoms was lacking. Furthermore, kidney function at cohort entry was not associated with symptom development. However, each mL/min/1.73 m2 of annual kidney function decline was associated with an extra annual increase of 0.23 (0.07; 0.39) in the number of symptoms and 0.87 (0.35; 1.40) in overall symptom severity.

CONCLUSIONS

A faster kidney function decline was associated with a steeper increase in both symptom number and severity. Considering the modest association, our results seem to suggest that repeated thorough assessment of symptom development during outpatient clinic visits, in addition to the monitoring of kidney function decline, is important for clinical decision-making.

A study of quality of life among hemodialysis patients and its associated factors using kidney disease quality of life instrument-SF36 in Riyadh, Saudi Arabia

We aimed in this study to assess the quality of life for kidney-ill patients using Kidney Disease Quality of Life Instrument-SF36 (KDQOL-SF36) and the impact of other demographic, clinical, and social factors on patients' QOL. The quality of life was assessed using an Arabic version of KDQOL-36. The KDQOL-36 subscales Physical Component Summary (PCS), Mental Component Summary (MCS), Burden of Kidney Disease, and Effects of Kidney Disease were calculated. The effect of sex, diabetic status, diabetes mellitus, marital and status employment status, etc. on these subscales was evaluated. Reliability was determined by calculating Cronbach's alpha. A total of 254 patients were enrolled. The mean age was 58.2 (standard deviation 18.2) years; 61% were male, 56.7% diabetic and 20.1% were employed. The mean domain scores on the PCS, MCS, burden of kidney disease, and effects of kidney disease subscales were 49.4, 38.7, 52.6, and 37.2, respectively. Afternoon shift patients score highest among all shifts in MCS and PCS (P = 0.0001). The MCS score (38.7 ± 28.7) was significantly lower than PCS (49.4 ± 16.5) (P = 0.0001). The "effect of kidney disease" subscale was higher in males (P = 0.02), employed patients (P = 0.02), in the afternoon dialysis shift (0.0001). For PCS higher scores were seen in males (P = 0.0001), in non-diabetics (compared to diabetics) (P = 0,006), in the employed patients (P = 0.02). The highest score was seen in the "burden of kidney disease" subscale and the lowest in the "effects of kidney disease" subscale. Higher scores were seen in males, in nondiabetics, in the employed patients.

Low protein diets for non-diabetic adults with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is defined as reduced function of the kidneys present for 3 months or longer with adverse implications for health and survival. For several decades low protein diets have been proposed for participants with CKD with the aim of slowing the progression to end-stage kidney disease (ESKD) and delaying the onset of renal replacement therapy. However the relative benefits and harms of dietary protein restriction for preventing progression of CKD have not been resolved. This is an update of a systematic review first published in 2000 and updated in 2006, 2009 and 2018.

OBJECTIVES

To determine the efficacy of low protein diets in preventing the natural progression of CKD towards ESKD and in delaying the need for commencing dialysis treatment in non-diabetic adults.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 7 September 2020 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) or quasi RCTs in which adults with non-diabetic CKD (stages 3 to 5) not on dialysis were randomised to receive a very low protein intake (0.3 to 0.4 g/kg/day) compared with a low protein intake (0.5 to 0.6 g/kg/day) or a low protein intake compared with a normal protein intake (≥ 0.8 g/kg/day) for 12 months or more.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies and extracted data. For dichotomous outcomes (death, all causes), requirement for dialysis, adverse effects) the risk ratios (RR) with 95% confidence intervals (CI) were calculated and summary statistics estimated using the random effects model. Where continuous scales of measurement were used (glomerular filtration rate (GFR), weight), these data were analysed as the mean difference (MD) or standardised mean difference (SMD) if different scales had been used. The certainty of the evidence was assessed using GRADE.

MAIN RESULTS

We identified 17 studies with 2996 analysed participants (range 19 to 840). Four larger multicentre studies were subdivided according to interventions so that the review included 21 separate data sets. Mean duration of participant follow-up ranged from 12 to 50 months. Random sequence generation and allocation concealment were considered at low risk of bias in eleven and nine studies respectively. All studies were considered at high risk for performance bias as they were open-label studies. We assessed detection bias for outcome assessment for GFR and ESKD separately. As GFR measurement was a laboratory outcome all studies were assessed at low risk of detection bias. For ESKD, nine studies were at low risk of detection bias as the need to commence dialysis was determined by personnel independent of the study investigators. Five studies were assessed at high risk of attrition bias with eleven studies at low risk. Ten studies were at high risk for reporting bias as they did not include data which could be included in a meta-analysis. Eight studies reported funding from government bodies while the remainder did not report on funding. Ten studies compared a low protein diet with a normal protein diet in participants with CKD categories 3a and b (9 studies) or 4 (one study). There was probably little or no difference in the numbers of participants who died (5 studies 1680 participants: RR 0.77, 95% CI 0.51 to 1.18; 13 fewer deaths per 1000; moderate certainty evidence). A low protein diet may make little or no difference in the number of participants who reached ESKD compared with a normal protein diet (6 studies, 1814 participants: RR 1.05, 95% CI 0.73 to 1.53; 7 more per 1000 reached ESKD; low certainty evidence). It remains uncertain whether a low protein diet compared with a normal protein intake impacts on the outcome of final or change in GFR (8 studies, 1680 participants: SMD -0.18, 95% CI -0.75 to 0.38; very low certainty evidence). Eight studies compared a very low protein diet with a low protein diet and two studies compared a very low protein diet with a normal protein diet. A very low protein intake compared with a low protein intake probably made little or no difference to death (6 studies, 681 participants: RR 1.26, 95% CI 0.62 to 2.54; 10 more deaths per 1000; moderate certainty evidence). However it probably reduces the number who reach ESKD (10 studies, 1010 participants: RR 0.65, 95% CI 0.49 to 0.85; 165 per 1000 fewer reached ESKD; moderate certainty evidence). It remains uncertain whether a very low protein diet compared with a low or normal protein intake influences the final or change in GFR (6 studies, 456 participants: SMD 0.12, 95% CI -0.27 to 0.52; very low certainty evidence). Final body weight was reported in only three studies. It is uncertain whether the intervention alters final body weight (3 studies, 89 participants: MD -0.40 kg, 95% CI -6.33 to 5.52; very low certainty evidence).Twelve studies reported no evidence of protein energy wasting (malnutrition) in their study participants while three studies reported small numbers of participants in each group with protein energy wasting. Most studies reported that adherence to diet was satisfactory. Quality of life was not formally assessed in any studies.

AUTHORS' CONCLUSIONS

This review found that very low protein diets probably reduce the number of people with CKD 4 or 5, who progress to ESKD. In contrast low protein diets may make little difference to the number of people who progress to ESKD. Low or very low protein diets probably do not influence death. However there are limited data on adverse effects such as weight differences and protein energy wasting. There are no data on whether quality of life is impacted by difficulties in adhering to protein restriction. Studies evaluating the adverse effects and the impact on quality of life of dietary protein restriction are required before these dietary approaches can be recommended for widespread use.

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.

Particular aspects of gastroenterological disorders in chronic kidney disease and end-stage renal disease patients: a clinically focused review

Besides renal disease, gastrointestinal (GI) disorders are frequently reported in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). Related gastrointestinal symptoms tend to increase as the renal disease progresses. Also, in patients with ESRD, the modality of dialysis is related to particular forms of GI disorders.The kidney can interact with the digestive organs through functional endogenous systems such as the 'kidney-colon axis' and the 'kidney-liver axis'. Digestive diseases are one of the visible manifestations of the disturbance between hemostatic, hemodynamic and immunological balance in such patients.No clear management guidelines currently exist for many of the gastrointestinal problems that accompany renal failure. This review aims to describe the particular aspects of GI diseases present in CKD/ESRD. We focus our discussion in the specificities of epidemiology, diagnosis, and prognosis of such disorders between the different segments of the digestive system.

Outcome of kidney function after ischaemic and zero-ischaemic laparoscopic and open nephron-sparing surgery for renal cell cancer

Background

Nephron-sparing surgery (NSS) remains gold standard for the treatment of localised renal cell cancer (RCC), even in case of a normal contralateral kidney. Compared to radical nephrectomy, kidney failure and cardiovascular events are less frequent with NSS. However, the effects of different surgical approaches and of zero ischaemia on the postoperative reduction in renal function remain controversial.

We aimed to investigate the relative short- and long-term changes in estimated glomerular filtration rate (eGFR) after ischaemic or zero-ischaemic open (ONSS) and laparoscopic NSS (LNSS) for RCC, and to analyse prognostic factors for postoperative acute kidney injury (AKI) and chronic kidney disease (CKD) stage ≥3.

Methods

Data of 444 patients (211 LNSS, 233 ONSS), including 57 zero-ischaemic cases, were retrospectively analysed. Multiple regression models were used to predict relative changes in renal function. Natural cubic splines were used to demonstrate the association between ischaemia time (IT) and relative changes in renal function.

Results

IT was identified as significant risk factor for short-term relative changes in eGFR (ß = − 0.27) and development of AKI (OR, 1.02), but no effect was found on long-term relative changes in eGFR. Natural cubic splines revealed that IT had a greater effect on patients with baseline eGFR categories ≥G3 concerning short-term decrease in renal function and development of AKI. Unlike LNSS, ONSS was significantly associated with short-term decrease in renal function (ß = − 13.48) and development of AKI (OR, 3.87). Tumour diameter was associated with long-term decrease in renal function (ß = − 1.76), whereas baseline eGFR was a prognostic factor for both short- (ß = − 0.20) and long-term (ß = − 0.29) relative changes in eGFR and the development of CKD stage ≥3 (OR, 0.89).

Conclusions

IT is a significant risk factor for AKI. The short-term effect of IT is not always linear, and the impact also depends on baseline eGFR. Unlike LNSS, ONSS is associated with the development of AKI. Our findings are helpful for surgical planning, and suggest either the application of a clampless NSS technique or at least the shortest possible IT to reduce the risk of short-time impairment of the renal function, which might prevent AKI, particularly regarding patients with baseline eGFR category ≥G3.

Low protein diets for non-diabetic adults with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is defined as reduced function of the kidneys present for 3 months or longer with adverse implications for health and survival. For several decades low protein diets have been proposed for participants with CKD with the aim of slowing the progression to end-stage kidney disease (ESKD) and delaying the onset of renal replacement therapy. However the relative benefits and harms of dietary protein restriction for preventing progression of CKD have not been resolved. This is an update of a systematic review first published in 2000 and updated in 2006 and 2009.

OBJECTIVES

To determine the efficacy of low protein diets in preventing the natural progression of CKD towards ESKD and in delaying the need for commencing dialysis treatment in non-diabetic adults.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 2 March 2018 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) or quasi RCTs in which adults with non-diabetic chronic kidney disease (stages 3 to 5) not on dialysis were randomised to receive a very low protein intake (0.3 to 0.4 g/kg/d) compared with a low protein intake (0.5 to 0.6 g/kg/d) or a low protein intake compared with a normal protein intake (≥ 0.8 g/kg/d) for 12 months or more.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies and extracted data. For dichotomous outcomes (death, all causes), requirement for dialysis, adverse effects) the risk ratios (RR) with 95% confidence intervals (CI) were calculated and summary statistics estimated using the random effects model. Where continuous scales of measurement were used (glomerular filtration rate (GFR), weight), these data were analysed as the mean difference (MD) or standardised mean difference (SMD) if different scales had been used. The certainty of the evidence was assessed using GRADE.

MAIN RESULTS

We identified an additional six studies to include 17 studies with 2996 analysed participants (range 19 to 840). Four larger multicentre studies were subdivided according to interventions so that the review included 21 separate data sets. Mean duration of participant follow-up ranged from 12 to 50 months.Random sequence generation and allocation concealment were considered at low risk of bias in eleven and nine studies respectively. All studies were considered at high risk for performance bias as they were open-label studies. We assessed detection bias for outcome assessment for GFR and ESKD separately. As GFR measurement was a laboratory outcome all studies were assessed at low risk of detection bias. For ESKD, nine studies were at low risk of detection bias as the need to commence dialysis was determined by personnel independent of the study investigators. Five studies were assessed at high risk of attrition bias with eleven studies at low risk. Ten studies were at high risk for reporting bias as they did not include data which could be included in a meta-analysis. Eight studies reported funding from government bodies while the remainder did not report on funding.Ten studies compared a low protein diet with a normal protein diet in participants with CKD categories 3a and b (9 studies) or 4 (one study). There was probably little or no difference in the numbers of participants who died (5 studies 1680 participants: RR 0.77, 95% CI 0.51 to 1.18; 13 fewer deaths per 1000; moderate certainty evidence). A low protein diet may make little or no difference in the number of participants who reached ESKD compared with a normal protein diet (6 studies, 1814 participants: RR 1.05, 95% CI 0.73 to 1.53; 7 more per 1000 reached ESKD; low certainty evidence). It remains uncertain whether a low protein diet compared with a normal protein intake impacts on the outcome of final or change in GFR (8 studies, 1680 participants: SMD -0.18, 95% CI -0.75 to 0.38; very low certainty evidence).Eight studies compared a very low protein diet with a low protein diet and two studies compared a very low protein diet with a normal protein diet. A very low protein intake compared with a low protein intake probably made little or no difference to death (6 studies, 681 participants: RR 1.26, 95% CI 0.62 to 2.54; 10 more deaths per 1000; moderate certainty evidence). However it probably reduces the number who reach ESKD (10 studies, 1010 participants: RR 0.65, 95% CI 0.49 to 0.85; 165 per 1000 fewer reached ESKD; moderate certainty evidence). It remains uncertain whether a very low protein diet compared with a low or normal protein intake influences the final or change in GFR (6 studies, 456 participants: SMD 0.12, 95% CI -0.27 to 0.52; very low certainty evidence).Final body weight was reported in only three studies. It is uncertain whether the intervention alters final body weight (3 studies, 89 participants: MD -0.40 kg, 95% CI -6.33 to 5.52; very low certainty evidence).Twelve studies reported no evidence of protein energy wasting (malnutrition) in their study participants while three studies reported small numbers of participants in each group with protein energy wasting. Most studies reported that adherence to diet was satisfactory. Quality of life was not formally assessed in any studies.

AUTHORS' CONCLUSIONS

This review found that very low protein diets probably reduce the number of people with CKD 4 or 5, who progress to ESKD. In contrast low protein diets may make little difference to the number of people who progress to ESKD. Low or very low protein diets probably do not influence death. However there are limited data on adverse effects such as weight differences and protein energy wasting. There are no data on whether quality of life is impacted by difficulties in adhering to protein restriction. Studies evaluating the adverse effects and the impact on quality of life of dietary protein restriction are required before these dietary approaches can be recommended for widespread use.

Assessment of quality of life in patients undergoing hemodialysis using WHOQOL-BREF questionnaire: a multicenter study

Background

Assessment of quality of life (QOL) of patients with end-stage renal disease has become increasingly important, both in order to evaluate the influence of the disease on patients and the type of renal replacement therapy they require. Therefore, in this study, we aimed to assess QOL in patients undergoing hemodialysis and evaluated the effects of various sociodemographic factors affecting QOL of such patients in Nepal.

Methods

A cross-sectional study was conducted among 150 patients with chronic kidney disease undergoing hemodialysis at two major centers in Nepal. Demographic data including age, sex, ethnicity, educational status, marital status, employment, income, duration of illness, and duration on hemodialysis were collected. QOL was assessed using the World Health Organization Quality of life (WHOQOL-BREF) questionnaire. Four domains (physical, psychological, social, and environmental) and two items (overall perception of QOL and health) of the WHOQOL-BREF were the primary end points of this study. Bivariate relationship between sociodemographic factors and QOL scores were analyzed using independent samples t-test and one-way analysis of variance. Multiple linear regression analysis was performed to determine independent predictors of QOL.

Results

Following QOL scores were recorded: environmental domain (53.17±15.59), psychological domain (51.23±18.61), social domain (49.86±21.64), and physical domain (45.93±16.90). Older age was associated with a better QOL score in the social domain (p=0.005), and employed patients scored better in the environmental domain (p=0.019). Unemployed patients and those of the Terai/Madhesi ethnic group had significantly low scores in overall perception of health (p<0.05) as compared to other groups. Low income status and increased duration on hemodialysis were found to be the only independent negative predictors of QOL in patients with hemodialysis (p<0.05).

Conclusion

Patients with chronic kidney disease on dialysis had overall low QOL scores in all four domains. Age, ethnicity, employment status, income, and duration on hemodialysis affected one or more domains of QOL in such patients. Low income status and increased duration on hemodialysis were the only independent negative predictors of QOL of patients on maintenance hemodialysis.

Association between vitamin D deficiency and health-related quality of life in patients with chronic kidney disease from the KNOW-CKD study

Vitamin D deficiency is a growing health problem in both the general population and in patients with chronic kidney disease (CKD). However, the relationship between serum 25-hydroxyvitamin D levels and health-related quality of life in CKD is not well established. This study examined the association between vitamin D deficiency and quality of life in pre-dialysis CKD patients. Serum 25-hydroxyvitamin D levels and the Korean version of the Kidney Disease Quality of Life short form were obtained for 1844 pre-dialysis CKD patients in the prospective KoreaN cohort Study for Outcomes in patients With Chronic Kidney Disease (KNOW-CKD). The baseline estimated glomerular filtration rate was 50.26 ± 0.71 mL/min/1.73 m2. We identified 1294 (70.2%) patients with vitamin D deficiency, defined as a 25-hydroxyvitamin D level < 20 ng/ml. The scores of the kidney disease component summary, physical component summary, and mental component summary in the vitamin D deficiency group were significantly lower compared to the scores of those without vitamin D deficiency. The serum 25-hydroxyvitamin D level was independently associated with the kidney disease component summary and mental component summary scores (β = 0.147, p = 0.003 and β = 0.151, p = 0.047). In conclusion, there was a significant association between serum 25-hydroxyvitamin D levels and kidney disease component summary and mental component summary scores in pre-dialysis CKD patients.

Quality of life development during initial hemodialysis therapy and association with loss of residual renal function

INTRODUCTION

Health related quality of life (HRQOL) is markedly reduced in hemodialysis patients compared to the general population. We investigated the course of self-reported HRQOL over time and the association with selected factors, focusing on changes in glomerular filtration rate (GFR).

METHODS

Eighty-two newly started hemodialysis patients from the SAFIR cohort filled out the Kidney Disease Quality of Life Short Form Version 1.3 (KDQOL-SF^TM ) questionnaire at baseline, 6 and 12 months. The SAFIR study was a randomized, placebo-controlled, double-blind intervention study, examining the effects of the angiotensin II receptor blocker irbesartan. HRQOL was a secondary outcome measure. Main inclusion criteria: Dialysis vintage <1 year, left ventricular ejection fraction >30% and urinary output >300 mL/day. GFR was measured with mean creatinine and urea clearance from 24-hour urine collections at baseline, 6 and 12 months.

FINDINGS

Irbesartan treatment did not affect HRQOL. Patients were pooled into one group for further analyses. Decline in GFR correlated significantly with decreasing HRQOL over time. HRQOL was stable over time, with a slight nonsignificant tendency toward improved HRQOL. The largest HRQOL-differences (positive values equal improved HRQOL) observed during the 12 month study period were (mean[95% confidence interval]): Burden of kidney disease:6.4[-2.2;15.0], Role limitations-physical:12.7[-2.1;27.5], and Role limitations-emotional:9.7[-5.2;24.6]. Comorbidity, especially diabetes, hospital admissions, female gender, and age were strongly associated with lower HRQOL in cross sectional analysis.

DISCUSSION

Preservation of residual renal function seems to be important for HRQOL. In newly started HD patients, HRQOL showed little change after 12 months. HRQOL was negatively affected by comorbidity, especially diabetes, hospital admissions, female gender, and age.

Health-related quality of life assessment in end-stage renal failure

End-stage renal failure (ESRF) is a life-threatening condition and survival can be maintained only with renal replacement therapy. Furthermore, the complications of ESRF, its treatment and co-existing diseases have been found to have a significant impact on the physical health of patients. It is well documented that the health status of the renal patient population is worse than that of the general healthy population; for this reason the assessment of quality of life of ESRF patients has received considerable attention.

During the 1990s, the focus of health assessment moved away from the disease itself towards health status and wellbeing. The widespread use of the 36-item short-form (SF-36) questionnaire has promoted this. In ESRF studies from data using the SF-36 questionnaire it has been shown that it is the physical functional component of health that is most affected by the patient's condition, with co-morbidity having a significant impact.

There is growing consensus that health-related quality of life is more than just an assessment of health status. Rather, it is the relative importance given by the individuals themselves to the impact of the disease on their life. While this approach is emerging, some of the tools which have been developed to measure individualised quality of life require further scientific validation for use with the ESRF population.

Religiosity and Health-Related Quality of Life: A Cross-Sectional Study on Filipino Christian Hemodialysis Patients

This study aimed to measure the religiosity and health-related quality of life of Filipino Christian HD patients. A cross-sectional study of 100 HD patients was conducted. The Duke University Religion Index and the Ferrans and Powers QLI Dialysis Version-III were used. Data were analyzed using descriptive statistics and Pearson r correlation. Attendance to organizational religious activities and NORA were found to be correlated with some of the dimensions of HRQoL. Intrinsic religiosity showed a strong, positive correlation with HRQoL. It is essential to attend to and nourish their religious needs. Holistic approach in providing care to HD patients, with emphasis on spiritual care, is encouraged to improve their total health.

Gastrointestinal symptoms, inflammation and hypoalbuminemia in chronic kidney disease patients: a cross-sectional study

Background

Few studies have focused on investigating hypoalbuminemia in patients during earlier stages of chronic kidney disease (CKD). In particular, little is known about the role of gastrointestinal (GI) symptoms. Our goal in this paper is to study how GI symptoms relate to serum albumin levels in CKD, especially in the context of and compared with inflammation.

Methods

We performed a cross-sectional study of 3599 patients with chronic kidney disease enrolled in the Chronic Renal Insufficiency Cohort (CRIC) study. All subjects were asked to complete the Modification of Diet in Renal Disease (MDRD) study patient symptom form. Our main predictor is GI symptom score. Serum level of C-reactive protein (CRP) was measured as well. Main outcome measures are serum albumin levels and prevalence of hypoalbuminemia.

Results

Of the participants assessed, mean serum albumin was 3.95 ± 0.46 g/dL; 12.7 % had hypoalbuminemia. Patients with lower estimated glomerular filtration rate (eGFR) were likely to have more GI symptoms (apparent at an eGFR <45 ml/min/1.73 m²). Patients with worse GI symptoms had lower dietary protein intake. GI symptoms, like inflammation, were risk factors for lower serum albumin levels. However, adding GI symptom score or CRP into the multivariable regression analysis, did not attenuate the association between lower eGFR and lower albumin or hypoalbuminemia.

Conclusions

Increased prevalence of GI symptoms become apparent among CKD patients at relatively high eGFR levels (45 ml/min/1.73 m²), long before ESRD. Patients with more severe GI symptoms scores are more likely to have hypoalbuminemia. But our data do not support GI symptoms/decreased protein intake or inflammation as being the main determinants of serum albumin level in CKD patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-015-0209-z) contains supplementary material, which is available to authorized users.

Quality of well-being outcomes in the National Emphysema Treatment Trial

BACKGROUND

Surgical and medical treatments for emphysema may affect both quality and quantity of life. The purpose of this article is to report outcomes from the National Emphysema Treatment Trial (NETT) using an index that combines quality and quantity of life.

METHODS

This was a prospective randomized clinical trial. Following pulmonary rehabilitation, 1,218 patients with severe emphysema were randomly assigned to maximal medical therapy or to lung volume reduction surgery (LVRS). A generic quality-of-life measure, known as the Quality of Well-being Scale (QWB), was administered at baseline and again at 6, 12, 24, 36, 48, 60, and 72 months following treatment assignment.

RESULTS

At baseline, QWB scores were comparable for the Medical and LVRS groups. For both groups, scores significantly improved following the rehabilitation program. The QWB scores before death for patients in the LVRS group improved up to the year 2 visit, whereas scores for the Medical group dropped significantly following the baseline visit. Imputing zeros (0) for death, QWB scores decreased significantly for both groups. With or without scoring death as 0, the LVRS group achieved better outcomes, and the significant differences were maintained until the sixth year. Over 6 years of follow-up, LVRS produced an average of 0.30 quality-adjusted life years (QALYs), or the equivalent of about 3.6 months of well life.

CONCLUSIONS

Compared with maximal medical therapy alone, patients undergoing maximal medical therapy plus LVRS experienced improved health-related quality of life and gained more QALYs.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00000606; URL: www.clinicaltrials.gov.

Impact of chronic kidney disease and anemia on physical function in patients with chronic heart failure

OBJECTIVE

The aim of this study was to confirm the effects of chronic kidney disease (CKD) and anemia on physical function and to clarify whether the interaction between CKD and anemia has an additive effect.

DESIGN

Eligible subjects were chronic heart failure (HF) patients who were discharged between March 2007 and August 2009. A total of 102 chronic HF patients (33% females; mean age: 68 ± 14 years) were enrolled in the present study. CKD was defined as an estimated glomerular filtration rate of <60 ml/min/1.73 m(2), and anemia was defined as a hemoglobin level of <12 g/dl in males and of <11 g/dl in females. The Short Physical Performance Battery (SPPB) was used to assess physical function.

RESULTS

The adjusted mean SPPB score was lower in patients with both CKD and anemia than in those with neither of the diseases or with either disease alone (p < 0.05).

CONCLUSION

This study found that CKD and anemia are independently associated with reduced physical function.

Mild chronic kidney disease and functional impairment in community-dwelling older adults

BACKGROUND

chronic kidney disease (CKD) has been associated with an increased risk of death and cardiovascular events, but its relationship with non-vascular outcomes, including functional impairment (FI), is less well understood.

OBJECTIVE

in this study, we review the association between CKD and FI, adjusting for potential confounders and risk factors, with a primary outcome of impairment in any instrumental ADL (IADL) or basic ADL (BADL).

DESIGN

the Cardiovascular Multimorbidity in Primary Care Study (CLARITY) is a cross-sectional study of community-dwelling adults.

SETTING

participants were adults living in the West of Ireland attending university-affiliated general practices.

SUBJECTS

all participants were adults aged ≥50 years living in the community.

METHODS

CKD was defined as an estimated glomerular filtration rate (eGFR) ≤60 ml/min/1.73 m(2). A standardised self-reported health questionnaire to measure activities of daily living (ADL) was completed by participants. Logistic regression analyses were used to determine the independent association between CKD and FI.

RESULTS

a total of 3,499 patients were included with a mean age of 66.2 ± 10.3 years. 18.0% (n = 630) had CKD (mean eGFR 50.2 ± 9.2 ml/min/1.73m(2)), 21.9% (n = 138) of which had a diagnosis of CKD documented in medical records. 40.4% (n = 1,413) reported FI and multivariable adjustment showed CKD to be independently associated with FI (OR: 1.43, 1.15-1.78), impairment in IADL (OR: 1.43, 1.15-1.78) and impairment in BADL (OR: 1.39, 1.11-1.75).

CONCLUSION

our study shows even mild CKD is associated with FI, independent of age, gender, co-morbidities, traditional vascular risk factors and cardiovascular events.

Relationship between psychiatric disorders and quality of life in nondialysis patients with chronic kidney disease

BACKGROUND

The aim of this study was to investigate the relationship between psychiatric disorders (anxiety and depression) and quality of life (QOL) in nondialysis patients with chronic kidney disease (CKD).

METHODS

QOL was evaluated in a sample of 57 nondialysis patients with CKD using the 36-item Short Form Health Survey questionnaire comprising 8 scales, including the physical component summary and mental component summary measures. Depression and anxiety were estimated using the Hamilton Depression Rating Scale and Hamilton Anxiety Rating Scale, respectively.

RESULTS

Depression and anxiety scores were negatively correlated with 7 of the 8 scales of the Short Form 36 questionnaire, and with the physical component summary and mental component summary scores, despite 38.6% patients with depression and 54.4% with anxiety, whereas QOL in the depression group, the anxiety group, and the anxiety and depression comorbid group was lower than that for those without the corresponding psychiatric disorders (P < 0.05).

CONCLUSIONS

This study demonstrates that depression and anxiety, commonly encountered in patients with CKD, could be a risk factor for QOL in these patients.

Prognostic Factors Influencing Postoperative Development of Chronic Kidney Disease in Patients with Small Renal Tumors who Underwent Partial Nephrectomy

BACKGROUND

The objective of this study was to determine factors associated with the postoperative development of chronic kidney disease (CKD) following partial nephrectomy.

PATIENTS AND METHODS

This study included 109 patients with normal renal function treated with partial nephrectomy for small renal tumors. Of these, 73 and 36 patients underwent open partial nephrectomy (OPN) and laparoscopic partial nephrectomy (LPN), respectively.

RESULTS

Among several parameters, there was a significant difference only in the ischemia time between the OPN and LPN groups. During the median observation period of 53.4 months, CKD, defined as estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m(2), developed in 29 (39.7%) and 14 (38.9%) patients in the OPN and LPN groups, respectively. Univariate analysis identified age at surgery, diabetes and preoperative eGFR as significant predictors of the postoperative development of CKD; however, only age at surgery and preoperative eGFR appeared to be independently related to CKD-free survival. In fact, there was a significant difference in the CKD-free survival between patients without any independent risk factor and those with at least one of these independent risk factors.

CONCLUSIONS

Careful management following partial nephrectomy is necessary for elderly patients and/or those with impaired renal function, even mild, before surgery.

Altered taste perception and nutritional status among hemodialysis patients

OBJECTIVE

The objective of this study was to examine the association between altered taste perception and nutritional status among hemodialysis patients.

DESIGN

We performed a post hoc analysis of data from the Hemodialysis study (n = 1,745). Taste perception was assessed at baseline and then updated annually using an item from a quality of life survey that asked "During the past 4 weeks, to what extent were you bothered by loss of taste?" Responses were categorized as normal taste perception if subjects answered "not at all" or altered taste perception if they reported any degree of bother. Time-updated logistic regression models were used to evaluate predictors of altered taste perception. Time-updated linear regression models were used to examine the association between altered taste perception and indices of nutritional status. Multivariable proportional hazards and Poisson models were used to assess association between altered taste perception and mortality and hospitalization, respectively.

RESULTS

At baseline, 34.6% reported altered taste perception, which was associated with poorer baseline nutritional status. On time-updated analysis, altered taste perception was associated with a persistently higher proportion of subjects requiring enteral nutritional supplements and lower serum albumin, serum creatinine, normalized protein catabolic rate, protein intake, sodium intake, and mid-arm muscle circumference. Altered taste perception at baseline was independently associated with increased all-cause mortality: adjusted hazard ratio (95% confidence interval) of 1.17 (1.01-1.37), although not with increased rate of hospitalization.

CONCLUSION

Altered taste perception was common among prevalent hemodialysis patients and was independently associated with poorer indices of nutritional status and increased all-cause mortality.

Evaluation of physical symptoms in patients on peritoneal dialysis

Introduction. Little is known about physical symptoms in peritoneal dialysis (PD) Patients. This study aims to determine the prevalence of symptoms (general and abdominal) in PD patients. Methods. A cross-sectional study, with subsequent followup, using an author-designed 21 symptoms questionnaire (15 nonabdominal and 6 abdominal). Each symptom was assessed on a scale 0-3 for severity (none-severe) and frequency (never-every day). Results. We studied 41 patients, mean age 60 ± 15 years, 56% male, 19.5% diabetics, and 51.5% on APD. Mean number of symptoms was 9.5 ± 3.9 and total symptoms score was 28.5 ± 12 with abdominal scores of 6.4 ± 4.8. Most frequent symptoms were lack of energy, itching, cramps, poor sleep, and loss of appetite. A second evaluation in 20 patients disclosed no statistical difference between the first and second assessments, or between subgroups. Cramps were the only symptoms which decreased over time (P = 0.120). Lack of energy did not correlate with haemoglobin, neither did itching with phosphate level. Conclusions. Physical symptoms are frequent and troublesome; they relate to advanced kidney disease and not specifically to PD. Symptoms remain stable over time and do not appear to relate to dialysis parameter markers.

Symptoms characteristic of heart failure among CKD patients without diagnosed heart failure

BACKGROUND

Epidemiological studies typically diagnose heart failure (HF) at the time of hospitalization, and have not evaluated the prevalence of HF symptoms in CKD patients without a prior HF diagnosis.

METHODS AND RESULTS

We modified the Kansas City Cardiomyopathy Questionnaire (KCCQ) to detect and quantify symptoms characteristic of HF (dyspnea, edema, and fatigue) among 2883 chronic kidney disease (CKD) patients without diagnosed heart failure in the Chronic Renal Insufficiency Cohort (CRIC). The KCCQ is a 23-item instrument that quantifies the impact of dyspnea, fatigue, and edema on physical, social, and emotional functions (scored 0 to 100). The median KCCQ score was 92, and 25% had KCCQ scores <75. Compared with cystatin C‑based estimated glomerular filtration rate >50 mL·min·1.73 m(2) (reference), estimated glomerular filtration rate 40 to 50, 30 to 40, and <30 were independently associated with lower KCCQ scores (<75); adjusted odds ratios and (95% CI): 1.38 (1.06-1.78), 1.39 (1.09-1.82), and 2.15 (1.54-3.00), respectively. Lower hemoglobin (Hb) levels also had independent associations with KCCQ <75: Hb >14 g/dL (reference), Hb 13 to 14 g/dL (1.03; 0.76-1.40), Hb 12 to 13 g/dL (1.41; 1.04-1.91), Hb 11 to 12 g/dL (1.56; 1.12-2.16); and Hb <1 g/dL (1.65; 1.15-2.37).

CONCLUSION

CKD patients without diagnosed HF have a substantial burden of symptoms characteristic of HF, particularly among those with lower estimated glomerular filtration rate and hemoglobin levels.

Depression, screening and quality of life in chronic kidney disease

INTRODUCTION

To determine the prevalence of positive screens for depression and to assess quality of life (QoL) and usefulness of the brief and easily administered Patient Health Questionnaire-2 (PHQ-2) for depression screening in the chronic kidney disease (CKD) population; and to explore the relationship between depressive symptoms and markers of inflammation.

METHODS

Seventy-one adult patients with estimated glomerular filtration rate <60 mL/min/1.73 m or proteinuria, but not on dialysis, were enrolled. QoL was assessed using the Short Form-36. The Center for Epidemiological Studies Depression Scale (CES-D) and PHQ-2 were used to screen for depression. Serum ferritin, albumin, C-reactive protein and hematocrit were also measured as markers of inflammation.

RESULTS

The PHQ-2 and CES-D were significantly correlated (P < 0.05). Positive scores on the CES-D or PHQ-2 had significantly lower Short Form-36 scores. Mean hemoglobin values were significantly lower in patients who screened positive for depression either by CES-D (12.2 ± 1.7 versus 13.2 ± 1.7, P < 0.05) or by PHQ-2 (12 ± 1.6 versus 13.4 ± 1.6, P < 0.01). Neither PHQ-2 nor CES-D correlated with other markers of inflammation in this sample.

CONCLUSION

Both the CES-D and the PHQ-2 can identify patients with CKD who need further evaluation for depression. The PHQ-2 seems to be a useful screen for depression and impaired QoL in a renal clinic setting. Patients with CKD and lower hemoglobin may be at greater risk for depression than those with normal values.

Impaired renal function is associated with worse self-reported outcomes after kidney transplantation

PURPOSE

We sought to determine the association between health-related quality of life (HRQOL) and graft function in renal transplant recipients.

DESIGN AND METHODS

We enrolled 577 kidney transplant recipients aged 18-74 years (response rate 87%). Recipients with multiple or multi-organ transplantation, creatine kinase >200 U/L, acute renal failure or cellular rejection (n = 64), and without creatinine assessments in 3 months pre-enrollment (n = 127) were excluded. The questionnaire included Euro QOL 5 Dimensions (EQ-5D), Health Utility Index III (HUI-III), Kidney Disease Quality of Life-36 (KDQOL36) which include a generic section (RAND SF-12). Data on medical conditions, therapy regimens, and biochemistry results were extracted from clinical charts. We used general linear models adjusted for demographic, socioeconomic, and clinical characteristics to assess the association between HRQOL and severity of chronic kidney disease (CKD).

RESULTS

Patients with more advanced CKD were more likely to be African-American, covered by public insurance, more likely to have shorter time after transplantation, higher phosphorus and lower hemoglobin, serum albumin, and calcium levels. All HRQOL scales were inversely associated with CKD severity. All associations were robust to adjustment for possible confounders.

CONCLUSIONS

Several health-related quality of life dimensions may be affected by poor renal function after transplantation.

Performance-based functional assessment of patients undergoing transcatheter aortic valve implantation

BACKGROUND

Very few data exist on the functional evaluation of patients with severe symptomatic aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). The aims of this prospective study were (1) to evaluate the Duke Activity Status Index (DASI) as a measure of functional status pre-TAVI and post-TAVI, (2) to determine the clinical parameters associated with DASI changes after TAVI, and (3) to compare functional status as evaluated by DASI and the New York Heart Association (NYHA) class with exercise capacity as evaluated by the 6-minute walk test (6MWT) in such patients.

METHODS

A total of 76 patients (80 ± 8 years old) who underwent successful TAVI were included. All patients completed the DASI self-questionnaire at baseline and at 6 months after TAVI, and 46 patients also performed a 6MWT.

RESULTS

The mean DASI increased from 10.3 ± 5.4 to 16.3 ± 8.3 at 6 months after TAVI (P < .0001). However, the DASI did not change or even decreased to some extent in 30% of patients after TAVI. Renal dysfunction as evaluated by the estimated glomerular filtration rate was identified as the independent predictor of DASI impairment after TAVI (OR 1.7 for each decrease in estimated glomerular filtration rate of 10 mL/min/1.73 m(2), 95% CI 1.3-2.3, P = .005). The mean distance walked increased from 165.9 ± 77.6 to 211.8 ± 78.7 m (P = .0001) at follow-up. The DASI showed a good correlation with the distance walked at baseline (r = 0.55, P < .0001) and at follow-up (r = 0.66, P < .0001). The NYHA class improved to some degree in all but 5 patients; however, the NYHA class did not correlate with the results of DASI and the 6MWT.

CONCLUSIONS

Transcatheter aortic valve implantation was associated with a significant increase in functional status at 6-month follow-up as evaluated by the DASI, although no improvement was observed in about one third of patients. The presence of baseline renal dysfunction better determined this lack of improvement in functional status. The DASI, but not the NYHA class, correlated with distance walked in the 6MWT. These results suggest that the DASI might become a useful tool for evaluating both candidates for and the impact of TAVI procedures.

Longitudinal association of depressive symptoms with rapid kidney function decline and adverse clinical renal disease outcomes

BACKGROUND AND OBJECTIVES

Depression is a risk indicator for adverse outcomes in dialysis patients, but its prognostic impact in individuals who are not yet on dialysis is unknown. This study examines whether depressive symptoms are longitudinally associated with renal function decline, new-onset chronic kidney disease (CKD), ESRD, or hospitalization with acute kidney injury (AKI).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Depressive symptoms were measured in a longitudinal cohort study with the 10-item Centers for Epidemiologic Studies Depression scale using a previously validated cut-off value (≥8). CKD at study entry and during follow-up was defined as an estimated GFR (eGFR) < 60 ml/min per m(2). Outcomes were rapid decline in eGFR (>3 ml/min per m(2) per year), new-onset CKD, ESRD (U.S. Renal Data System-based), and AKI (based on adjudicated medical record review). The median follow-up duration was 10.5 years.

RESULTS

Depressed participants (21.2%) showed a higher prevalence of CKD at baseline compared with nondepressed participants in multivariable analysis. Depression was associated with a subsequent risk of rapid decline in eGFR, incident ESRD, and AKI, but not incident CKD in unadjusted models. In multivariable analyses, only associations of depressive symptoms with AKI remained significant.

CONCLUSIONS

Elevated depressive symptoms are associated with subsequent adverse renal disease outcomes. The depression-related elevated risk of AKI was independent of traditional renal disease risk factors and may in part be explained by the predictive value of depression for acute coronary syndromes and heart failure hospitalizations that can be complicated by AKI.

Perceived social support and quality of life in Iranian hemodialysis patients

PURPOSE

To describe the relationship between perceived social support and the quality of life in hemodialysis patients from an Islamic cultural background in Iran.

DESIGN

A cross-sectional, correlational design was used. Data were collected in hemodialysis units affiliated to Iran University of Medical Sciences. Two hundred and two Muslim hemodialysis patients were selected by census during 2007.

METHODS

The Persian versions of the Personal Resources Questionnaire 85 (PRQ-85) Part II and the Ferrans and Powers Quality of Life Index-dialysis version were used. The data were analyzed using chi-square test and Spearman's rho correlation coefficients.

FINDINGS

There were a statistically significant relationship between perceived social support and health-functioning (r = .65, p < or = .05), socioeconomic (r = .67, p < or = .05), psychological-spiritual (r = .63, p < or = .05), and family subscales of quality of life (r = .51, p < or = .05). Total quality of life was also significantly correlated with perceived social support (r = 0.72, p= .00).

CONCLUSIONS

Perceived social support is associated with quality of life in Iranian hemodialysis patients.

CLINICAL RELEVANCE

It is important to reflect on the impact of culture and religion of Iran on quality of life of hemodialysis patients and their perceived social support.

Health-related quality of life in hypertension, chronic kidney disease, and coexistent chronic health conditions

With the increasing prevalence of hypertension, there has been a growing interest in understanding the health-related quality of life (HRQOL) of patients with hypertension. Although hypertension is often perceived as asymptomatic, it is associated with impaired HRQOL because of complications or comorbidities, awareness of the diagnosis, and adverse effects from antihypertensive medications. This article focuses on the literature published since 2000, on HRQOL in elderly hypertensive individuals as well as hypertensives with co-existent diseases, including chronic kidney disease, cardiovascular disease, and diabetes mellitus. Most of the studies found that hypertensive individuals with co-existent co-morbidities tend to have lower HRQOL than those with hypertension alone, and identified the number of co-morbid illnesses as an independent determinant of HRQOL. The most pronounced effect was noted in the physical function domains of HRQOL. Studies have also examined the effects on HRQOL of specific classes of antihypertensive drugs without specific demonstration of superiority of one drug class over another in terms of HRQOL measures. Although there is evidence in favor of angiotensin-converting enzyme-inhibition for improving renal and cardiovascular outcomes in hypertensive patients, its role in ameliorating HRQOL outcomes remains to be established.

Physical and psychological burden of chronic kidney disease among older adults

INTRODUCTION

The purpose of the study is to determine if functional status and quality of life (QoL) vary with glomerular filtration rate (GFR) among older adults.

METHODS

We studied adults aged 45 years and older participating in the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort study. Data included demographic and health information, serum creatinine and hemoglobin, the 4-item Center for Epidemiologic Studies Depression Scale (CES-D-4), the 4-item Cohen's Perceived Stress Scale (PSS-4), reported health status and inactivity and the Medical Outcomes Study Short Form-12 (SF-12) QoL scores.

RESULTS

CKD (GFR <60 ml/min/1.73 m(2)) was present in 11.6% of the subjects. As GFR declined, the SF-12 physical component score, adjusted for other participant attributes, declined from 38.9 to 35.9 (p = 0.0001). After adjustment for other risk factors, poorer personal health scores (p < 0.0001) and decreased physical activity (p < 0.0001) were reported as GFR declined. In contrast, after adjusting for other participant characteristics, depression scores and stress scores and the mental component score of the SF-12 were not associated with kidney function.

CONCLUSION

Older individuals with CKD in the US population experience an increased prevalence of impaired QoL that cannot be fully explained by other individual characteristics.

The Minimally Clinically Important Difference in Generic Utility-Based Measures

PURPOSE

To evaluate the use of utility-based generic quality of life measures for establishing the minimally clinically important difference (MCID).

BACKGROUND

Utility-based quality of life measures place levels of wellness on a continuum anchored by death (0.00) and optimum function (1.00). Preference measurement studies are used to define the meaning of points along the continuum. Health states that differ by less than 0.03 units cannot be discriminated by panels of judges as different from one another. Thus, 0.03 is a reasonable MCID for these measures.

METHOD

Three published studies of patients with Chronic Obstructive Pulmonary Disease (COPD) reported data on the Quality of Well-being Scale (QWB) before and after pulmonary rehabilitation. One of the studies also randomly assigned patients to lung volume reduction surgery or to maximal medical therapy. These patients were followed for an average of 29 months.

RESULTS

All three evaluations of pulmonary rehabilitation showed changes on the QWB in excess of the proposed 0.03 MCID. QWB changes for patients assigned to lung volume reduction surgery were close to the MCID threshold at one year but grew stronger in subsequent years. Using Norman's 0.50 standard deviation method, all three estimates of rehabilitation effectiveness and the outcomes one year following surgery fall below the MCID.

CONCLUSION

Different methods for estimating MCID lead to different conclusions about the meaning of quality of life changes following pulmonary rehabilitation and lung volume reduction surgery. The preference scaling system in generic utility-based quality of life measures provides a metric that is directly interpretable and avoids many of the criticisms of MCID measures. The method is sensitive enough to suggest clinically meaningful benefits of rehabilitation and surgery. Further, quality adjusted life years offer a valuable metric for policy analysis. Utility-based measures of health related quality of life should gain greater use in COPD outcomes research.

Quality of life in simultaneous pancreas-kidney transplant recipients

BACKGROUND

Simultaneous pancreas-kidney transplantation (SPK Tx) allows dialysis and insulin therapy to be discontinued and improves the complications of diabetes mellitus type 1 (DM1). This study measure quality of life (QoL) in SPK transplant recipients and determine if there are differences in QoL between these patients and those with DM1 in renal replacement therapy (RRT).

METHODS

Short Form Health Survey 36-Item (SF-36) was administered to 69 SPK transplant recipients and 34 patients with DM1 under RRT. A descriptive analysis, multiple linear regression, ANOVA, and ordinal regression (PLUM) models were constructed.

RESULTS

QoL was higher in SPK transplant recipients than in patients receiving RRT. The best results were in the recently transplanted patients. Respect to Spanish population the men with SPK transplants scored higher on vitality and lower on general health, role limitations-physical and role limitations-emotional. Women with SPK transplants scored lower on general health. Among patients under RRT, men scored lower on the general health, physical functioning, vitality, and bodily pain while women scored lower on all dimensions. In both groups, greater age was associated with better mental health.

CONCLUSION

Positive predictive factors of QoL are SPK Tx and age while negative predictive factors are female sex and RRT.

Health-related quality of life in CKD Patients: correlates and evolution over time

BACKGROUND AND OBJECTIVES

Very few large-scale studies have investigated the determinants of health-related quality of life (HRQOL) in chronic kidney disease (CKD) patients not on dialysis or the evolution of HRQOL over time.

DESIGN AND SETTING

A prospective evaluation was undertaken of HRQOL in a cohort of 1186 CKD patients cared for in nephrology clinics in North America. Baseline and follow-up HRQOL were evaluated using the validated Kidney Disease Quality Of Life instrument.

RESULTS

Baseline measures of HRQOL were reduced in CKD patients in proportion to the severity grade of CKD. Physical functioning score declined progressively with more advanced stages of CKD and so did the score for role-physical. Female gender and the presence of diabetes and a history of cardiovascular co-morbidities were also associated with reduced HRQOL (physical composite score: male: 41.0 +/- 10.2; female: 37.7 +/- 10.8; P < 0.0001; diabetic: 37.3 +/- 10.6; nondiabetic: 41.6 +/- 10.2; P < 0.0001; history of congestive heart failure, yes: 35.4 +/- 9.7; no: 40.3 +/- 10.6; P < 0.0001; history of myocardial infarction, yes: 36.1 +/- 10.0; no: 40.2 +/- 10.6; P < 0.0001). Anemia and beta blocker usage were also associated with lower HRQOL scores. HRQOL measures declined over time in this population. The main correlates of change over time were age, albumin level and co-existent co-morbidities.

CONCLUSIONS

These observations highlight the profound impact CKD has on HRQOL and suggest potential areas that can be targeted for therapeutic intervention.

Quality of Life: Concept and Definition

This paper will consider 4 topics: (1) the definition of health-related quality of life, (2) the measurement of health-related quality of life, (3) the relationship between exercise and health-related quality of life in the general population, and (4) the relationship between exercise and health-related quality of life in patients with COPD. The paper presents data from the National Health Interview Survey, the San Diego COPD Rehabilitation Trials, and the National Emphysema Treatment Trial (NETT).

Chronic Renal Insufficiency Cohort (CRIC) Study: baseline characteristics and associations with kidney function

BACKGROUND AND OBJECTIVES

The Chronic Renal Insufficiency Cohort (CRIC) Study was established to examine risk factors for the progression of chronic kidney disease (CKD) and cardiovascular disease (CVD) in patients with CKD. We examined baseline demographic and clinical characteristics.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Seven clinical centers recruited adults who were aged 21 to 74 yr and had CKD using age-based estimated GFR (eGFR) inclusion criteria. At baseline, blood and urine specimens were collected and information regarding health behaviors, diet, quality of life, and functional status was obtained. GFR was measured using radiolabeled iothalamate in one third of participants.

RESULTS

A total of 3612 participants were enrolled with mean age +/- SD of 58.2 +/- 11.0 yr; 46% were women, and 47% had diabetes. Overall, 45% were non-Hispanic white, 46% were non-Hispanic black, and 5% were Hispanic. Eighty-six percent reported hypertension, 22% coronary disease, and 10% heart failure. Mean body mass index was 32.1 +/- 7.9 kg/m(2), and 47% had a BP >130/80 mmHg. Mean eGFR was 43.4 +/- 13.5 ml/min per 1.73 m(2), and median (interquartile range) protein excretion was 0.17 g/24 h (0.07 to 0.81 g/24 h). Lower eGFR was associated with older age, lower socioeconomic and educational level, cigarette smoking, self-reported CVD, peripheral arterial disease, and elevated BP.

CONCLUSIONS

Lower level of eGFR was associated with a greater burden of CVD as well as lower socioeconomic and educational status. Long-term follow-up of participants will provide critical insights into the epidemiology of CKD and its relationship to adverse outcomes.

Impact of anemia on physical function and survival among patients with coronary artery disease

BACKGROUND

Anemia is a purported risk factor for adverse outcomes, particularly among patients with cardiac disease. Although anemia at the time of discharge has been associated with poor functional status and survival, its impact over time is not clear.

HYPOTHESIS

Among patients with significant coronary artery disease (CAD), anemia (hemoglobin < 11 g/dL) is prevalent, and is associated with poor physical function (PF) and survival over time.

METHODS

Patients with significant CAD at the time of cardiac catheterization (n = 1, 821) were enrolled into a single-center, observational, and prospective study. All patients were followed for up to 1 y for clinical events and self-reported PF. Prevalence of anemia at discharge and its' associations with outcomes over time were examined.

RESULTS

Anemia at the time of discharge was very common (40.4%), and was associated with increased odds of death at 12 mo (odds ratio [OR] 1.55, 95% confidence interval [CI] 1.12-2.15), yet other clinical factors accompanying anemia accounted for this association (adjusted OR 1.13, 95% CI 0.79-1.62). Discharge anemia was also associated with significantly lower self-reported PF at 6 and 12 mo (p < 0.05 for both); however, other clinical factors accompanying anemia also accounted for these associations.

CONCLUSIONS

Although discharge anemia is highly prevalent, its association with adverse outcomes is largely explained by baseline patient characteristics. Further research is needed to clarify the relationship between anemia and outcomes in this population and to identify subpopulations that do not recover independently and for whom available therapies may be beneficial.

Health-related quality of life in emphysema

Patients with emphysema may experience reduced health-related quality of life (HRQOL). HRQOL measures have evolved from two different measurement traditions: psychometric theory and decision theory. Psychometric methods typically create a profile of outcomes, whereas decision theory methods offer a summary score on a continuum ranging from 0.0 (for death or worst possible health) to 1.0 (for best possible health). Decision theory methods are better suited for cost-effectiveness studies. Generic HRQOL measures can be applied to any disease population, whereas disease-targeted measures are tailored to a specific clinical condition. Disease-targeted measures are typically more sensitive to clinical change, but cannot offer a comparison basis for different clinical conditions. This article reviews the measurement of HRQOL in patients with emphysema. The National Emphysema Treatment Trial (NETT) offers an example of the application of both generic and disease-targeted, as well as profile and decision theory, methods. The NETT illustrates how HRQOL measures can be used to assess outcomes and estimate cost-effectiveness in a major clinical trial.