Nutritional Status and Depression, Sleep Disorder, and Quality of Life in Hemodialysis Patients

Association of dietary fiber with subjective sleep quality in hemodialysis patients: a cross-sectional study in China

BACKGROUND

Poor sleep quality is a common problem among hemodialysis (HD) patients. Dietary fiber is a key component of a healthy diet and is beneficial for a variety of health outcomes; however, evidence of an association between dietary fiber consumption and subjective sleep quality has not been established among HD patients. Therefore, we determined the association between dietary fiber consumption and the subjective sleep quality in Chinese maintenance HD patients, taking into account fiber type and source.

METHODS

Dietary intake was assessed with a validated food frequency questionnaire in a cross-sectional study including 741 maintenance HD patients between December 2021 and January 2022. The daily intake of dietary fiber was categorized into three groups. The lowest tertile was used as the reference category. Sleep quality of patients was accurately calculated using the Pittsburgh sleep quality index standard questionnaire. Multivariable logistic regression model and restricted cubic spline analysis were performed to assess the relationship between dietary fiber consumption and poor sleep quality.

RESULTS

Compared with the lowest tertile group of dietary fiber intake, the highest tertile group had a lower prevalence of poor sleep quality. After adjustment for potential confounders, a higher intake of total dietary fiber (OR_{tertile 3 (T3) to tertile 1 (T1)}= 0.51, 95% CI: 0.31-0.85), total insoluble dietary fiber (OR_{T3 to T1} =0.54, 95% CI: 0.33-0.89), and soluble dietary fiber in vegetables (OR_{T3 to T1} =0.61, 95% CI: 0.40-0.93) were associated with a lower prevalence of poor sleep quality. Furthermore, significant linear trends were also observed (p < 0.05). No significant interactions were observed in subgroup analyses.

CONCLUSION

A higher intake of dietary fiber was inversely associated with the poor sleep quality. These findings support the current recommendations that dietary fiber is essential for health and well-being.Key messagesThis study was conducted because there was not prior evidence connecting sleep quality and dietary fiber consumption in hemodialysis patients.In the present study a cross-sectional design was used to assess the association between dietary fiber consumption and poor sleep quality.Intake of total dietary fiber, total insoluble dietary fiber, and soluble dietary fiber in vegetables were negatively associated with poor sleep quality among maintenance hemodialysis patients.

Decreased Intracellular to Total Body Water Ratio and Depressive Symptoms in Patients with Maintenance Hemodialysis

Objective

Depression is a common psychiatric disorder and related to poor outcomes in patients undergoing maintenance hemodialysis (MHD). Previous studies have reported some associations between sarcopenia and depressive symptoms. Recently, intracellular water (ICW) and total body water (TBW) have been found to reflect muscle function and muscle mass. ICW/TBW ratio is a marker of sarcopenia that is simple to assess. However, the relationship between ICW/TBW ratio and depression has not been explored in MHD patients.

Methods

In our cross-sectional and multi-center study, 3300 adult MHD patients were included from June 1, 2021, to August 30, 2021. Depressive symptoms were evaluated using the Beck Depression Inventory-II (BDI-II). TBW and ICW were measured by Body Composition Monitor (BCM). Multivariable logistic regression, stratified analyses, and interactive analyses were conducted to assess the relationship between ICW/TBW ratio and depression.

Results

About 16.5% of the 3300 MHD patients were found to have depressive symptoms. The prevalence of depression increased with decreasing quartiles of ICW/TBW ratios, and decreased ICW/TBW ratio was independently associated with depression after adjusting for potential confounders. Patients in Quartile 1 of ICW/TBW ratios were more likely to have depressive symptoms (odds ratio 1.55, 95% confidence interval 1.07-2.22; p=0.002) than those in Quartile 4. History of diabetes and education status had interactive roles in the relationship between depression and ICW/TBW ratios (p < 0.05). The association of ICW/TBW ratios and depression existed in patients of both genders and different education levels, but only in non-diabetic patients.

Conclusion

In MHD patients, the decreased ratio of ICW/TBW was independently related to high depression rates.

Factors affecting quality of daytime and nighttime sleep among dialysis patients: A single center experience

BACKGROUND

Hemodialysis is the most common treatment modality for patients with chronic kidney disease (CKD). Excessive daytime sleepiness and poor nighttime sleep is a common problem among these patients. Patients on maintenance hemodialysis (MHD) are regularly exposed to impaired fluid balance, which may cause overhydration of varying degree. However, the role of hydration status in sleep quality has not been explored in Indian setting. Hence, this study was undertaken to assess the factors affecting sleep quality among patients on MHD in a tertiary care hospital.

MATERIAL AND METHODS

Patients (N = 55) were enrolled if they aged above18 years, on MHD for at least 3 months, and gave consent. The daytime sleep quality was assessed using Epworth Sleepiness Scale (ESS) and Insomnia Severity Index (ISI). The data were analyzed using SPSS version 20 and STATA software.

RESULTS

The mean age of the patients was 40.4 ± 14.7 years. The prevalence rate of predialysis fluid overload was 85.4%. The median ESS score was 7 and ISI score was 3 indicating normal daytime sleep and not significant insomnia. Multivariate regression with variables adjustment showed that interdialytic weight gain (P = 0.33), tingling sensation (P = 0.36) and numbness (P = 0.35) were significant predictive factors for quality of sleep.

CONCLUSION

The major factors affecting sleep quality were numbness, tingling sensation, and interdialytic weight gain. Fluid overload did not play any role in sleep quality. Another study may be carried out on assessment of pattern, duration, quality of sleep in multiple dialysis sessions, and effect of optimizing fluid status on the sleep parameters.

Sleep Quality After Intradialytic Oral Nutrition: A New Benefit of This Anabolic Strategy? A Pilot Study

Background

Since disturbances of appetite and sleep are closely related and both affect metabolic disorders, it would be expected that a renal specific oral nutritional supplement (RS-ONS) that covers the energy the patient does not consume on the HD day, could contribute to improve the nutritional status and body composition, as well as sleep quality. There is still scarce information related to this topic.

Aim

To evaluate the effect of the use of intra-dialytic RS-ONS vs. RS-ONS at home on sleep quality, nutritional status, and body composition in patients on HD.

Methods

Adult patients &lt; 65 years, with ≥3 months on HD were invited to participate in an open randomized pilot study (ISRCTN 33897). Patients were randomized to a dialysis-specific high-protein supplement provided during the HD session (Intradialytic oral nutrition [ION]) or at home (control), during non-HD days (thrice weekly, for both) 12 weeks. The primary outcome was sleep quality defined by the Pittsburgh Sleep Quality Index (PSQI) score. Nutritional assessment included Malnutrition Inflammation Score (MIS), bioelectrical impedance analysis, anthropometry, 3-day food records, and routine blood chemistries.

Results

A total of 23 patients completed the study. Age was median 35 (range 24–48 years), 42% were women. At baseline, the PSQI score was median 4 (range 2–7), and MIS showed a median of 6 (range 5–8); there were no baseline differences between groups. After intervention, both groups improved their MIS scores and similarly when we analyzed the whole cohort (pre- vs. post-intervention P &lt; 0.01). Patients in the ION group improved the overall PSQI score to median 3 (2–5), and assessment of sleep duration and sleep disturbances (pre- vs. post-intervention P &lt; 0.05), with a trend toward an effect difference compared to patients consuming the supplement at home (P for treatment-effect across arms 0.07 for PSQI score and 0.05 for sleep latency).

Conclusion

Oral supplementation improved nutritional status in the whole cohort, but only ION improved the PSQI score. More studies are needed to explore the nutritional strategies that influence the relationship between sleep and nutritional status in HD patients.

Impact of malnutrition on health-related quality of life in persons receiving dialysis: a prospective study

Health-related quality of life (HRQoL) is severely impaired in persons receiving dialysis. Malnutrition has been associated with some measures of poor HRQoL in cross-sectional analyses in dialysis populations, but no studies have assessed the impact of malnutrition and dietary intake on change in multiple measures of HRQoL over time. We investigated the most important determinants of poor HRQoL and the predictors of change in HRQoL over time using several measures of HRQoL. We enrolled 119 haemodialysis and thirty-one peritoneal dialysis patients in this prospective study. Nutritional assessments (Subjective Global Assessment (SGA), anthropometry and 24-h dietary recalls) and HRQoL questionnaires (Short Form-36 (SF-36) mental (MCS) and physical component scores (PCS) and European QoL-5 Dimensions (EQ5D) health state (HSS) and visual analogue scores (VAS)) were performed at baseline, 6 and 12 months. Mean age was 64 (14) years. Malnutrition was present in 37 % of the population. At baseline, malnutrition assessed by SGA was the only factor independently (and negatively) associated with all four measures of HRQoL. No single factor was independently associated with decrease in all measures of HRQoL over 1 year. However, prevalence/development of malnutrition over 1 year was an independent predictor of 1-year decrease in EQ5D HSS, and 1-year decrease in fat intake independently predicted the 1-year decline in SF-36 MCS and PCS, and EQ5D VAS. These findings strengthen the importance of monitoring for malnutrition and providing nutritional advice to all persons on dialysis. Future studies are needed to evaluate the impact of nutritional interventions on HRQoL and other long-term outcomes.

Severity of protein-energy wasting and obesity are independently related with poor quality of life in peritoneal dialysis patients

Protein-energy wasting (PEW) and poor health-related quality of life (HRQoL) are independently associated with morbi-mortality in continuous ambulatory peritoneal dialysis (CAPD). PEW may reduce HRQoL; however, we hypothesized HRQoL is affected differentially by PEW degrees or by individual criteria of nutritional status. AIM: To evaluate HRQoL according to PEW severity and nutritional status indicators in CAPD. This is a cross-sectional study in 151 patients. Subjective global assessment (SGA) was employed, and nutritional status classified as normal, mild-moderate PEW, and severe PEW. HRQoL was evaluated using Kidney Disease Quality of Life Short Form™, including physical (PCS), mental (MCS) and kidney disease (KDCS) components, and their subscales. Dietary intake, anthropometric and biochemical variables were measured. Forty-six percent of patients were well-nourished, 44% had mild-moderate PEW, and 10% severe PEW. Compared with well-nourished patients, those with mild-moderate (p=0.06) and severe (p=0.005) PEW had lower HRQoL score [68 (52-75), 55 (45-72), 46 (43-58), respectively]. PCS, MCS, and KDCS and their subscales had lower values as PEW was more severe. Patients with obesity and hypoalbuminemia had significantly lower HRQoL overall and component scores than their counterparts. Dietary intake was not associated with quality of life. In multivariate analysis obesity, PEW (by SGA), hypoalbuminemia, and low educational level predicted poor HRQoL (χ² 58.2, p<0.0001). As conclusion, PEW severity was related with worse HRQoL, either as overall score or in every component or subscale in CAPD patients. Poor HRQoL was predicted independently by PEW severity and obesity; additional predictors were hypoalbuminemia and low education.

Is malnutrition a determining factor of health-related quality of life in hemodialysis patients? A cross-sectional design examining relationships with a comprehensive assessment of nutritional status

PURPOSE

To identify relationships between health-related quality of life (HRQOL) and nutritional status in hemodialysis (HD) patients.

METHOD

Secondary data from a cross-sectional survey was utilized. HRQOL was assessed for 379 HD patients using the generic Short Form 36 (SF-36) and disease-specific Kidney-Disease Quality of Life-36 (KDQOL-36). Malnutrition was indicated by malnutrition inflammation score (MIS) ≥ 5, and presence of protein-energy wasting (PEW). The individual nutritional parameters included the domains of physical status, serum biomarkers, and dietary intake. Multivariate associations were assessed using the general linear model.

RESULTS

MIS ≥ 5 was negatively associated with SF-36 scores of physical functioning (MIS < 5 = 73.4 ± 8.0 SE vs MIS ≥ 5 = 64.6 ± 7.7 SE, P < 0.001), role-limitation-physical (MIS < 5 = 65.3 ± 14.3 SE vs MIS ≥ 5 = 52.9 ± 14.0 SE, P = 0.006), general health (MIS < 5 = 53.7 ± 7.5 SE vs MIS ≥ 5 = 47.0 ± 7.1 SE, P = 0.003), and PCS-36 (MIS < 5 = 40.5 ± 3.3 SE vs MIS ≥ 5 = 35.9 ± 3.1 SE, P < 0.001); and KDQOL-36 score of symptoms/problems (MIS < 5 = 78.9 ± 5.6 SE vs MIS ≥ 5 = 74.8 ± 5.4 SE, P = 0.022), but not with PEW by any tool. Of individual nutritional parameters, underweight (68.1 ± 5.4 SE, P = 0.031), normal weight (63.8 ± 2.8 SE, P = 0.023), and overweight (64.3 ± 2.9 SE, P = 0.003) patients had significantly higher physical functioning scores compared to obese patients (44.8 ± 5.5 SE). Serum albumin levels were positively associated with physical functioning (P = 0.041) score. HGS was also positively associated with physical functioning (P = 0.036), and vitality (P = 0.041) scores. Greater dietary phosphorus intakes were significantly associated with lower scores for role limitation-physical (P = 0.008), bodily pain (P = 0.043), and PCS-36 (P = 0.024).

CONCLUSION

Malnutrition diagnosis by MIS, but not PEW, indicated associations with HRQOL in HD patients. Individual nutritional parameters that related to higher HRQOL were BMI < 30 kg/m², better dietary phosphorus control, greater muscle strength and higher visceral protein pool.

Depression in dialysis

PURPOSE OF REVIEW

The aim of this study was to examine updated prevalence rates, risk factors and the prognosis, diagnosis and treatments for depression among dialysis patients.

RECENT FINDINGS

Depression influences prognosis, complications, quality of life (QOL), treatment and costs for dialysis patients worldwide. Reported prevalence of depression is 13.1-76.3%; it is higher for dialysis than transplant and higher post than predialysis. Reported depression rates with peritoneal dialysis (PD) compared with in-centre haemodialysis (HD) are inconsistent. Related medical factors are known, but suspected associated patient characteristics including gender and race remain unexplored. Associations between depression in dialysis and QOL, mortality, pathophysiological mechanisms of increased mortality, infection and pathways of inflammation-mediated and psychosocial factors require clarification. Several depression screening instruments are validated for dialysis patients - the Structured Clinical Interview for DSM disorders (SCID) remains the gold standard - but authors suggest the diagnostic standard should be higher than for the general population. Short-term studies indicate nonpharmacological therapy achieves clinical effects for depression in dialysis patients, but research on long-term effects is needed.

SUMMARY

Depression management through early screening and continuous care models emphasizing dynamic relationships between healthcare teams, patients and families should be encouraged. Large-scale studies of short-term and long-term benefits of pharmacological and nonpharmacological depression management are warranted.

The Association of Sleep Quality and Vitamin D Levels in Hemodialysis Patients

Background

To date, hemodialysis (HD) is the most common therapy for chronic kidney disease (CKD) patients. However, it causes different complications such as sleep disorders. Sleep regulation is connected to vitamin D; hence, its deficiency might influence the quality and duration of sleep. This study is aimed at evaluating the correlation of sleep quality and vitamin D levels in 80 HD patients.

Methods

This cross-sectional study was performed on 80 hemodialysis patients admitted to 29 Bahman hospitals in Tabriz, Iran. Before beginning of dialysis, serum 25 (OH) D levels were assessed among patients and the sleep patterns and sleep quality of patients were accurately calculated by the Pittsburgh sleep quality index (PSQI) standard questionnaire.

Results

Our results showed that 22 HD patients (27.5%) had severe sleep disorders. In addition, it was found that serum levels of vitamin D had significant correlation with sleep quality (r = −0.341, p = 0.002) in general, even after adjusting confounding factors such as calcium (Ca), phosphate (P), and parathyroid hormone (PTH) level. In poor sleepers (PSQI ≤ 5), a negative correlation was observed between the levels of vitamin D and PSQI score (r = −0.397, p = 0.004). PSQI scores in the normal range of PTH (r = −0.377, p = 0.006) and in >600 pg/ml of PTH (r = −0.675, p = 0.011) had a correlation with vitamin D levels. The level of vitamin D was the single independent predictor of sleep efficiency (β coefficient = −0.386, p = 0.001).

Conclusion

The present project reported that the positive effect of vitamin D is associated with sleep disorder in HD patients. In future studies, normal levels of Ca and P should be considered along with normal vitamin D levels among the included patients.

Malnutrition and Sarcopenia Combined Increases the Risk for Mortality in Older Adults on Hemodialysis

Aim: Sarcopenia and malnutrition are highly prevalent in older adults undergoing hemodialysis (HD) and are associated with negative outcomes. This study aimed to evaluate the role of sarcopenia and malnutrition combined on the nutritional markers, quality of life, and survival in a cohort of older adults on chronic HD. Methods: This was an observational, longitudinal, and multicenter study including 170 patients on HD aged >60 years. Nutritional status was assessed by 7-point-subjective global assessment (7p-SGA), body composition (anthropometry and bioelectrical impedance), and appendicular skeletal muscle mass (Baumgartner's prediction equation). Quality of life was assessed by KDQoL-SF. The cutoffs for low muscle mass and low muscle strength established by the 2019 European Working group on sarcopenia for Older People (EWGSOP) were used for the diagnosis of sarcopenia. Individuals with a 7p-SGA score ≤5 were considered malnourished, individuals with low strength or low muscle mass were pre-sarcopenic, and those with low muscle mass and low muscle strength combined as sarcopenic. The sample was divided into four groups: sarcopenia and malnutrition; sarcopenia and no-malnutrition; no-sarcopenia with malnutrition; and no-sarcopenia and no-malnutrition. Follow-up for survival lasted 23.5 (12.2; 34.4) months. Results: Pre-sarcopenia, sarcopenia, and malnutrition were present in 35.3, 14.1, and 58.8% of the patients, respectively. The frequency of malnutrition in the group of patients with sarcopenia was not significantly higher than in the patients without sarcopenia (66.7 vs. 51.2%; p = 0.12). When comparing groups according to the occurrence of sarcopenia and malnutrition, the sarcopenia and malnutrition group were older and presented significantly lower BMI, calf circumference, body fat, phase angle, body cell mass, and mid-arm muscle circumference. In the survival analysis, the group with sarcopenia and malnutrition showed a higher hazard ratio 2.99 (95% CI: 1.23: 7.25) for mortality when compared to a group with no-sarcopenia and no-malnutrition. Conclusion: Older adults on HD with sarcopenia and malnutrition combined showed worse nutritional parameters, quality of life, and higher mortality risk. In addition, malnutrition can be present even in patients without sarcopenia. These findings highlight the importance of complete nutritional assessment in patients on dialysis.

Severity of protein-energy wasting and obesity are independently related with poor quality of life in peritoneal dialysis patients

Protein-energy wasting (PEW) and poor health-related quality of life (HRQoL) are independently associated with morbi-mortality in continuous ambulatory peritoneal dialysis (CAPD). PEW may reduce HRQoL; however, we hypothesized HRQoL is affected differentially by PEW degrees or by individual criteria of nutritional status. AIM: To evaluate HRQoL according to PEW severity and nutritional status indicators in CAPD. This is a cross-sectional study in 151 patients. Subjective global assessment (SGA) was employed, and nutritional status classified as normal, mild-moderate PEW, and severe PEW. HRQoL was evaluated using Kidney Disease Quality of Life Short Form™, including physical (PCS), mental (MCS) and kidney disease (KDCS) components, and their subscales. Dietary intake, anthropometric and biochemical variables were measured. Forty-six percent of patients were well-nourished, 44% had mild-moderate PEW, and 10% severe PEW. Compared with well-nourished patients, those with mild-moderate (p=0.06) and severe (p=0.005) PEW had lower HRQoL score [68 (52-75), 55 (45-72), 46 (43-58), respectively]. PCS, MCS, and KDCS and their subscales had lower values as PEW was more severe. Patients with obesity and hypoalbuminemia had significantly lower HRQoL overall and component scores than their counterparts. Dietary intake was not associated with quality of life. In multivariate analysis obesity, PEW (by SGA), hypoalbuminemia, and low educational level predicted poor HRQoL (χ2 58.2, p<0.0001). As conclusion, PEW severity was related with worse HRQoL, either as overall score or in every component or subscale in CAPD patients. Poor HRQoL was predicted independently by PEW severity and obesity; additional predictors were hypoalbuminemia and low education.

The association between dietary inflammatory index with sleep quality and obesity amongst iranian female students: A cross-sectional study

BACKGROUND

Overweight, obesity and lack of sleep quality as inflammatory states are the common problems amongst college students and the Association of Dietary Inflammatory Index (DII) with these problems amongst this population is unknown. We aimed to evaluate the relationship of the DII with obesity and sleep quality amongst Iranian female students.

METHODS

The present cross-sectional study was conducted on 249 female college students. The Dietary Inflammatory Index (DII) was calculated using a valid and reliable 147-item food frequency questionnaire (FFQ). To assess sleep quality, Pittsburgh Sleep Quality Index (PSQI) was used. Odds Ratio (OR) and 95% Confidence Intervals (CIs) were estimated for anthropometric indices and sleep quality according to the DII score. Linear regression was used to estimate the relationship between DII score with sleep and anthropometric indices.

RESULTS

There was a significant association evident between DII and sleep quality (>5 is considered as poor quality of sleep); ie, the odds ratios between DII quartile 2 vs 1 (unadjusted model: OR = 0.33 (CI: 0.14-0.74), P for trend = .002; model 1: the fully adjusted OR = 0.31(CI: 0.12-0.78), P for trend = .005; model 2:OR = 0.30 (CI: 0.12-0.78), P for trend = .005) to quartile 4(unadjusted model: OR = 1.13(CI: 0.45-2.80); model 1: OR = 1.11(CI: 0.44-2.79); model 2:OR = 1.13(CI: 0.44-2.87), P for trend = .005). Also, odds ratios increased significantly from quartile 2 to quartile 4 in all models for DII and sleep quality. According to the continuous score of DII, there was a significant positive association between DII and sleep quality in all three models: unadjusted, model 1, and model 2 (OR = 1.21 (CI: 1.05-1.40), OR = 1.21 (CI: 1.03-1.43), and OR = 1.22 (CI: 1.03-1.44), respectively.

CONCLUSIONS

In this study, after removing the effect of confounding factors, participants in the highest quartile of DII score had significantly higher PSQI global score.

Pittsburgh Sleep Quality Index score predicts all-cause mortality in Chinese dialysis patients

BACKGROUND

The relationship between Pittsburgh Sleep Quality Index (PSQI) score and survival of dialysis patients has not been well studied. The aim of this study was to explore the association between PSQI score and all-cause mortality in dialysis patients.

METHODS

Fifty-one hemodialysis and 58 peritoneal dialysis patients were enrolled in this study. PSQI score > 5 and ≤ 5 indicated "poor sleepers" and "good sleepers", respectively. The primary outcome was all-cause mortality. Kaplan-Meier survival curve and Cox proportional hazards regression analysis were performed.

RESULTS

The median PSQI score was 7.0 (4.0-10.0). Sixty-seven (61.5%) patients had poor sleep quality (SQ). Compared with good sleepers, poor sleepers had significantly lower levels of hemoglobin [74.0 (61.0, 85.0) vs. 78.0 (68.0, 97.0), P = 0.03] and serum bicarbonate (18.0 ± 4.5 vs. 20.0 ± 3.7, P = 0.022). The follow-up time was 69.1 ± 29.9 months. By multivariate Cox proportional hazards analysis, PSQI total score was the independent risk factor of all-cause mortality [hazard ratio (HR) 1.20, 95% confidence interval (CI) 1.05-1.36, P = 0.007]. Restricted cubic spline (RCS) analysis showed that 7 was the cutoff value at which the effect of PSQI score on mortality changed. Patients with a PSQI score > 7 had a 2.96-fold increased risk of all-cause mortality (HR 2.96, 95% CI 1.15-7.61, P = 0.025).

CONCLUSIONS

PSQI score can be used as a predictor of all-cause mortality in dialysis patients, and those with PSQI > 7 were associated with increased odds of mortality.

Frequency of depressive symptoms in Syrian refugees and Turkish maintenance hemodialysis patients during COVID-19 pandemic

Introduction

Pneumonia of unknown cause was detected on 30 December 2019 in China. It was categorized as an outbreak and named as COVID-19 by the World Health Organization. The pandemic affects all people, but patient groups such as hemodialysis (HD) patients have been particularly affected. We do not know if refugees suffered more during the outbreak. In this study, we compared depressive symptom frequency between Syrian refugee HD patients and Turkish ones.

Methods

The study had a single-center, cross-sectional design. Demographic and clinical data were collected retrospectively from patients’ files containing details about past medical history, demographic variables and laboratory values. Validated Turkish and Arabic forms of Beck Depression Inventory (BDI) were used to assess depressive symptoms. BDI scores were compared according to nationality, demographic features and clinical data. A BDI score more than 14 was accepted as suspicion of depression.

Results

119 patients were enrolled in the study. After the exclusion of 22 patients, 75 Turkish and 22 Syrian patients were included for further analysis. The median BDI (interquartile range) score for Turkish and Syrian patients were 12 (7–23) and 19.5 (12.7–25.2), respectively (p = 0.03). Suspicion of depression was present at 42.7% of Turkish, and 72.7% of Syrian HD patients (p = 0.013). Regarding all patients, phosphorus level, Kt/V, and nationality were significantly different between patients with and without suspicion of depression (p = 0.023, 0.039, 0.013, respectively).

Conclusion

Syrian patients had higher BDI scores and more depressive symptoms than Turkish patients. Additional national measures for better integration and more mental support to Syrian HD patients are needed.

The effects of omega-3 on the sleep quality of patients with uremic pruritus undergoing hemodialysis: a randomized crossover study

OBJECTIVES

Information on sleep quality and its effective factors in the patients undergoing hemodialysis are important factors in future planning for improving sleep quality and ultimately the quality of life in these patients. The present study investigated the effect of omega-3 on the sleep quality of hemodialysis patients.

METHODS

The 52 hemodialysis patients were randomized into two groups and underwent two different treatment modes (A and B). The first group was given omega-3 and cetirizine and the second group only received cetirizine for six weeks. After one week wash out, the study was followed by crossover treatment in both groups for six weeks. Sleep quality and pruritus severity were evaluated in patients before the intervention and at the end of each treatment period using the Pittsburgh Sleep Quality Index and the Yosipovitch Itch Questionnaire. The collected data was analyzed using repeated measures ANOVA and the Pearson correlation coefficient.

RESULTS

The results of the study showed that majority of the patients (94.2%) had poor sleep quality (sleep score > 5 based on the questionnaire) and 5.8% of the patients had favorable sleep quality (sleep score < 5). Repeated measures ANOVA showed that sleep quality scores were different in two groups in phases 0, I and II (p <0.001).

CONCLUSIONS

Sleep quality improved in both modes but more improvement was observed in mode A. Therefore, omega-3 fatty acids can be used as a suitable method for improving sleep quality in hemodialysis patients.

Differences and Effects of Metabolic Fate of Individual Amino Acid Loss in High-Efficiency Hemodialysis and Hemodiafiltration

OBJECTIVE

The objective of the study was to quantify the loss and arterial blood concentration of the three main classes of amino acids (AAs)-nonessential amino acids (NEAAs), essential amino acids (EAAs), and branched-chain amino acids-as resulting from high-efficiency hemodialysis (HED) and hemodiafiltration (HDF). We moreover aimed to identify the different fates and metabolic effects manifested in patients undergoing hemodialysis and the consequences on body composition and influence of nutritional decline into protein energy wasting.

DESIGN AND METHODS

Identical dialysis monitors, membranes, and dialysate/infusate were used to ensure consistency. Ten patients were recruited and randomized to receive treatment with on-line modern HED and HDF. Arterial plasma concentrations of individual AAs were compared in healthy volunteers and patients undergoing hemodialysis, and AA levels outflowing from the dialyzer were evaluated. Baseline AA plasma levels of patients undergoing hemodialysis were compared with findings obtained 1 year later.

RESULTS

A severe loss of AA with HED/HDF was confirmed: a marked loss of total AAs (5 g/session) was detected, corresponding to more than 65% of all AAs. With regard to individual AAs, glutamine displayed a consistent increase (+150%), whereas all other AAs decreased after 12 months of HD/HDF. Only a few AAs, such as proline, cysteine, and histidine maintained normal levels. The most severe metabolic consequences may result from losses of EAAs such as valine, leucine, and histidine and from NEAAs including proline, cysteine, and glutamic acid eliciting the onset of hypercatabolism threatening muscle mass loss.

CONCLUSION

Dialysis losses, together with the effect of chronic uremia, resulted in a reduction of fundamental EAAs and NEAAs, which progressively led our patients after 12 months to a deterioration of lean mass toward sarcopenia. Therefore, the reintroduction of a correctly balanced AA supplementation in patients undergoing HD to prevent or halt decline of hypercatabolism into cachexia is recommended.

The effects of depression and age on sleep disturbances in patients with non-dialysis stage 3-5 chronic kidney disease: a single-center study

PURPOSE

Sleep disturbances have a negative impact on the prognosis of chronic kidney disease (CKD). However, information on the prevalence and predictors is limited. This study aimed to evaluate the prevalence and explore clinical factors affecting the quality of sleep in patients with non-dialysis CKD.

METHODS

Participants included 152 adult non-dialysis patients with stage 3-5 CKD. Demographic and clinical data were collected. Sleep quality and depression were assessed using the Pittsburgh Sleep Quality Index (PSQI) and Beck Depression Inventory (BDI), respectively. Sleep disturbances were defined as a PSQI score ≥ 5. Logistic regression was conducted to explore the independent factors of sleep disturbances. Clinical parameters were correlated with BDI scores using linear regression models.

RESULTS

The total prevalence of patients with sleep disturbances was 66.4%. Older age, higher BDI scores, lower estimated glomerular filtration rate (eGFR) changes per month (△eGFR/m) before the study, and lower serum magnesium levels were found in patients with sleep disturbances. BDI scores (odds ratio [OR] 1.224, 95% confidence interval [CI] 1.091-1.373, p = 0.001) and age (OR 1.041, 95% CI 1.013-1.069, p = 0.003) were independent predictors of sleep disturbances. Serum uric acid levels (β - 0.629, 95% CI - 1.244 to - 0.013, p = 0.046), △eGFR/m before the study (β - 0.454, 95% CI - 0.885 to - 0.024, p = 0.039), and daily protein intake (β - 0.052, 95% CI - 0.102 to - 0.002, p = 0.043) were negatively associated with BDI scores.

CONCLUSION

A high overall prevalence of sleep disturbances was found in patients with non-dialysis stage 3-5 CKD. Depression, as a manageable predictor, should be managed, especially in elderly patients.

The screening score of Mini Nutritional Assessment (MNA) is a useful routine screening tool for malnutrition risk in patients on maintenance dialysis

PURPOSE

Malnutrition is prevalent in patients on dialysis and is associated with morbidity and mortality. Nutritional status can be assessed by a variety of biochemical and physical parameters or nutritional assessment scores. Most of these methods are expensive or cumbersome to use and are not suitable for routine repetitive follow-up in dialysis patients. The Mini Nutritional Assessment (MNA) has a short form screening set (MNA-SF), which would be suitable as a screening tool, but has not been validated yet in dialysis patients. We aimed to assess whether the MNA is an appropriate tool for identifying nutritional problems in dialysis patients.

METHOD

MNA, routine biochemistry, physical parameters, comorbidities were assessed in cross-sectional multicentric cohorts of hemodialysis and peritoneal dialysis patients with a longitudinal follow up of 2 years for mortality.

RESULTS

In this cohort of 216 patients, mortality was 27.3% at a follow up of 750±350 days. The mean MNA-SF score was 9.9±1.8, with 30.1%, 59.3% and 10.6% of patients categorized as having normal nutritional status, at risk for malnutrition and malnourished, respectively. The screening score was associated with mortality (HR 0.86, 95% CI 0.75-0.98 per point). With normal nutrition as reference, adjusted mortality was 2.50 (95% CI 1.16-5.37) and 3.89 (95% CI 1.48-10.13) for patients at risk for malnutrition and with malnutrition, respectively. After recalibrating the MNA full score for the specificity of some of its domains for dialysis patients, the MNA-SF had a good sensitivity and specificity for not being well nourished (0.95 and 0.63 respectively) in the full score, and a high negative predictive value (0.91).

CONCLUSION

The MNA-SF is independently associated with 2 year mortality in dialysis patients. It has a high negative predictive value for excluding being at risk or having malnutrition in the full score. Therefore, it can be advocated as a screening tool for nutritional status in dialysis patients.

Sleep Quality in Iranian Hemodialysis Patients: A Systematic Review and Meta-analysis

Background:

Hemodialysis is a major therapeutic method for many chronic kidney disease patients that causes complications. One of these complications tends to be sleep disorders. This study was performed through systematic review and meta-analysis to determine the prevalence of low sleep quality in hemodialysis patients in Iran.

Materials and Methods:

Journal papers written in English and Persian searched from January 2000 to July 2018 were selected. The search keywords included (Prevalence OR Epidemiology) AND (hemorenodialysis OR hemodialysate OR 'intermittent chronic haemodialysis' OR 'intermittent chronic hemodialysis' OR 'intermittent haemodialysis' OR 'intermittent hemodialysis' OR 'kidney dialysis' OR 'renal dialysis') AND ('sleep problem' OR 'sleep disturbance' OR 'sleep disorder' OR 'sleep quality' OR 'chronobiology disorders' OR dyssomnia). To determine the pooled prevalence, the stochastic DerSimonian-Laird model was used, computing the effect size with its 95 per cent confidence interval. The main international electronic databases were Embase, PubMed/MEDLINE, ISI/Web of Science (WOS), Scopus, Psych INFO, and Iranian databases such as MagIran, SID and Irandoc. The data were analysed using the Stata (version 13.0).

Results:

After searching through the databases and other resources, 21 articles (7 in Persian and 14 in English language) were included. The overall prevalence of low sleep quality in dialysis patients was 75.30 per cent (95 per cent confidence interval, 70.08–82.50). The heterogeneity study showed moderate heterogeneity among studies (I² = 50.30 per cent, p < 0.05).

Conclusions:

The results of this study showed that the prevalence of low sleep quality in hemodialysis patients has become a common problem. Thus, patients' sleep quality need to be evaluated periodically.

Prevalence and predictors of depression among hemodialysis patients: a prospective follow-up study

BACKGROUND

Even though depression is one of the most common psychiatric disorders, it is under-recognized in hemodialysis (HD) patients. Existing literature does not provide enough information on evaluation of predictors of depression among HD patients. The objective of the current study was to determine the prevalence and predictors of depression among HD patients.

METHODS

A multicenter prospective follow-up study. All eligible confirmed hypertensive HD patients who were consecutively enrolled for treatment at the study sites were included in the current study. HADS questionnaire was used to assess the depression level among study participants. Patients with physical and/or cognitive limitations that prevent them from being able to answer questions were excluded.

RESULTS

Two hundred twenty patients were judged eligible and completed questionnaire at the baseline visit. Subsequently, 216 and 213 patients completed questionnaire on second and final follow up respectively. The prevalence of depression among patients at baseline, 2nd visit and final visit was 71.3, 78.2 and 84.9% respectively. The results of regression analysis showed that treatment given to patients at non-governmental organizations (NGO's) running HD centers (OR = 0.347, p-value = 0.039) had statistically significant association with prevalence of depression at final visit.

CONCLUSIONS

Depression was prevalent in the current study participants. Negative association observed between depression and hemodialysis therapy at NGO's running centers signifies patients' satisfaction and better depression management practices at these centers.

Association of Dialysis Malnutrition Score with Hypoglycemia and Quality of Life among Patients with Diabetes on Maintenance hemodialysis

Objective

To determine the association between Dialysis Malnutrition Score (DMS), hypoglycemia and quality of life among patients with Diabetes on Maintenance Hemodialysis (MHD).

Methodology

Ninety-two diabetic patients on maintenance hemodialysis were assessed using a standardized data collection tool, Dialysis Malnutrition Score, WHOQoL-BREF questionnaire, anthropometric measurements and hourly blood sugar monitoring during the dialysis session. Association among DMS, hypoglycemia and quality of life were assessed along with other associated variables.

Results

Based on the DMS, 62% of patients were malnourished. Those with malnutrition were significantly older (p=0.0006) and female (p=0.013). Only 6.5% of the participants developed hypoglycemia during dialysis. Those with poor nourishment in the DMS showed a significant trend of decrease in the quality of life (physical (p<0.001), psychological (p<0.001) and social (p=0.004) and is associated with the occurrence of hypoglycemia (p<0.001).

Conclusion

Malnutrition is prevalent in diabetic patients on MHD using DMS. A higher DMS score is highly correlated with increased risk of hypoglycemia and decreased quality of life hence detection of malnutrition is important to prevent further nutritional depletion, hypoglycemia and poor patient outcomes by implementing preventive measures such as nutritional counselling and psychosocial interventions.

Is Nutrition Specific Quality of Life Associated With Nutritional Status?

OBJECTIVE

The study purpose was to explore the relationship between nutritional status, as measured by Subjective Global Assessment (SGA), and Health Related Quality of Life measured using the Nutrition Specific Quality of Life (NS-QoL), tool among participants on maintenance hemodialysis (MHD). The study aim was to determine if NS-QoL may be an adjuvant tool for detecting changes in nutritional status among patients on MHD.

DESIGN, SETTING, AND SUBJECTS

This is a cross-sectional, secondary analysis of data from a multi-center study. Participants were adult (>18) men and women on MHD (n = 145) recruited from 3 institutions in the Northeastern United States.

METHODS

Statistical tests were conducted to determine the relationship between key demographic characteristics (age, sex, dialysis vintage, gender, and ethnicity) and SGA and NS-QoL. Spearman's correlation examined the relationship between the independent variable, SGA and the dependent variable, NS-QoL. A univariate general linear model was conducted to adjust for confounding variables.

MAIN OUTCOME MEASURE

The relationship between overall SGA score and composite NS-QoL score.

RESULTS

The sample consisted of 85 men (58.6%), with a mean age of 55.3 ± 11.9 years, who were largely African-American (84.1%) and non-Hispanic (77.2%). Mean SGA score was 5.5 ± 1.0, and the mean NS-QoL composite score was 9.51 ± 3.77. No key demographic characteristics had a statistically significant relationship with SGA, whereas sex (P < .001) and race (P = .015) both had statistically significant relationships with NSQoL. After adjusting for the variables of race and sex, NS-QoL score was positively correlated with SGA composite score (P = .042); as NS-QoL score increased so did the SGA score.

CONCLUSION

The present study found a positive linear correlation between NS-QoL composite score and SGA, as well as 5 SGA subcomponent scores and NS-QoL. These findings indicate that NS-QoL can complement the SGA to provide information about a patient's nutritional status.

Educational approaches focusing on the quality of life of people with chronic kidney disease receiving hemodialysis: an integrative review

Abstract Introduction: The impact of chronic kidney disease (CKD) on the quality of life of patients receiving hemodialysis is widely studied. Despite the vast amount of literature on the topic, it is still important to investigate the educational approaches related to this population’s quality of life, evolution, and treatment. Objective: To systematically review the literature on educational approaches focusing on people with CKD receiving hemodialysis. Methods: An integrative systematic review of studies published between 2010 and 2015 was conducted using the PubMed, LILACS, PROQUEST, SCIENCEDIRECT, and SciELO databases using the keywords “quality of life and hemodialysis and adults”, with their translation equivalents in Portuguese and Spanish. Results: The studies included in this review investigated biological conditions, treatment adherence, psychosocial conditions, and even spiritual influence. These studies unanimously recognized the validity of educational approaches, be it for treatment adherence, actor´s empowerment, or self-knowledge, as well as the importance of addressing a wider patient view and participatory therapy planning. Conclusion: The quality of life of people with CKD is a widely and differently studied topic, but the number of educational approaches focusing on this group of patients is modest and poorly represented in the existing literature. The few studies that address this topic are in complete agreement about the importance and relevance of educational approaches for people with CKD. We conclude that patient adherence, participation, and empowerment should be considered and encouraged.

A comparison of anxiety and depression between pre-dialysis chronic kidney disease patients and hemodialysis patients using hospital anxiety and depression scale

Objective:

Tocompare frequency of anxiety and depression between pre-dialysis chronic kidney disease (CKD) and hemodialysis patients (ESRD) in Pakistan.

Methods:

This study was conducted in an out-patient department and hemodialysis unit of Sharif Medical City Hospital. Inclusion criteria included age above 18 years and a diagnosis of CKD including both pre-dialysis CKD and ESRD patients. Patients were screened for anxiety and depression using hospital anxiety and depression scale (HADS).

Results:

A total of 156 patients were included in the study. Out of these patients, 81 (51.9%) had ESRD and 75 (48.1%) had pre-dialysis CKD. Mean age of all patient was 47.3±18.3 years, 96 (61.5%) were males and 60 (38.5%) were females. Median duration of renal disease was 16 months (IQR 8-36 months). Anxiety and depression were present in 111 (71.2%) and 113 (72.4%) of all patients respectively. Moderate to severe anxiety and depression were present in 54 (34.6%) and 60 (38.5%) patients respectively. In multiple logistic regression model, after adjusting for other variables, ESRD vs. pre-dialysis CKD was significantly associated with moderate to severe depression (AOR 2.26 (1.1-5.1).

Conclusion:

Both anxiety and depression are common in pre-dialysis CKD and ESRD patients. Patients with ESRD have higher frequency of depression compared to pre-dialysis CKD patients.

Comparing Tests Assessing Protein-Energy Wasting: Relation With Quality of Life

OBJECTIVE

Protein-energy wasting (PEW), a state of decreased bodily protein and energy fuels, is highly prevalent among hemodialysis patients. The best method to determine PEW, however, remains debated. As an independent, negative association between PEW and quality of life (QOL) has been demonstrated, establishing which nutrition-related test correlates best with QOL may help to identify how PEW should preferably be assessed.

DESIGN AND METHODS

Data were used from CONTRAST, a cohort of end-stage kidney disease patients. At baseline, Subjective Global Assessment (SGA), Malnutrition Inflammation Score (MIS), Geriatric Nutritional Risk Index, composite score on protein-energy nutritional status, normalized protein nitrogen appearance, body mass index, serum albumin, and serum creatinine were determined. QOL was assessed by the Kidney Disease Quality of Life Short Form 1.3. The present study reports on 2 general and 11 kidney disease-specific QOL scores. Spearman's rho (ρ) was calculated to determine correlations between nutrition-related tests and QOL domains. Twelve months after randomization, a sensitivity analysis was performed to test the robustness of the results.

RESULTS

Of 714 patients, 489 representative subjects were available for analysis. All tests correlated with the Physical Component Score, except body mass index. Only SGA and MIS correlated significantly with the Mental Component Score. SGA correlated significantly with 10 of 11 kidney disease-specific QOL domains. The MIS not only correlated significantly with all (11) kidney disease-specific QOL domains but also with higher correlation coefficients.

CONCLUSION

Of the 8 investigated nutrition-related tests, only MIS correlates with all QOL domains (13 of 13) with the strongest associations.

Malnutrition-inflammation score and quality of life in hemodialysis patients: is there any correlation?

Background:

Malnutrition, inflammation and poor quality of life are prevalent among hemodialysis (HD) patients. Health-related quality of life is an important determinant of hospitalization and mortality in HD patients.

Objectives:

The aim of this study was to assess the correlation between quality of life and malnutrition-inflammation status according to subjective global assessment (SGA) and malnutrition-inflammation scores (MIS) in HD patients.

Patients and Methods:

We randomly selected 87 of 180 stable HD patients from two HD centers. Those on hemodialysis for at least three months and with malnutrition according to the SGA scores were included in this study. They were divided into two groups of mild to moderate malnutrition (n = 39) and severe malnutrition (n = 49) based on the SGA scores. Serum levels of transferrin, albumin, blood urea nitrogen, creatinine, kt/v, body mass index and malnutrition-inflammation scores were measured in all patients. Health-related quality of life was assessed by validated short form-12 (SF-12) questionnaire for each patient. These values were compared between the two groups of patients by independent sample t-test and Mann-Whitney U test. The correlations of nutritional variables with SGA and MIS scores were determined by Pearson and Spearman correlation tests.

Results:

There were no differences in measured parameters between the two groups except for MIS scores. Those with severe malnutrition showed higher MIS scores. All quality of life aspects and total scores (PCS, MCS) (rather than social functioning (SF) aspect) were significantly different between the two groups, which showed lower physical and mental scores in severely-malnourished patients. Physical functioning (PF), role limitations due to physical heath (RP), general health (GH), mental health (MH), SF, role limitation due to emotional health (RE), vitality (VT) aspects and total scores (PCS and MCS) had negative significant correlations with MIS and SGA scores (All P values < 0.05). No correlation was found between MIS and SGA scores and other measured variables.

Conclusions:

This study focused on important effects of malnutrition and inflammation on health-related quality of life aspects, both physically and mentally in HD patients. SGA and MIS are highly correlated with quality of life in HD patients.

Prevalence of sleep disorders among ESRD patients

Sleep disorders are common among the patients undergoing dialysis in end stage renal disease (ESRD). Although variable, their prevalence has been reported to be higher when compared to the general population. The most frequently reported complaints are insomnia, restless leg syndrome (RLS), sleep-disordered breathing and excessive daytime sleepiness (EDS). The aim of this study was to assess the prevalence of sleep disorders in end stage renal disease patients on regular hemodialysis (group I with 30 patients) and CKD patients (group II with 30 patients) in comparison to 30 normal population (control group). In addition to laboratory investigations which included creatinine clearance using Cockroft and Gault formula, hemoglobin level (Hb), blood urea, serum creatinine, serum albumin, serum calcium and phosphorus and lipid profile, all subjects underwent one night of laboratory-based polysomnography (PSG) consisting of a standard montage of electroencephalography (EEG) (C3/A1 and O2/C3 or O1/C4), monopolar left and right electrooculography (EOG) referenced to the opposite mastoid, surface mentalis electromyography (EMG), respiratory airflow (measured by thermistor) and effort (piezoelectric sensors), electrocardiography (ECG), anterior tibialis EMG and pulse oximetry. For hemodialysis subjects, this study was performed on a night immediately following hemodialysis treatment. The results showed that patients on hemodialysis have sleep disorders, and that sleep disorders are common in group I and II than control group. The percentage of sleep disorders in hemodialysis patients were as follows: insomnia (69%), followed by obstructive sleep apnea syndrome OSAS (24%), RLS and periodic limb movement PLM (18%), nightmares (13%), EDS (12%), sleepwalking (2%), possible rapid eye movement behavior disorders RED (2%), possible narcolepsy (1.4%). While the percentage of sleep disorders in CKD patients were as follows: insomnia (54%), followed by RLS (19%), PLM (12%), OSAS (16%), nightmares (15%), EDS (15%), sleepwalking (4%), possible RBD (3%), possible narcolepsy (1%). There was inverse correlation between sleep disorders and Hb, albumin and creatinine clearance; also there was positive correlation between sleep disorder and phosphorus. We concluded that the sleep disorders are common in CKD patients either on conservative management or on regular hemodialysis. Treatment of anemia, hyperphosphatemia and hypoalbuminemia may improve sleep disorders among those patients.

A review of the neuro- and systemic inflammatory responses in post concussion symptoms: Introduction of the "post-inflammatory brain syndrome" PIBS

Post-concussion syndrome is an aggregate of symptoms that commonly present together after head injury. These symptoms, depending on definition, include headaches, dizziness, neuropsychiatric symptoms, and cognitive impairment. However, these symptoms are common, occurring frequently in non-head injured controls, leading some to question the existence of post-concussion syndrome as a unique syndrome. Therefore, some have attempted to explain post-concussion symptoms as post-traumatic stress disorder, as they share many similar symptoms and post-traumatic stress disorder does not require head injury. This explanation falls short as patients with post-concussion syndrome do not necessarily experience many key symptoms of post-traumatic stress disorder. Therefore, other explanations must be sought to explain the prevalence of post-concussion like symptoms in non-head injury patients. Many of the situations in which post-concussion syndrome like symptoms may be experienced such as infection and post-surgery are associated with systemic inflammatory responses, and even neuroinflammation. Post-concussion syndrome itself has a significant neuroinflammatory component. In this review we examine the evidence of neuroinflammation in post-concussion syndrome and the potential role systemic inflammation plays in post-concussion syndrome like symptoms. We conclude that given the overlap between these conditions and the role of inflammation in their etiologies, a new term, post-inflammatory brain syndromes (PIBS), is necessary to describe the common outcomes of many different inflammatory insults. The concept of post-concussion syndrome is in its evolution therefore, the new term post-inflammatory brain syndromes provides a better understanding of etiology of its wide-array of symptoms and the wide array of conditions they can be seen in.

Major barriers responsible for malnutrition in hemodialysis patients: challenges to optimal nutrition

Background:

Nutritional barriers may contribute to malnutrition in hemodialysis (HD) patients. Higher rates of morbidity and mortality rates have been reported in malnourished HD patients. These patients are faced with different challenges affecting their nutritional status.

Objectives:

The aim of this cross-sectional study was to identify most important barriers responsible for malnutrition in HD patients.

Patients and Methods:

We randomly selected 255 of 800 stable HD patients from three HD centers with an age range of 18-85 years, who had been on hemodialysis for at least three months without any acute illness. Each patient was interviewed to evaluate malnutrition [subjective global assessment (SGA), malnutrition inflammation score (MIS)], and potential medical, behavioral and socioeconomic barriers. Body composition of patients was checked through bioelectrical impedance analysis (BIA). Routine clinical markers of malnutrition such as serum albumin and total protein were measured using standard automated techniques. Binary logistic regression model was used to find the association between nutritional markers and potential barriers.

Results:

Patients with higher SGA had lower knowledge about general nutrition [odds ratio (OR), 1.3], potassium (OR, 1.89), difficulty chewing (OR, 1.16), and shopping (OR, 1.16). Those with greater MIS scores had poor appetite (OR, 1.3), depression (OR, 1.21), and difficulty with cooking (OR, 1.15). Lower BCM (body cell mass) was associated with poor appetite (OR, 0.92) and needed help for cooking (OR, 0.88). Patients with higher BFMI (body fat mass index) had insufficient general nutrition (OR, 1.15), and protein (OR, 1.27) knowledge, and needed help for shopping (OR, 1.14). Moreover, patients with higher SGA scores were those with older age and longer duration of HD.

Conclusions:

Three medical barriers (poor appetite, depression and difficulty chewing), one behavioral barrier (poor total nutrition, protein, and potassium knowledge), and one socioeconomic barrier (needing help for shopping and cooking) were independently associated with nutritional markers.

Psychological stress and strain on employees in dialysis facilities: a cross-sectional study with the Copenhagen Psychosocial Questionnaire

Background

Work in dialysis facilities involves long term contact with chronically ill patients. International comparisons make it clear that dialysis work is being concentrated, staff is being reduced and more patients are being treated. It is more than 20 years since the last German publication on job strains and job satisfaction experienced by dialysis staff was published. The present study examines the stress and strain currently experienced by the staff of German dialysis facilities.

Methods

The staff of 20 dialysis facilities were surveyed with the Copenhagen Psychosocial Questionnaire (COPSOQ). The questionnaire was extended by adding dialysis-specific questions. The data from the dialysis facilities were assessed by comparison with other professions in medical care - nurses and geriatric nurses - using data recorded in the German COPSOQ database.

Results

A total of 367 employees took part in the study, corresponding to a response rate of 55%. For almost all psychosocial aspects, the dialysis staff regarded the stress and strain as being more critical than did the geriatric nurses. There were some positive differences in comparison to hospital nursing, including less conflict between work and private life. However, there were also negative differences, such as fewer possibilities of influencing the work.

Conclusions

The results of the study show that dialysis work exhibits both positive and negative aspects in comparison with other healthcare professions. The results in the different facilities were highly variable, indicating that the deficits found in the individual scales are not inevitable consequences of working in dialysis in general, but are influenced and might be favourably altered by the individual facilities.

The role of adipocytokines on depressive symptoms of patients with chronic kidney disease

OBJECTIVE

The aim of this study is to evaluate depression and anxiety scores among chronic kidney disease (CKD) patients and to search the changes of serum concentrations of adipokines with respect to emotional disturbances of CKD patients.

PATIENTS AND METHODS

150 patients recruited into this cross-sectional analytic study. Study groups were control, hemodialysis, predialysis, peritoneal dialysis and kidney transplantation groups. Fasting morning serum leptin, ghrelin, acylated ghrelin, neuropeptide Y, adiponectin, resistin levels of all of the groups were measured using ELISA (Sandwich) method. A screening interview based on the Structured Clinical Interview for DSM-IV and self-report scales (The Beck Depression [BDI] and The Beck Anxiety Inventory [BAI] and Brief Symptom Inventory [BSI] which is self report scales) were administered and conducted by a trained interviewer.

RESULTS

BDI scores were significantly higher in hemodialysis and predialysis groups compared to control group (p = 0.009). Somatization sub scores of BSI were significantly higher in hemodialysis and peritoneal dialysis groups compared to control group (p = 0.041). Also positive symptom distress index scores of BSI were significantly higher in hemodialysis and transplantation groups compared to control group (p = 0.047). BDI score were significantly negatively correlated with duration of education (r = -0.165, p = 0.045), positively correlated with presence of protein energy wasting (r = 0.198, p = 0.016), and resistin levels (r = 0.233, p = 0.004).

CONCLUSION

CKD patients had higher BDI, BSI-somatization, BSI-positive symptom distress index scores compared to control group. High serum resistin levels, presence of protein energy wasting might have a role in development of depressive disorders of patients with chronic kidney disease.

Malnutrition-inflammation score is associated with handgrip strength in nondialysis-dependent chronic kidney disease patients

OBJECTIVE

The malnutrition-inflammation score (MIS) is a nutritional scoring system that has been associated with muscle strength among dialysis patients. We aimed to test whether MIS is able to predict muscle strength in nondialysis-dependent chronic kidney disease (NDD-CKD) individuals.

DESIGN AND METHODS

This was a cross-sectional study conducted at the Dante Pazzanese Institute of Cardiology, Hypertension, and Nephrology Division outpatient clinic. We evaluated 190 patients with NDD-CKD stages 2-5 (median 59.5 [interquartile range 51.4-66.9] years; 64% men). MIS was calculated without computing dialysis vintage to the scoring. HGS was assessed in the dominant arm. Anthropometric, laboratory, and body composition parameters were recorded.

RESULTS

A strong negative correlation was found between HGS and MIS (r = -0.42; P ≤ .001) in univariate analysis. In multivariate regressions, adjustment for age, sex, diabetes, glomerular filtration rate, body cell mass, and C-reactive protein did not materially diminish these relationships.

CONCLUSIONS

MIS shares strong links with objective measures of muscle strength in NDD-CKD patients.

Quality of life and protein-energy wasting in kidney transplant recipients

PURPOSE

Chronic kidney disease has profound effects on the health-related quality of life (HRQoL) of patients, with serious physiological, psychological and socio-economic implications. The co-occurrence of protein-energy wasting and inflammation in end-stage renal disease patients is associated with worse HRQoL and increased mortality. We designed this study to examine the relationship between nutritional and inflammatory status and HRQoL in kidney transplant recipients.

METHODS

Data from 100 randomly selected kidney transplant patients were analyzed in a cross-sectional survey. Socio-demographic parameters, laboratory results, transplantation-related data, comorbidities, medication and malnutrition-inflammation score (MIS) (Kalantar Score) were tabulated at baseline. Patients completed the Kidney Disease Quality of Life-SF (KDQoL-SF™) self-administered questionnaire.

RESULTS

Mean age was 51 ± 13 years, median (interquartile range, IQR) time since transplantation 66 (83) months, 57% were men, and 19% had diabetes. The median (IQR) MIS was 3 (3). The MIS significantly and negatively correlated with almost all HRQoL domains analyzed, and this association remained significant in multivariate linear regression analysis for the log-transformed scores on energy/fatigue (β = -0.059 P < 0.001), bodily pain (β = -0.056 P = 0.004), physical functioning (β = -0.029, P = 0.022) and symptoms/problems (β = -0.023 P = 0.005) domains after statistical correction for age, gender, eGFR, dialysis vintage, Charlson Comorbidity Index and occupational status. Additionally, cubic spline analyses revealed linearly increasing, "dose-response" relationship between almost all domains of KDQoL-SF™ and the MIS.

CONCLUSIONS

Malnutrition-inflammation score is independently associated with different dimensions of HRQoL in kidney transplant recipients.

Lack of association between objectively assessed sleep disorders and inflammatory markers among kidney transplant recipients

PURPOSE

In patients on dialysis, the results of studies examining the association between sleep disorders and inflammation are controversial. We assessed the association between inflammatory markers and different sleep disorders in a large sample of kidney transplant recipients.

METHODS

Cross-sectional study of 100 randomly selected kidney transplant patients who underwent one-night polysomnography ("sleep disorders evaluation in patients after kidney transplantation study") to diagnose obstructive sleep apnea (OSA) and periodic limb movements in sleep (PLMS). Athens Insomnia Scale (AIS) was utilized to assess the prevalence of insomnia. Sociodemographic information and data about medication, comorbidity and laboratory parameters were collected. Levels of inflammatory markers, such as C-reactive protein, serum albumin, white blood cell count, interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α), were measured.

RESULTS

The mean age was 51 ± 13 years, 43% were women, and the prevalence of diabetes was 19%. We found no significant difference in the levels of inflammatory markers between patients with versus without OSA and PLMS. Apnea-hypopnea index showed a significant association with white blood cell count (ρ = 0.23), and weak (ρ < |0.15|), non-significant correlation with the other inflammatory markers. PLM index showed weak (ρ < |0.15|), non-significant correlation with all markers of inflammation. The serum IL-6 level was significantly higher in patients with insomnia (AIS ≥ 10) than in non-insomniacs [median (IQR): 3.2(2.6-5.1) vs. 1.7(1.2-2.9) ng/l; P = 0.009]. The levels of other inflammatory markers were similar between insomniacs and non-insomniacs.

CONCLUSIONS

We did not find any association between the presence of objectively assessed sleep disorders and inflammatory markers in kidney transplant patients.

Risk factors for depressive symptoms in a large population on chronic hemodialysis

Despite their significant influence on the quality of life, depressive symptoms are not usually included as a clinical parameter in the evaluation of hemodialysis patients. We aimed to identify depressive symptoms and associated risk factors in a large group of individuals with end-stage renal disease (ESRD) on chronic hemodialysis. This was a cross-sectional study of 400 consecutive patients. Cases were analyzed according to the presence/absence of depressive symptoms. All individuals were investigated by interview, and all variables were measured concurrently. Depressive symptoms were evaluated by the Beck Depression Inventory (BDI-II ≥16) and sleep quality by the Pittsburgh Sleep Quality Index (PSQI > 5). Among the 400 patients (59% male), depressive symptoms were present in 77 (19.3%). Depressive symptoms were more common in women and were independently associated with poor sleep quality (P = <0.005), unemployment (P = 0.001), diabetes (P = 0.02), hypoalbuminemia (P = 0.01), low education (P = 0.03), and pruritus (P = 0.04). Women with ESRD on chronic hemodialysis are at increased risk of depression. Furthermore, unemployment and the presence of diabetes, hypoalbuminemia, low education, and pruritus are significantly associated with depressive symptoms. Depressive symptoms are also independently associated with poor quality sleep and studies about the effects of sleep hygiene therapy on depressive symptoms are warranted.

Quality of sleep and day-time sleepiness in chronic hemodialysis: a study of 400 patients

OBJECTIVE

Impaired sleep has potential health consequences in chronic hemodialysis patients. To date, this issue has not been examined in studies involving a large number of subjects. This study aimed to identify factors associated with poor sleep quality and excessive day-time sleepiness (EDS) in dialysis patients.

MATERIAL AND METHODS

This cross-sectional observational study involved 400 patients (59% male) from three hemodialysis centers (SD-HEMOFOR). Quality of sleep was evaluated by the Pittsburgh Sleep Quality Index (PSQI), EDS by the Epworth Sleepiness Scale (ESS), risk of obstructive sleep apnea (OSA) by the Berlin questionnaire and comorbidity severity by the Charlson Comorbidity Index (CCI).

RESULTS

Poor sleep quality (PSQI >5) was found in 227 individuals (57%) and was associated with older age (p = 0.001), diabetes (p = 0.03), heart failure (p < 0.005), hypoalbuminemia (p = 0.01), low transferrin saturation (TSAT) (p = 0.009), higher CCI score (p = 0.01) and depression (p < 0.005). Independent factors were older age, heart failure, low TSAT and depressive symptoms. Day-time somnolence was present in 108 patients (27%) and was independently associated with stroke [odds ratio (OR) = 2.84, CI 1.03-7.76), lower hemoglobin concentration (OR = 2.45, CI 0.95-3.03) and high risk of OSA (OR = 1.65, CI 1.03-2.63). High risk of OSA (n = 120; 30%), was associated with hypertension (p < 0.001), overweight/obesity (p = 0.001), older age (p = 0.003) and symptoms of depression (p = 0.01).

CONCLUSIONS

Poor sleep quality and EDS were prevalent on chronic hemodialysis. Heart failure, low TSAT and depressive symptoms were independently associated with poor sleep quality. Stroke, anemia and high risk of OSA were independently associated with EDS. These results provide new insight into possible treatment strategies.

Impact of sleep quality on cardiovascular outcomes in hemodialysis patients: results from the frequent hemodialysis network study

BACKGROUND

Poor sleep quality is a common, persistent, and important problem to patients with end-stage renal disease (ESRD). This report examines whether sleep quality is associated with dialysis treatment factors and other modifiable clinical factors in a large group of hemodialysis (HD) patients.

METHODS

Cross-sectional analyses were conducted on baseline data collected from participants in the Frequent Hemodialysis Network trials. Sleep quality was measured using the Medical Outcomes Study Sleep Problems Index II (SPI II), a 9-item measure of sleep quality with higher scores reflecting poorer sleep quality.

RESULTS

The participants had an age of 51.2 ± 13.6 years, 61% were male, 38% were black, and 42% had diabetes. Higher pre-dialysis serum phosphorus (per 0.5 mg/ml) (OR 0.91; 95% CI 0.85, 0.96) and depression (OR 0.16; 95% CI 0.10, 0.25) were independently associated with decrements in sleep quality. There was also a difference in time to recovery from dialysis for the fourth versus the first SPI II quartile (5.1 h; p < 0.0001).

CONCLUSION

These findings underscore the link between sleep and daytime function and suggest that improving sleep may provide an opportunity to improve outcomes in ESRD. Whether sleep problems may be improved by reduction of serum phosphorus or treatment of depression in the HD population merits further investigation.

Association between the Malnutrition-Inflammation Score and depressive symptoms in kidney transplanted patients

OBJECTIVE

Depressive symptoms and the Malnutrition-Inflammation Complex Syndrome (MICS) are prevalent in patients with chronic kidney disease. The complex relationship between MICS and depression has never been studied in kidney transplanted (Tx) patients. Here we evaluate the association between the Malnutrition-Inflammation Score (MIS) (Kalantar score) and depressive symptoms in Tx patients.

METHODS

Cross-sectional data of 973 prevalent Tx patients were analyzed. Sociodemographic and anthropometric characteristics and clinical and laboratory data were collected, and serum levels of inflammatory markers [C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α)] were measured. The Center for Epidemiologic Studies-Depression (CES-D) scale, the MIS and the Charlson Comorbidity Index (CCI) were computed. We used linear regression analysis to examine whether the relationship between MIS and CES-D score is independent from sociodemographic and laboratory parameters.

RESULTS

The CES-D score, corrected for age, gender and estimated glomerular filtration rate weakly but significantly correlated with serum IL-6 and the CCI (0.124 and 0.103, respectively; P<.05 for both) and marginally significantly with CRP (0.06; P=.06). We found a moderate correlation between CES-D score and MIS (0.262; P<.001). In a multivariable linear regression model, the MIS was independently associated with the CES-D score (B=0.110; P<.001).

CONCLUSIONS

The MIS was significantly associated with depressive symptoms after adjusting for important covariables in patients after renal transplantation.