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So S, Lei Li KC. Prognostication After Dialysis Withdrawal. Kidney Int Rep 2024; 9:2117-2124. [PMID: 39081756 PMCID: PMC11284357 DOI: 10.1016/j.ekir.2024.04.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 04/17/2024] [Accepted: 04/19/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction Dialysis withdrawal represents an increasingly common cause of death in patients receiving kidney replacement therapy internationally. Prognostic information about stopping dialysis guides clinicians counseling patients and families regarding end-of-life care. However, few studies examine prognostication after withdrawal. We aimed to determine median survival time after withdrawal of dialysis, and to determine which patient and dialysis-related factors are significantly associated with prognosis. Methods This retrospective cohort study used registry data. We included all adult patients from the Western Renal Services who were receiving peritoneal dialysis (PD) or hemodialysis prior to death, whose cause of death was documented as "withdrawal from dialysis" and whose date of death was between January 1, 2016 and June 30, 2022. Demographic, clinical, and biochemical data was extracted. The primary outcome was time-to-death, defined as days from last dialysis session to date of death. Results Median survival time from last dialysis to death for the PD group (n = 53) was 4 days (interquartile range [IQR]: 3-10 days), not significantly different from the hemodialysis group which was 6 days (IQR: 2-11 days, P = 0.72). For PD, the only variable significantly associated with survival time was reason for withdrawing (P = 0.01). Median survival time was significantly longer for patients withdrawing for psychosocial reasons compared to those withdrawing for other reasons (P = 0.002). For hemodialysis (n = 186), variables significantly associated with survival time from last dialysis to death was reason for withdrawing (P = 0.001), urine production at the time of withdrawal (P = 0.005), serum sodium (P = 0.02) and smoking status (P = 0.009). Conclusion Median survival time was longer for withdrawals for psychosocial reasons compared to medical reasons. The data presented could inform withdrawal discussions regarding prognostication and end-of-life planning with patients and family.
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Affiliation(s)
- Sarah So
- Department of Renal Medicine, Nepean Kidney Research Center, Nepean Hospital, Kingswood, Sydney, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
| | - Kelly Chen Lei Li
- Department of Renal Medicine, St George Hospital, Kogarah, Sydney, New South Wales, Australia
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El-Magd ES, Schouten RW, Nadort E, Shaw PKC, Smets YFC, Vleming LJ, Dekker FW, Broekman BFP, Honig A, Siegert CEH. Dialysis withdrawal and symptoms of anxiety and depression: a prospective cohort study. BMC Nephrol 2023; 24:219. [PMID: 37488483 PMCID: PMC10367409 DOI: 10.1186/s12882-023-03267-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 07/10/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND An important aspect of end-of-life decisions in dialysis patients is elective withdrawal from dialysis therapy. Several studies have shown that clinical factors, such as comorbidity, play a role in dialysis withdrawal. The role of symptoms of anxiety and depression is largely unknown. The. METHODS A prospective multi-center study has been set up to investigate anxiety and depressive symptoms longitudinally in dialysis patients. Anxiety and depressive symptoms were investigated using the Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) as baseline. Adverse events, including dialysis withdrawal and mortality were registered during follow-up. Multivariable cox proportional hazard models were used with anxiety and depression as the independent variable and dialysis withdrawal as the outcome variable. Models included age, sex, ethnicity and a set of clinical comorbidities. RESULTS A total of 687 patients were included between 2012 and 2017, with a median follow-up of 3.2 years. A total of 48 patients (7%) withdrew from dialysis therapy, and subsequently deceased. Anxiety and depressive symptoms at baseline showed an association with dialysis withdrawal with hazard ratios of 2.31 (1.09-4.88) for anxiety and 2.56 (1.27-5.15) for depressive symptoms, independent of somatic comorbidities. DISCUSSION Withdrawal from dialysis therapy is associated with anxiety and depressive symptoms. Dialysis patients with more severe depressive and anxiety symptoms were more vulnerable for dialysis withdrawal. Insight in factors that play a role in dialysis withdrawal could aid patients and clinicians making an informed decision and develop clinical guidelines.
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Affiliation(s)
- Essam S El-Magd
- Department of Nephrology, OLVG Hospital, Amsterdam, The Netherlands.
| | - Robbert W Schouten
- Department of Nephrology, OLVG Hospital, Amsterdam, The Netherlands
- Department of Internal Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Els Nadort
- Department of Psychiatry and Medical Psychology, OLVG Hospital, Amsterdam, The Netherlands
| | | | - Yves F C Smets
- Department of Nephrology, OLVG Hospital, Amsterdam, The Netherlands
| | - Louis-Jean Vleming
- Department of Nephrology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Birit F P Broekman
- Department of Psychiatry and Medical Psychology, OLVG Hospital, Amsterdam, The Netherlands
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam Mental Health, Amsterdam, The Netherlands
| | - Adriaan Honig
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Carl E H Siegert
- Department of Nephrology, OLVG Hospital, Amsterdam, The Netherlands
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Sousa H, Ribeiro O, Christensen AJ, Figueiredo D. Mapping Patients' Perceived Facilitators and Barriers to In-Center Hemodialysis Attendance to the Health Belief Model: Insights from a Qualitative Study. Int J Behav Med 2023; 30:97-107. [PMID: 35275346 DOI: 10.1007/s12529-022-10075-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous research has shown that deliberate withdrawal, skipping, and/or shortening hemodialysis sessions has become a major health problem associated with poor clinical outcomes and early mortality in patients with end-stage renal disease (ESRD). However, patients' experiences with this treatment remain largely unexplored. This study aimed to explore patients' perceived facilitators and barriers to in-center hemodialysis attendance and map these findings to the Health Belief Model. METHODS A qualitative exploratory study was conducted with a purposive sample. Semi-structured interviews were conducted and submitted to thematic analysis. RESULTS Twenty-four patients (66.2 ± 12.3 years old; length of time on hemodialysis: 35.2 ± 51.5 months) were interviewed. Five major facilitators (social support, perceived benefits, self-efficacy, time on dialysis, and risk/susceptibility perception) and two barriers (lack of knowledge about ESRD and hemodialysis, and psychosocial costs) were identified. CONCLUSION Adherence to the prescribed regimen of hemodialysis attendance is a complex and multidimensional phenomenon that involves an interaction between modifying factors (social support, disease and treatment knowledge, time on dialysis) and patients' perceived benefits, perceived risks, self-efficacy, and treatment costs. This study findings expand knowledge by suggesting that perceiving health benefits from the beginning of treatment, self-efficacy to deal with dialysis demands, and purpose in life are important facilitators of adherence to in-center hemodialysis sessions. Furthermore, it suggests that the impact of the hemodialysis regimen on the emotional well-being of family members is an important barrier. Future interventions should focus on skills training to promote self-efficacy and family coping with the demands of in-center hemodialysis, improve disease and treatment knowledge, and help balance perceived benefits with dialysis costs.
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Affiliation(s)
- Helena Sousa
- Center for Health Technology and Services Research (CINTESIS.UA), Department of Education and Psychology, University of Aveiro, Campus Universitário de Santiago, Aveiro, 3810-193, Portugal.
| | - Oscar Ribeiro
- Center for Health Technology and Services Research (CINTESIS.UA), Department of Education and Psychology, University of Aveiro, Campus Universitário de Santiago, Aveiro, 3810-193, Portugal
| | - Alan J Christensen
- Department of Psychology, East Carolina University, North Carolina, 27858, USA
| | - Daniela Figueiredo
- Center for Health Technology and Services Research (CINTESIS.UA), School of Health Sciences, University of Aveiro, Campus Universitário de Santiago, 3810-193, Aveiro, Portugal
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Pojatić Đ, Nikić D, Tolj I, Pezerović D, Šantić A, Degmečić D. Alexithymia, Phosphorus Levels, and Sleep Disorders in Patients on Hemodialysis. J Clin Med 2022; 11:jcm11113218. [PMID: 35683604 PMCID: PMC9181024 DOI: 10.3390/jcm11113218] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/28/2022] [Accepted: 06/02/2022] [Indexed: 02/04/2023] Open
Abstract
Alexithymia, or the inability to distinguish between bodily feelings and emotions, has been linked to poor sleep quality in some studies. Rare studies examined the associations between electrolyte phosphorus in patients on hemodialysis and their sleep quality, daytime sleepiness, and alexithymia with inflammatory factors. Hemodialysis is a treatment method for terminal renal patients that involves the diffusion of unwanted metabolic products through the dialyzer membrane. Our study aimed to examine whether there was a difference in phosphorus levels, inflammatory factors, and daytime sleepiness according to the hemodialysis patients’ levels of alexithymia. The study involved 170 HD patients that had been treated with chronic dialysis for more than three months. Prior to the hemodialysis procedure, laboratory findings were sampled. Respondents completed the Pittsburgh Sleep Quality Index, the Toronto Alexithymia Scale 26, and the Epworth Sleepiness Scale, and were questioned about depression. The results showed that alexithymic HD patients exhibited significantly higher leukocyte counts, lower predialysis phosphorus values, and more pronounced daily sleepiness than the alexithymia-free group (Mann−Whitney U test, p = 0.02, p = 0.005, and p < 0.001, respectively). We concluded that alexithymia was an independent predictor of high daytime sleepiness in HD patients (OR = 1.05, 95% CI 1.02 to 1.09).
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Affiliation(s)
- Đorđe Pojatić
- Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, 31 000 Osijek, Croatia; (Đ.P.); (I.T.); (D.P.); (A.Š.)
- Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, 31 000 Osijek, Croatia
- Department of Internal Medicine, General County Hospital Vinkovci, 32 100 Vinkovci, Croatia
| | - Dajana Nikić
- Department of Plant Sciences, Faculty of Biosciences, Norwegian University of Life Sciences, P.O. Box 5003, N-1432 As, Norway;
| | - Ivana Tolj
- Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, 31 000 Osijek, Croatia; (Đ.P.); (I.T.); (D.P.); (A.Š.)
- Department of Internal Medicine, University Hospital Osijek, 31 000 Osijek, Croatia
| | - Davorin Pezerović
- Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, 31 000 Osijek, Croatia; (Đ.P.); (I.T.); (D.P.); (A.Š.)
- Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, 31 000 Osijek, Croatia
- Department of Internal Medicine, General County Hospital Vinkovci, 32 100 Vinkovci, Croatia
| | - Andrijana Šantić
- Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, 31 000 Osijek, Croatia; (Đ.P.); (I.T.); (D.P.); (A.Š.)
- Department of Psychiatry, University Hospital Osijek, 31 000 Osijek, Croatia
| | - Dunja Degmečić
- Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, 31 000 Osijek, Croatia; (Đ.P.); (I.T.); (D.P.); (A.Š.)
- Department of Psychiatry, University Hospital Osijek, 31 000 Osijek, Croatia
- Correspondence: ; Tel.: +385-31-511794
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Chen JHC, Lim WH, Howson P. Changing landscape of dialysis withdrawal in patients with kidney failure: Implications for clinical practice. Nephrology (Carlton) 2022; 27:551-565. [PMID: 35201646 PMCID: PMC9315017 DOI: 10.1111/nep.14032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 02/09/2022] [Accepted: 02/19/2022] [Indexed: 11/29/2022]
Abstract
Dialysis withdrawal has become an accepted treatment option for patients with kidney failure and is one of the leading causes of death in patients receiving dialysis in high-income countries. Despite its increasing acceptance, dialysis withdrawal currently lacks a clear, consistent definition. The processes and outcomes of dialysis withdrawal have wide temporal and geographical variability, attributed to dialysis patient selection, influence from cultural, religious and spiritual beliefs, and availability of kidney replacement therapy and conservative kidney management. As a complex, evolving process, dialysis withdrawal poses an enormous challenge for clinicians and healthcare teams with various limitations precluding a peaceful and smooth transition between active dialysis and end-of-life care. In this review, we examine the current definitions of dialysis withdrawal, the temporal and geographical patterns of dialysis withdrawal, international barriers in the decision-making process (including dialysis withdrawal during the COVID-19 pandemic), and gaps in the current dialysis withdrawal recommendations for clinical consideration and future studies.
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Affiliation(s)
- Jenny H C Chen
- Faculty of Medicine, University of Wollongong, Wollongong, Australia.,Wollongong Hospital, Wollongong, Australia
| | - Wai H Lim
- Department of Nephrology, Sir Charles Gairdner Hospital, Perth, Australia.,Faculty of Medicine, University of Western Australia, Perth, Australia
| | - Prue Howson
- Department of Nephrology, Sir Charles Gairdner Hospital, Perth, Australia
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Chen JHC, Brown MA, Jose M, Brennan F, Johnson DW, Roberts MA, Wong G, Cheikh Hassan H, Kennard A, Walker R, Davies CE, Boudville N, Borlace M, Hawley C, Lim WH. Temporal changes and risk factors of death from early withdrawal within 12 months of dialysis initiation - a cohort study. Nephrol Dial Transplant 2021; 37:760-769. [PMID: 34175956 PMCID: PMC8951200 DOI: 10.1093/ndt/gfab207] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Indexed: 11/16/2022] Open
Abstract
Background Mortality risk is high soon after dialysis initiation in patients with kidney failure, and dialysis withdrawal is a major cause of early mortality, attributed to psychosocial or medical reasons. The temporal trends and risk factors associated with cause-specific early dialysis withdrawal within 12 months of dialysis initiation remain uncertain. Methods Using data from the Australia and New Zealand Dialysis and Transplant Registry, we examined the temporal trends and risk factors associated with mortality attributed to early psychosocial and medical withdrawals in incident adult dialysis patients in Australia between 2005 and 2018 using adjusted competing risk analyses. Results Of 32 274 incident dialysis patients, 3390 (11%) experienced death within 12 months post-dialysis initiation. Of these, 1225 (36%) were attributed to dialysis withdrawal, with 484 (14%) psychosocial withdrawals and 741 (22%) medical withdrawals. These patterns remained unchanged over the past two decades. Factors associated with increased risk of death from early psychosocial and medical withdrawals were older age, dialysis via central venous catheter, late referral and the presence of cerebrovascular disease; obesity and Asian ethnicity were associated with decreased risk. Risk factors associated with early psychosocial withdrawals were underweight and higher socioeconomic status. Presence of peripheral vascular disease, chronic lung disease and cancers were associated with early medical withdrawals. Conclusions Death from dialysis withdrawal accounted for >30% of early deaths in kidney failure patients initiated on dialysis and remained unchanged over the past two decades. Several shared risk factors were observed between mortality attributed to early psychosocial and medical withdrawals.
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Affiliation(s)
- Jenny H C Chen
- School of Medicine, University of Wollongong, Wollongong, Australia
- Depatment of Renal Medicine, Wollongong Hospital, Wollongong, Australia
- Correspondence to: Jenny H.C. Chen; E-mail:
| | - Mark A Brown
- Department of Nephrology, St George Hospital, Sydney, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
| | - Matthew Jose
- School of Medicine, The University of Tasmania, Hobart, Australia
- Department of Nephrology, Royal Hobart Hospital, Hobart, Australia
| | - Frank Brennan
- Department of Nephrology, St George Hospital, Sydney, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Centre for Health Services Research, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
- Australasian Kidney Trials Network, Brisbane, Australia
| | - Matthew A Roberts
- School of Medicine, Monash University, Melbourne, Australia
- Renal Service, Eastern Health, Melbourne, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia
| | - Hicham Cheikh Hassan
- School of Medicine, University of Wollongong, Wollongong, Australia
- Depatment of Renal Medicine, Wollongong Hospital, Wollongong, Australia
| | - Alice Kennard
- School of Medicine, Australian National University, Canberra, Australia
- Department of Nephrology, Canberra Hospital, Canberra, Australia
| | - Rachael Walker
- Sydney School of Public Health, University of Sydney, Sydney, Australia
- School of Nursing, Eastern Institute of Technology, Napier, New Zealand
| | - Christopher E Davies
- Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Neil Boudville
- Medical School, University of Western Australia, Perth, Australia
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Monique Borlace
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, Australia
| | - Carmel Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Centre for Health Services Research, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
- Australasian Kidney Trials Network, Brisbane, Australia
| | - Wai H Lim
- Medical School, University of Western Australia, Perth, Australia
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
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