Depression, insomnia and sleep apnea in patients on maintenance hemodialysis

Sleep apnoea syndrome prevalence in chronic kidney disease and end-stage kidney disease patients: a systematic review and meta-analysis

Background

Several studies have examined the frequency of sleep apnoea (SA) in patients with chronic kidney disease (CKD), reporting different prevalence rates. Our systematic review and meta-analysis aimed to define the clinical penetrance of SA in CKD and end-stage kidney disease (ESKD) patients.

Methods

Ovid-MEDLINE and PubMed databases were explored up to 5 June 2023 to identify studies providing SA prevalence in CKD and ESKD patients assessed by different diagnostic methods, either sleep questionnaires or respiration monitoring equipment [such as polysomnography (PSG), type III portable monitors or other diagnostic tools]. Single-study data were pooled using the random-effects model. The Chi2 and Cochrane-I2 tests were used to assess the presence of heterogeneity, which was explored performing sensitivity and/or subgroup analyses.

Results

A cumulative analysis from 32 single-study data revealed a prevalence of SA of 57% [95% confidence interval (CI) 42%-71%] in the CKD population, whereas a prevalence of 49% (95% CI 47%-52%) was found pooling data from 91 studies in ESKD individuals. The prevalence of SA using instrumental sleep monitoring devices, including classical PSG and type III portable sleep monitors, was 62% (95% CI 52%-72%) and 56% (95% CI 42%-69%) in CKD and ESKD populations, respectively. Sleep questionnaires revealed a prevalence of 33% (95% CI 16%-49%) and 39% (95% CI 30%-49%).

Conclusions

SA is commonly seen in both non-dialysis CKD and ESKD patients. Sleep-related questionnaires underestimated the presence of SA in this population. This emphasizes the need to use objective diagnostic tools to identify such a syndrome in kidney disease.

Impact of Hemodialysis on Sleep Disorders in Patients With End-Stage Renal Disease in a Tertiary Care Academic Hospital

INTRODUCTION

Although hemodialysis (HD) has prolonged the survival of patients with end-stage renal disease (ESRD), it has also adversely affected the sleep and emotional state of these patients. We evaluated the impact of HD on sleep duration, quality, and other sleep-related disorders.

METHODS

We recruited consecutive adult patients visiting our tertiary care dialysis unit. We included only ESRD patients who had an estimated glomerular filtration rate (eGFR) of <15 mL/min/1.73m2. We excluded patients with unrelated comorbidities or on medications that could affect sleep. Basic demographic information, anthropometric data, and appropriate lab investigations were obtained. Objective information related to their sleep duration and quality was asked using a predefined proforma. Subjective sleep scores were obtained by using the Pittsburgh sleep quality index (PSQI), Epworth sleepiness scale (ESS), and insomnia severity index (ISI). For comparison, the patients were divided into HD and conservative treatment (CT) groups based on their treatment modality. The baseline characteristics of the patients were noted. The Shapiro-Wilk test was used to test normality. Correlations were obtained by using Student's t-test for parameters that were normally distributed and the Mann-Whitney-Wilcoxon test for those that were not.

RESULTS

Of the 56 patients we studied, 59% were males. The average age and body mass index (BMI) were 45.7 years and 20.98 kg/m2, respectively. Overall, 41% of patients were assigned to the HD group, and the remaining to the CT group. The CT group had fewer comorbidities compared to the HD group. The average sleep duration was similar in both groups (HD: 6.64 hours, CT: 6.49 hours). There was a weak-to-moderate positive correlation between the sleep scores. Overall, one-half of the patients had excessive daytime sleepiness (EDS) (46.43%) and insomnia (48.21%), and two-thirds of them were poor sleepers (66.07%). Symptoms suggestive of sleep-disordered breathing (SDB) were seen in 25% of patients, restless legs syndrome (RLS) in 19.64% of patients, and periodic limb movement disorder (PLMD) in 44.64% of patients. Patients undergoing HD had poorer sleep quality compared to the CT group (p=0.038). The odds of developing poor sleep were 3.6 times higher in the HD group.

CONCLUSION

This cross-sectional study focuses on the quantification of objective and subjective deterioration of sleep quality in ESRD patients on HD. The prevalence of EDS (63.64%), insomnia (51.52%), and poor sleep quality (84.84%) in the HD group was more than the previously reported values. The PSQI, ESS, and ISI scores were higher in HD patients, indicating poorer sleep quality. Our study highlights the underestimation of sleep disorders in HD patients in underserved areas. The results warrant a meticulous evaluation of the same by a keen nephrologist, followed by referral to sleep providers where necessary.

Identification of discriminative neuroimaging markers for patients on hemodialysis with insomnia: a fractional amplitude of low frequency fluctuation-based machine learning analysis

BACKGROUND AND OBJECTIVE

Insomnia is one of the common problems encountered in the hemodialysis (HD) population, but the mechanisms remain unclear. we aimed to (1) detect the spontaneous brain activity pattern in HD patients with insomnia (HDWI) by using fractional fractional amplitude of low frequency fluctuation (fALFF) method and (2) further identify brain regions showing altered fALFF as neural markers to discriminate HDWI patients from those on hemodialysis but without insomnia (HDWoI) and healthy controls (HCs).

METHOD

We compared fALFF differences among HDWI subjects (28), HDWoI subjects (28) and HCs (28), and extracted altered fALFF features for the subsequent discriminative analysis. Then, we constructed a support vector machine (SVM) classifier to identify distinct neuroimaging markers for HDWI.

RESULTS

Compared with HCs, both HDWI and HDWoI patients exhibited significantly decreased fALFF in the bilateral calcarine (CAL), right middle occipital gyrus (MOG), left precentral gyrus (PreCG), bilateral postcentral gyrus (PoCG) and bilateral temporal middle gyrus (TMG), whereas increased fALFF in the bilateral cerebellum and right insula. Conversely, increased fALFF in the bilateral CAL/right MOG and decreased fALFF in the right cerebellum was observed in HDWI patients when compared with HDWoI patients. Moreover, the SVM classification achieved a good performance [accuracy = 82.14%, area under the curve (AUC) = 0.8202], and the consensus brain regions with the highest contributions to classification were located in the right MOG and right cerebellum.

CONCLUSION

Our result highlights that HDWI patients had abnormal neural activities in the right MOG and right cerebellum, which might be potential neural markers for distinguishing HDWI patients from non-insomniacs, providing further support for the pathological mechanism of HDWI.

Depression in Patients on Hemodialysis: A Dilapidated Facet

Introduction

End-stage renal disease (ESRD) has increased in India due to the growing load of non-communicable diseases. The most prevalent psychological issue among these patients has been identified as depression, which may have an impact on treatment success. Around 20% to 90% of hemodialysis patients experience depression. The current study aimed to determine the prevalence of depression among patients undergoing hemodialysis as well as the relationship between this condition and the sociodemographic and clinical parameters of the patients.

Methods

Basic demographic information and particulars of chronic morbidity, duration, and the number of cycles of hemodialysis per week were noted. The Beck Depression Inventory (BDI) score was administered to screen for depression.

Results

A total of 92 participants were enrolled in the study; 69 (75%) were males. The mean age of participants was 52 years. Hypertension (100%) was the most common co-morbidity followed by diabetes mellitus (38%). The mean duration of chronic kidney disease was 3.9 years. The majority (68.5%) had hemodialysis twice per week. Forty-one percent (41%) screened positive for borderline clinical depression or more. The mean BDI score was 17.07. The number of hemodialyses per week had a significant relation with depression with an odds ratio of 4.16 and 95% CI of 1.4-12.38.

Conclusion

Depression is prevalent among patients with chronic kidney disease who are on dialysis. The management of this preventable illness demands a repertoire of measures such as launching a program for the detection and treatment of depression combining psychiatric professionals and social volunteer organizations.

A cross-sectional study on assessing depression among hemodialysis patients

Depression is the most common disorder of psychiatric illness experienced by hemodialysis patients. Failure to measure depression may diminish their well-being. The main objective of this study is to assess depression in hemodialysis patients. The primary goal is to find out the prevalence of depression among chronic kidney disease (CKD) patients. The secondary goal is to find the association between age, sex, and the severity of depression among patients with CKD. This cross-sectional study was performed at the Nephrology Department of King Fahad Hospital, Tabuk, from December 2021 to April 2022. Depression was assessed using a validated Arabic version of the Zung Self-Rating Depression Scale, which is a self-administered questionnaire to assess depression. The mean age of subjects was 42.13 years (standard deviation = 15.65), most of them were in the age group of 18-29 and 40-49 years (n = 59, 24.58%), and the majority were male (n = 128, 53.33%). The depression prevalence among hemodialysis patients was 74.58%. Majority of the patients were with mild depression (n = 175, 72.92%). No significant difference was found for depression among different age groups or genders with ongoing hemodialysis, in our study. Even though the prevalence of depression was high, mostly they were in the mild category. Depression should be assessed frequently, and psychological counseling should be given to improve the well-being of patients.

Association between Financial Hardship and Symptom Burden in Patients Receiving Maintenance Dialysis: A Systematic Review

BACKGROUND

Many patients on maintenance dialysis experience financial hardship. Existing studies are mainly cost analyses that quantify financial hardship in monetary terms, but an evaluation of its impact is also warranted. This review aims to explore the definition of financial hardship and its relationship with symptom burden among patients on dialysis.

METHODS

A literature search was conducted in November 2020, using six electronic databases. Studies published in English that examined the associations between financial hardship and symptom burden were selected. Two reviewers independently extracted data and appraised the studies by using the JBI Critical Appraisal Checklists.

RESULTS

Fifty cross-sectional and seven longitudinal studies were identified. Studies used income level, employment status, healthcare funding, and financial status to evaluate financial hardship. While relationships between decreased income, unemployment, and overall symptom burden were identified, evidence suggested that several symptoms, including depression, fatigue, pain, and sexual dysfunction, were more likely to be associated with changes in financial status.

CONCLUSION

Our findings suggest that poor financial status may have a negative effect on physical and psychological well-being. However, a clear definition of financial hardship is warranted. Improving this assessment among patients on dialysis may prompt early interventions and minimize the negative impact of financial hardship.

Auricular Acupressure for Insomnia in Patients With Maintenance Hemodialysis: A Systematic Review and Meta-Analysis

Background: Insomnia is one of the common problems in patients with maintenance hemodialysis (MHD). Previous studies have reported the beneficial effects of auricular acupressure (AA) for insomnia in patients with MHD. This study aimed to critically evaluate the efficacy and safety of AA for insomnia in patients with MHD. Methods: Web of Science, Embase, PubMed, Cochrane Library, Chinese Biomedical Database, Wanfang Data, Chinese Science and Technology Periodicals database, and China National Knowledge Infrastructure were systematically searched from inception to April 30, 2020, to identify any eligible randomized controlled trials. MHD patients with insomnia were included regardless of age, gender, nationality, or race. The experimental interventions included AA alone or AA combined with other therapies. The control interventions included placebo, no treatment, or other therapies. The primary outcome was sleep quality measured by the Pittsburgh Sleep Quality Index (PSQI). RevMan 5.3 software was used for statistical analysis. Results: Eight studies involving 618 participants were included for statistical analysis. A meta-analysis showed no significant difference of PSQI global score after 8 weeks of AA treatment compared with estazolam (p = 0.70). Other narrative analyses revealed that PSQI global score was significantly attenuated after AA treatment in comparison with mental health education (p = 0.03, duration of 4 weeks; p = 0.02, duration of 8 weeks), AA plus routine nursing care compared with routine nursing care alone (p < 0.0001), and AA plus footbath compared with footbath alone (p = 0.01), respectively. A meta-analysis showed that AA could significantly increase the response rate (reduction of PSQI global score by 25% and more) in comparison with estazolam (p = 0.01). Other narrative analyses reported that the response rate was significantly increased after AA treatment compared with sham AA (p = 0.02), AA compared with mental health education (p = 0.04), and AA plus routine nursing care compared with routine nursing care alone (p = 0.0003), respectively. Conclusion: The present findings suggest that AA may be an alternative treatment for insomnia in patients with MHD. However, more large-scale, high-quality trials are still warranted to confirm these outcomes.

Association of Insomnia in Patients with Chronic Kidney Disease on Maintenance Hemodialysis

Objective To determine the frequency of insomnia in patients with chronic kidney disease (CKD) on maintenance hemodialysis (HD) Study design Cross-sectional (descriptive) Study duration From July 20, 2019, to January 20, 2020 Study settings Department of Nephrology, Khyber Teaching Hospital, Peshawar Materials and methods A total of 148 patients diagnosed with CKD and on maintenance HD were selected for the study in a consecutive sampling manner and checked for insomnia. Results Out of 148 patients included in the study, there were 64.9% male and 35.1% female patients. The mean duration of CKD (months) was 13.9 ± 6.3. The mean number of sessions for hemodialysis done in all patients was 16.8 ± 5.3. On careful interviewing of the patient, difficulty in falling asleep was recorded in 28.4%, difficulty in staying asleep in 41.9%, problems in waking up early in 34.5%, and insomnia interfering in routine life activities in 28.4%. Overall, insomnia was recorded in 36.5% of patients and was found to have a significant correlation with the number of dialysis sessions (p-value 0.000). Conclusion Insomnia is a frequent disorder associated with CKD patients on maintenance HD. There are very few studies establishing its pathogenesis and risk factors. We recommend further multicenter studies to detect the course of insomnia in association with CKD on HD and its potential impact on the overall quality of life of patients with CKD.

Obstructive sleep apnea and depression: A systematic review and meta-analysis

INTRODUCTION

The present study aimed to review the association between obstructive sleep apnea (OSA) and depression and compare the prevalence of depression among people with and without OSA.

METHODS

Systematic review and meta-analysis following PRISMA guidelines. We searched for papers published between 1 January 2010 and 20 October 2019 listed on the following databases: Embase, Ovid MEDLINER(R) and PsychINFO. The search terms included a combination of keywords related to sleep apnea and depression. We also completed a manual search of the references listed in the articles retrieved and grouped them according to study design: cross-sectional, case-control and longitudinal. Scale scores were standardised for comparison.

RESULTS

Our search strategy yielded 1158 papers, of which 34 were considered suitable of review and 11 reported data that could be used for meta-analysis. Data from the 6 cross-sectional studies found no compelling evidence of an association between OSA and depression (odds ratio = 1.12, 95 % confidence interval, 95 %CI = 0.78, 1.47), but the meta-analysis of 5 longitudinal studies indicated that people with OSA were at greater risk of developing depression during follow-up than those without OSA (non-specific risk ratio (RR) = 2.18, 95 %CI = 1.47, 2.88), although there was evidence of high study heterogeneity (I² = 72.8 %).

DISCUSSION

The results of this systematic review and meta-analysis of observational studies is consistent with the hypothesis that OSA may increase the risk of depression. Sample characteristics and various methodological issues create uncertainty about the validity and generalizability of these associations.

Quality of life in caregivers compared with dialysis recipients: The Co-ACTIVE sub-study of the ACTIVE dialysis trial

AIM

To compare quality of life (QOL) of caregivers of dialysis patients with the cared for patients and population norms.

METHODS

The ACTIVE Dialysis study randomized participants to extended (median 24 h/week) or standard (median 12 h/week) haemodialysis hours for 12 months. A subgroup of participants and their nominated caregivers completed QOL questionnaires including the EuroQOL-5 Dimension-3 Level (EQ5D-3 L), short form-36 (SF-36, also allowing estimation of the SF-6D), as well as a bespoke questionnaire and the personal wellbeing index (PWI). Caregiver QOL was compared with dialysis patient QOL and predictors of caregiver QOL were determined using multivariable regression.

RESULTS

There were 54 patients and caregiver pairs, predominantly from China. Caregivers mean (SD) age was 53.4 (11.3) years, 60% were female, 71% cared for their spouse/partner, and 36% were educated to university level. Caregivers had better physical but similar mental QOL compared with dialysis patients (mean SF-36 physical component summary: 46.9 ± 8.7 vs 40.4 ± 10.2, P < 0.001; mental component summary: 47.8 ± 9.7 vs 49.6 ± 12.0, P = 0.84). Health utility measured with EQ5D-3 L was not significantly different between caregivers and dialysis patients (mean 0.869 ± 0.185 vs 0.798 ± 0.227, P = 0.083). Caregiver PWI was 43.7 ± 15.5, significantly lower than the Chinese population norm (68.2 ± 14.2, P < 0.001). Higher physical and mental QOL among caregivers was predicted by university education but not age, gender or daily hours caring.

CONCLUSION

Caregivers have higher physical and equivalent mental QOL to dialysis patients but poorer personal well-being than the Chinese population. University education predicts better QOL and may be a surrogate for socioeconomic or other factors. (NCT00649298).

Prevalence of Depression, Anxiety and Insomnia in Chronic Kidney Disease Patients and their Co-Relation with the Demographic Variables

BACKGROUND

Chronic kidney disease (CKD) is an emerging health problem in both developed and developing countries. Depression, anxiety and sleep disturbances are highly prevalent in patients with chronic disease, but remain undertreated despite significant negative consequences on patients' health. Assessment of key components of mental health early in disease course will help to identify high risk subjects in whom modifying these predictors will help in providing active and healthy life in CKD patients.

METHODS

We did a cross sectional study in 200 patients of CKD stage III to V-D fulfilling the eligibility criteria who were on follow up in a single tertiary care center in the state of Haryana, India. We assessed the prevalence of anxiety, depression and insomnia and their correlation with demographic variables in these patients. The structured questionnaire used in this study gathered information on respondent demographic and disease characteristics, and information obtained from the HADS and PSQI questionnaire. Factors associated with anxiety, depression and insomnia were examined by a multiple logistic regression analysis.

RESULTS

The prevalence of anxiety, depression and insomnia were found to be 71%, 69% and 86.5% respectively. As the CKD stage advanced, the prevalence as well as severity of these parameters increased. Anxiety, depression and sleep quality were found to be significantly correlated to unemployment, low income, low education, urban residence and presence of co-morbidities. The anxiety, depression and insomnia scores were found to have a strong negative correlation with eGFR, hemoglobin, serum calcium (p <0.01) and a positive correlation with TLC, blood urea, serum creatinine and serum phosphate (p <0.05).

CONCLUSION

We observed a high prevalence of anxiety, depression and insomnia in CKD patients. There is a need to develop strategies to accurately identify "high risk" subjects who may benefit from preventive measures before complications occur. By identifying CKD patients with high risk of developing these mental health related issues, healthcare provider may be better able to ensure the provision of appropriate rehabilitation to this population.

Burden of Care and Quality of Life Among Caregivers for Adults Receiving Maintenance Dialysis: A Systematic Review

RATIONALE & OBJECTIVE

Dialysis is a burdensome and complex treatment for which many recipients require support from caregivers. The impact of caring for people dependent on dialysis on the quality of life of the caregivers has been incompletely characterized.

STUDY DESIGN

Systematic review of quantitative studies of quality of life and burden to caregivers.

SETTING & STUDY POPULATION

Caregivers of adults receiving maintenance dialysis.

SELECTION CRITERIA FOR STUDIES

The Cochrane Library, Embase, PsycINFO, CINAHL, PubMed, and MEDLINE were systematically searched from inception until December 2016 for quantitative studies of caregivers. Pediatric and non-English language studies were excluded. Study quality was assessed using a modified Newcastle-Ottawa scale.

DATA EXTRACTION

2 independent reviewers selected studies and extracted data using a prespecified extraction instrument.

ANALYTICAL APPROACH

Descriptive reports of demographics, measurement scales, and outcomes. Quantitative meta-analysis using random effects when possible.

RESULTS

61 studies were identified that included 5,367 caregivers from 21 countries and assessed the impact on caregivers using 70 different scales. Most (85%) studies were cross-sectional. The largest identified group of caregivers was female spouses who cared for recipients of facility-based hemodialysis (72.3%) or peritoneal dialysis (20.6%). Caregiver quality of life was poorer than in the general population, mostly comparable with caregivers of people with other chronic diseases, and often better than experienced by the dialysis patients cared for. Caregiver quality of life was comparable across dialysis modalities.

LIMITATIONS

Heterogeneity in study design and outcome measures made comparisons between studies difficult and precluded quantitative meta-analysis. Study quality was generally poor.

CONCLUSIONS

Quality of life of caregivers of dialysis recipients is poorer than in the general population and comparable to that of caregivers of individuals with other chronic diseases. The impact of caring for recipients of home hemodialysis or changes in the impact of caring over time have not been well studied. Further research is needed to optimally inform dialysis programs how to educate and support caregivers.

Prevalence and clinical correlates of depression in chronic kidney disease patients in a tertiary care hospital

BACKGROUND

Prognosis and associated complications of chronic kidney disease (CKD) may result in psychological distress and mood disorders especially depression. Prevalence and clinical correlates of depression in CKD patients in the Indian context are not well studied and established.

MATERIALS AND METHODS

This cross-sectional study included 84 CKD patients. The diagnosis was made based on the diagnostic and statistical manual, 4^th edition criteria; psychiatric disorders were ruled out through the mini-neuropsychiatric interview. Montgomery-Asberg Depression Rating Scale was used to assess the severity of depression. Suicidal ideations were evaluated by using a modified scale of suicidal ideations. Data were analyzed using Epi Info 7 software.

RESULTS

The prevalence of major depression was 44.05%, while the prevalence of depressive symptoms was 82.14%. Age of the patients (P = 0.0065), patients on dialysis (P < 0.0001), and serum creatinine levels >5 (P = 0.0180) showed a statistically significant association with depression. The prevalence of depression was significantly associated with dialysis (P < 0.0001). The severity of depression and the severity of suicidal ideations were well correlated with each other (P < 0.0001).

CONCLUSION

The increased prevalence of depression and suicidal ideations was observed in CKD patients. We strongly recommend initiating screening of depression in CKD patients for appropriate rehabilitation and improved the quality of life.

A holistic approach to factors affecting depression in haemodialysis patients

Depression in dialysis populations is affected by co-morbid diseases, such as cardiovascular disease, diabetes, and immune dysfunction, and it also includes high suicide risk and frequent hospitalizations. Depressive disorders have a close association with malnutrition and chronic inflammation, as well as with cognitive impairment. Impaired cognitive function may be manifested as low adherence to dialysis treatment, leading to malnutrition. Additionally, chronic pain and low quality of sleep lead to high rates of depressive symptoms in haemodialysis patients, while an untreated depression can cause sleep disturbances and increased mortality risk. Depression can also lead to sexual dysfunction and non-adherence, while unemployment can cause depressive disorders, due to patients' feelings of being a financial burden on their family. The present review provides a holistic approach to the factors affecting depression in haemodialysis, offering significant knowledge to renal professionals.

Relationship of Hemodialysis Shift With Sleep Quality and Depression in Hemodialysis Patients

This descriptive correlational study was aimed at determining the relationship of hemodialysis shift with sleep quality and depression in 310 hemodialysis patients. Demographic and Clinical Questionnaires, the Pittsburgh sleep quality index, and Beck's Depression Inventory were used to ascertain the aforementioned relationship. Among the patients, 59.6% reported poor sleep quality and 44.8% reported experiencing depression. Results show that these conditions were significantly related to many factors. Although dialysis shift was not significantly related to sleep quality and depression, sleep quality was found significantly associated with age, female gender, illiteracy, unemployment, residence in rural areas, diabetes, addiction to sedatives, and phosphorus levels. A significant relationship was also found between depression and phosphorus levels. Logistic regression predicted age, gender, illiteracy, unemployment, residence in rural areas, and addiction to sedatives as factors for poor sleep quality. A body mass index (BMI) above 30, decreased urea, and increased phosphorus were predicted as factors for increased depression.

Sleep Parameters in Short Daily versus Conventional Dialysis: An Actigraphic Study

Previous studies have observed worse sleep quality in patients undergoing conventional dialysis as compared to daily dialysis. Our aim was to compare the sleep parameters of patients undergoing daily or conventional dialysis using an objective measure (actigraphy). This cross-sectional study was performed in three dialysis centers, including a convenience sample (nonprobability sampling) of 73 patients (36 patients on daily hemodialysis and 37 patients on conventional hemodialysis). The following parameters were evaluated: nocturnal total sleep time (NTST), expressed in minutes; wake time after sleep onset (WASO), expressed in minutes; number of nighttime awakenings; daytime total sleep time (DTST), expressed in minutes; number of daytime naps; and nighttime percentage of sleep (% sleep). The Mini-Mental State Examination and the Beck Depression Inventory were also administered. The mean age was 53.4  ±  17.0 years. After adjustment of confounding factors using multiple linear regression analysis, no difference in actigraphy parameters was detected between the groups: NTST (p = 0.468), WASO (p = 0.88), % sleep (p = 0.754), awakenings (p = 0.648), naps (p = 0.414), and DTST (p = 0.805). Different from previous studies employing qualitative analysis, the present assessment did not observe an influence of hemodialysis modality on objective sleep parameters in chronic renal patients.

Pharmacological and Non-pharmacological Treatment Options for Depression and Depressive Symptoms in Hemodialysis Patients

Depression is a mental disorder with a high prevalence among patients with end stage renal disease (ESRD). It is reported that depression afflicts approximately 20-30% of this patient population, being associated, amongst other, with high mortality rate, low adherence to medication and low perceived quality of life. There is a variety of medications known to be effective for the treatment of depression but due to poor adherence to treatment as well as due to the high need for medications addressing other ESRD comorbidities, depression often remains untreated. According to the literature, depression is under-diagnosed and undertreated in the majority of the patients with chronic kidney disease. In the current review the main pharmacological and non-pharmacological approaches and research outcomes for the management of depressive symptoms in hemodialysis patients are discussed.

Indicators and correlates of psychological disturbance in Chinese patients receiving maintenance hemodialysis: a cross-sectional study

PURPOSE

Depression and anxiety have been considered as the most common comorbidities in maintenance hemodialysis (MHD) patients. This study aimed to assess mental disorder in hemodialysis patients and to study the indicators and correlates of psychological disturbance among patients receiving MHD in China.

METHODS

A cross-sectional study was conducted in 187 outpatients undergoing regular hemodialysis for at least 3 months. All the participants completed the Hospital Anxiety and Depression Scale (HADS), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue, Chinese mainland version), Pittsburgh Sleep Quality Index (PSQI), Family APGAR Index (PAGAR), Family Adaptability and Cohesion Evaluation Scale (FACES II, Chinese version) and the Social Functioning Questionnaire (SFQ).

RESULTS

Based on the cutoff point of HADS-D/A ≥ 8, 51 (27.3%) and 29 (15.5%) patients reported depression and anxiety, respectively; 26 (13.9%) of all reported both depression and anxiety. Depressive patients had lower economic status, less subsidies, less than 3 years duration on hemodialysis and comorbidities when compared to patients without depression (all P < 0.05). HADS-D showed positive correlations with HADS-A, PSQI and SFQ and negative correlations with FACIT-Fatigue, PAGAR, family cohesion and adaptability (all P < 0.001). Patients with better family cohesion showed higher level of psychosocial well-being no matter their economic status. Binary logistic regression analysis demonstrated that anxiety (OR 1.80, P < 0.001) and bad social functioning (OR 1.31, P < 0.001) were independently associated with depression.

CONCLUSION

More attention should be paid on assessment and management psychological disturbance, and development family/social/medical supporting system for Chinese patients receiving MHD.

Depression in patients with chronic kidney disease on dialysis in Saudi Arabia

OBJECTIVE

Patients with chronic kidney disease on hemodialysis experience considerable psychological stress due to physical and social changes brought on by illness, increasing the risk of depressive disorder (DD). We examined the prevalence of DD and depressive symptoms, identified treatments for depression, and determined baseline demographic, social/behavioral, physical, and psychological correlates.

METHODS

A convenience sample of 310 dialysis patients in Jeddah, Saudi Arabia, was screened for DD using the Structured Clinical Interview for Depression and for depressive symptoms using the Hamilton Depression Rating Scale (HDRS). Established measures of psychosocial and physical health characteristics were administered, along with questions about current and past treatments. Bivariate and multivariate analyses identified independent correlates of DD and symptoms.

RESULTS

The prevalence of DD was 6.8 % (major depression 3.2 %, minor depression 3.6 %), and significant depressive symptoms were present in 24.2 % (HDRS 8 or higher). No patients with DD were being treated with antidepressant medication, whereas 28.6 % (6 of 21) were receiving counseling. Being a Saudi national, married, in counseling, or having a history of antidepressant were associated with DD in bivariate analyses. Correlates of depressive symptoms HDRS in multivariate analyses were Saudi nationality, marital status, stressful life events, poor physical functioning, cognitive impairment, overall severity of medical illness, and history of family psychiatric problems.

CONCLUSIONS

The prevalence of DD and depressive symptoms is lower in Saudi dialysis patients than in the rest of the world, largely untreated, and is associated with a distinct set of demographic, psychosocial, and physical health characteristics.

Auricular acupressure helps improve sleep quality for severe insomnia in maintenance hemodialysis patients: a pilot study

BACKGROUND

Insomnia is common in patients undergoing maintenance hemodialysis (MHD). Long-term use of sedative-hypnotic agents is often correlated with increasing adverse effects. Auricular acupressure therapy (AAT) applied to specific auricular acupoints for managing insomnia has achieved favorable outcomes in a hemodialysis unit. This pilot study was performed to demonstrate the potential of AAT for insomnia in MHD patients and to prepare for a future randomized controlled trial.

METHODS

Eligible patients were enrolled into this descriptive pilot study and received AAT designed to manage insomnia for 4 weeks. Questionnaires that used the Pittsburgh sleep quality index (PSQI) were completed at baseline, after a 4-week intervention, and 1 month after completion of treatment. Sleep quality and other clinical characteristics, including sleeping pills taken, were statistically compared between different time points.

RESULTS

A total of 22 patients were selected as eligible participants and completed the treatment and questionnaires. The mean global PSQI score was significantly decreased after AAT intervention (p<0.05). Participants reported improved sleep quality (p<0.01), shorter sleep latency (p<0.05), less sleep disturbance (p<0.01), and less daytime dysfunction (p=0.01). They also exhibited less dependency on sleep medications, indicated by the reduction in weekly estazolam consumption from 6.98±4.44 pills to 4.23±2.66 pills (p<0.01). However, these improvements were not preserved 1 month after treatment.

CONCLUSION

In this single-center pilot study, complementary AAT for MHD patients with severe insomnia was feasible and well tolerated and showed encouraging results for sleep quality.

[Evaluation and analysis of insomnia in chronic hemodialysis]

L'insomnie est aussi fréquente chez les hémodialysés chroniques qu'elle est négligée par le personnel soignant, davantage attelé à gérer les complications qui accompagnent l'insuffisance rénale chronique terminale et la dialyse chronique. Notre travail a eu pour but de déterminer la prévalence de l'insomnie et les facteurs qui lui sont associés, afin de pouvoir, dans un temps futur, lui dédier une stratégie de prise en charge adaptée. Il s'agit d'une étude transversale incluant 93 hémodialysés chroniques, dont nous avons étudié les données sociodémographiques, biologique, dialytiques; nous avons également collecté les caractéristiques de l'insomnie, et enfin mis en exergue les facteurs associés à sa survenue. L'insomnie a été définie par un score total supérieur ou égal à 15 au questionnaire de l'I.S.I (Insomnia Severity Index). Ainsi, la prévalence de l'insomnie est de 67,7% (n=63); l’âge moyen est de 55,6±12,7 (22-82) ans, le sexe ratio de 24 Hommes/39 Femmes, la durée moyenne en hémodialyse de 94,6 ± 58,2 (6-252) mois. 45 des patients insomniaques sont dialysés deux fois par semaine. Cette insomnie concernait le début de la nuit dans 52,3% des cas, le milieu de la nuit dans 55,5% des cas, et le petit matin dans 19,04% des cas. Les troubles associés à cette insomnie ont été: la somnolence diurne dans 79,3% des cas (n=50), le syndrome de la jambe sans repos dans 17,4% des cas (n=11), et les cauchemars dans 30,1% des cas (n=19). Une prise régulière d'hypnogènes a été notée chez 20 patients (31,7%). En analyse univariée, les facteurs associés à la survenue de l'insomnie sont l’âge avancé des patients, le sexe féminin, l'ancienneté en hémodialyse, la fréquence de deux séances de dialyse par semaine, le taux d'urée en prédialyse, le score de Charlson, la présence d'une douleur chronique (depuis plus de trois mois), la dépression et enfin l'hypertension artérielle. En analyse multivariée, on retient l’âge avancé des patients, le sexe féminin, l'ancienneté en dialyse et la fréquence de deux séances de dialyse par semaine. En conclusion, les troubles du sommeil et en particulier l'insomnie chez les hémodialysés chroniques sont fréquents et multifactoriels. Une attention particulière doit leur être accordée, incluant une collaboration régulière et étroite entre néphrologues et psychologues, psychiatres et spécialistes du sommeil.

Evaluation of objective and subjective indicators of death in a period of one year in a sample of prevalent patients under regular hemodialysis

Background

To identify objective and subjective indicators of death in prevalent hemodialysis (HD) patients in a follow-up study of 12 months.

Methods

The study included end-stage renal disease patients undergoing HD and analyzed demographic and laboratory data from the dialysis unit's records. Baseline data concerning socioeconomic status, comorbidity, quality of life level, coping style and depression were also assessed. For variables that differed in the comparison between survivors and non-survivors, Cox proportional hazards for death were calculated.

Results

The mortality rate was 13.0%. Non-survivors differed in age, comorbidity, inclusion on the transplant waiting list and physical functioning score. The hazard ratios of death were 8.958 (2.843-28.223; p < 0.001) for comorbidity, 3.992 (1.462-10.902; p = 0.007) for not being on the transplant waiting list, 1.038 (1.012-1.066; p = 0.005) for age, and 0.980 (0.964-0.996; p = 0.014) for physical functioning.

Conclusions

Comorbidity, not being on the transplant waiting list, age and physical functioning, which reflects physical status, must be seen as risk indicators of death among patients undergoing HD.