Chia-Chi Chou

Depression and suicide risk in hemodialysis patients with chronic renal failure.

Background Depression and suicide are well established as prevalent mental health problems for patients on hemodialysis. Objective The authors examined the demographic and psychological factors associated with depression among hemodialysis patients and elucidated the relationships between depression, anxiety, fatigue, poor health-related quality of life, and increased suicide risk. Method This cross-sectional study enrolled 200 end-stage renal disease patients age ≥18 years on hemodialysis. Psychological characteristics were assessed with the Mini-International Neuropsychiatric Interview, the Hospital Anxiety and Depression Scale, the short-form Health-Related Quality of Life Scale, and Chalder Fatigue Scale, and structural equation modeling was used to analyze the models and the strength of relationships between variables and suicidal ideation. Results Of the 200 patients, 70 (35.0%) had depression symptoms, and 43 (21.5%) had had suicidal ideation in the previous month. Depression was significantly correlated with a low body mass index (BMI) and the number of comorbid physical illnesses. Depressed patients had greater levels of fatigue and anxiety, more common suicidal ideation, and poorer quality of life than nondepressed patients. Results revealed a significant direct effect for depression and anxiety on suicidal ideation. Conclusion Among hemodialysis patients, depression was associated with a low BMI and an increased number of comorbid physical illnesses. Depression and anxiety were robust indicators of suicidal ideation. A prospective study would prove helpful in determining whether early detection and early intervention of comorbid depression and anxiety among hemodialysis patients would reduce suicide risk.

The relationship between psychological factors, inflammation, and nutrition in patients with chronic renal failure undergoing hemodialysis.

Objective: Hemodialysis has an adverse impact on the immunological, nutritional, and emotional status of patients. The biochemical markers of inflammation and nutrition were studied as well as the relationship of these factors to emotional symptoms. Method: One hundred and ninety-five patients undergoing hemodialysis were enrolled. The mean age was 58.5 years. Emotional symptoms were assessed using the Mini International Neuropsychiatric Interview, Hospital Anxiety and Depression Scale, Chalder Fatigue Scale, and Short-form Health-related Quality of Life. Venus blood was collected for laboratory assessment of serum hemoglobin, albumin, ferritin, C-reactive protein, interleukin (IL) 1β), IL-6, and tumor necrosis factor a. Results: Among the 195 subjects (92 men and 103 women), 47 (24.1%) fulfilled the criteria for a major depressive disorder (MDD). The IL-6 level in patients with a MDD was significantly higher than in the patients without a MDD. Significant correlation was observed among the following factors: IL-6, fatigue, and quality of life for both physical and mental components. The albumin levels showed a significant correlation with the IL-6 and depression scores. Conclusions: These results show that the serum levels of albumin and IL-6 might be laboratory markers associated with the expression of emotional symptoms in patients undergoing hemodialysis. Prospective studies are needed to determine the causal relationships among these variables.

Factors associated with chronic musculoskeletal pain in patients with chronic kidney disease

BackgroundChronic musculoskeletal (MS) pain is common in patients with chronic kidney disease (CKD) undergoing haemodialysis. However, epidemiological data for chronic MS pain and factors associated with chronic MS pain in patients with early- or late-stage CKD who are not undergoing dialysis are limited.MethodA cross-sectional study to evaluate the prevalence of chronic MS pain and factors associated with chronic MS pain in patients with early- and late-stage CKD who were not undergoing dialysis, was conducted. In addition, the distribution of pain severity among patients with different stages of CKD was evaluated.ResultsOf the 456 CKD patients studied, 53.3% (n = 243/456) had chronic MS pain. Chronic MS pain was independently and significantly associated with hyperuricemia as co-morbidity, as well as with the calcium × phosphate product levels. In CKD patients with hyperuricemia, chronic MS pain showed a negative, independent significant association with diabetes mellitus as a co-morbidity (odds ratio: 0.413, p = 0.020). However, in the CKD patients without hyperuricemia as a co-morbidity, chronic MS pain showed an independent significant association with the calcium × phosphate product levels (odds ratio: 1.093, p = 0.027). Furthermore, stage-5 CKD patients seemed to experience more severe chronic MS pain than patients with other stages of CKD.ConclusionChronic MS pain is common in CKD patients. Chronic MS pain was independently and significantly associated with hyperuricemia as co-morbidity, and with the calcium × phosphate product levels in early- and late-stage CKD patients who were not on dialysis.

Association between uremic toxins and depression in patients with chronic kidney disease undergoing maintenance hemodialysis

OBJECTIVE Patients with chronic kidney disease (CKD) who are undergoing maintenance hemodialysis have a higher prevalence of depression than the general population. The underlying cause of this association is unknown, but may be related to accumulation of uremic toxins. Little is known about the association of accumulation of uremic toxins and depression in hemodialysis patients. METHOD We conducted a cross-sectional study of 209 CKD patients from a single institution to evaluate the associations of a soluble small uremic toxin (urea), a soluble large uremic toxin (β2 microglobulin) and two protein-bound uremic toxins [total p-cresol sulfate (PCS) and indoxyl sulfate (IS)] with the presence of depression. RESULTS A total of 47 patients (22.4%) had depression. Depressive patients had lower body mass index, lower serum creatinine, lower serum albumin and lower total IS. Univariate and multivariate logistic regression analyses that adjusted for age, gender and other statistically significant variables indicated that depression was significantly and independently associated with lower serum albumin and lower total IS. The levels of urea, β2 microglobulin and PCS were not significantly associated with depression. CONCLUSION Our results indicate that depression in patients with CKD was significantly and independently associated with lower serum albumin and lower total IS. However, the pathological mechanisms underlying these associations are unknown.

The association of uremic toxins and inflammation in hemodialysis patients.

Background Cardiovascular disease is the leading cause of mortality in hemodialysis patients and is associated with chronic inflammation. Elevation of uremic toxins, particular protein-bound uremic toxins, is a possible cause of hyper-inflammation in hemodialysis patients. But the association between uremic toxins and inflammatory markers in hemodialysis is still unclear. Methods We conducted a cross-sectional study to evaluate the association of the serum uremic toxins and inflammatory markers in hemodialysis patients. Results The uremic toxins were not associated with inflammatory markers- including high sensitivity C-reactive protein, IL(Interleukin) -1β, IL-6, tumor necrosis factor-α. In multiple linear regression, serum levels of total p-cresol sulfate (PCS) were independently significantly associated with serum total indoxyl sulfate (IS) (standardized coefficient: 0.274, p<0.001), and co-morbidity of diabetes mellitus (DM) (standardized coefficient: 0.342, p<0.001) and coronary artery disease (CAD) (standardized coefficient: 0.128, p = 0.043). The serum total PCS levels in hemodialysis with co-morbidity of DM and CAD were significantly higher than those without co-morbidity of DM and CAD (34.10±23.44 vs. 16.36±13.06 mg/L, p<0.001). Serum levels of total IS was independently significantly associated with serum creatinine (standardized coefficient: 0.285, p<0.001), total PCS (standardized coefficient: 0.239, p = 0.001), and synthetic membrane dialysis (standardized coefficient: 0.139, p = 0.046). Conclusion The study showed that serum levels of total PCS and IS were not associated with pro-inflammatory markers in hemodialysis patients. Besides, serum levels of total PCS were independently positively significantly associated with co-morbidity of CAD and DM.

Association between cold dialysis and cardiovascular survival in hemodialysis patients

BACKGROUND Higher cardiovascular mortality has been noted in patients with chronic kidney disease (CKD). CKD patients are also known to have impaired energy expenditure but the role of energy expenditure in cardiovascular disease is not yet known. Furthermore, the association between cold dialysis (CD) and clinical outcomes in hemodialysis patients is unclear. METHODS This was a single-center retrospective cohort study consisting of two groups: a CD group with dialyzate temperature <35.5 °C and a standard dialysis (SD) group with dialyzate temperature between 35.5 and 37 °C. The end points of the study were overall mortality, cardiac mortality and non-cardiac mortality. The study analyzed the associations between dialyzate temperature and long-term survival in CD and SD groups. Propensity score analysis was used to control for intergroup baseline differences. RESULTS Baseline characteristics of both groups were similar. Kaplan-Meier analysis showed that CD was significantly associated with a lower risk for overall mortality (P = 0.006) and cardiac mortality (P = 0.023) but not for non-cardiac mortality or infectious mortality. After multivariate Cox regression analysis, adjusting for propensity scores and other possible confounding factors, CD remained a significant beneficial factor for overall mortality (P = 0.030) and cardiac mortality (P = 0.034). CONCLUSION Our studies show that CD is significantly and independently associated with a lower risk for overall mortality and cardiac mortality.

Low plasma DHEA-S increases mortality risk among male hemodialysis patients.

OBJECTIVE The incidence of chronic kidney disease (CKD) is on the rise. CKD patients are at high risk of cardiovascular (CVD) and all-cause mortality. CKD patients have several endocrine disorders, including low levels of dehydroepiandrosterone sulfate (DHEA-S). In the general population, low levels of DHEA-S are associated with high CVD and all-cause mortality. The aim of this study was to analyze the prognostic value of plasma DHEA-S on the survival of CKD patients on hemodialysis. METHOD This was a single-center prospective cohort study on two hundred CKD patients on hemodialysis, which assessed the prognostic value of plasma DHEA-S on their survival. RESULT We found that plasma DHEA-S levels were negatively associated with age, and positively associated with dialysis duration and plasma creatinine, albumin, and phosphate levels in hemodialysis men. Elderly patients with co-morbidities (i.e. diabetes mellitus, congestive heart failure, and chronic obstructive pulmonary disease), poorer fluid control which was evaluated by higher cardiothoracic ratio, and low plasma creatinine and albumin levels seemed to have poor prognosis in hemodialysis men. Furthermore, low plasma DHEA-S levels were significantly associated with CVD-related [hazard ratio (HR)=3.877; P=0.021], non-CVD-related (HR=3.522; P=0.016), and all-cause mortality (HR=3.667; P=0.001) in hemodialysis men. But low plasma DHEA-S levels were not significantly associated with CVD-related, non-CVD-related, and all-cause mortality in hemodialysis women. Multivariate Cox regression analysis suggested that low plasma DHEA-S levels are significantly and independently associated with all-cause mortality in hemodialysis men (HR=2.933; P=0.033). CONCLUSION The study suggested that low plasma DHEA-S was independently and significantly associated with all-cause mortality in CKD hemodialysis men.

Factors Associated with Mortality from Non-Occlusive Mesenteric Ischemia in Dialysis Patients

Background. Among dialysis patients, acute mesenteric ischemia is mostly caused by non-occlusive mesenteric ischemia (NOMI). There is a very high mortality rate associated with this complication, but prognostic factors associated with NOMI are not well-known. Method. In this study, we retrospectively reviewed the records of dialysis patients to identify prognostic factors associated with mortality from NOMI. Overall, there were 541 patients on hemodialysis (HD) and 158 patients on peritoneal dialysis (PD) in our hospital from January 2007 to December 2008. Among these 699 patients, we diagnosed NOMI by surgical and/or radiological criteria. A total of 12 dialysis patients (9 on HD and 3 on PD) developed NOMI during the study period. Result. The incidence of NOMI was 1.04% per patient-year for all dialysis patients (0.95% for HD and 1.35% for PD patients). Most of the 12 patients had chronic hypotension (83.3%, 10/12). Four patients expired following development of NOMI. Our results showed that mortality was significantly higher in patients who were administered a cyclooxygenase (COX) inhibitor prior to ischemia. Hypobicarbonemia during NOMI, which might indicate the severity of hypoperfusion, is also associated with higher mortality. Conclusion. NOMI is rare in dialysis patients. COX inhibitor administration should be given with caution in long-term hypotensive dialysis patients.

Prescription of psychotropic drugs in patients with chronic renal failure on hemodialysis

Abstract Objective: Patients on hemodialysis commonly have comorbid depression and require treatment with psychotropic drugs. This study aimed to investigate the prevalence of the use of psychotropic drugs among patients on hemodialysis and to elucidate the factors associated with use of each class of psychotropic medication. Methods: This cross-sectional study enrolled 195 hemodialysis patients with a mean age of 58.5 years. Patients were assessed using the Mini International Neuropsychiatric Interview, Hospital Anxiety and Depression Scale, Chalder Fatigue Scale and Short-form Health-related Quality of Life. We analyzed the frequency of psychiatric outpatient department visits within six months prior to interview and psychotropic drugs use within one month prior to interview, including antidepressants, antipsychotics, mood stabilizers, benzodiazepines (BZDs) and hypnotics. Results: Of the 195 patients, 47 (24.1%) fulfilled the DSM-IV criteria for major depressive disorder (MDD). Only 6.4% of patients diagnosed with MDD visited the psychiatry outpatient department within six months prior to interview. Of the total patients, the proportions with use of antidepressants, antipsychotics, mood stabilizers, BZDs and hypnotics were 5.6%, 1.0%, 3.1%, 42.6% and 20.0%, respectively. Having MDD was an independent factor associated with taking antidepressants (adjusted OR = 3.98, p = 0.036) and taking hypnotics (adjusted OR = 2.75, p = 0.011). Conclusions: Depression is generally undetected or not well-managed among hemodialysis patients in the clinical setting. Only a small proportion of depressed patients received antidepressant treatment. BZDs and/or hypnotics might be exorbitantly prescribed. Clinicians should pay more attention to patients’ emotional distress and provide appropriate treatment.

Lack of association between plasma Dehydroepiandrosterone Sulfate (DHEA-S) levels and depression in hemodialysis patients: A cross-sectional study

OBJECTIVE Depression is common in hemodialysis patients. Reduced DHEA-S levels have been shown to be associated with depression in general population. Abnormalities in hormone production and metabolism are found in hemodialysis patients. However, the association between DHEA-S levels and depression in hemodialysis patients has not been established. METHOD We conducted a cross-sectional study, in which 80 patients under regular hemodialysis were studied, and their serum DHEA-S levels were analyzed. RESULTS The prevalence of depression in our studied hemodialysis population is 37.5% (30/80). The DHEA-S level was 1138.1+/-1216.9 ng/mL in male patients and 502.1+/-389.4 ng/mL in female patients. The levels were not significantly different between patients with or without depression (910.8+/-1127.1 ng/mL vs. 769.3+/-848.3 ng/mL, P=0.533). As compared to the non-depressed patients, the depressed patients were more likely to be male, with lower body mass index, consuming more alcohol, and with more co-morbidity. The prevalence of depression was not associated with age, educational background, smoking, duration of dialysis, hemoglobin, albumin, CRP, ferritin, and urea clearance (Kt/V and URR). The serum DHEA-S levels exhibited significant and independent associations with age, gender, diabetes mellitus, and the levels of serum albumin. CONCLUSION The study suggested a lack of association between plasma DHEA-S levels and depression in hemodialysis patients.