Christopher Thiam Seong Lim

Depression, anxiety and stress among patients with dialysis and the association with quality of life

Studies addressing the nature of relationship between psychological symptoms and quality of life among dialysis patients in Malaysia are scarce. Hence, this study is intended to investigate the association between psychological symptoms such as depression, anxiety and stress on the quality of life in dialysis patients. A cross sectional multicentre study was conducted from May to October 2012 at 15 centres that provide haemodialysis and/or peritoneal dialysis. Apart from socio-demographic profile data collection, WHOQOL-BREF and DASS21 questionnaires were administered to study subjects. All three psychological symptoms had significant impact on quality of life domains of physical health, psychological health, social impact, perceived environment and overall quality of life. These findings suggest that subjects with symptoms of depression, anxiety and stress had poorer quality of life than those without, highlighting the negative impact of psychological symptoms.

Quality of life in dialysis: A Malaysian perspective

There is a growing interest to use quality of life as one of the dialysis outcome measurement. Based on the Malaysian National Renal Registry data on 15 participating sites, 1569 adult subjects who were alive at December 31, 2012, aged 18 years old and above were screened. Demographic and medical data of 1332 eligible subjects were collected during the administration of the short form of World Health Organization Quality of Life questionnaire (WHOQOL‐BREF) in Malay, English, and Chinese language, respectively. The primary objective is to evaluate the quality of life among dialysis patients using WHOQOL‐BREF. The secondary objective is to examine significant factors that affect quality of life score. Mean (SD) transformed quality of life scores were 56.2 (15.8), 59.8 (16.8), 58.2 (18.5), 59.5 (14.6), 61.0 (18.5) for (1) physical, (2) psychological, (3) social relations, (4) environment domains, and (5) combined overall quality of life and general health, respectively. Peritoneal dialysis group scored significantly higher than hemodialysis group in the mean combined overall quality of life and general health score (63.0 vs. 60.0, P < 0.001). Independent factors that were associated significantly with quality of life score in different domains include gender, body mass index, religion, education, marital status, occupation, income, mode of dialysis, hemoglobin, diabetes mellitus, coronary heart disease, cerebral vascular accident and leg amputation. Subjects on peritoneal dialysis modality achieved higher combined overall quality of life and general health score than those on hemodialysis. Religion and cerebral vascular accident were significantly associated with all domains and combined overall quality of life and general health.

Predictor of cardiovascular risks in end stage renal failure patients on maintenance dialysis.

Objective: Cardiovascular disease (CVD) is the main cause of morbidity and premature mortality in end stage renal failure patients (ESRD) receiving dialysis. The aim of our study was to evaluate the impact of various risk factors in this group of high CVD risk patients in local population. Methods: We carried out a cross-sectional retrospective study in a single hospital. A total of 136 ESRF patients, consisted of 43 haemodialysis (HD) and 93 continuous ambulatory peritoneal dialysis (CAPD) patients, were recruited and followed up for 36 months duration. Midweek clinical and laboratory data were collected. The occurrence of existing and new CVD events was recorded. Results: Multiple Logistic Regression showed pre-existing cardiovascular event (odds ratio, 4.124; 95% confidence interval [CI], 0.990 to 17.187), elevated total cholesterol level (odds ratio, 0.550; 95% CI, 0.315 to 0.963), elevated serum phosphate level (odds ratio, 5.862; 95% CI, 1.041 to 33.024) and elevated random blood glucose level (odds ratio, 1.193; 95% CI, 1.012 to 1.406) were significantly associated with occurrence of CVD events. Conclusions: History of cardiovascular event before the initiation of dialysis, elevated level of serum phosphate and random blood glucose levels are the risk factors of CVD whereas paradoxically a high total cholesterol level has CVD protective effect towards the ESRF patients.

The significance of tubular and glomerular proteinuria in critically ill patients with severe acute kidney injury.

Objective: Critically ill patients with acute kidney injury (AKI) frequently need acute renal replacement therapy (aRRT). We evaluated an inexpensive, rapid quantitative and qualitative analysis of proteinuria on the course of AKI patients requiring aRRT in intensive care. Method: This was a prospective, observational study of critically ill patients with severe established AKI or Acute on Chronic Kidney Injury (AoCKI) requiring aRRT. Urine samples were analyzed using Sodium-Dodecyl-Sulphate-Polyacryamide Gel Electrophoresis (SDS-PAGE). Results: A total of 30 critically ill patients were studied. Those who died have higher APACHE II (29 ± 6 vs. 20 ± 5, p<0.001), multi-organ failure (0.7 ± 0.5 vs. 0.2 ± 0.4, p < 0.02) and Tubular/Glomerular ratio (114 ± 60 vs. 75± 37, p < 0.05).The renal non-recoverers have higher baseline creatinine (415 ± 328 vs. 125± 19 umol/l, p < 0.01), urinary Dipstick value (1.8±0.8 vs. 0.5±0, p <0.05) and Glomerular score (3.0 ± 1.8 vs. 0.6 ± 0.2, p < 0.02).Heavy tubular proteinuria also predicts a longer duration of interim dialysis support and mortality whereas glomerular proteinuria correlates with development of chronicity and End Stage Renal Disease (ESRD). Conclusions: The dominant presence of tubular proteinuria is associated with poor survival in patients who have high APACHE II score and multi-organ failure. It also correlates with a longer duration of dialysis support in survivals. Renal Non-recoverers had heavy dominant presence of glomerular proteinuria. SDS-PAGE proteinuria analysis offers a reliable and inexpensive method to prognosticate proteinuria in this group of critically ill patients.

Risk profiles of referred chronic kidney disease patients in a tertiary nephrology centre.

Objective: To determine the risk profile of chronic kidney disease (CKD) patients. Methods: This is an observational cross sectional study involving 130 patients for which data was collected prospectively.. Sixty five subjects with an estimated glomerular filtration rate (eGFR) below 120 ml/min/1.73 m2 were recruited via random sampling technique from nephrology clinic in a tertiary nephrology referral center. Medical history, demographic data, urinary and serum biochemistry tests were obtained. Results: Most of the CKD patients who were referred to the nephrology clinic were asymptomatic. The most common laboratory abnormalities noted among CKD patients were proteinuria, anaemia and hyperkalaemia. Advancing age, pre-existing morbidities such as diabetes mellitus, hypertension and overweight are characteristics that are strongly associated with the referred CKD patients. Conclusions: Most of the referred CKD patients are in advanced age with diabetes, hypertension and overweight. Majority of the CKD remained asymptomatic despite in the advance stage of CKD. This strongly calls for cost effective screening for population at risk.

Clinical course after parathyroidectomy in adults with end-stage renal disease on maintenance dialysis

Abstract Background Parathyroidectomy (PTX) is done in cases of secondary hyperparathyroidism from chronic kidney disease to improve renal osteodystrophy. Despite this widespread practice, clinical outcomes regarding the benefits of this procedure are still lacking. Most studies in the literature have opted to report the laboratory outcome instead. Our study aimed to evaluate the postoperative clinical course for patients who had undergone total PTX without autoimplantation. Methods and results All patients who underwent PTX between January 2010 and February 2014 in a tertiary referral center were included in this study and followed up for 12 months. Laboratory outcome parameters include various preoperative and postoperative serial measurements of laboratory parameters. Patients’ hospitalizations and mortality records post-PTX were also retrieved and recorded. In all, 90 patients were included in this study. The mean age was 48 ± 18 years. The majority of the patients (54.4%) were male and 90% were on hemodialysis. The mean duration of dialysis was 8.0 ± 5.0 years. Indications for PTX were symptomatic bone pain (95.6%), fractures (3.3%) and calciphylaxis (1.1%). Mean preoperative values for serum calcium, phosphate, alkaline phosphatase and intact parathyroid hormone (iPTH) were 2.40 ± 0.23mmol/L, 1.92 ± 0.51 mmol/L, 689.60 ± 708.50 U/L and 311.90 ± 171.94 pmol/L, respectively. The majority (92.2%) had all four glands removed and 92.2% of the glands showed hyperplasic changes. One year after PTX, 90 patients (100%) had serum iPTH <8 pmol/L and 28 patients (31%) had unmeasurable iPTH levels. A total of 15% of patients had hospitalizations for various reasons and of these, 50% were within 90 days. The mean hospital stay was 14.4 ± 18.6 days. The mortality rate was 4.4% and of these, 25% were in first 30 days. Causes of death were mainly from sepsis (75%) and acute coronary syndrome (25%). One patient (1.1%) had a relapse. Conclusions Even though PTX markedly reduces postoperative serum iPTH levels, it carries with it significant risk of morbidity and mortality.

DASS21: A useful tool in the psychological profile evaluation of dialysis patients ☆ ☆☆

Background: The effect of dialysis treatment is complex, with both clinical and socio‐psychological effects. In this study, we aimed to assess the psychological status of this growing population of end‐stage renal disease. Methods: Using the Short Form of Depression, Anxiety and Stress Scale (DASS21) questionnaire, we aimed (1) to measure the psychological states of hemodialysis (HD) or peritoneal dialysis (PD) subjects from 15 sites, (2) to compare DASS21 scores between HD and PD, and (3) to identify the associated demographic and medical factors of better psychological states. Results: A total of 1,332 were eligible for analysis. Stress (48%) recorded the highest negative emotional states, followed by depression (37%) and anxiety (20%). By multivariate analysis, normal body mass index weight status, religion and absence of coronary artery disease were associated with lower score for depression, anxiety and stress, respectively. Tertiary education was associated with the lowest score in depression and anxiety, whereas HD had a lower score in stress than PD. A younger age was associated with worse DASS21 score of anxiety and stress. Conclusions: Obesity, religion and coronary artery disease were significantly associated with all 3 symptoms of depression, anxiety and stress. Older age has a protective effect on anxiety and stress. Further study is needed to evaluate the relationship between these significant factors and each psychological state.

A rare case of Ralstonia mannitolilytica infection in an end stage renal patient on maintenance dialysis during municipal water contamination

Ralstonia mannitolilytica is a gram negative soil bacterium. Ralstonia infection though rare, has become the emerging nosocomial pathogens in hospital settings. Various clinical manifestations had been described as well as the mode of transmission. Despite its low virulence factor, it is able to survive under harsh condition and this may potentially cause significant morbidity and mortality especially in immunocompromised patients. Outbreak of Ralstonia mannitolilytica infections in the hospital are typically associated with contaminated medical supplies or instruments. We described here a case of Ralstonia mannitolilytica infection in a dialysis patient that occurred during the municipal reservoir water contamination crisis. In this report, we will also describe the behaviour of Ralstonia genus and its 4 main species, namely R. pickettii, R. solanacearum, R. insidiosa, and R. mannitolilytica and the choices of antibiotic therapy based on literature review.

Resolution of rare palatal brown tumour after parathyroidectomy.

A 21-year-old end stage renal failure patient on peritoneal dialysis for 5 years presented with progressive and painless hard palate swelling. This has caused her discomfort in eating and swallowing. Clinical examination revealed a non-tender but firm hard palate mass measuring approximately 3 cm 9 2.5 cm. Incisors gapping were also noted. Blood investigations were: calcium 2.31 mmol/L, phosphate 2.60 mmol/L, iPTH 359.4 pmol/L, alkaline phosphatase 1003 iu/L, albumin 31 g/L, haemoglobin 8.1 g/dL. Dental surgeon was referred and diagnostic biopsy was performed. Tissue biopsy revealed scattered basophilic mineralizations within the uninflammed fibrocellular tissue with presence of multinucleated giant cells, features characteristic of the brown tumour (osteitis fibrosa cystica). Palatal brown tumour is a rare presentation of hyperparathyroidism. The patient was counselled and underwent total parathyroidectomy. Histology revealed 4 hyperplastic glands weighing 0.4, 1.1, 0.3 and 0.7 g. After 17 months of follow up, the tumour resolved fully with iPTH 1.76 pmol/ l, calcium 1.96 mmol/l, phosphate 1.66 mmol/l, albumin 26 g/L and alkaline phosphatase 67 iu/L (Figs. 1, 2, 3). Fig. 1 Palatal brown tumour: Before parathyroidectomy

Erythema nodosum masking nephrogenic systemic fibrosis as initial skin manifestation

BackgroundNephrogenic systemic fibrosis (NSF) is a complication of the gadolinium-based contrast agent used in imaging studies. It is typically characterised by hard, erythematous and indurated skin plaques with surrounding subcutaneous oedema. Distinct papules and subcutaneous nodules can also be seen. Fibrocytes in NSF are immunohistochemically positive for CD34.Case presentationWe present a case of NSF occurred after gadolinium exposure in which the initial presentation mimics an erythema nodosum (EN)-like picture. An initial skin biopsy showed EN. Subsequently the patient developed progressive skin and joints contracture. A repeated skin biopsy done three months later confirmed the diagnosis of NSF. As far as we are aware, this is the second reported case of NSF that mimicked the presentation of EN in the early phase of the disease.ConclusionsThe appearance of EN-like disease can be one of the early manifestations of NSF. We hope that early recognition of this unusual presentation can alert the physician or nephrologist to the potential diagnosis of NSF.