Diane Wuerth

Depression and its association with peritonitis in long-term peritoneal dialysis patients.

BACKGROUND Depression is the most common psychological disorder among patients with end-stage renal disease and has been associated with mortality in patients maintained on hemodialysis therapy. Peritonitis is the leading cause of technique failure among long-term peritoneal dialysis (PD) patients. This prospective study is designed to examine the relationship between depression and peritonitis. METHODS All patients on long-term PD therapy in our unit between January 1, 1997, and January 31, 2002, completed a Beck Depression Inventory (BDI) assessment at 6-month intervals. BDI scores were analyzed 2 ways. First, patients were placed into either group I (BDI score < 10) or group II (BDI score > or = 11) and were reclassified based on subsequent scores. Second, multivariable analysis was performed looking at initial BDI score as a risk factor for peritonitis, adjusting for age older than 65 years, diabetes, coronary artery disease, and race. RESULTS One hundred sixty-two patients were enrolled, and 281 individual BDI assessments were completed. There was a significantly greater incidence of diabetes and coronary artery disease in group II. Rates for overall and gram-positive peritonitis were significantly greater in group II patients compared with group I patients. Using Cox regression, only BDI score of 11 or greater was associated with the development of peritonitis (hazard ratio, 2.7; 95% confidence interval, 1.2 to 6.0). CONCLUSION There is an association between BDI score of 11 or greater and the development of peritonitis. Whether treatment of depression can impact on the rate of peritonitis remains to be examined.

Identification and treatment of depression in a cohort of patients maintained on chronic peritoneal dialysis.

Depression is the most commonly encountered psychological problem in patients with end-stage renal disease (ESRD). Depression has recently been shown to significantly impact on the morbidity and mortality of patients undergoing therapy for ESRD. The present study was designed as a pilot study to evaluate the feasibility of screening a large cohort of patients maintained on chronic peritoneal dialysis (CPD) for depression and then pharmacologically treating those patients assessed to have clinical depression. One hundred thirty-six patients maintained on CPD in our CPD unit were screened for depression using the Beck Depression Inventory (BDI), a self-administered questionnaire. Patients with scores of 11 or greater were referred to a trained psychiatric interviewer for further evaluation to confirm the diagnosis of clinical depression and determine whether the patient was a candidate for antidepressant medication. Sixty-seven patients had BDI scores of 11 or greater, and 60 of these patients were asked to participate in further evaluation and possible therapy. Only 27 patients agreed to further study and were evaluated by a trained psychiatric interviewer for clinical depression. Twenty-three of these patients were assessed to have clinical depression, and 22 patients were eligible for antidepressant medication based on their scores on the Hamilton Depression Scale and psychiatric interview. Eleven patients completed a 12-week course of therapy with antidepressant medication, and their BDI scores decreased from a mean of 17.1 +/- 6.9 (SD) to a mean of 8.6 +/- 3.2. Seven patients were treated with sertraline, 2 patients with bupropion, and 2 patients with nefazodone. It is concluded that (1) depression is commonly present in patients maintained on CPD, (2) the BDI is a useful tool to use to screen for clinical depression, and (3) clinical depression is treatable with medication in this patient population.

Health related quality of life and the CKD patient: challenges for the nephrology community

The compromised health-related quality of life (HRQOL) of patients with chronic kidney disease is now well documented. The recent mandate by the Center for Medicare Services in the United States that all dialysis units monitor HRQOL as a condition of coverage has focused attention on the importance of these measures. The challenge for the nephrology care team is understanding how to interpret and utilize the information obtained from these HRQOL measurements. Can HRQOL of these patients be improved? The present review addresses this issue by commenting on strategies that have been used to improve the HRQOL of chronic kidney disease patients. A systematic approach is suggested for nephrology care providers to attempt to evaluate and improve the HRQOL of CKD patients.

The identification and treatment of depression in patients maintained on dialysis.

The high incidence of depression in end‐stage renal disease (ESRD) patients is well documented. Our group and others have estimated that 20–30% of ESRD patients experience major depression. Several recent studies have emphasized the relationship between depressive symptoms and mortality and morbidity in both hemodialysis (HD) and peritoneal dialysis (PD) patients. We screened 380 PD patients for depression using the Beck Depression Inventory (BDI). The mean patient age was 59.9 ± 14.1 (SD) years, 55% were Caucasian, 51% were male, and 39% had diabetes. The mean BDI score was 12.1 ± 7.7; 49% had a score of 11 or greater. Fifty‐five percent refused further assessment to confirm the diagnosis of major depression, while 45% of patients eligible for treatment agreed to further assessment. Their mean BDI was 18.8 ± 6.2. Eighty‐four percent were diagnosed with major depression on direct interviews and offered pharmacologic treatment, 16% did not meet the criteria for a diagnosis of depression, and 50% successfully completed 12 weeks of pharmacologic treatment. The BDI score of these patients at the start of treatment was 17.4 ± 6.6, and at completion of treatment it was 8.4 ± 3.0. Thirty‐eight percent of treatment failures were in those who were also diagnosed with a DSM‐IV personality disorder. Major depression is common in PD patients, and is potentially treatable with pharmacologic therapy. However, there are major problems providing a depression assessment and treatment program to such patients. Problems include refusal to complete depression assessment and patients with axis 2 personality disorders who have difficulty complying with treatment. Although depression treatment can improve depressive symptoms, it is unclear whether such therapy will improve medical outcomes.

PSYCHOSOCIAL FACTORS IN PATIENTS WITH CHRONIC KIDNEY DISEASE: The Identification and Treatment of Depression in Patients Maintained on Dialysis

The high incidence of depression in end‐stage renal disease (ESRD) patients is well documented. Our group and others have estimated that 20–30% of ESRD patients experience major depression. Several recent studies have emphasized the relationship between depressive symptoms and mortality and morbidity in both hemodialysis (HD) and peritoneal dialysis (PD) patients. We screened 380 PD patients for depression using the Beck Depression Inventory (BDI). The mean patient age was 59.9 ± 14.1 (SD) years, 55% were Caucasian, 51% were male, and 39% had diabetes. The mean BDI score was 12.1 ± 7.7; 49% had a score of 11 or greater. Fifty‐five percent refused further assessment to confirm the diagnosis of major depression, while 45% of patients eligible for treatment agreed to further assessment. Their mean BDI was 18.8 ± 6.2. Eighty‐four percent were diagnosed with major depression on direct interviews and offered pharmacologic treatment, 16% did not meet the criteria for a diagnosis of depression, and 50% successfully completed 12 weeks of pharmacologic treatment. The BDI score of these patients at the start of treatment was 17.4 ± 6.6, and at completion of treatment it was 8.4 ± 3.0. Thirty‐eight percent of treatment failures were in those who were also diagnosed with a DSM‐IV personality disorder. Major depression is common in PD patients, and is potentially treatable with pharmacologic therapy. However, there are major problems providing a depression assessment and treatment program to such patients. Problems include refusal to complete depression assessment and patients with axis 2 personality disorders who have difficulty complying with treatment. Although depression treatment can improve depressive symptoms, it is unclear whether such therapy will improve medical outcomes.

Depression and end-stage renal disease: a therapeutic challenge

Hedayati et al. document a 26.5% incidence of clinical depression and a strong association between depression and hospitalizations and mortality in hemodialysis patients. We can no longer ignore the impact of depression on end-stage renal disease patients. Appropriate therapeutic regimens and trials need to be explored.

Therapy Insight: sexual dysfunction in patients with chronic kidney disease.

Sexual dysfunction is common in people with chronic kidney disease (CKD). Sexual dysfunction in these patients should be thought of as a multifactorial problem that is affected by a variety of physiological and psychological factors, as well as by comorbid conditions. Assessment of sexual difficulties in patients with CKD, therefore, involves a careful investigation of a variety of domains. The development of treatment strategies presents challenges as it is often difficult to determine the primary factor(s) responsible for the sexual dysfunction. It is important to think of the treatment in the overall context of the management of various medical problems presented by patients with CKD. It must be remembered that the design of therapeutic approaches for each patient is dependent on the systematic evaluation of the functional and psychosocial problems presented, and assessment of the cause(s) of sexual dysfunction.

The treatment of depression in patients maintained on dialysis

There has been an epidemic of end-stage renal disease (ESRD), which is apparent from the recent annual reports of the US Renal Data System [1]. The number of patients starting dialysis has more than doubled in the last 11 years [1]. The high mortality and rising expense in providing care for these patients place an increasing burden on the US health care system [1]. This has resulted in an expansion of research exploring and understanding those factors that impact on the outcome of patients with ESRD, and designing therapeutic strategies to effectively intervene in those conditions and problems that negatively impact on patient outcomes and quality of life. The psychosocial problems presented by patients with ESRD have interested a variety of investigators since dialysis therapy was first introduced [2–8]. Recently, there has been more attention focused on these psychosocial problems as researchers have become more aware of the relationship between some of these areas of psychosocial difficulty and patient outcomes [4–8]. However, developing therapeutic strategies to deal with areas of psychosocial difficulty has presented challenges to physicians, nurses, and mental health workers caring for patients maintained on dialysis. The health care team needs to coordinate not only the dialysis regimen, but also the complex care required by patients with multiple medical problems receiving many medications. The team then needs to develop strategies to better understand the impact that the dialysis treatment has, not only on the patient, but also on the patients’ activities of daily life, and ability to function in a family. How to effectively assess this impact presents a major challenge. How does a clinical treatment team develop practical therapeutic strategies to assess and treat the many psychosocial problems that are the result of living with this chronic illness? The problem of depression

Chronic peritoneal dialysis patients diagnosed with clinical depression: results of pharmacologic therapy.

Depression has been documented as the most frequently encountered psychological problem in end‐stage renal disease (ESRD) patients and has been correlated with both mortality and morbidity in these patients. Previous work by our group has shown that clinical depression is treatable with psychotropic medications in these patients, but that only a limited number of ESRD patients with depression will successfully complete a course of pharmacologic therapy. From July 1997 to October 2002, all chronic peritoneal dialysis (PD) patients in our facility were encouraged to be screened for depression utilizing the self‐administered Beck Depression Inventory (BDI) questionnaire. Based on previous work, a score ≥11 on this questionnaire was used to indicate a possible diagnosis of clinical depression; patients with BDI scores ≥11 were encouraged to complete a more formal evaluation for the presence of clinical depression. A total of 320 BDI questionnaires were completed during the study period: 134 patients. (42%) scored ≥11 on the BDI, 69 of the 134 patients (51%) with BDI scores ≥11 agreed to further evaluation. Sixty of these 69 patients (87%) were diagnosed with clinical depression based on scores ≥18 on the Hamilton Depression Scale and standard Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM‐IV) criteria. Forty‐four patients with clinical depression agreed to pharmacologic treatment. However, only 23 of the 44 patients (52%) successfully completed a 12‐week course of drug therapy. Two unit social work reviewers systematically reviewed the records of these 21 patients who did not complete therapy and assessed the reasons for their inability to complete treatment. Reasons identified included eight patients who experienced acute medical problems, three who were active substance abusers, and two who reported medication side effects. The remaining eight patients who did not complete the 12 weeks of therapy were examined by applying the axis 1 and axis 2 DSM‐IV criteria. Axis 1 is used to diagnose clinical disorders and axis 2 is used to diagnose personality disorders. While all these patients met the DSM‐IV axis 1 criteria for clinical depression, eight of these patients met axis 2 criteria for personality disorders; five patients had borderline personality disorders, one had a narcissistic personality disorder, one had a factitious disorder, and one had features of avoidant personality disorder. While some chronic PD patients can be successfully treated for clinical depression with psychotropic medication prescribed by the dialysis medical team, not all patients will agree to be evaluated for clinical depression and accept pharmacologic treatment. Others cannot or will not complete treatment when additional psychiatric disorders exist. These patients may require additional intervention when diagnosed with clinical depression and a personality disorder. Further trials are warranted.

A One-Year Trial of In-Center Daily Hemodialysis with an Emphasis on Quality of Life

Background/Aims: Hemodialysis is associated with acute changes in several physiologic factors. Previous studies have suggested significant clinical and quality of life (QOL) benefits of daily hemodialysis (DHD) compared with 3 times weekly hemodialysis (CHD). We conducted a prospective trial to evaluate the effects of switching chronic hemodialysis patients to in-center DHD for a 12-month period. Methods: There were no exclusion criteria. Patients received hemodialysis 6 times per week. The study set a standardized weekly Kt/V (stdKt/V) goal of 3.0. A broad array of clinical parameters was determined. QOL was assessed with multiple instruments. Results: Eleven subjects completed 12 months and 12 completed 6 months on DHD. Significant changes relative to baseline at 12 months of DHD included decreased BP and improvements in QOL parameters by multiple techniques. 100% of patients at 12 months wished to continue DHD. Conclusions: DHD offers advantages over CHD with respect to improved QOL and BP control.