Jung-Woo Noh

Association of depression with malnutrition in chronic hemodialysis patients

BACKGROUND Depression is the most common psychological complication and may increase mortality in chronic hemodialysis patients. Because depression could be associated with poor oral intake and activation of proinflammatory cytokines that could further increase mortality by malnutrition, we investigated the relation between depression and nutritional status in chronic hemodialysis patients. METHODS Sixty-two Korean patients completed the Beck Depression Inventory (BDI) questionnaire, and the diagnosis of depression was confirmed by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for major depressive disorder. Nutritional status was evaluated using serum albumin level, normalized protein catabolic rate, subjective global assessment (SGA), and anthropometric measurement. RESULTS Mean BDI score was 22.7 +/- 11.4, and 35 patients (56.5%) had a BDI score greater than 21, which is the suggested cutoff score for the diagnosis of depression for the Korean population. Of 40 patients who had a score higher than 18 on the BDI, 34 patients met DSM-IV criteria for major depressive disorder. BDI score correlated negatively with a variety of nutritional parameters: serum albumin level (r = -0.47; P < 0.001), normalized protein catabolic rate (r = -0.32; P < 0.05), SGA (r = -0.47; P < 0.01), triceps skinfold thickness (r = -0.40; P < 0.05), midarm muscle circumference (r = -0.57; P < 0.01), and body mass index (r = -0.28; P < 0.05). Multiple regression analysis also identified BDI score as an independent determinant for all kinds of nutritional parameters. CONCLUSION In patients on chronic hemodialysis therapy, depression is related closely to nutritional status and could be an independent risk factor for malnutrition.

Treatment of depression and effect of antidepression treatment on nutritional status in chronic hemodialysis patients.

Background:Depression, which is the most common psychological complication in patients with end-stage renal disease (ESRD), has an impact on the clinical outcome and is associated with malnutrition in chronic hemodialysis patients. This study evaluated the effect of antidepression treatment on nutritional status in depressed chronic hemodialysis patients. Methods:Sixty-two ESRD patients who underwent dialysis for more than 6 months were interviewed and completed a Beck Depression Inventory assessment. Thirty-four patients who had scores greater than 18 on the Beck Depression Inventory score and met Diagnostic and Statistical Manual of Mental Disorders, 4th Edition criteria for major depressive disorder were selected to receive paroxetine 10 mg/day and psychotherapy for 8 weeks. The remaining 28 patients were assigned to the control group. Change in the severity of depressive symptoms was ascertained by administering the Hamilton Depression Rating Scale. Nutritional status was evaluated by normalized protein catabolic rate, serum albumin and blood urea nitrogen level. Results:All patients successfully completed 8 weeks of antidepression treatment. Antidepression treatment decreased the severity of depressive symptoms (Hamilton Depression Rating Scale score: 16.6 ± 7.0 versus 15.1 ± 6.6, P < 0.01) and increased normalized protein catabolic rate (1.04 ± 0.24 versus 1.17 ± 0.29 g/kg/day, P < 0.05), serum albumin (37.3 ± 2.0 versus 38.7 ± 3.2 g/l, P < 0.005), and prehemodialysis blood urea nitrogen level (24.3 ± 5.6 versus 30.2 ± 7.9 mmol/L, P < 0.001). In the control group, no change was noted during the study period. Conclusion:This study suggests that antidepressant medication with supportive psychotherapy can successfully treat depression and improve nutritional status in chronic hemodialysis patients with depression.

Rapid analysis of plasma paraquat using sodium dithionite as a predictor of outcome in acute paraquat poisoning.

Background:Paraquat poisoning can be lethal, and aggressive treatments might have little or no effect on severely poisoned patients. Accordingly, a convenient prognostic test is necessary to guide therapy for acute paraquat poisoning. Sodium dithionite reduces paraquat to a blue radical form in alkaline plasma with a paraquat detection sensitivity of 2.0 mg/L, which is a 100% lethal concentration at 10 to 12 hours postingestion. The prognostic utility of this simple reaction was examined prospectively. Methods:Of 233 paraquat-poisoned patients, who were taken to the hospital within 12 hours after ingestion, the plasma samples obtained on arrival were tested using the sodium dithionite reaction. Standard saline containing 2.0 mg/L paraquat was used as the positive control. The test result was interpreted as being positive when the plasma test yielded a blue color darker than that of the positive control. The effects of aggressive treatment, including cyclophosphamide pulse and continuous venovenous hemofiltration, were evaluated retrospectively. Results:The discharge survival rate was 41.6% (97 of 233). Ninety-seven of 142 patients with negative or equivocal plasma dithionite test survived. However, all 91 patients with positive plasma dithionite test died of multiorgan failure. Cyclophosphamide and/or continuous venovenous hemofiltration could not improve survival. Conclusions:In this single-center study, a positive plasma dithionite test was associated with 100% mortality, despite aggressive treatment. In contrast, negative or equivocal tests were associated with a 68% survival rate. It is believed that after further verification, this test can be used to guide therapy and predict the outcomes of patients suffering acute paraquat poisoning.

Relationship between Cognitive Impairment and Depression in Dialysis Patients

Purpose Patients with chronic kidney disease frequently show cognitive dysfunction. The association of depression and cognitive function is not well known in maintenance dialysis patients. We evaluated cognitive impairment and depression, as well as their relationship in regards to methods of dialysis, maintenance hemodialysis (MHD) and chronic peritoneal dialysis (CPD). Materials and Methods Fifty-six maintenance dialysis patients were recruited and their clinical and laboratory data were collected. The Korean version of the mini-mental state exam (K-MMSE) was applied to screen the patients cognitive function, while the Korean version of the Beck Depression Inventory (K-BDI) was used for depression screening. Results The average age of the participants was 54.2±10.2 years; 29 (51.8%) were female. The average dialysis vintage was 4.2±3.8 years. The CPD group showed significantly higher K-MMSE score (27.8±2.9 vs. 26.1±3.1, p=0.010) and lower K-BDI score (12.0±8.4 vs. 20.2±10.4, p=0.003) compared with the MHD group. The percentage of patients with depression symptoms was higher in the MHD group (51.7% vs. 18.5%). There was a negative correlation between cognitive function and prevalence of depressive symptoms. Depression and education level were shown to be independent predictors for cognitive impairment in multivariate analysis. Conclusion Cognitive impairment was closely correlated with depression. It is important to detect cognitive impairment and depression early in maintenance dialysis patients with simple bedside screening tools.

Effect of Route of EPO Administration on Hemodialysis Arteriovenous Vascular Access Failure: A Randomized Controlled Trial

BACKGROUND Vascular access failure is a major cause of morbidity and hospitalization in hemodialysis populations worldwide. Erythropoietin (EPO) potentially can contribute to vascular access stenosis and occlusion by promoting intimal hyperplasia and thrombosis. Intravenous administration of EPO results in a severe, but transient, increase in drug concentration within the vascular access, whereas subcutaneous administration leads to a mild, but sustained, increase in the systemic circulation. The effect of route of administration of EPO on vascular access outcomes is uncertain. STUDY DESIGN Randomized controlled trial. SETTING & PARTICIPANTS 78 Korean hemodialysis patients were randomly assigned to receive either intravenous (n = 40) or subcutaneous (n = 38) EPO. INTERVENTIONS EPO was administered during dialysis, and the dose was titrated to maintain hemoglobin levels between 9 to 12 g/dL. All patients received EPO 2 or 3 times/wk. Study duration was 4 to 77 months. OUTCOMES & MEASUREMENTS The primary end point was time to vascular access failure. Analysis was performed using Cox regression analysis. RESULTS The incidence of access failure was 4.7%/patient-year in the intravenous-therapy group and 12.0%/patient-year in the subcutaneous-therapy group, with an unadjusted hazard ratio of 3.24 (95% confidence interval, 1.31 to 8.00; P = 0.01). After adjustment for dialysis access type, vascular access age, previous intervention, serum phosphorus level, and diabetes mellitus, subcutaneous EPO administration was independently associated with increased vascular access failure (hazard ratio, 3.56; 95% confidence interval, 1.20 to 10.58; P = 0.02). There were no significant differences in either hemoglobin concentration or EPO dosage between the 2 groups during the study period. LIMITATIONS Relatively small sample size and lack of complete symmetry between the 2 groups with respect to some baseline characteristics. CONCLUSIONS This study suggests that the risk of vascular access failure may be greater with subcutaneous compared with intravenous administration of EPO in hemodialysis patients.

The prevention of contrast-induced nephropathy by simultaneous hemofiltration during coronary angiographic procedures: A comparison with periprocedural hemofiltration

BACKGROUND Periprocedural (6 h pre- and 24 h post-angiography) hemofiltration appears to effectively prevent contrast-induced nephropathy (CIN) in chronic kidney disease (CKD) patients undergoing coronary angiography. However, this procedure over-uses medical resources, and the cessation of hemofiltration during coronary angiography results in persistent renal injury. In comparison, simultaneous hemofiltration performed only during coronary angiography requires fewer medical resources and can provide instantaneous protection against CIN. METHODS Sixty-eight CKD patients (serum creatinine, 2.51±1.15 mg/dL) undergoing coronary angiography were randomized in a 1:2 ratio to receive either periprocedural (n=23) or simultaneous (n=45) hemofiltration. The expected CIN rate was similar for the two groups (41.3% versus 40.0%, p=0.769). RESULTS On day 3 after contrast exposure, four and seven patients in the periprocedural and simultaneous groups, respectively experienced CIN (17.4% versus 15.6%, p=0.846). On days 5-30, seven and three patients in the periprocedural and simultaneous groups, respectively experienced CIN (30.4% versus 6.7%, p=0.009). The serum creatinine levels of patients in the periprocedural group transiently decreased on day 1 and persistently increased during days 5-30 compared with the simultaneous group. This difference between the two groups in terms of creatinine levels over time was statistically significant (F statistic=6.830; p=0.001, by ANCOVA). The cost of hemofiltration was doubled in the periprocedural group (

Extracellular Fluid/Intracellular Fluid Volume Ratio as a Novel Risk Indicator for All-Cause Mortality and Cardiovascular Disease in Hemodialysis Patients

1066±83 versus

Lysophosphatidylcholine, Oxidized Low-Density Lipoprotein and Cardiovascular Disease in Korean Hemodialysis Patients: Analysis at 5 Years of Follow-up

504±40, p<0.001). CONCLUSIONS Simultaneous hemofiltration provide equal early (day 3) and better late-stage (days 5-30) renal protection against CIN at a significantly lower cost compared with periprocedural hemofiltration.

Serum globotriaosylceramide assay as a screening test for fabry disease in patients with ESRD on maintenance dialysis in Korea.

Background In hemodialysis patients, fluid overload and malnutrition are accompanied by extracellular fluid (ECF) expansion and intracellular fluid (ICF) depletion, respectively. We investigated the relationship between ECF/ICF ratio (as an integrated marker reflecting both fluid overload and malnutrition) and survival and cardiovascular disease (CVD) in the context of malnutrition-inflammation-arteriosclerosis (MIA) complex. Methods Seventy-seven patients from a single hemodialysis unit were prospectively enrolled. The ECF/ICF volume was measured by segmental multi-frequency bioimpedance analysis. MIA and volume status were measured by serum albumin, C-reactive protein (CRP), pulse wave velocity (PWV) and plasma B-type natriuretic peptide (BNP), respectively. Results The mean ECF/ICF ratio was 0.56±0.06 and the cut-off value for maximum discrimination of survival was 0.57. Compared with the low ECF/ICF group, the high ECF/ICF group (ratio≥0.57, 42%) had higher all-cause mortality, CVD, CRP, PWV, and BNP, but lower serum albumin. During the 5-year follow-up, 24 all-cause mortality and 38 CVD occurred (18 and 24, respectively, in the high ECF/ICF group versus 6 and 14 respectively in the low ECF/ICF group, P<0.001). In the adjusted Cox analysis, the ECF/ICF ratio nullifies the effects of the MIA and volume status on survival and CVD and was an independent predictor of all-cause mortality and CVD: hazard ratio (95% confidence interval); 1.12 (1.01–1.25) and 1.09 (1.01–1.18) for a 0.01 increase in the ECF/ICF ratio. The degree of malnutrition (albumin), inflammation (CRP), arteriosclerosis (PWV), and fluid overload (BNP) were correlated well with the ECF/ICF ratio. Conclusions Hemodialysis patients with high ECF/ICF ratio are not only fluid overloaded, but malnourished and have stiff artery with more inflammation. The ECF/ICF ratio is highly related to the MIA complex, and is a major risk indicator for all-cause mortality and CVD.

Impact of sarcopenia on long-term mortality and cardiovascular events in patients undergoing hemodialysis

Although oxidized low-density lipoprotein (LDL) and lysophosphatidylcholine (LPC) have been proposed as important mediators of the atherosclerosis, the long-term contribution to the risk of cardiovascular disease (CVD) in hemodialysis patients has not been evaluated. This study investigated the relation between oxidized LDL and LPC levels with long term risk of CVD. Plasma oxidized LDL and LPC levels were determined in 69 Korean hemodialysis patients as a prospective observational study for 5 yr. During the observation period, 18 cardiovascular events (26.1%) occurred including 6 deaths among the hemodialysis patients. The low LPC level group (≤ 254 µM/L, median value) had much more increased risk of CVD compared to the high LPC level group (> 254 µM/L) (P = 0.01). However, serum levels of oxidized LDL were not significantly different between groups with and without CVD. In adjusted Cox analysis, previous CVD, (hazard ratio [HR], 5.68; 95% confidence interval [CI], 1.94-16.63, P = 0.002) and low LPC level (HR, 3.45; 95% CI, 1.04-11.42, P = 0.04) were significant independent risk factors for development of CVD. It is suggested that low LPC, but not oxidized LDL, is associated with increased risk of CVD among a group of Korean hemodialysis patients.