Marta Novak

Introduction to health measurement scales

Both research and clinical decision making rely on measurement scales. These scales vary with regard to their psychometric properties, ease of administration, dimensions covered by the scale, and other properties. This article reviews the main psychometric characteristics of scales and assesses their utility.

Psychological Distress and Depression in Patients with Chronic Kidney Disease

Depressive disorders are 1.5–4 times more prevalent in medically ill patients than in the general population. Mood disorders can be regarded as the final common pathway developing from the interaction among multiple pathophysiological, psychological, and socioeconomic stressors that chronic illness imposes on the individual. Symptoms of clinical depression affect approximately 25% patients on hemodialysis and can be associated with low quality of life and increased mortality. The epidemiology of depressive disorders is less well studied in the renal transplant population. However, depression is a risk factor for poor outcomes, such as graft failure and death after renal transplantation. A high prevalence of severe psychological distress in patients with advanced CKD and its impact on CKD outcomes call for screening and intervention integrated in routine renal care. Preliminary data indicate that some of the selective serotonin reuptake inhibitor agents and time‐limited, manualized, structured psychotherapies can be safe and effective for treating depression in this population.

Comorbid depression is associated with increased healthcare utilization and lost productivity in persons with diabetes: a large nationally representative Hungarian population survey.

Objective: To estimate the prevalence of depression among people with diabetes and to examine the association of comorbid depression with lost productivity and health resource utilization in persons with and without diabetes. Methods: Cross-sectional survey, enrolling 12,643 individuals aged >18 years. Clustered, stratified sampling procedure was utilized. This sample represented 0.16% of the Hungarian adult population according to age, gender, and geographic regions. The severity of depressive symptoms was measured by the abbreviated Beck Depression Inventory. Results: The prevalence of diabetes in the sample was 6.2% (95% Confidence Interval (CI) = 5.7–6.6), and 13.4% (95% CI = 12.8–13.9) were classified as depressed. Adults with diabetes were two times more likely to have depression (adjusted odds ratio (OR) = 1.83, 95% CI = 1.53–2.19, p < .001) versus individuals without diabetes. Compared with nondepressed people with diabetes, those with diabetes and comorbid depression were older, less educated, more likely to be female and physically inactive, less likely to be employed, and married and had more comorbidities. In multivariate regression analyses, people with diabetes and depression had significantly greater odds of prolonged bed days due to illness (≥20 days) (OR = 2.6, 95% CI = 1.69–3.88, p < .001), prolonged length of hospital stay (≥18 days) (OR = 2.1, 95% CI = 1.27–3.45, p = .004), and multiple hospital admissions (≥2) (OR = 1.8, 95% CI = 1.13–2.82, p = .01) compared with nondepressed diabetic patients. Conclusions: These findings further document the association between depression and health resource utilization and lost productivity in people with diabetes. Screening and treating depression are important for everyday clinical care and public health initiatives to improve health outcomes for people with diabetes. BDI = Beck Depression Inventory; BMI = body mass index; LOS = length of hospital stay.

Sleep disorders, depressive symptoms and health-related quality of life—a cross-sectional comparison between kidney transplant recipients and waitlisted patients on maintenance dialysis

BACKGROUND Kidney transplantation is believed to improve health-related quality of life (HRQoL) of patients requiring renal replacement therapy (RRT). Recent studies suggested that the observed difference in HRQoL between kidney transplant recipients (Tx) vs patients treated with dialysis may reflect differences in patient characteristics. We tested if Tx patients have better HRQoL compared to waitlisted (WL) patients treated with dialysis after extensive adjustment for covariables. METHODS Eight hundred and eighty-eight prevalent Tx patients followed at a single outpatient transplant clinic and 187 WL patients treated with maintenance dialysis in nine dialysis centres were enrolled in this observational cross-sectional study. Data about socio-demographic and clinical parameters, self-reported depressive symptoms and the most frequent sleep disorders assessed by self-reported questionnaires were collected at enrollment. HRQoL was assessed by the Kidney Disease Quality of Life Questionnaire. RESULTS Patient characteristics were similar in the Tx vs WL groups: the proportion of males (58 vs 60%), mean ± SD age (49 ± 13 vs 49 ± 12) and proportion of diabetics (17 vs 18%), respectively, were all similar. Tx patients had significantly better HRQoL scores compared to the WL group both in generic (Physical function, General health perceptions, Energy/fatigue, Emotional well-being) and in kidney disease-specific domains (Symptoms/problems, Effect- and Burden of kidney disease and Sleep). In multivariate regression models adjusting for clinical and socio-demographic characteristics, sleep disorders and depressive symptoms, the modality of RRT (WL vs Tx) remained independently associated with three (General health perceptions, Effect- and Burden of kidney disease) out of the eight HRQoL dimensions analysed. CONCLUSIONS Kidney Tx recipients have significantly better HRQoL compared to WL dialysis patients in some, but not all, dimensions of quality of life after accounting for differences in patient characteristics. Utilizing multidimensional disease-specific questionnaires will allow better understanding of treatment, disease and patient-related factors potentially affecting quality of life in patients with chronic medical conditions.

Symptoms of Depression in Kidney Transplant Recipients: A Cross-sectional Study

BACKGROUND Depression is associated with impaired quality of life and increased morbidity and mortality in patients with end-stage renal disease. Little is known about the prevalence and correlates of depression in kidney transplant recipients. In this study, we aimed to compare depressive symptoms between kidney transplant recipients and wait-listed dialysis patients and identify the correlates of depressive symptoms in the transplant recipient population. STUDY DESIGN Observational cross-sectional study using the Center for Epidemiologic Studies Depression Scale (CES-D) to assess the severity of depressive symptoms. A cutoff score of 18 was used to identify the presence of depression. SETTING & PARTICIPANTS 1,067 kidney transplant recipients and 214 wait-listed dialysis patients were asked to participate; the final analysis included 854 kidney transplant and 176 wait-listed dialysis patients, respectively. PREDICTORS Sociodemographic and clinical variables. OUTCOME Severity of depressive symptoms and presence of depression (CES-D score > or = 18). RESULTS The prevalence of depression was 33% versus 22% in wait-listed versus transplant patients, respectively (P = 0.002). In multivariate regression, number of comorbid conditions, estimated glomerular filtration rate, perceived financial situation, and marital status were significant and independent predictors of depression in the transplant recipient group. Treatment modality was associated significantly with the presence of depression, even after adjustment for clinical and sociodemographic variables (OR, 2.01; 95% CI, 1.25-3.23; P = 0.004). LIMITATIONS Self-reported measurement of depressive symptoms. CONCLUSIONS The prevalence of depression is lower in transplant recipients than in wait-listed patients. However, one-fifth of transplant patients are still at high risk of clinically significant depression. Comorbid conditions, socioeconomic status, and treatment modality predicted depressive symptoms in patients with end-stage renal disease.

Diagnosis and management of insomnia in dialysis patients.

Sleep‐related complaints affect 50–80% of patients on dialysis. Sleep disorders impair quality of life significantly. Increasing evidence suggests that sleep disruption has a profound impact both on an individual and on a societal level. The etiology of sleep disorders is often multifactorial: biologicsocialand psychological factors play a role. This is especially true for insomniawhich is the most common sleep disorder in different populationsincluding patients on dialysis. Biochemical and metabolic changeslifestyle factorsdepressionanxietyand other underlying sleep disorders can all have an effect on the development and persistence of sleep disruptionleading to chronic insomnia. Insomnia is defined as difficulty initiating or maintaining sleepor having nonrestorative sleep. It is also associated with daytime consequencessuch as sleepiness and fatigueand impaired daytime functioning. In most casesthe diagnosis of insomnia is based on the patients historybut in some patients objective assessment of sleep pattern may be necessary. Optimally the treatment of insomnia involves the combination of both pharmacologic and nonpharmacologic approaches. In some cases acute insomnia resolves spontaneouslybut if left untreatedit may lead to chronic sleep problems. The treatment of chronic insomnia is often challenging. There are only a few studies specifically addressing the management of this sleep disorder in patients with chronic renal disease. Considering the polypharmacy and altered metabolism in this patient populationtreatment trials are clearly needed. This article reviews the diagnosis of sleep disorders with a focus on insomnia in patients on dialysis.

Anemia in kidney transplanted patients

Abstract:  Background:  Although a known cardiovascular risk factor, anemia in the renal transplant recipients has only recently been receiving an increasing attention.

Depressive Symptoms and Mortality in Patients After Kidney Transplantation: A Prospective Prevalent Cohort Study

Objective: To analyze in a prospective cohort study if depressive symptoms are an independent predictor of mortality in kidney transplant recipients. Methods: Data from 840 transplanted patients followed at a single outpatient transplant center were analyzed. Sociodemographic parameters and clinical data were collected at enrollment (between August 2002 and February 2003). Participants completed the Center for Epidemiologic Studies-Depression (CES-D) scale. Depression was defined as CES-D score of ≥18. Data on 5-year outcomes (death censored graft loss or mortality) were collected. Results: The prevalence of depression was 22%. Mortality was higher (21% versus 13%; p = .004) in patients with versus without depression. In a multivariate Cox proportional hazard model, both the baseline CES-D score (hazard ratiofor each 1-point increase = 1.02; 95% confidence interval, 1.00–1.04) and the presence of depression at baseline (hazard ratiopresence = 1.66; 95% confidence interval, 1.12–2.47) were significantly associated with mortality. The baseline CES-D score also significantly predicted death censored graft loss (hazard ratiofor each 1-point increase = 1.03; 95% confidence interval, 1.01–1.05). Conclusion: Depressive symptoms are an independent predictor of mortality in kidney transplanted patients. CES-D = Center for Epidemiologic Studies-Depression scale; CKD = chronic kidney disease; CNI = calcineurin inhibitor; CRP = C-reactive protein; CsA = cyclosporine A; DOPPS = Dialysis Outcomes and Practice Patterns Study; GFR = estimated glomerular filtration rate; ESRD = end-stage renal disease; ESRD-SI = End-Stage Renal Disease Severity Index; Hb = hemoglobin; HLA = human leukocyte antigen; HR = hazard ratio; IQR = interquartile range.

ASSOCIATION OF THE MALNUTRITION-INFLAMMATION SCORE WITH CLINICAL OUTCOMES IN KIDNEY TRANSPLANT RECIPIENTS

BACKGROUND The combination of chronic malnutrition and inflammation, often termed malnutrition-inflammation complex syndrome or protein-energy wasting, is common in patients with chronic kidney disease. It is associated with increased mortality in patients on maintenance dialysis therapy. We assessed the association of malnutrition-inflammation score (MIS) with all-cause mortality and death-censored transplant loss or death with a functioning transplant in a sample of kidney transplant recipients. STUDY DESIGN Prospective prevalent cohort study. SETTING & PARTICIPANTS Data from 993 prevalent transplant recipients were analyzed. Sociodemographic parameters, laboratory data, medical and transplant history, comorbid conditions, estimated glomerular filtration rate, and MIS were tabulated at baseline and annually thereafter. PREDICTOR MIS, a 30-point scale expressed per 1 standard deviation (1 SD) unit or categorized as <3 (reference), 3-5, 6-8, and >8. The MIS is derived from 10 components, each with 4 levels of severity from 0 (normal) to 3 (severely abnormal). Higher score reflects more severe degree of malnutrition and inflammation status. OUTCOMES All-cause mortality and death-censored transplant loss or death with a functioning transplant. Association of MIS with total mortality was assessed using time-dependent Cox regression analysis, and the association of MIS with death-censored transplant loss or death with a functioning transplant was assessed using semiparametric competing-risks regression analysis. RESULTS Mean age was 51 ± 13 years, 57% of patients were men, and 21% had diabetes. Percentages of patients in the MIS categories <3, 3-5, 6-8, and >8 were 40%, 32%, 20%, and 8%, respectively. In multivariable time-dependent Cox regression analyses, time-varying MIS score was a significant predictor of all-cause mortality (HR per 1-SD increase, 1.59; 95% CI, 1.37-1.85), death with a functioning transplant (HR per 1-SD increase, 1.48; 95% CI, 1.23-1.78), and death-censored transplant loss (HR per 1-SD increase, 1.34; 95% CI, 1.04-1.71). Compared with MIS <3, HRs for all-cause mortality for MIS of 3-5, 6-8, and >8 were 1.53 (95% CI, 0.74-3.15), 3.66 (95% CI, 1.87-7.14), and 6.82 (95% CI, 3.34-13.91), respectively. LIMITATIONS Single-center study, small number of outcomes. CONCLUSIONS The MIS, a simple tool to assess the presence of malnutrition-inflammation complex syndrome, predicts mortality in kidney transplant recipients.

Association between restless legs syndrome and depression in patients with chronic kidney disease.

Restless legs syndrome (RLS) is reportedly associated with depression. This association may be mediated by both sleep-dependent and sleep-independent mechanisms. Here we analyze the association between RLS and depressive symptoms in patients with chronic kidney disease (CKD). We also assessed whether the relationship is independent of insomnia. In a cross-sectional study, socio-demographic parameters, laboratory data, and medical history were collected from 788 kidney transplant patients and 161 dialyzed patients. Insomnia, depression, and the presence of RLS symptoms were assessed with standard questionnaires. Patients with probable RLS had a higher prevalence of depressive symptoms than those without RLS (56% vs. 22% with vs. without RLS, respectively; P<.001). Patients presenting RLS symptoms had higher Athens Insomnia Scale (AIS) scores than patients without RLS [median AIS score (interquartile range): 7 (6) vs. 3 (4) with vs. without RLS, respectively; P<.001]. The AIS score correlated with the CES-D score (Spearmans rho=0.54, P<.001). In multivariate analysis, the presence of RLS symptoms was independently associated with depressive symptoms (OR=3.96, 95% CI 2.21-7.1, P<.001). This relationship remained significant even after including insomnia in the model (OR=2.9, CI 1.55-5.43, P<.001). The presence of RLS symptoms is associated with depression in patients with CKD. This relationship remained significant even after accounting for insomnia. Sleep-independent mechanisms may also contribute to the association between RLS and depression in patients with CKD.