Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in renal transplantation between 1990 and 2002 in Spain.

Background. Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II type 1 receptor blockers (ARB) decrease cardiovascular mortality and slow the progression of renal disease in non-transplant patients, but their impact on kidney transplant outcome has not been well established.Methods. Patients receiving a renal allograft in Spain in 1990, 1994, 1998 and 2002 were considered for the present study. Only adult (>/=18 years) recipients of a single kidney transplant functioning at the end of the first year were considered. A total of 4842 patients with clinical data about ACEI/ARB therapy were included.Results. During the initial 2 years after transplant, ACEI/ARB were less frequently used in the 1990 and 1994 cohorts than in 1998 and 2002 (15.1%, 24.6%, 33.5% and 45.1%, respectively; P < 0.001). During the first year, a total of 1063 patients (22.8%) received ACEI/ARB treatment, and graft survival (50.0% for treated patients and 51.4% for untreated, P = ns), death-censored graft survival (60.6% versus 63.5%, P = ns) and patient survival (68.8% versus 66.6%, P = ns) were not different. During the initial 2 years, 1472 patients (31.4%) received treatment with ACEI/ARB, and graft survival tended to be higher in treated patients (54.4% and 50.9%, P = 0.063). Since there was an interaction between ACEI/ARB treatment and year of transplant, graft survival was analysed in each cohort. Cox regression analysis including the propensity score for ACEI/ARB treatment showed an association between ACEI/ARB treatment and graft survival in the 2002 cohort (relative risk 0.36 and 95% confidence interval 0.17-0.75, P = 0.007). Death-censored graft survival (63.8% versus 63.1%, P = ns) and patient survival (68.1% and 66.5%, P = ns) were not significantly different.Conclusions. The use of ACEI/ARB during the initial 2 years after transplantation was associated with a better graft survival, but this effect was only observed in the 2002 cohort.

Psychosocial factors and health-related quality of life in hemodialysis patients.

Several sociodemographic and clinical variables are known to influence the health-related quality of life (HRQOL) of patients with kidney disease, yet the relationship between psychological factors and the HRQOL measured by the Kidney Disease Quality of Life Short-Form (KDQOL-SF) is incompletely understood. The objective of this study was to examine the relationship between psychosocial status (depressive symptoms, trait anxiety, and social support) and KDQOL-SF scales in hemodialysis (HD) patients by controlling the effects of sociodemographic and clinical variables. The HRQOL of 194 patients from 43 dialysis centers in Spain was assessed by completing the KDQOL-SF, and evaluating depressive Symptoms (Cognitive Depression Index), trait anxiety (Trait Anxiety Inventory) and degree of social support (Scale of Perceived Social Support). We also recorded several sociodemographic and clinical variables. Two regression models were estimated for each of the 19 scales in the KDQOL-SF. In the first model, we only included sociodemographic and clinical-factors, while the second model also took into consideration psychosocial variables. These last factors (trait anxiety and depressive symptoms, not social support) were found to increase the proportion of explained variability, with highest standardized regression coefficients observed for most KDQOL-SF scales. Depressive symptoms were related to a poor HRQOL when there was a strong physical component, while trait anxiety was mainly related to emotional upset and social relationships. We were able to conclude that trait anxiety and depressive symptoms are strongly associated with the HRQOL assessed by the KDQOL-SF in HD patients. The effects of these factors should therefore be considered when evaluating the quality of life of this type of patient.

Psychosocial factors and quality of life in young hemodialysis patients with low comorbidity.

BACKGROUND: The current predominance of older patients, diabetic patients and high-comorbidity patients among the hemodialysis (HD) population has probably influenced the definition of the effects of renal disease on health-related quality of life (HRQOL), and these effects can be different in the patient subgroup without these characteristics. This multicenter study aimed to assess HRQOL in non-diabetic HD patients, aged < 65 yrs and with low comorbidity, and to study the effects of the demographic, clinical and psychosocial characteristics on their HRQOL. METHODS: 117 patients from 43 Spanish HD centers participated in the study. Patients completed the Kidney Disease Quality of Life Short-Form questionnaire (KDQOL-SF) and screening for depressive symptoms, anxiety symptoms and social support. Various sociodemographic and clinical variables were also recorded. RESULTS: HD patients' HRQOL showed a profile similar to that of the general HD population, with low physical health scores, but normal mental health scores. Multivariate analysis demonstrated that gender, older age, non-working status, low social support and low levels of hemoglobin (Hb), Kt/V or protein catabolic rate (PCR), had a negative effects, but these effects were of relatively small magnitude and appeared only in some scales. The most important independent predictors of HRQOL were anxiety state and depressive symptoms. CONCLUSIONS: In non-diabetic HD patients, aged < or = 65 yrs and with low comorbidity, psychological factors (anxiety state and depressive symptoms) are crucial HRQOL determinants. These variables should be considered when assessing HRQOL in HD patients with these demographic and clinical characteristics.

Increasing the hematocrit has a beneficial effect on quality of life and is safe in selected hemodialysis patients. Spanish Cooperative Renal Patients Quality of Life Study Group of the Spanish Society of Nephrology.

Target hematocrit/hemoglobin values in dialysis patients are still controversial. The Spanish Cooperative Renal Patients Quality of Life Study Group (including 34 hemodialysis units) conducted a prospective, 6-mo study of the effect on patient functional status and quality of life of using epoetin to achieve normal hematocrit in hemodialysis patients with anemia. The possible adverse effects of increased hematocrit, patient hospitalization, and epoetin requirements were also studied. The study included 156 patients (age range, 18 to 65 yr). Given the minimal experience in the safety of increasing hematocrit in dialysis patients to normal levels with epoetin, stable patients on hemodialysis who had received epoetin treatment for at least 3 mo and had a stable hemoglobin level of > or = 9 g/dl were included in the study. Patients with antecedents of congestive cardiac failure, ischemic cardiopathy, diabetes mellitus, uncontrolled hypertension, cerebrovascular accident or seizures, malfunction of the vascular access or severe comorbidity (defined by a comorbidity index), and those over 65 yr of age were excluded from the study. Quality of life was measured with the Sickness Impact Profile (SIP) and Karnofsky scale. Patients completed questionnaires at home at onset and conclusion of the 6-mo study. Mean hematocrit increased from 30.9 to 38.4% and hemoglobin from 10.2 to 12.5 g/dl during the study. Health indicator scores improved significantly: mean Physical Dimension (SIP) from 5.38 to 4.1 (P < 0.005); mean Psychosocial Dimension from 9.2 to 7 (P < 0.001); mean global SIP from 8.9 to 7.25 (P < 0.001); mean Karnofsky scale score from 75.6 to 78.4 (P < 0.01). (SIP is scaled so that lower scores represent better functional status, and vice versa for the Karnofsky scale). Therefore, functional status and quality of life improved with increased hematocrit. No deaths occurred. Three patients (2%) were censored for hypertension and nine (5.7%) for thrombosis of the vascular access. The cumulative probability of thrombosis of the vascular access was 0.067. The average epoetin dose rose from 93 +/- 62 U/kg per wk at onset to 141 +/- 80 U/kg per wk at conclusion, a 51% increase. The number of patients hospitalized decreased and hospital lengths of stay were shorter during the study period than in the same patients in the 6-mo period preceding the study (P < 0.05). Nine patients (5.7%) had thrombosis of the vascular access. There were no changes in the prevalence of arterial hypertension, but three patients (2%) showed hypertension that was difficult to control. It is concluded that normalization of hematocrit in selected hemodialysis patients, i.e., nondiabetic patients without severe cardiovascular or cerebrovascular comorbidities, improves quality of life and decreases morbidity without significant adverse effects.