The Burden of Frailty on Mood, Cognition, Quality of Life, and Level of Independence in Patients on Hemodialysis: Regina Hemodialysis Frailty Study.

BACKGROUND: The prevalence of frailty is disproportionately increased in patients with chronic kidney disease (CKD) in comparison with non-CKD counterparts and is the highest in patients on hemodialysis (HD). While the cross-sectional measurement of frailty on HD has been associated with adverse clinical events, there is a paucity of data on longitudinal assessment of frailty and its relationship to outcomes. OBJECTIVE: The objectives were to (1) evaluate changes in frailty status, level of independence, mood, cognition, and quality of life (QoL) over a 12-month period and (2) explore the relationship between frailty status and level of independence, mood, cognition, and QoL at 2 different time points (at baseline and at 1 year). DESIGN: This is a prospective cohort study involving 100 prevalent HD patients. SETTING: Regina General Hospital and Wascana Dialysis Unit in Regina, Saskatchewan, Canada, between January 2015 and January 2017. PATIENTS: One hundred prevalent HD patients underwent frailty assessments using the Fried criteria at baseline and 1 year later. MEASUREMENTS: Frailty was assessed using the Fried criteria, which included assessments of unintentional weight loss, weakness (handgrip strength), slowness (walking speed), and questionnaires for physical activity and self-perceived exhaustion. Cognition, mood, and QoL were measured using questionnaires (Montreal Cognitive Assessment [MoCA], Geriatric Depression Scale [GDS], and EuroQol [EQ-5D] utility scores and visual analog scale [VAS], respectively). METHODS: Frailty status was reported as a binary variable: frail vs. nonfrail (prefrail and robust). Differences across baseline and 1-year groups were assessed using McNemar's test or Wilcoxon signed-rank test, as appropriate. We assessed the differences between frail and nonfrail groups using the Mann-Whitney U test or chi-square test/Fisher's exact test where appropriate. RESULTS: Ninety-seven of the 100 patients had complete initial assessments. The median (interquartile range [IQR]) duration of dialysis at baseline was 35.5 (13.75-71.75 months). One year later, 22 had died, 10 refused assessments, and 3 had relocated. In comparison with baseline vs 1 year, the number of frail patients was 68.1% vs. 67.7%; prefrail 26.8% vs. 26.1%; robust 5.1% vs. 6.2%; MoCA ≥24, 69% vs. 64.5%; GDS score ≥ 2, 52.8% vs. 47.7%; median EQ-5D utility score 0.81 vs. 0.77; and median EQ-VAS 60 vs. 50. Similarly, in comparison with baseline vs. 1 year, the number of independent patients was 82% vs. 63%, independent with support 17% vs. 31%, and long-term care home 0% vs. 3.1%. Eighteen of the 22 patients (82%) who died were frail. At 1 year, the median (IQR) MoCA was 24 (19-25) vs. 25 (21-26; P = .039) and median (IQR) GDS was 2 (1-3) vs. 1(0-2; P = .034). Likewise, median (IQR) EQ-5D utility score was 0.78 (0.6-0.82) vs. 0.81 (0.78-0.85; P = .023). There were significant changes in self-care (27% vs. 0%), P = 0.006, and daily activities (68.2% vs. 38.1%), P = 0.021. LIMITATIONS: This is a single-center study, so direct inferences must be interpreted in the context of the demographics of the study population. Patients were undergoing dialysis for a median of 36 months before undergoing initial assessment. CONCLUSIONS: Frailty and prefrailty in our dialysis patients is near-ubiquitous and will need to be proactively addressed to improve subsequent health care outcomes.

CONTEXTE: La prévalence de la fragilité augmente de façon disproportionnée chez les patients atteints d'insuffisance rénale chronique (IRC) comparativement aux patients non-IRC, et est encore plus élevée chez les patients hémodialysés. Bien que la mesure transversale de la fragilité en hémodialyse soit associée à des événements cliniques indésirables, très peu de données existent sur cette mesure et sur son lien avec les résultats. OBJECTIFS: Les objectifs étaient: 1) évaluer les changements dans l'état de fragilité, le niveau d'indépendance, l'humeur, la cognition et la qualité de vie (QdV) sur une période de 12 mois et; 2) explorer la relation entre l'état de fragilité et ces mêmes facteurs à deux moments précis, soit à l'inclusion et après un an. TYPE D'ÉTUDE: Étude de cohorte prospective portant sur 100 patients hémodialysés. CADRE: L'hôpital général et l'unité de dialyse Wascana Dialysis de Régina, en Saskatchewan (Canada) entre janvier 2015 et janvier 2017. SUJETS: Les critères de Fried ont servi à évaluer la fragilité de 100 patients hémodialysés à l'inclusion et après douze mois. MESURES: La fragilité a été évaluée selon les critères de Fried, soit un questionnaire mesurant l'activité physique et le niveau d'épuisement perçu, ainsi que des évaluations pour une perte de poids involontaire, la faiblesse (force de préhension) et la lenteur (vitesse de marche). Des questionnaires ont servi à évaluer la cognition (Montreal Cognitive Assessment [MoCA]), l'humeur (échelle de dépression gériatrique [EDG]) et la QdV (scores d'utilité de l'EuroQol [EQ-5D] et échelle analogue visuelle [VAS]). MÉTHODOLOGIE: La fragilité a été rapportée comme une variable binaire: fragile ou non fragile (préfragile et robuste). Les différences de fragilité entre l'inclusion et un an ont été déterminées par le test McNemar ou par le test de rang de Wilcoxon, selon le cas. Les différences entre les groupes fragiles et non fragiles ont été déterminées par le test U de Mann­Whitney U test ou le test de Chi-Deux/test exact de probabilité de Fisher, le cas échéant. RÉSULTATS: Sur les 100 sujets retenus, 97 avaient complété les évaluations initiales. À l'inclusion, les patients étaient en hémodialyse depuis une période médiane (EIQ) de 35,5 mois (13,75 à 71,75 mois). Un an plus tard, 22 patients étaient décédés, dix ont refusé d'être évalués et trois étaient relocalisés. La proportion de patients jugés fragiles s'établissait à 68,1 % à l'inclusion et à 67,7 % après un an. Ces proportions étaient de 26,8 % contre 26,1 % pour les patients jugés préfragiles et de 5,1 % contre 6,2 % pour les patients robustes. Les patients avaient obtenu un score égal ou supérieur à 24 pour le MoCA dans une proportion de 69 % à l'inclusion contre 64,5 % un an plus tard. Ces mêmes proportions s'établissaient à 52,8 % contre 47,7 % pour un score égal ou supérieur à 2 pour l'EDG. La médiane du score d'utilité EQ-5D était de 0,81 à l'inclusion et de 0,77 un an plus tard, alors que le score médian à la VAS était de 60 contre 50. Parallèlement, la proportion de patients indépendants est passée de 82 % à l'inclusion à 63 % un an plus tard, les patients indépendants avec support sont passés de 17 à 31% et les patients en centre de soins de longue durée de 0 à 3,1 %. La grande majorité des patients décédés (18/22; 82%) étaient jugés fragiles. Après un an, le score médian (IQR) au MoCA était de 24 (19-25) pour les patients fragiles contre 25 (21-26), p=0.039 pour les non fragiles. Respectivement, le score médian (IQR) à l'EDG était de 2 (1-3) contre 1 (0-2), p=0,034, et la médiane (IQR) au score d'utilité EQ-5D était de 0,78 (0,6-0,82) contre 0,81 (0,78-0,85), p=0,023. Une différence significative a été observée dans l'autonomie des patients (27% contre 0%; p=0,006) et dans la capacité de vaquer aux activités quotidiennes (68,2 % contre 38,1 %; p=0,021). LIMITES: Il s'agit d'une étude monocentrique et ainsi, les interférences directes doivent être interprétées dans le contexte démographique de la population étudiée. Les patients étaient traités en hémodialyse depuis 36 mois (médiane) avant leur première évaluation. CONCLUSION: La fragilité et la préfragilité est omniprésente chez les patients hémodialysés et devra être adressée de façon proactive pour améliorer les résultats en santé.

Successful Use of Renal Denervation in Patients With Loin Pain Hematuria Syndrome-The Regina Loin Pain Hematuria Syndrome Study.

INTRODUCTION: Loin pain hematuria syndrome (LPHS) is characterized by severe unilateral or bilateral loin pain that suggests a renal origin but occurs in the absence of identifiable or relevant urinary tract disease. Hematuria can either be microscopic or macroscopic, but the renal abnormalities responsible for the hematuria are unexplained. Debilitating pain refractory to conventional pain medications is the main cause of morbidity. METHODS: We conducted a single-arm, single-center study. Twelve patients between the ages of 21 and 62 years (11 female, 1 male) with LPHS underwent endovascular ablation of the renal nerves between July 2015 and November 2016, using the Vessix renal denervation system. The primary objective was to achieve 30% reduction in self-reported pain with the McGill Pain Questionnaire (MPQ) at 6 months. The secondary objectives were to measure changes in disability (Oswestry Disability Index [ODI]), mood (Geriatric Depression Scale [GDS]), and quality of life (EuroQol-5D [EQ-5D] and the MOS 36-Item Short Form Survey [SF-36]) scores from baseline to 6 months postprocedure. RESULTS: Ten of 12 patients at 3 months and 11 of 12 patients at 6 months reported a >30% reduction in pain based on the MPQ at 3 and 6 months. We found consistent improvements in MPQ, ODI, GDS, EQ-5D, and SF-36 scores from baseline to 6 months postprocedure. CONCLUSION: We conclude that renal denervation is associated with a considerable improvement in pain, disability, quality of life, and mood. Our results suggest that percutaneous catheter-based delivery of radiofrequency energy is a safe, rapid treatment option that should be considered in all patients with LPHS.

A Case Report of Nephrotic Syndrome While Undergoing Quinine Therapy.

We summarize the case of an 81-year-old Caucasian female who presented to her family physician with signs and symptoms of nephrotic syndrome following a brief exposure to quinine. Prior to that visit, she was clinically well with no chronic medical ailments and met with her family physician for annual physical assessments. She had taken 11 tablets of quinine for nocturnal leg cramps over the course of 28 days before starting to notice mild peripheral edema, which subsequently progressed, leading to a family physician review. Her initial serum albumin level was 12 g/L, and a 24-hour urine protein output was quantified at 8.14 g/day; she was diagnosed as having nephrotic syndrome. A kidney biopsy confirmed the diagnosis of minimal change disease (MCD). Quinine therapy was stopped, and she was initiated on a tapering regime of prednisone with concurrent cyclosporine therapy. Within a fortnight of starting therapy, she went into remission and her immunosuppressive medications were rapidly tapered and discontinued. This paper reports an association between the use of quinine and subsequent MCD. This case report proposes that the use of quinine has an association with, and may be causal for, the development of minimal change disease. As this is yet an unreported adverse effect, this paper seeks to increase the knowledge of the varied and numerous effects of quinine.

Use of synthetic adrenocorticotropic hormone in patients with IgA nephropathy.

BACKGROUND: Synthetic adrenocorticotropic hormone (ACTH) has been demonstrated to be effective in patients with membranous nephropathy, minimal change disease and some histological subtypes of focal segmental glomerulosclerosis. Its clinical impact in patients with IgA nephropathy is currently unclear. CASE PRESENTATION: In this report, we describe the clinical use of ACTH in patients with IgA nephropathy. Three female patients (24-44 years) with overt proteinuria received intramuscular (IM) ACTH for varying time periods (8-14 months). Pre-treatment urine protein varied from 2.9 g/d to 4.3 g/d. CONCLUSIONS: There was complete remission in one patient on ACTH monotherapy and in the other two when prescribed as a steroid-sparing agent in combination with cyclophosphamide. All three had resolution in proteinuria to less than 1 g/d and maintained their GFR to baseline values. There were no reported side effects at a once a week dose. This study illustrates that ACTH is an effective agent that is well tolerated with minimal side effects and can be used as an alternative to prednisone in patients with IgA nephropathy.

Cyclooxygenase-2 inhibitor-induced acute interstitial nephritis.

A 64-year-old female patient presented to the emergency department with a 3-week history of persistent nausea and vomiting. Her serum creatine prior to admission was 118 µmol/L and on presentation was elevated to 420 µmol/L. On clinical history, she indicated that 3 weeks prior, she had been initiated on a cyclooygenase-2 (COX-2) inhibitor, celecoxib, for her osteoarthritis of her knees. Renal biopsy confirmed the diagnosis of acute interstitial nephritis (AIN). Celecoxib was discontinued and the patient's renal function improved to a discharge creatine of 205-220 µmol/L. Nine months later, her creatine had decreased to 195 µmol/L and she was initiated on tapering doses of prednisone therapy for 4 months, after which time her creatine had improved further to 143 µmol/L. She was later transitioned to mycophenolatemofetil for 9 months and her creatine improved to 110 µmol/L. This report provides further evidence that COX-2 inhibitors are associated with AIN.

Renal Denervation in Patients With Loin Pain Hematuria Syndrome.

Loin pain hematuria syndrome (LPHS) is a painful and incapacitating condition that typically affects young women. Treatment options, including opiates and/or surgical denervation of the renal nerves by autotransplantation, have variable success. In this report, we describe the successful use of endovascular renal nerve ablation in this population. Four women with LPHS and intractable pain unresponsive to conservative measures underwent endovascular ablation of the renal nerves between July and November 2015 using the Vessix renal denervation system. The number and frequency of pain medications and responses to the EQ-5D, McGill Pain Questionnaire, Geriatric Depression Score, 36-Item Short-Form Health Survey, and Oswestry Disability Index were measured at baseline and 3 and 6 months postprocedure to evaluate changes in pain, disability, quality of life, and mood. There were improvements in pain, disability, and quality of life from baseline to 6 months postprocedure. By 6 months, 2 of 4 patients had discontinued all pain medications, whereas the other 2 had reduced their doses of these medications by 75%. These results suggest that percutaneous catheter-based renal nerve ablation with radiofrequency energy may be a treatment option for some patients with LPHS.