Expansion of Patient Education Programming Regarding Live Donor Liver Transplantation via Virtual Group Encounters During the COVID-19 Pandemic.

During the coronavirus 2019 pandemic we converted our liver transplant waitlist candidate education and support program to a virtual format and expanded it to include ongoing engagement sessions aimed to educate and empower patients to maximize opportunity for live donor liver transplantation. Over a period of 6 months from April 2020 to Sept 2020 we included 21 patients in this pilot quality improvement program. We collected data regarding patient response and potential donor referral activity. Overall, patient response was positive, and some patients saw progress toward live donor liver transplantation by fostering inquiry of potential live liver donors. Optimization of logistical aspects of the program including program flow, technology access, and utilization is required to enhance patient experience. Long-term follow-up is needed to assess impact on the outcome of transplantation rates. Future data collection and analysis should focus on assessment of any potential disparity that may result from utilization of virtual programming. Herein we provide a framework for this type of virtual program and describe our experience.

An approach to addressing depression in patients with chronic kidney disease.

Depressive symptoms and clinical depression are commonly noted in patients with end-stage renal disease and chronic kidney disease (not on dialysis). This association is important since depressive symptoms have been associated with both an impaired quality of life and increased morbidity and mortality. It is, therefore, important to develop strategies to screen patients with chronic kidney disease for depression and to develop strategies to treat clinical depression in this group of patients.

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.

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.

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.

Patients' descriptions of specific factors leading to modality selection of chronic peritoneal dialysis or hemodialysis.

OBJECTIVES: There has been increasing interest in understanding how patients with chronic renal failure choose between chronic peritoneal dialysis (CPD) and hemodialysis (HD) for renal replacement therapy. The purpose of the present study was to examine the influences and specific factors that patients identify as significant in choosing a specific dialysis modality for treatment of their end-stage renal disease (ESRD). PATIENTS AND DESIGN: 40 patients (20 CPD, 20 HD) who had started dialysis within the preceding 6 months were randomly selected to participate in the study. A structured interview was conducted with the patients, discussing and exploring what factors patients thought were important in helping them decide their treatment modality. The format of the interview was open-ended. Based on patients' comments, a taxonomy of the specific factors that influenced the patients' decisions was developed. SETTING: The study was conducted in a freestanding CPD unit and two freestanding HD units. RESULTS: All 20 CPD patients reported choosing their treatment modality; only 8 of the 20 HD patients reported having a choice of treatment modality. 18 of the 22 patients who participated in predialysis educational programs opted for CPD. 83% of the patients reported that their physician was important in influencing their treatment choice; however, the CPD patients relied more on written material and the opinions of their spouse/significant other or other family members in making their decisions. Issues of autonomy and control were important for 95% of patients choosing CPD. Both CPD and HD patients cited a variety of treatment-specific factors. The three most frequently cited reasons for choosing CPD were (1) flexibility of schedule (19 patients), (2) convenience of performing CPD in their own home (19 patients), and (3) the option of doing dialysis at night while sleeping (8 patients). The 8 HD patients who selected their treatment modality cited the desirability of having a planned schedule (7 patients) and letting nurses or other take care of them (5 patients). CONCLUSIONS: The present study explored factors perceived by patients as being important in determining their choice of renal replacement therapy. A taxonomy of patient influences and concerns has been developed to provide caregivers with a framework to structure their educational strategies and assist patients with progressive renal failure in making an informed choice of therapeutic modality for their ESRD treatment.

The BDI and the SF36: which tool to use to screen for depression?

Recent studies have suggested a relationship between depression--as assessed by the Beck Depression Inventory (BDI)--and mortality in end-stage renal disease (ESRD) patients. A recent study from the Dialysis Outcomes and Practice Patterns Study (DOPPS) indicated an association between mortality in a large cohort of hemodialysis patients and the patients' responses in the preceding 4 weeks to two questions on the Kidney Disease Quality of Life, Short Form (KDQOL-SF36): "Have you felt downhearted and blue?" and "Have you felt so down in the dumps that nothing could cheer you?" A BDI score > or = 11 and a score < or = 3 for the two questions on the SF36 were considered to suggest the presence of depressive symptoms; both scores have been associated with increased mortality in hemodialysis patients. We aimed to examine the relationship of the two SF36 questions with depressive symptoms as assessed by the BDI. All patients on chronic peritoneal dialysis (CPD) therapy and daily hemodialysis therapy in our units between June 2000 and January 2002 were asked to complete a BDI and an SF36. We recorded 135 tests in 80 CPD patients, and 76 tests in 17 daily hemodialysis patients. Correlation coefficients (r2 values) of the responses to the two questions on the SF36 and the BDI scores demonstrated a significant relationship between the scores. The r2 values for the CPD patients' two SF36 responses and the BDI scores were -0.622 and -0.506; the r2 values for the daily hemodialysis patients were -0.363 and -0.317. The sensitivity and specificity for each SF36 response to be < or = 3 when the BDI was > or = 11 were 82.4% and 68.6% for the "downhearted and blue" question and 65% and 67% for the "down in the dumps" question. Whether the two questions on the SF36 that suggest depression can replace the BDI as a screening tool requires further study. Furthermore, it is unclear if the two questions on the SF36 are predictive of mortality because of their association with clinical depression or because of other issues.

Comparison of quality-of-life assessment in Russia and the United States in chronic peritoneal dialysis patients.

Numerous reports of quality-of-life data in chronic peritoneal dialysis (CPD) patients in the United States and Western Europe use the short form questionnaire (SF-36). Few centers in Europe have reported data examining the incidence of depression in CPD patients. Depression has been shown to correlate with morbidity and mortality in dialysis patients. A high incidence of clinical depression is seen in end-stage renal disease patients in the United States. We thought it could be important to compare depression measurements between the United States and European countries. Quality-of-life data of the peritoneal dialysis patients from the New Haven continuous ambulatory peritoneal dialysis (CAPD) unit and from the New Technology Center at Hospital #31 in St. Petersburg were compared. The Beck Depression Inventory (BDI) and the SF-36, which includes the mental component score (MCS) and the physical component score (PCS), were administered to the patients. The study participants included 147 Russian and 96 U.S. patients. The BDI, PCS, and MCS scores were similar in both groups. The BDI scores in the Russian patients indicated that a high incidence of clinical depression likely exists in that patient population. The utility of the BDI in assessing quality-of-life issues in Europe and Russia requires further evaluation.

Psychosocial assessment of the patient on chronic peritoneal dialysis: an overview.

The psychosocial assessment of the patient with end-stage renal disease is critically important because (1) there is growing evidence that the psychosocial status of the patient impacts medical outcomes and (2) the objective of therapy is to maximize a patient's sense of well-being and quality of life. This is particularly true for patients receiving a home-based therapy such as chronic peritoneal dialysis. The present review outlines a possible structure and format for performing psychosocial evaluations for patients maintained on chronic peritoneal dialysis. But, each facility must design its own format, making sure that the critical domains discussed in this review are addressed.

Effects of home hemodialysis on health-related quality of life measures.

In recent years, there has been an increased interest in performing hemodialysis (HD) more frequently than thrice weekly, particularly in the home setting. This interest has been stimulated by some studies that have indicated significant benefits to performing more frequent HD on various medical and quality of life outcome measures. However, only a few studies using varying quality of life instruments have critically examined the impact of frequent HD on the quality of life of patients. Although not consistent across studies, results suggest a positive impact of more frequent HD on patients' quality of life. It is hoped that the results of two landmark studies, now in progress (the Frequent Hemodialysis Network trial and the FREEDOM study), will provide more insight into the impact of more frequent HD on quality of life.

Hemodialysis and peritoneal dialysis: patients' assessment of their satisfaction with therapy and the impact of the therapy on their lives.

This study was undertaken to examine patient satisfaction with peritoneal dialysis (PD) and hemodialysis (HD) therapies, focusing attention on the positive and negative impact of the therapies on patients' lives. Patients were recruited from a free-standing PD unit and two free-standing HD units. A total of 94% (n = 62) of eligible PD and 84% (n = 84) of eligible HD patients participated. HD patients were significantly older and had higher Charlson Comorbidity Index scores than the PD patients, but there were no differences in duration of dialysis treatment, prevalence of diabetes, educational backgrounds, or home situations. Patients were asked to rate their overall satisfaction with and the overall impact of their dialysis therapy on their lives, using a 1 to 10 Likert scale. In addition, patients were asked to rate the impact of their therapy on 15 domains that had been cited previously as being important for patients' quality of life. The mean satisfaction score for PD patients (8.02 +/- 1.41) was higher than for HD patients (7.4 +/- 1.4; P = 0.15). PD patients indicated that there was less impact of the dialysis treatment on their lives globally (7.25 +/- 2.12 versus 6.19 +/- 2.83; P = 0.019). In addition, PD patients noted less impact of the therapy in 14 of the 15 domains examined. With the use of a proportional odds model analysis, the only significant predictor of overall satisfaction and impact of therapy was dialysis modality (P = 0.037 and P = 0.021, respectively). Patients also were asked to comment freely on the positive and negative effects of the dialysis treatments on their lives, and a taxonomy of patient perceptions and concerns was developed. This study suggests that PD patients in general are more satisfied with their overall care and believe that their treatment has less impact on their lives than HD 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.

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 > or =11 on this questionnaire was used to indicate a possible diagnosis of clinical depression; patients with BDI scores > or =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 > or =11 on the BDI, 69 of the 134 patients (51%) with BDI scores > or =11 agreed to further evaluation. Sixty of these 69 patients (87%) were diagnosed with clinical depression based on scores > or =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.