Post-Traumatic Stress Disorder and Post-Traumatic Growth following Kidney Transplantation.

Background: Kidney transplantation (KT) is a life-saving therapy for kidney failure. However, KT recipients can suffer from debilitating depression, post-traumatic stress disorder (PTSD), and suicide. In contrast to PTSD, post-traumatic growth (PTG) is a positive psychologic change in response to a challenging situation. PTG has been studied in other chronic diseases, but less is known about its role in the setting of KT. We sought to elucidate the prevalence, predictors, and the effect of PTSD and PTG on post-KT outcomes. We also considered the roles of benefit finding and resilience. Methods: In a literature review, we identified publications that examined PTSD, PTG, benefit finding, and/or resilience in KT recipients. We excluded case reports and first-person narratives. Publications meeting the specified criteria after full text review underwent data abstraction and descriptive analysis. Results: Of the 1013 unique citations identified, 39 publications met our criteria. PTSD was the most common construct evaluated (16 publications). Resilience was studied in 11 publications, PTG in nine, and benefit finding in five. Up to 21% of adult and 42% of pediatric KT recipients may experience PTSD, which is associated with lower quality of life (QOL), impaired sleep, and other psychiatric comorbidity. PTG was associated with improved QOL, kidney function, and reduced risk of organ rejection. Although benefit finding tended to increase post KT, resilience remained stable post KT. Like PTG, resilience was associated with lower psychologic distress and increased treatment adherence and confidence in the health care team. Conclusions: PTG, resilience, and benefit finding appear to reduce the risk of PTSD, promote well-being, and reduce risk of graft failure in KT recipients. Future research to understand these relationships better will allow clinicians and researchers to develop interventions to promote PTG, resilience, and benefit finding, and potentially improve post-transplant outcomes such as adherence and reducing risk of organ rejection.

Psychiatric Diagnoses in Children With CKD Compared to the General Population.

Rationale & Objective: Children with chronic kidney disease (CKD) are subject to physical and psychosocial challenges, which may confer greater risk of developing psychiatric disorders. We sought to examine key psychiatric diagnoses in children with CKD compared with those in the general pediatric population and assess the correlation between parent-reported diagnosis and self-reported symptoms of depression. Study Design: Cross-sectional. Setting & Participants: Children ages 2-17 years receiving current medical care who participated in the Chronic Kidney Disease in Children Study (CKiD) or the National Survey of Children's Health. Exposure: CKD. Outcomes: Parent-reported diagnoses of depression, anxiety, or attention-deficit and hyperactivity disorder (ADHD). Analytical Approach: Using Poisson regression, we determined the age, sex, and race-adjusted prevalence ratio comparing diagnoses between children with CKD and those in the general population overall and within subgroups of sex, race, maternal education status, and CKD stage. Secondarily, we examined the correlation between depression status using standardized self-reported screening instrument scores and parent-reported diagnosis. Results: Eight hundred seventy-five children with CKD and 72,699 children in the general population were included. Those with CKD had an adjusted prevalence ratio of 1.32 (95% CI, 1.01-1.73) for depression, 0.72 (95% CI, 0.52-0.99) for anxiety, and 1.03 (95% CI, 0.86-1.25) for ADHD. The results were similar across subgroups of CKD stage, sex, race, or maternal education. The correlation between parent-reported diagnosis and instrument-detected depression was weak, r = 0.13 (95% CI, 0.03-0.23). Limitations: Retrospective parent- or self-reported data were used. Conclusions: Children with CKD had a higher prevalence of parent-reported depression, equivalent prevalence of attention-deficit and hyperactivity disorder, and lower prevalence of anxiety diagnoses compared to other children. These findings are inconsistent with results of prior studies and suggest that baseline assessments used in CKiD may have limited utility in describing psychiatric disorders among children with CKD. Improved mental health assessment approaches in pediatric nephrology are needed.

Dialysis disequilibrium on CKRT: avoiding the steep slippery slope.

BACKGROUND: Current guidelines for initiation of kidney replacement do not include specific recommendations for prescription parameters and monitoring. CASE OUTLINE: A 16-year-old girl presented with kidney failure with creatinine of 19.8 mg/dL and BUN of 211 mg/dL. She initiated continuous kidney replacement therapy (CKRT) with clearance of 1,300 mL/min/1.73 m2 which was increased to 1,950 mL/min/1.73 m2 at 17 h of stable therapy. COMPLICATIONS: At 31 h of therapy, she developed generalized seizure activity. CT imaging was negative for acute intracranial process, and EEG demonstrated diffuse encephalopathy. CKRT was discontinued, and BUN was noted to be 47 mg/dL at that time (a 79% reduction from presenting BUN). KEY MANAGEMENT POINTS: • The potential for development of DDS is not isolated to intermittent hemodialysis and may occur later in presentation. • A decreased clearance rate should be considered in those with risk factors for development of dialysis disequilibrium syndrome (DDS). • Frequent monitoring of BUN/serum osmolality is important to allow for adjustment of the KRT prescription following initiation of therapy. • Additional research is needed to guide risk assessment for DDS and therapeutic timing and goals in the early stages of KRT initiation. • Inclusion of more specific guidelines surrounding DDS would assist in providing important support for nephrologists. LIST OF RELEVANT GUIDELINES: KDIGO clinical practice guideline for acute kidney injury [1] Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease [2] The Renal Association Clinical Practice Guideline Acute Kidney Injury (AKI) [3] The Japanese Clinical Practice Guideline for Acute Kidney Injury [4].

A multi-state evaluation of the association between mental health and firearm storage practices.

Firearm storage method is a potentially modifiable risk factor for suicide. Using data from a large, multi-state survey, we sought to determine whether there is an association between mental health and household firearm storage practices, and characterize that association by state of residence. Participants who endorsed the presence of a household firearm and answered the mental health questions in the 2016-2017 Behavioral Risk Factor Surveillance System from eight states were included (n=26,949). Exposures were recent poor mental health (≥14 vs. 0-13 days/past month), and diagnosis of depression. Outcomes were household firearm storage practices (loaded, and both loaded and unlocked). Using Poisson regression, we calculated adjusted prevalence ratios (aPR) overall and stratified by state of residence. Of adults endorsing a household firearm, 35.1% reported storing a firearm loaded, and of those, 53.4% reported that the firearm was both loaded and unlocked. Neither recent poor mental health nor depression was associated with loaded (aPR 1.14 [95% CI: 0.95-1.37] and aPR 0.94 [95% CI 0.80-1.09], respectively) or loaded and unlocked (aPR 1.08 [95% CI 0.88-1.42] and aPR 1.04 [95% CI 0.88-1.22], respectively) firearm storage. In the setting of highly prevalent loaded firearm storage, no differences in storage practices by mental health indicators were observed across eight states despite disparate firearm policies and local culture. The lack of difference in storage practices by mental health indicators across several states highlights an opportunity to improve means safety counseling practices, and the need for dedicated evaluation of state-level firearm storage policies.

Internet and Video Game Addictions: Diagnosis, Epidemiology, and Neurobiology.

In the past 2 decades, there has been substantial increase in availability and use of digital technologies, including the Internet, computer games, smart phones, and social media. Behavioral addiction to use of technologies spawned a body of related research. The recent inclusion of Internet gaming disorder as a condition for further study in the DSM-V invigorated a new wave of researchers, thereby expanding our understanding of these conditions. This article reviews current research, theory, and practice regarding the diagnosis, epidemiology, and neurobiology of Internet and video game addictions.

Clinical reasoning: a 12-year-old boy with ascending weakness.

A 12-year-old boy presented with 3 weeks of calf pain, tripping, and progressive inability to walk. The onset was preceded by a sore throat 4 weeks prior, but no recent immunizations and no sick contacts. He began having problems "catching his toes" for 2 weeks. He had no visual complaints and no bowel or bladder incontinence. He had no recent travel and there were no heavy metal or solvent exposures. He had no prior medical history and he was on no prescription medications. Developmentally, he was on track and had just successfully completed fifth grade. However, he was reported to be behaviorally oppositional, especially regarding his diet which was restricted to beef jerky, yogurt from a squeeze tube, and fruit drinks. Family history included diabetic peripheral neuropathy in his mother, idiopathic peripheral neuropathy in his maternal grandfather, and left lower extremity neuropathy from trauma in his father. There was no known family history of recurrent pressure palsies or cardiac problems.