Evaluating Hyponatremia in Non-Diabetic Uremic Patients on Peritoneal Dialysis.

UNLABELLED: ♦ BACKGROUND: An approach to hyponatremia in uremic patients on peritoneal dialysis (PD) necessitates the assessment of intracellular fluid volume (ICV) and extracellular volume (ECV). The aim of the study was to evaluate the association of plasma sodium (Na(+)) concentration and body fluid composition and identify the causes of hyponatremia in non-diabetic PD patients. ♦ METHODS: Sixty non-diabetic uremic patients on PD were enrolled. Baseline body fluid composition, biochemistry, hand-grip test, peritoneal membrane characteristics, dialysis adequacy, Na(+) and water balance, and residual renal function (RRF) were measured. These parameters were reevaluated for those who developed hyponatremia, defined as serum Na(+) concentration < 132 mmol/L and a decline in serum Na(+) > 7 mmol/L, during monthly visits for 1 year. Body fluid composition was determined by multi-frequency bioelectrical impedance (BIA). ♦ RESULTS: There was no significant correlation between serum Na(+) concentrations and any other parameters except a negative correction with overnight ultrafiltration (UF) amount (p = 0.02). The ICV/ECV ratio was positively correlated with serum albumin (p < 0.005) and hand grip strength (p < 0.05). Over 1 year, 9 patients (M:F = 3:6, aged 35 - 77) with 4 different etiologies of hyponatremia were identified. Hyponatremic patients with a body weight (BW) loss had either an increased ICV/ECV ratio associated with primarily a negative Na(+) balance (n = 2) or a reduced ratio of ICV/ECV associated with malnutrition (n = 2). In contrast, hyponatremic patients with a BW gain had either a reduced ICV/ECV ratio associated with a rapid loss of RRF and a higher peritoneal permeability (n = 2) or a normal to increased ICV/ECV ratio associated with high water intake (n = 3). ♦ CONCLUSION: Besides BW change and ultrafiltration rate, the assessment of ICV/ECV ratio is valuable in identifying the etiologies of hyponatremia in PD and provides a guide for optimal therapy.

Women on hemodialysis have lower self-reported health-related quality of life scores but better survival than men.

BACKGROUND: Hemodialysis patients suffer from poor quality of life and survival. A retrospective cohort study was performed to examine the sex differences in self-reported quality of life and mortality in a Taiwanese hemodialysis cohort. METHODS: A total of 816 stable hemodialysis patients were included. Patients completed two questionnaires: the 36-item Short Form Health Survey Questionnaire (SF-36, Taiwan Standard Version 1.0) to assess health-related quality of life (HRQoL) and the Beck Depression Inventory (BDI, Chinese Version) to assess depressive mood. Mortality outcomes were recorded for a seven-year follow-up period. RESULTS: After adjustment for confounding factors, women had significantly higher BDI scores (P=.003), lower physical functioning (P<.001), bodily pain (P<.001), mental health (P=0007), and physical component scale (PCS) scores (P<.001). There were 284 deaths recorded. In the Cox-proportional hazard model, women had significantly lower mortality than men (P<.001). CONCLUSIONS: Women on hemodialysis had more depression-related symptoms and poor self-reported HRQoL, but better survival than men. The sex difference in psychological and HRQoL issues deserves greater concern because this relates to clinical care and further study.

Yellowish discoloration of dialyzer.

A 43-year-old Chinese man with chronic viral hepatitis and end-stage renal disease, receiving conventional hemodialysis for 6 years, presented with general malaise and abdominal fullness. After 4.5 hours of hemodialysis, the hollow fibers of the dialyzer turned yellow. Biochemistry studies showed hyperbilirubinemia. The actual serum bilirubin (7.4 mg/dL) could be proved. Abdominal echography survey was negative. Hyperbilirubinemia was secondary to acute exacerbation of chronic viral hepatitis. Anuria and skin hyperpigmentation in uremia lack the tea-color urine and mask clinical jaundice in the presence of hyperbilirubinemia. Careful observation of dialyzer yellowish discoloration gave us timely discovery of patient's hyperbilirubinemia.

Comparison of self-reported health-related quality of life between Taiwan hemodialysis and peritoneal dialysis patients: a multi-center collaborative study.

PURPOSE: The maintenance of good health-related quality of life (HRQoL) is an important goal for end-stage renal disease (ESRD) patients. Whether hemodialysis (HD) and peritoneal dialysis (PD) have different impacts on HRQoL is a concern shared by both physicians and patients. A comparison study of HRQoL between Taiwanese HD and PD patients was conducted. METHODS: ESRD patients at 14 hospitals or dialysis centers in northern Taiwan were recruited in this cross-sectional study. The Chinese-language version of the 36-item Short Form Health Survey Questionnaire (SF-36, Taiwan Standard Version 1.0) was used to evaluate HRQoL. Ordinal regression analyses were used to explore the independent association between HRQoL scores and dialysis modality. By Bonferroni correction test, a P value of <0.005 was regarded as significant. RESULTS: A total of 866 HD patients and 301 PD patients were included. After adjusting for confounding factors, no difference in HRQoL was found among the entire cohort and the diabetic subgroup. CONCLUSION: This study demonstrated that Taiwanese HD and PD patients had similar HRQoL. The current survey improves our understanding of the association of HRQoL with dialysis modality in Taiwan ESRD population.

Are both psychological and physical dimensions in health-related quality of life associated with mortality in hemodialysis patients: a 7-year Taiwan cohort study.

BACKGROUND: Psychological depression and physical disability are closely correlated in hemodialysis patients. A retrospective cohort study was conducted to examine the independent association of physical and psychological functioning with mortality in a hemodialysis cohort in Taiwan. METHODS: A total of 888 stable hemodialysis patients were included. Patients completed two questionnaires: the 36-item Short Form Health Survey Questionnaire (SF-36, Taiwan Standard Version 1.0) and the Beck Depression Inventory (BDI, Chinese Version). Mortality outcomes were recorded for a seven-year follow-up period. RESULTS: There were 303 deaths recorded. BDI scores were inversely related to all health-related quality of life (HRQoL) domains (p < 0.001). In the Cox-proportional hazard model, only poor physical dimension of HRQoL was independently associated with higher mortality. CONCLUSION: Poor physical dimension in HRQoL is a strong predictor of mortality among hemodialysis patients in Taiwan. Psychological depression is closely correlated with poor HRQoL but does not predict mortality.

Association of leptin with hemodialysis-related muscle cramps: a cross-sectional study.

BACKGROUND/AIMS: The mechanism of muscle cramp in hemodialysis patients is not well understood. Leptin, a middle molecule uremic toxin, is able to affect neuronal activity. This study aimed to determine the association between leptin and hemodialysis-related muscle cramps. METHODS: A total of 79 hemodialysis patients were enrolled. The episodes of hemodialysis-related muscle cramps were recorded over a 28-day period. Serum levels of leptin were measured on the 15th day, a mid-week dialysis session. RESULTS: Frequent hemodialysis-related cramps were associated with old age and elevated serum leptin levels. The risk of frequent hemodialysis-related cramps increased with increasing tertiles of leptin concentration. This relationship remained significant after adjustment for age, mean ultrafiltration ratio, gender, body mass index, insulin, resistin, c-reactive protein, albumin, peripheral arterial disease, electrolytes, and beta(2)-microglobulin. CONCLUSION: Leptin levels are associated with frequent hemodialysis-related cramps. Further studies are necessary to elucidate the underlying mechanisms.

Impact of spiritual and religious activity on quality of sleep in hemodialysis patients.

BACKGROUND: Sleep disorders are common in hemodialysis (HD) patients. This study examined the relationship between quality of sleep (QoS) and religious/spiritual activity in HD patients. METHODS: The study subjects were 861 HD patients from 14 dialysis clinics in Taiwan. QoS and religious/spiritual activity were evaluated by the Pittsburgh Sleep Quality Index (PSQI) questionnaire and the Royal Free Questionnaire respectively. RESULTS: There was no difference in clinical parameters between the good and poor sleepers. Although total scores of religious and spiritual activity did not correlate with global PSQI score, patients who held strong 'spiritual' beliefs reported more problems in 'sleep disturbances', while those who exercised religious beliefs more strongly reported less trouble in 'daytime dysfunction'. CONCLUSION: There is no significant correlation between QoS and religious/spiritual activity globally. However, the spiritual and religious activity did associate with different components of QoS.

Quality of sleep and psychosocial factors for patients undergoing peritoneal dialysis.

OBJECTIVES: Sleep disorders are common in end-stage renal disease patients. This study examined the relationship between self-reported quality of sleep (QoS) and certain psychosocial domains for patients on peritoneal dialysis (PD). METHODS: The study subjects included 190 PD patients from 7 urban dialysis clinics in Northern Taiwan, from whom we obtained biochemical parameters and demographic data. QoS, quality of life (QoL), religious/spiritual activity, and depression were assessed using the Pittsburgh Sleep Quality Index (PSQI) questionnaire, Medical Outcomes Study Short Form (SF-36) for QoL, the Royal Free Questionnaire, and the Beck Depression Inventory, respectively. RESULTS: The average PSQI score was 9.1 +/- 4.1 and, in total, 85.8% of all patients were poor sleepers (global PSQI > or =5). There was no difference in age, gender, and mode or duration of PD between good and poor sleepers. Biochemical data did not differ between the two groups. Widowed patients experienced significantly poorer QoS than patients with other marital status (PSQI scores: 12.3 +/- 4.9 vs 8.88 +/- 4.0, p = 0.006). The percentage of patients that held a bachelor's degree or above was significantly higher in good sleepers (55.6% vs 29.4%, p = 0.008). The PSQI value correlated negatively with the QoL scale in both physical (r = -0.295, p < 0.001) and mental domains (r = -0.410, p < 0.001), and correlated positively with the depression scale (r = 0.351, p < 0.001). There appeared to be no association between QoS and spiritual/religious activity (r = -0.097, p = 0.223). CONCLUSIONS: Psychosocial factors including depression, patients' perceptions regarding QoL, marital status, and educational background correlated significantly to the subjective QoS for PD patients. When dealing with sleep disorders in PD patients, physicians should pay considerable attention to their psychosocial backgrounds.

Sexual dysfunction in peritoneal dialysis patients.

BACKGROUND/AIMS: Sexual dysfunction in patients undergoing peritoneal dialysis (PD) is highly prevalent, but studies addressing this issue are scarce. This cross-sectional study aims to evaluate sexual dysfunction and the determinants among PD patients. METHODS: All chronic PD patients in 8 PD centers were asked to complete a self-reported questionnaire - the International Index of Erectile Function (IIEF) for men and the Index of Female Sexual Function (IFSF) for women - so that sexual function could be assessed. They also answered the Beck Depression Inventory (BDI) to measure depressive symptoms. RESULTS: Among 294 patients invited for study, 54 men (mean age 48.8 +/- 10.8 years) and 45 women (mean age 43.6 +/- 7.4 years) were willing to and completed the sexual function questionnaires. The median IIEF score in the men was 56.25. The prevalence of erectile dysfunction, identified by the score in erectile domain of IIEF

Impact of near-death experiences on dialysis patients: a multicenter collaborative study.

BACKGROUND: People who have come close to death may report an unusual experience known as a near-death experience (NDE). This study aims to investigate NDEs and their aftereffects in dialysis patients. STUDY DESIGN: Cross-sectional study. SETTING & PARTICIPANTS: 710 dialysis patients at 7 centers in Taipei, Taiwan. PREDICTOR: Demographic characteristics, life-threatening experience, depression, and religiosity. OUTCOMES: NDE and self-perceived changes in attitudes or behaviors. MEASUREMENTS: Greyson's NDE scale, Royal Free Questionnaire, 10-Question Survey, Ring's Weighted Core Experience Index, and Beck Depression Inventory. RESULTS: 45 patients had 51 NDEs. Mean NDE score was 11.9 (95% confidence interval, 11.0 to 12.9). Out-of-body experience was found in 51.0% of NDEs. Purported precognitive visions, awareness of being dead, and "tunnel experience" were uncommon (<10%). Compared with the no-NDE group, subjects in the NDE group were more likely to be women and younger at life-threatening events. Both frequency of participation in religious ceremonies and pious religious activity correlated significantly with NDE score in patients with NDEs (P < 0.01 and P = 0.01, respectively). The NDE group reported being kinder to others (P = 0.04) and more motivated (P = 0.02) after their life-threatening events than the no-NDE group. LIMITATIONS: Determining the incidence of NDEs is dependent on self-reporting. Many NDEs occurred before the patient began long-term dialysis therapy. Causality between NDE and aftereffects cannot be inferred. CONCLUSIONS: NDE is not uncommon in the dialysis population and is associated with positive aftereffects. Nephrology care providers should be aware of the occurrence and aftereffects of NDEs. The high occurrence of life-threatening events, availability of medical records, and accessibility and cooperativeness of patients make the dialysis population very suitable for NDE research.

The association of higher depressive symptoms and sexual dysfunction in male haemodialysis patients.

BACKGROUND: The prevalence of sexual dysfunction among male haemodialysis patients is high. Sexual dysfunction is composed of both physiological and psychological factors. However, the role of psychological depression is still obscure. METHODS: A multicentre cross-sectional study of 411 male haemodialysis patients was conducted to define the determinants of sexual dysfunction. Mid-week pre-dialytic biochemical and haematological parameters were obtained. All patients were required to complete three questionnaires by themselves: (i) the International Index of Erectile Function (IIEF, Chinese version); (ii) the Beck Depression Inventory (BDI, Chinese version) and (iii) the 36-item Short Form Health Survey Questionnaire (SF-36, Taiwan Standard Version 1.0). RESULTS: In total, 154 male patients completed the IIEF questionnaire. Their mean age was 50.2 +/- 10.7 years. A linear multivariable regression analysis demonstrated advanced age, diabetes and the presence of depressive symptoms to be independently associated with sexual dysfunction. Subjects with sexual dysfunction had significantly lower quality of life scores. CONCLUSIONS: The presence of depressive symptoms, highly prevalent in haemodialysis patients, is an independent factor of sexual dysfunction in male haemodialysis patients. In a comprehensive approach to the management of sexual dysfunction, a thorough evaluation of psychological depression must be included.

Effect of soya protein on serum lipid profile and lipoprotein concentrations in patients undergoing hypercholesterolaemic haemodialysis.

Clinical trials have shown that soya protein reduces the concentrations of some atherogenic lipids in subjects with normal renal function. The present study examined the effects of soya protein on serum lipid concentrations and lipoprotein metabolism in patients on hypercholesterolaemic haemodialysis. Twenty-six hypercholesterolaemic (total cholesterol > or =6.21 mmol/l) patients on haemodialysis were studied in a randomized, double-blind, placebo-controlled clinical trial. After a 4-week run-in phase, the subjects were randomly assigned to two groups. Isolated soya protein or milk protein 30 g was consumed daily as a beverage at breakfast or post-dialysis for 12 weeks. Soya protein substitution resulted in significant reductions in total cholesterol (17.2 (sd 8.9 )%), LDL-cholesterol (15.3 (sd 12.5 )%), apo B (14.6 (sd 12.1 )%) and insulin (23.8 (sd 18.7) %) concentrations. There were no significant changes in HDL-cholesterol or apo A-I. These results indicate that replacing part of the daily protein intake with soya protein has a beneficial effect on atherogenic lipids and favourably affects lipoprotein metabolism in hypercholesterolaemic patients undergoing haemodialysis.

Variable effects of soy protein on plasma lipids in hyperlipidemic and normolipidemic hemodialysis patients.

BACKGROUND: Hyperlipidemic factors contribute to the high cardiovascular risk in hemodialysis patients. Soy protein has decreased some atherogenic lipid concentrations in subjects with normal renal function. This study evaluates the effect of soy protein on serum lipid profiles in hyperlipidemic and normolipidemic hemodialysis patients. METHODS: Nineteen hyperlipidemic and 18 normolipidemic hemodialysis patients were enrolled in a randomized, double-blind, placebo-controlled, clinical trial. After a 4-week run-in phase, subjects in each category were randomly assigned to 2 groups. Thirty grams of isolated soy protein or milk protein was consumed daily as a beverage at breakfast or postdialysis for 12 weeks. RESULTS: In hyperlipidemic subjects, soy protein intake significantly decreased total cholesterol levels by 18.6% (95% confidence interval [CI], -11.4 to -25.8; P = 0.04), triglyceride levels by 43.1% (95% CI, -34.0 to -52.2; P = 0.02), non-high-density lipoprotein cholesterol levels by 23.6% (95% CI, -14.7 to -32.5; P < 0.01), apolipoprotein B levels by 15.4% (95% CI, -5.4 to -25.4; P = 0.01), and insulin levels by 49.8% (95% CI, -23.3 to -66.1; P < 0.01). Low-density lipoprotein cholesterol concentration was decreased significantly (-25.8%; 95% CI, -8.3 to -42.7; P = 0.01), and high-density lipoprotein cholesterol level was increased significantly (17%; 95% CI, 2 to 32.0; P = 0.03), but there was no significant difference compared with the milk protein group (-5.5% +/- 16.9% and 7.0% +/- 11.8%, respectively). There were no significant changes in serum lipid and lipoprotein concentrations in normolipidemic subjects. CONCLUSION: These results indicate soy protein substitution has lipid-lowering effects in hyperlipidemic hemodialysis patients. However, soy protein intake had little effect on plasma lipid levels in normolipidemic hemodialysis patients.

Sexual dysfunction in female hemodialysis patients: a multicenter study.

BACKGROUND: Sexual function is one aspect of physical functioning. Sexual dysfunction, no matter the etiology, could cause distress. In female hemodialysis patients, sexual problems have often been neglected in clinical performance and research. METHODS: We conducted this study by use of self-reported questionnaires. A total of 578 female hemodialysis patients in northern Taiwan were included in this study. Demographic data, comorbid diseases, medications in use, biochemical, and hematologic parameters were analyzed. All patients were asked to complete by themselves three questionnaires: (1) the Index of Female Sexual Function (IFSF) to assess sexual function; (2) the Beck Depression Inventory (BDI) (Chinese version) to rate the severity of depressive symptoms; and (3) the 36-item Short Form Health Survey Questionnaire (SF-36, Taiwan Standard Version 1.0) to survey their quality of life. RESULTS: A total of 138 female patients were enrolled into further analysis. The mean age was 48.7 +/- 11.2 years old. The mean IFSF score was 24.5 +/- 9.3. Age, BDI score, and serum triglyceride levels were the independent factors of dysfunction in each sexual functional dimension. Patients with higher IFSF scores had significantly higher scores in physical functioning and mental health (P= 0.007 and 0.018, respectively). Patients with higher intercourse satisfaction had significantly higher general health scores (P= 0.001). CONCLUSION: Sexual dysfunction is frequent in the female hemodialysis population. It is strongly associated with increasing age, dyslipidemia, and depression. The subjects with sexual dysfunction had poorer quality of life. The diagnosis and treatment of sexual dysfunction should be included in the clinical assessment.

Nutritional and inflammatory markers in the prediction of mortality in Chinese hemodialysis patients.

BACKGROUND/AIMS: The prevalence of cardiovascular disease and mortality rate is relatively low in Chinese dialysis patients. This study aimed to evaluate the predictive value of nutritional and inflammatory markers in Chinese hemodialysis patients. METHODS: A total of 158 patients (70 men and 88 women, age 59.9 +/- 13.2 years) were studied. Nutritional and inflammatory markers, including subjective global assessment (SGA), insulin-like growth factor-1, albumin, tumor necrosis factor-alpha, interleukin (IL)-1beta, IL-6, serum amyloid A (SAA), and C-reactive protein (CRP), were measured. These patients were followed up until April 2004 (36 months) to determine the incidence and causes of death. RESULTS: SGA (p = 0.001), IL-1beta (p = 0.032), SAA (p = 0.031), IL-6 (p = 0.001) and CRP (p < 0.001) were found to be significant predictors of mortality. After adjusting with age, sex, diabetes, coronary artery disease, Kt/Vurea, and duration on dialysis, CRP (odds ratio = 4.58; p = 0.038) and SGA (odds ratio = 6.57; p = 0.004) remained the independent predictors of mortality. The adjusted mortality rate was highest for patients with a high CRP level and malnutrition (assessed by SGA). CONCLUSIONS: SGA and CRP levels are the most significant predictors of mortality in Chinese dialysis patients. Chinese dialysis patients with a high CRP level tend to be at higher risk of mortality only if they are malnourished.

Health-related quality of life of hemodialysis patients in Taiwan: a multicenter study.

BACKGROUND/AIMS: Health-related quality of life (HRQOL) is an important determinant of treatment effectiveness in dialysis patients. To our knowledge, there are no reports evaluating HRQOL of hemodialysis (HD) in Chinese patients. The purpose of this study is to present our results about HRQOL using the 36-Item Short-Form (SF-36) questionnaire on Taiwanese hemodialysis patients. METHODS: HRQOL was measured by using the SF-36 questionnaire in 497 HD patients in five hospitals. RESULTS: The following attributes, male gender, age <50 years old, higher education level (HEL), marriage status, employment status (EPS), less comorbid medical condition (CMC), and non-diabetic patients (NDP) were all predicted on a better Physical Component Scale (PCS). Age <50 years old, body mass index >18.5, HEL, EPS and NDP were all predicted on a higher Mental Component Scale (MCS). Scales contributing to a summary measure of physical health, the PCS score was significantly lower in women (35.0 +/- 12.3) than in men (37.9 +/- 12.3). However, there was no difference in the MCS score between women and men. In multivariate analysis, age, CMC, diabetes, serum creatinine (SCr), and erythropoietin responsiveness were significant independent predictors of PCS. Diabetes, educational level, SCr, and erythropoietin responsiveness were significant independent predictors of MCS. All of the individual scales were lower in Taiwanese HD patients than in both the general Taiwanese and US population. Each of the individual scales and MCS scores were substantially lower in the Taiwan HD group than in the US HD cohort. However, the bodily pain of PCS was significantly higher in the Taiwan HD group, although the mean PCS scores for the Taiwan HD group and the US HD study participants were nearly equal at 36.3 and 36.1, respectively. CONCLUSION: The physical and mental aspects of quality of life are substantially lower for Taiwanese HD patients, except for higher bodily pain tolerance. A number of demographic and clinical characteristics have a significant impact on HRQOL in Taiwanese HD patients.

Isolation effectively prevents the transmission of hepatitis C virus in the hemodialysis unit.

BACKGROUND AND PURPOSE: Many preventative strategies have been proposed to control hepatitis C virus (HCV) infection in the hemodialysis unit. The effectiveness of isolation as a preventive policy remains unclear. The aim of this study was to evaluate the effect of an isolation policy on the incidence of hepatitis C in our hemodialysis unit. METHODS: A total of 325 hemodialysis patients with a mean age of 62 +/- 14 years and a mean duration of dialysis of 4.8 +/- 4.4 years, who were treated from January 1993 to December 2000 were included in this retrospective study. Data were collected from medical records. HCV antibody was monitored at 6-month intervals. During the period before September 1997 all patients were dialyzed in a single room. Isolation started after September 1997, when an additional room became available. Patients positive for either hepatitis B or C were clustered in 1 area (Area 1). Anti-HCV-negative and hepatitis B surface antigen (HBsAg)-negative patients were assigned either to a segregated zone (Area 2) adjacent to Area 1 in the same room or to a separate independent room (Area 3). Dialyzers were not reused and hygienic precautions remained the same throughout the study period. RESULTS: Forty months after the implementation of the isolation policy, there was significant reduction in the total prevalence (49.7 vs 31.7%, p < 0.01) and incidence (9.1 vs 2.9 % patient-years, p < 0.01) of HCV infection. Seroconversion of anti-HCV was detected in 9 patients, 7 in Area 1, 2 in Area 2, with no new cases in Area 3. The incidence of seroconversion of anti-HCV was significantly different in the 3 areas. Regression analysis indicated that isolation was the most prominent independent factor in reducing seroconversion of anti-HCV. CONCLUSIONS: These results support the use of an isolation policy to combat HCV infection among hemodialysis patients, particularly in high prevalence units.