Beyond quality of life: a cross sectional study on the mental health of patients with chronic kidney disease undergoing dialysis and their caregivers.

BACKGROUND: Patients with terminal chronic kidney disease (CKDT) requiring renal replacement therapies (RRT) undergo important changes in living habits and frequently need caregiving. These patients and their caregivers are risk groups for the development of physical and psychological symptoms. This study aimed to evaluate the prevalence of anxiety, depression, stress, fatigue, social support, and quality of life in patients with CKD and their caregivers. METHOD: This cross sectional study was conducted with 21 patients and their caregivers, from January to September 2015. We included patients aged over 18 years, with at least 6 months on dialysis treatment, and caregivers who were family members. The participants' social, demographic, clinical, laboratory, and psychological variables were evaluated. A descriptive analysis and an examination of the association between patients and caregivers were performed. RESULTS: Among patients, we observed that 38.1% had symptoms that indicated anxiety and depression. The average score for practical social support was 3.15 ± 0.769 and that for emotional social support was 3.16 ± 0.79. As for fatigue, 14.3% of patients reported being 'extremely tired' and 14.3% reported that they engaged in all the activities they usually performed before the illness. Further, 57.1% presented stress, and of these, 66.7% were at the resistance stage, with predominance of psychological symptoms in 60.0%. The quality of life domain in terms of functional capacity (FC) presented a correlation with haemoglobin level (r = 0.581, p = 0.006) and non-anaemic patients presented better FC. Among caregivers, we observed symptoms that indicated anxiety and depression in 33.3% of the sample. Caregivers exhibited an average score of 2.88 ± 0.77 for practical social support and 3.0 ± 0.72 for emotional social support. Further, 14.3% reported being 'extremely tired' and 28.8% reported that they engaged in all activities that they usually performed before the patient's illness. When comparing the two groups (patients vs. caregivers), we observed that they presented similar results for the presence of anxiety, depression, and fatigue. Caregivers received less social support than patients did. Both groups presented similar predominance of stress levels; however, patients presented more predominance of psychological symptoms. With reference to quality of life, patients and caregivers presented similar results on the social aspects, vitality, mental health, and mental domains. CONCLUSION: The mental health characteristics of patients and caregivers were similar, and within the context of dialysis for renal disease, both must undergo specific interventions.

Perspectivas sobre a morte em pacientes com doença renal crônica e seus cuidadores familiares: um olhar sobre a relação com a saúde mental e o suporte social / Perspectives on death in patients with chronic kidney disease and their family caregivers: a look at the relationship with mental health and social support

Introdução: A doença renal crônica (DRC) consiste em um contexto de diversas perdas para pacientes e cuidadores. Essa realidade corresponde a processos de elaboração de perdas e lutos com impactos sobre a saúde mental de ambos. Objetivo: Avaliar as perspectivas sobre a morte e correlacionar com aspectos de saúde mental e suporte social. Materiais e Métodos: Estudo transversal com 31 participantes, sendo 14 pacientes com doença renal crônica em diálise em um Hospital Universitário no interior de Minas Gerais, Brasil, e 17 familiares. Os instrumentos utilizados foram: questionário sociodemográfico e de saúde, o Questionário de Qualidade de Vida (SF-36); Escala Hospitalar de Ansiedade e Depressão (HADS), Escala de Percepção do Suporte Social (SPSS), Pictograma de Fadiga (PF), Inventário de Sintomas de Estresse de Lipp (ISSL) e Escalas Breves de Perspectivas Sobre Morte (EBPM). Para a análise estatística as variáveis foram descritas como média, desvio padrão, mediana ou frequência conforme sua característica. Foi realizada a correlação de Pearson ou Spearman, considerando p<0,05. O software estatístico SPSS 17.0. Resultados: Os pacientes eram 50% (n= 7) do sexo feminino com idade média de 54,71 (±15,96) anos e os cuidadores eram 70,58% (n= 12) do sexo feminino, com idade média de 50,82 (±14,88) anos. Na avaliação geral (n= 31), houve uma associação negativa do domínio físico do SF-36 com a perspectiva de "morte como coragem" (r= -0,37, p= 0,04), uma associação positiva dos sintomas de ansiedade (r= 0,36, p= 0,04) e de depressão (r= 0,46, p= 0,01) com a perspectiva de morte como "sofrimento e solidão" (EBPM-1). Nos pacientes (n= 14), houve uma associação negativa entre o suporte social prático e a EBPM-1 (r= -0,719, p= ,006). Nos cuidadores, houve uma associação positiva entre as fases do estresse e a EBPM-1 (r= 0,48, p= 0,05). Conclusão: As perspectivas sobre a morte se relacionam com aspectos de saúde mental e suporte social em pacientes com DRC e cuidadores.

Introduction: Chronic kidney disease (CKD) is a context of diverse losses for patients and caregivers. This reality corresponds to processes of processing losses and mourning with impacts on the mental health of both. Objective: To evaluate perspectives on death and correlate with aspects of mental health and social support. Materials and Methods: Cross-sectional study with 31 participants, 14 patients with chronic kidney disease undergoing dialysis at a University Hospital in Minas Gerais, Brazil, and 17 family members. The instruments used were: sociodemographic and health questionnaire, the Quality of Life Questionnaire (SF-36), Hospital Anxiety and Depression Scale (HADS), Perceived Social Support Scale (SPSS), Fatigue Pictogram (PF), Lipp Stress Symptom Inventory (ISSL) and Brief Perspectives on Death Scales (EBPM). For statistical analysis, variables were described as mean, standard deviation, median or frequency according to their characteristics. Pearson or Spearman correlation was performed, considering p<0.05. SPSS 17.0 statistical software. Results: Patients were 50% (n= 7) female with a mean age of 54.71 (±15.96) years and caregivers were 70.58% (n= 12) female, with a mean age of 50. 82 (±14.88) years. In the general assessment (n= 31), there was a negative association between the physical domain of the SF-36 and the perspective of "death as courage" (r= -0.37, p= 0.04), a positive association with symptoms of anxiety (r= 0.36, p= 0.04) and depression (r= 0.46, p= 0.01) with the prospect of death as "suffering and loneliness" (EBPM-1). In patients (n= 14), there was a negative association between practical social support and EBPM-1 (r= -0.719, p= .006). In caregivers there was a positive association between the phases of stress and EBPM-1 (r= 0.48, p= 0.05). Conclusion: Perspectives on death are related to aspects of mental health and social support in CKD patients and caregivers.

Evaluation of prevalence, biochemical profile, and drugs associated with chronic kidney disease-mineral and bone disorder in 11 dialysis centers.

INTRODUCTION: The diagnosis and treatment of mineral and bone disorder of chronic kidney disease (CKD-MBD) is a challenge for nephrologists and health managers. The aim of this study was to evaluate the prevalence, biochemical profile, and drugs associated with CKD-MBD. METHODS: Cross-sectional study between July and November 2013, with 1134 patients on dialysis. Sociodemographic, clinical, and laboratory data were compared between groups based on levels of intact parathyroid hormone (iPTH) (< 150, 150-300, 301-600, 601-1000, and > 1001 pg/mL). RESULTS: The mean age was 57.3 ± 14.4 years. The prevalence of iPTH < 150 pg/mL was 23.4% and iPTH > 601 pg/mL was 27.1%. The comparison between the groups showed that the level of iPTH decreased with increasing age. Diabetic patients had a higher prevalence of iPTH < 150 pg/mL (27.6%). Hyperphosphatemia (> 5.5 mg/dL) was observed in 35.8%. Calcium carbonate was used by 50.5%, sevelamer by 14.7%, 40% of patients had used some form of vitamin D and 3.5% used cinacalcet. Linear regression analysis showed a significant negative association between iPTH, age, and diabetes mellitus and a significant positive association between iPTH and dialysis time. CONCLUSION: The prevalence of patients outside the target for iPTH was 50.5%. There was a high prevalence of hyperphosphatemia (35.8%), and the minority of patients were using active vitamin D, vitamin D analogs, selective vitamin D receptor activators, and cinacalcet. These data indicate the need for better compliance with clinical guidelines and public policies on the supply of drugs associated with CKD-MBD.

Montreal Cognitive Assessment (MoCA) screening mild cognitive impairment in patients with chronic kidney disease (CKD) pre-dialysis.

INTRODUCTION: Individuals with chronic kidney disease (CKD) are at higher risk of developing cognitive impairment (CI), initially mild (MCI), potentially identifiable, but still poorly diagnosed and treated. The Montreal Cognitive Assessment (MoCA) has been indicated for MCI screening in CKD. OBJECTIVE: To assess MCI in patients with CKD not yet on dialysis. METHODS: Study conducted in 72 non-elderly subjects with pre-dialysis CKD. The neuropsychological assessment included: The global cognitive assessment test MoCA; the clock drawing (CD); the digit span forward (DSF) and reverse (DSR); phonemic verbal (VF) fluency (FAS) and semantics (animals); the fist-edge-palm (FEP); and the memory 10 pictures. RESULTS: The average age of the participants was 56.74 ± 7.63 years, with predominance of male sex (55.6%), mainly with ≥ 4 years of education (84.3%), with CKD cathegories 1, 2 and 3a and 3b (67.6%), hypertension (93.1%) and diabetes mellitus (52.1%). MCI (MoCA ≤ 24) was observed in 73.6% of the patients. We did not find association among MCI with demographic and clinical variables, but a tendency to association with age (p = 0.07), educational level (p= 0.06) and diabetes (0.06). The executive function tests CD, DS-reverse and FEP, individually were able to identify CI with good sensibility and negative predictive value compared to MoCA and together, showed the same capability to identify MCI when compared to MoCA. CONCLUSION: The MCI is common in non-elderly patients with CKD not yet on dialysis. Together, the CD, DSR and FEP showed similar performance in identify MCI in this population when compared to MoCA, suggesting impairment of executive functions.

Impact of baseline health-related quality of life scores on survival of incident patients on peritoneal dialysis: a cohort study.

INTRODUCTION: In an attempt to decrease mortality in patients with end-stage renal disease, an increase in the lifetime of these patients without much focus on health-related quality of life (HRQOL) was pursued for a long period of time. However, lately, an improvement in the quality of this extended lifetime has focused on both the physical as well as the social and emotional aspects, as these parameters may be associated with clinical outcomes in end-stage renal disease patients. AIM: To evaluate the impact of self-determined HRQOL at admission on survival of incident peritoneal dialysis (PD) patients. PATIENTS AND METHODS: A total of 1,624 incident Brazilian PD patients participating in a multicenter prospective cohort study (BRAZPD) were evaluated. HRQOL was assessed using the SF-36, divided into mental and physical components. Cox proportional regression analysis was used to determine the influence of HRQOL (mental and physical components) on mortality. Multivariate Cox proportional hazards analyses were used to adjust gradually for more potential explanatory variables: first for demographic variables, followed by additional adjustment for socioeconomic, clinical and laboratory variables. The significance level in all analyses was set at p < 0.05. All analyses were carried out with SPSS 17.0. RESULTS: Incident PD patients presented with low HRQOL scores on admission to therapy. Even after correction for sociodemographic variables, comorbidities, PD modality and laboratory parameters, HRQOL (both the mental and the physical components) remained a predictor [HR: 0.97 (CI: 0.95-0.98); HR: 0.97 (CI: 0.96-0.99), respectively] of survival. CONCLUSION: On admission to therapy, patients presenting with low HRQOL scores for both the mental and the physical components were associated with a higher mortality. These results suggest that early and timely intervention measures to improve the QOL of these patients are important.

Evaluation of prevalence, biochemical profile, and drugs associated with chronic kidney disease-mineral and bone disorder in 11 dialysis centers / Avaliação da prevalência, perfil bioquímico e drogas associadas ao distúrbio mineral ósseo-doença renal crônica em 11 centros de diálise

ABSTRACT Introduction: The diagnosis and treatment of mineral and bone disorder of chronic kidney disease (CKD-MBD) is a challenge for nephrologists and health managers. The aim of this study was to evaluate the prevalence, biochemical profile, and drugs associated with CKD-MBD. Methods: Cross-sectional study between July and November 2013, with 1134 patients on dialysis. Sociodemographic, clinical, and laboratory data were compared between groups based on levels of intact parathyroid hormone (iPTH) (< 150, 150-300, 301-600, 601-1000, and > 1001 pg/mL). Results: The mean age was 57.3 ± 14.4 years. The prevalence of iPTH < 150 pg/mL was 23.4% and iPTH > 601 pg/mL was 27.1%. The comparison between the groups showed that the level of iPTH decreased with increasing age. Diabetic patients had a higher prevalence of iPTH < 150 pg/mL (27.6%). Hyperphosphatemia (> 5.5 mg/dL) was observed in 35.8%. Calcium carbonate was used by 50.5%, sevelamer by 14.7%, 40% of patients had used some form of vitamin D and 3.5% used cinacalcet. Linear regression analysis showed a significant negative association between iPTH, age, and diabetes mellitus and a significant positive association between iPTH and dialysis time. Conclusion: The prevalence of patients outside the target for iPTH was 50.5%. There was a high prevalence of hyperphosphatemia (35.8%), and the minority of patients were using active vitamin D, vitamin D analogs, selective vitamin D receptor activators, and cinacalcet. These data indicate the need for better compliance with clinical guidelines and public policies on the supply of drugs associated with CKD-MBD.

RESUMO Introdução: O diagnóstico e tratamento do distúrbio mineral ósseo-doença renal crônica (DMO-DRC) é um desafio para os nefrologistas e gestores de saúde. O objetivo deste estudo foi avaliar a prevalência, perfil bioquímico, e drogas associadas a DMO-DRC. Métodos: Estudo transversal entre julho e novembro de 2013, em 11 centros com 1134 pacientes em diálise. Dados sociodemográficos, clínicos, e laboratoriais foram comparados entre os grupos, com base em níveis do paratormônio intacto (PTHi) (< 150,151-300, 301-600,601-1000, e > 1001 pg/mL). Resultados: A idade média foi de 57,3 ± 14,4 anos, 1071 pacientes estavam em hemodiálise, e 63 em diálise peritoneal. A prevalência de PTHi < 150 pg/mL foi 23,4% e PTHi > 601 pg/mL foi de 27,1%. A comparação dos grupos mostrou que o nível de PTHi diminuiu com o aumento da idade. Pacientes diabéticos apresentaram uma maior prevalência de PTHi < 150 pg/mL (27,6%). Carbonato de cálcio foi usado por 50,5%, Sevelamer por 14,7%, 40% dos pacientes utilizaram alguma forma de vitamina D, e 3,5% utilizaram cinacalcet. A hiperfosfatemia (> 5,5mg/dL) foi observada em 35,8%. A análise de regressão linear mostrou uma associação negativa significativa entre PTHi, idade, e diabetes mellitus e uma associação positiva significativa com o tempo em diálise. Conclusão: A prevalência de pacientes fora do alvo para PTHi foi de 50,5%. Houve uma alta prevalência de hiperfosfatemia e um baixo uso de vitamina D ativa, análogos da vitamina D, ativadores seletivos da vitamina D, e cinacalcet. Estes dados chamam a atenção para a necessidade de uma maior conformidade com as diretrizes e políticas públicas sobre o fornecimento de medicamentos associados à DMO-DRC.

Montreal Cognitive Assessment (MoCA) no rastreio de comprometimento cognitivo leve (CCL) em pacientes com doença renal crônica (DRC) pré-dialítica / Montreal Cognitive Assessment (MoCA) screening mild cognitive impairment in patients with chronic kidney disease (CKD) pre-dialysis

Resumo Introdução: Indivíduos com doença renal crônica (DRC) têm grande risco de desenvolver comprometimento cognitivo (CC), inicialmente leve (CCL), passível de identificação, mas ainda subdiagnosticado e subtratado. O Montreal Cognitive Assessment (MoCA) vem sendo indicado para rastreio de CCL na DRC. Objetivo: Avaliar o CCL em indivíduos com DRC pré-dialítica. Métodos: O estudo foi realizado em 72 indivíduos, não idosos, com DRC nos estágios pré-dialíticos. A avaliação neuropsicológica incluiu: o teste de cognição global MoCA; o teste do relógio (TDR); o Digit Span ordem direta (DOD) e inversa (DOI); o teste de fluência verbal (FV), fonêmica (FAS) e semântica (animais); o punho-borda-mão (PBM); e de memória 10 figuras. Resultados: A média de idade dos participantes foi de 56,74 ± 7,63 anos, com predominância de homens (55,6%), com escolaridade ≥ 4 anos (84,3%), a maioria com DRC 1, 2 e 3a e 3b (67,6%), hipertensa (93,1%) e diabética (52,1%). O CC (MoCA ≤ 24) foi observado em 73,6% dos usuários. Não encontramos associação das variáveis demográficas e clínicas com CC, mas tendência de associação com a idade (p = 0,07), com a escolaridade (p = 0,06) e com o DM (0,06). Os testes de função executiva, TDR, DOI e PBM, isoladamente, apresentaram boa sensibilidade e valor preditivo negativo comparados ao MoCA para a identificação de CC e, em conjunto, foram capazes de predizer o resultado do MoCA. Conclusão: O CCL é frequente em usuários não idosos com DRC pré-dialítica. O TDR, DOI e PBM associados são equivalentes ao MoCA na identificação do CC nessa população, sugerindo comprometimento de funções executivas.

Abstract Introduction: Individuals with chronic kidney disease (CKD) are at higher risk of developing cognitive impairment (CI), initially mild (MCI), potentially identifiable, but still poorly diagnosed and treated. The Montreal Cognitive Assessment (MoCA) has been indicated for MCI screening in CKD. Objective: To assess MCI in patients with CKD not yet on dialysis. Methods: Study conducted in 72 non-elderly subjects with pre-dialysis CKD. The neuropsychological assessment included: The global cognitive assessment test MoCA; the clock drawing (CD); the digit span forward (DSF) and reverse (DSR); phonemic verbal (VF) fluency (FAS) and semantics (animals); the fist-edge-palm (FEP); and the memory 10 pictures. Results: The average age of the participants was 56.74 ± 7.63 years, with predominance of male sex (55.6%), mainly with ≥ 4 years of education (84.3%), with CKD cathegories 1, 2 and 3a and 3b (67.6%), hypertension (93.1%) and diabetes mellitus (52.1%). MCI (MoCA ≤ 24) was observed in 73.6% of the patients. We did not find association among MCI with demographic and clinical variables, but a tendency to association with age (p = 0.07), educational level (p= 0.06) and diabetes (0.06). The executive function tests CD, DS-reverse and FEP, individually were able to identify CI with good sensibility and negative predictive value compared to MoCA and together, showed the same capability to identify MCI when compared to MoCA. Conclusion: The MCI is common in non-elderly patients with CKD not yet on dialysis. Together, the CD, DSR and FEP showed similar performance in identify MCI in this population when compared to MoCA, suggesting impairment of executive functions.