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Peritoneal dialysis (PD) is an underutilized form of renal replacement therapy. Recent data have emphasized that only 12% of end-stage renal disease (ESRD) patients are initiated on this form of therapy in the United States. Patients requiring PD have most often been referred to general surgeons for catheter placement. This has incurred additional delays in starting treatment and loss of decision-making control by the referring nephrologist. To address this issue, we developed and incorporated our own PD access placement program into the preexisting chronic kidney disease (CKD) education program. To date, 46 patients have undergone 71 procedures. These included 51 (72%) PD catheter insertions, 14 (20%) removals, and 6 (8%) repositioning procedures for poor drainage. PD catheter insertion was performed peritoneoscopically under local anesthesia and a Fogarty catheter was used to reposition a migrated catheter. All of the procedures were performed by nephrologists in a dedicated interventional nephrology (IN) laboratory. All six repositioning procedures failed to restore optimal drainage. Five of these patients had the catheter removed and a new catheter placed during the same procedure. Of these five patients, one had recurrence of poor drainage and opted for hemodialysis (HD). The sixth patient declined reinsertion and chose HD. Of the remaining seven removal procedures, three were due to fungal peritonitis, one due to bowel perforation, one due to severe depression, one due to transplant, and one catheter was removed at the request of the primary physician in a terminally ill patient. Eight of the 51 catheter insertions were during the initial admission of a catastrophic dialysis start. Two of these patients started acute PD and avoided catheter placement for HD. Thirty-seven of 46 patients have a functional PD catheter with a follow-up of 8.6 +/- 0.8 (mean +/- SE) months. During an 18-month period our PD population has increased from 43 to 80 patients. We conclude that a dedicated PD access placement program coupled with a CKD education program can have a dramatic impact on patient choice and PD growth.
Semin Dial
PMID:Peritoneal dialysis underutilization: the impact of an interventional nephrology peritoneal dialysis access program. 1275 90

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.
Semin Dial
PMID:Chronic peritoneal dialysis patients diagnosed with clinical depression: results of pharmacologic therapy. 1462

The most common cause of drop-out from continuous ambulatory peritoneal dialysis (CAPD) therapy is an insufficient dose of dialysis. Several reports and the Dialysis Outcomes Quality Initiative (DOQI) guidelines recommend maintaining a weekly creatinine clearance (CCr) of at least 60 L/1.73 m2. Previously, at our center, we found that many patients switched from CAPD to hemodialysis (HD) owing to insufficient solute clearance (less than 50 L/1.73 m2). We attempted to determine whether once-weekly HD would improve solute clearance. We treated 7 cases (6 men, 1 woman; average age: 54.3 +/- 4.5 years; mean duration of CAPD: 4.3 +/- 1.1 years) with once-weekly HD therapy (3.5 hours; 200 mL/hour). The average CCr was 45 +/- 2 L/1.73 m2. No ultrafiltration failure was found. Addition of once-weekly HD therapy improved CCr to 66 +/- 7 L/1.73 m2. That improvement was attributable to not only to the addition of HD therapy but also to an increase in peritoneal CCr for 3 consecutive days after completion of once-weekly HD therapy. Creatinine clearance and ultrafiltration were both significantly increased. Other clinical parameters such as blood pressure control, weight control, and dose of erythropoietin were significantly improved after introduction of once-weekly HD therapy. Moreover, uremic symptoms such as pruritus and depression were markedly improved. In conclusion, once-weekly HD therapy in conjunction with regular CAPD therapy improves solute clearance and symptoms related to uremia in CAPD patients with an insufficient dialysis dose.
Adv Perit Dial 2003
PMID:Once-weekly hemodialysis helps continuous ambulatory peritoneal dialysis patients who have insufficient solute removal. 1476 51

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.
Adv Perit Dial 2003
PMID:The BDI and the SF36: which tool to use to screen for depression? 1476 54

Preliminary findings indicate that daily hemodialysis positively impacts patients' energy/fatigue and other uremic and intradialytic symptoms. In addition to improvements in perceived symptoms, improvements in patients' perceived physical and psychosocial functioning have been reported. These findings have come from small series of patients, however, and may reflect an increased attention effect. Confirmation of preliminary findings and identification of changes in other quality of life outcomes await an adequately powered randomized clinical trial. Sleep quality, sexual functioning, and cognitive functioning are quality of life dimensions that may be impacted by daily hemodialysis but about which there is limited information in the preliminary data that exist. Understanding relationships among different levels of quality of life outcomes associated with daily hemodialysis requires consideration of emotional and psychological variables such as burden, depression, and satisfaction with care that may intervene between treatment and the quality of life outcomes that patients report. Deriving health utilities relevant to patient experience on different daily hemodialysis therapies, analyzing longitudinal quality of life outcomes reported by patients on daily hemodialysis, and investigating the effectiveness of daily hemodialysis for specific patient subgroups are research agendas that can provide information needed to facilitate treatment decision making in which quality of life has an important role.
Semin Dial
PMID:Quality of life and daily hemodialysis. 1504 8

We describe a patient with end-stage renal disease (ESRD) who developed depression over the period of dialysis initiation. Depression is an extremely common but underrecognized disorder in the dialysis population, which is one of the rationales for this case report. Here we present the epidemiology, mechanisms for diagnosis, associations with medical morbidity, and treatment modalities specifically for patients on dialysis.
Semin Dial
PMID:Depression: a common but underrecognized condition associated with end-stage renal disease. 1514 52

Major depressive disorder (MDD) is a highly prevalent disease, frequently characterized by recurrent or chronic course, and by comorbidity with other medical illnesses. The lifetime prevalence of MDD ranges up to 17% in the general population, and it almost doubles in patients with diabetes (9-27%), stroke (22-50%), or cancer (18-39%). Moreover, MDD worsens the prognosis, quality of life, and treatment compliance of patients with comorbid medical illnesses. Similar to what is observed with other comorbid illnesses, MDD worsens the outcome of kidney disease patients by increasing both morbidity and mortality. Treatment of depressive symptoms in renal failure patients increases medication acceptability and therefore potentially improves the overall patient outcome. The issue of the safety of antidepressant treatment in subjects with renal failure is frequently counterbalanced by the risks associated with depression comorbidity, provided that antidepressants with a low volume of distribution and low protein binding are prescribed, and most important, at low initial doses. Screening for CYP isoenzyme interactions with current medications is also recommended before starting antidepressant treatment.
Semin Dial
PMID:Depression and renal disease. 1577 49

Depression has been thought to be the most common psychiatric abnormality in hemodialysis (HD) patients. There are few data using psychiatric diagnostic criteria and a lack of large, well-designed epidemiologic research studies in patients with end-stage renal disease (ESRD) that can render definitive results on this topic. The prevalence of major depression or a defined psychiatric illness in ESRD patients is unknown, but is probably between 5% and 10%. The prevalence of increased levels of depressive affect is greater. Estimates of the prevalence will vary according to the screening techniques used. Depression could affect medical outcomes in ESRD patients through several mechanisms. Correlational analyses suggest stressors and protective factors play roles in mediating the level of depressive affect and associated outcomes. Although early studies suggested a deleterious effect of depression on survival in ESRD patients, more recent studies had failed to confirm such findings. The use of longitudinal analyses and larger samples has confirmed an association of depressive affect and morbidity and mortality in more contemporary ESRD populations. The importance of depressive affect compared with the presence of a defined psychiatric syndrome in mediating clinically important outcomes in patients with chronic kidney disease has not been determined. Studies of interventions designed to reduce levels of depressive affect in ESRD patients are urgently needed.
Semin Dial
PMID:Depression in end-stage renal disease patients treated with hemodialysis: tools, correlates, outcomes, and needs. 1577 51

Both peritoneal dialysis (PD) and hemodialysis (HD) patients have diminished quality of life (QOL) scores compared to healthy patients. QOL tends to decline over time, with the perception of the quality of physical health deteriorating more than mental health. However, many patients continue to feel hopeless, anxious, and worry about finances, loss of sexual function, family burden, and loss of independence. Depression is the most widely acknowledged psychosocial factor seen in patients with chronic kidney disease. Major depression occurs in 25% of patients facing impending dialysis. Once on PD, the proportion with major depression sharply declines to approximately 6%. This may be due to adjustment to dialysis, but may also be because depressive symptoms are associated with an increased risk of death. A low QOL score and depression are associated with higher comorbidity, poorer nutritional status, anemia, lower residual renal function, and increased hospitalization rates. Increased depressive scores are independently predictive of an elevated peritonitis risk, perhaps due to inattentiveness, or alternatively from a decrease in immune defenses. Small molecule clearances appear to have little to do with depressive symptoms. Depression is a significant problem in PD and other dialysis patients. There is an interrelationship between psychosocial factors, perception of illness, and clinical outcome that requires further study. Serial and simple measures of both depression and QOL should be obtained routinely in all PD patients. This permits rapid recognition of problems and may enhance patients' education on the importance of depression. Further research on interventions is urgently needed.
Semin Dial
PMID:Quality of life and psychological issues in peritoneal dialysis patients. 1577 55

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.
Semin Dial
PMID:The identification and treatment of depression in patients maintained on dialysis. 1577 59


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