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Withdrawal from dialysis is an appropriate decision for situations in which the burdens of treatment outweigh the benefits. Alternately, it can be viewed as a public health problem and suicide equivalent that contributes to the high mortality of end-stage renal disease (ESRD). More than one in five deaths of patients with ESRD are preceded by dialysis cessation, and approximately 15,000 Americans died last year following a determination to stop this life-support treatment. This article discusses what is known about the psychosocial aspects of the patients who terminate dialysis, the role of depression and other psychiatric disorders, the family perspective, and the relationship of these decisions to suicide.
Semin Dial
PMID:The psychiatric landscape of withdrawal. 1577 60

Peritonitis is a well-known cause of mortality in peritoneal dialysis (PD) patients. We carried out a retrospective study to disclose the clinical spectrum and risk profile of peritonitis-related mortality. We analyzed 693 episodes of infectious peritonitis suffered by 565 patients (follow-up 1149 patient-years). Death was the final outcome in 41 cases (5.9% of episodes), peritonitis being directly implicated in 15.2% of the global mortality and 68.5% of the infectious mortality observed. In 41.5% of patients with peritonitis-related mortality, the immediate cause of death was a cardiovascular event. Highest mortality rates corresponded to fungal (27.5%), enteric (19.3%), and Staphylococcus aureus (15.2%) peritonitis. Multivariate analysis disclosed thatthe baseline risk of peritonitis-related mortality was significantly higher in female [relative risk (RR) 2.13, 95% confidence interval (CI) 1.24-4.09, p = 0.02], older (RR 1.10/year, CI 1.06-1.14, p < 0.0005), and malnourished patients (RR 2.51, CI 1.21-5.23, p = 0.01) with high serum C-reactive protein (s-CRP) levels (RR 4.04, CI 1.45-11.32, p = 0.008) and a low glomerular filtration rate (RR 0.75 per mL/minute, CI 0.64 -0.87, p < 0.0005). Analysis of risk after a single episode of peritonitis and/or subanalysis restricted to peritonitis caused by more aggressive micro-organisms disclosed that overall comorbidity [odds ratio (OR) 1.21, CI 1.05-1.71, p = 0.005], depression (OR 2.35, CI 1.14-4.84, p = 0.02), and time on PD at the time of the event (OR 1.02/month, CI 1.00-1.03, p = 0.02) were other predictors of mortality. In summary, the etiologic agent is a definite marker of peritonitis-related mortality but gender, age, residual renal function, inflammation (s-CRP), malnutrition, and depression are other significant correlates of this outcome. Most of these risk factors are common to cardiovascular and peritonitis-related mortality, which may explain the high incidence of cardiovascular event as the immediate cause of death in patients with peritonitis-related mortality.
Perit Dial Int
PMID:Peritonitis-related mortality in patients undergoing chronic peritoneal dialysis. 1598 76

While advances in treatment strategies and pharmacotherapy have produced a dramatic reduction in the mortality of patients with heart failure during the past 15 years, there is still a major challenge to improve patient well being, reduce hospitalizations and reduce mortality further. The prevalence of heart failure is not decreasing, and heart failure is currently a cause for hospitalization in >25% of admissions to internal medicine and cardiology departments. It has recently become apparent that anaemia is present in 20-30% of patients with heart failure, and the severity of anaemia has important implications regarding outcome and prognosis. Anaemia may be due to a number of causes, including iron and vitamin deficiency, insidious blood loss, haemodilution, renal impairment and bone marrow depression with resistance to erythropoietin. In the presence of a damaged heart and often coronary artery disease, anaemia may worsen contractile ability and systolic function, while the necessary volume load and ventricular hypertrophy which accompany anaemia contribute to diastolic dysfunction. Preliminary data show that appropriate treatment of anaemia, based on correction of the underlying cause, with, in most patients, the addition of exogenous erythropoietin and iron therapy, improves ventricular function and clinical status. Treatment of anaemia has opened a new frontier in the management of heart failure. We await the results of ongoing clinical trials for more detailed information regarding appropriate haemoglobin targets, choice of medication and dosing and the degree of improvement that may be expected when the issue of anaemia is properly addressed.
Nephrol Dial Transplant 2005 Jul
PMID:Anaemia and heart failure: statement of the problem. 1602 30

Heart failure (HF) is a common disease associated with poor prognosis. Anaemia is commonly associated with HF due to bone marrow depression, reduced availability of iron and haemodilution, and is sometimes aggravated by too frequent blood testing. Low haemoglobin is very detrimental to the haemodynamic state of the patient with decreased cardiac output as it further diminishes the oxygen supply to the tissues. When anaemia is associated with HF. and renal failure, the patient enters a vicious cycle called cardio renal anaemia syndrome. The prognosis of patients with HF is worse as the haemoglobin is lower and even mild anaemia is associated with <1 year survival. Aggressive correction of the anaemia by subcutaneous injections of erythropoeitin and intravenous iron has been shown to improve the functional capacity and quality of life of patients with cardio renal anaemia syndrome and to reduce the need for hospitalization. However, intravenous iron can be detrimental because of increased formation of free radicals, oxidative stress and risk of infection. The level of haemoglobin needed to be achieved is not clear, but it seems indicated to maintain it above 12 g%.
Nephrol Dial Transplant 2005 Jul
PMID:Anaemia and heart failure: aetiology and treatment. 1602 33

Managing the failing allograft juxtaposes immunosuppressive management and routine chronic kidney disease care. The complications of immunosuppression can be more pronounced in those with renal failure (infection, anemia, bone disease). The withdrawal of immunosuppression may be associated with acute allograft rejection, arthralgias, and the development of antidonor antibodies. Likewise depression is prevalent. Improving well-being and overall survival necessitates proper titration of immunosuppressive medications and control of blood pressure, anemia, lipids, and glucose along with attention to treatment of depression.
Semin Dial
PMID:Managing the failing allograft. 1639 17

Sleep-related complaints affect 50-80% of patients on dialysis. Sleep disorders impair quality of life significantly. Increasing evidence suggests that sleep disruption has a profound impact both on an individual and on a societal level. The etiology of sleep disorders is often multifactorial: biologic, social, and psychological factors play a role. This is especially true for insomnia, which is the most common sleep disorder in different populations, including patients on dialysis. Biochemical and metabolic changes, lifestyle factors, depression, anxiety, and other underlying sleep disorders can all have an effect on the development and persistence of sleep disruption, leading to chronic insomnia. Insomnia is defined as difficulty initiating or maintaining sleep, or having nonrestorative sleep. It is also associated with daytime consequences, such as sleepiness and fatigue, and impaired daytime functioning. In most cases, the diagnosis of insomnia is based on the patient's history, but in some patients objective assessment of sleep pattern may be necessary. Optimally the treatment of insomnia involves the combination of both pharmacologic and nonpharmacologic approaches. In some cases acute insomnia resolves spontaneously, but if left untreated, it may lead to chronic sleep problems. The treatment of chronic insomnia is often challenging. There are only a few studies specifically addressing the management of this sleep disorder in patients with chronic renal disease. Considering the polypharmacy and altered metabolism in this patient population, treatment trials are clearly needed. This article reviews the diagnosis of sleep disorders with a focus on insomnia in patients on dialysis.
Semin Dial
PMID:Diagnosis and management of insomnia in dialysis patients. 1642 79

A high prevalence of depressive disorder, between 33% and 50%, has been reported in dialysis patients, although it is difficult to distinguish the physical symptoms like general fatigue, insomnia, and loss of appetite which are common among dialysis patients, from the psychiatric symptoms seen in depressive patients. Furthermore, co-occurrence of depression has been shown to be one of the risk factors of poor prognosis in dialysis patients, partly because depressed patients are less likely to adhere to their medication regimen and modify their lifestyle appropriately. The efficacy of psychiatric interventions, including pharmacotherapy and psychotherapy, has been examined for dialysis patients with co-occurrence of depression. Randomized controlled trials of psychiatric interventions for depression in dialysis patients are needed to investigate the impact of such interventions on depression, quality of life, and mortality.
Ther Apher Dial 2006 Aug
PMID:Diagnosis and treatment of depression in dialysis patients. 1691 Nov 85

Measurement of patient outcome by mental and social indexes such as quality of life (QOL) in addition to survival is a growing trend. We examined the feasibility of using a single global QOL question in peritoneal dialysis (PD) patients. We also examined the relationship that QOL has with uremic symptoms and depression in these patients. During a clinic visit, each PD patient completed a single-question QOL measure (0-10 scale, 10 being best). Patients' symptoms were assessed using a 10-symptom checklist, with each symptom scored on a Likert scale of 0 (none) to 5 (severe). We evaluated for depression using two questions from the Primary Care Evaluation of Mental Disorders. Serum albumin, hemoglobin, and phosphorus were obtained, but only phosphorus was associated with QOL on univariate analysis (p = 0.05) and therefore included in the multivariate model. Results (checklist score, depression, phosphorus, age, diabetes, and race) were analyzed using a sequential multivariate analysis with QOL as the dependent variable. The study population consisted of 64 PD patients [mean age: 47 +/- 16 years; 25% black; 23% with diabetes; 31% incident (< or =3 months)]. The median score on the single QOL question was 7 (range: 1-10). Patients scored a median of 9 (range: 0-31) out of 50 on the total symptom checklist. Among responding patients, 34% answered yes to at least one depression question. The sequential incremental r2 values associated with a poorer QOL were higher checklist score (r2 = 0.16, p < 0.02), presence of depression (r2 = 0.13, p < 0.00002), younger age (r2 = 0.06, p < 0.03), and presence of diabetes (r2 = 0.04, p < 0.05). In this model, PO4 and race were nonsignificant. Total r2 in the model was 0.48. The single measure of QOL, the checklist score, and the depression screening score were simple and easy to obtain during a routine clinic visit. We conclude that physical symptoms and depression are strongly associated with a simple single measure of QOL. The extent to which symptoms and depression can be improved by clinical intervention, and the subsequent effect on quality of life and survival, should be examined in longitudinal studies.
Adv Perit Dial 2006
PMID:The relationship between symptoms, depression, and quality of life in peritoneal dialysis patients. 1698 46

The pathogenesis of calciphylaxis, which has a rising incidence in the chronic dialysis population and a high mortality rate, is poorly understood. Abnormalities in the calcium-phosphorus-parathyroid axis are clinically related to calciphylaxis, but alone, they cannot explain this condition. Here, we present two patients who had chronic inflammatory conditions and hyperparathyroidism and who developed calciphylaxis. A 41-year-old white woman on hemodialysis following scleroderma, hepatitis C, liver transplant, and failed kidney transplant, developed progressive ulcerative lower extremity calciphylaxis lasting more than 3 years. She had evidence of severe hyperparathyroidism and elevated serum C-reactive protein (CRP). A 39-year-old white woman on continuous ambulatory peritoneal dialysis for 6 years for renal failure secondary to lupus nephritis, with sustained lupus activity during the dialysis period, developed rapidly progressing ulcerative calciphylaxis of the lower and upper extremities not responding to adequate treatment of hyperphosphatemia and hyperparathyroidism. Her condition culminated in death within 2 months of the appearance of the skin lesions. Her serum CRP was elevated on a sustained basis before the development of the calciphylaxis and rose to a very high level after appearance of the skin lesions. Inflammation may assist in the development of calciphylaxis through depression of serum levels of fetuin-A, an endogenous inhibitor of calcification that is also a negative acute-phase reactant. The interactions between inflammation-mediated changes in the levels of endogenous inhibitors of calcification and abnormalities in calcium-phosphorus metabolism merit intensive study in the future as potential mechanisms of calciphylaxis.
Adv Perit Dial 2006
PMID:Association between calciphylaxis and inflammation in two patients on chronic dialysis. 1698 64

This paper unravels the physical and psychological health problems of garment workers in Fiji. It is based on research work done between 1997-2007. Majority of the garment workers are women. The main physical health problems faced by workers are: 'Occupational fatigue syndrome', body pains, obesity, and bladder and kidney problems. The major psychological problems work stress and depression. Work stress and depression are caused by 'intensification of work' to meet daily targets, strict factory rules and regulations, poor pay, poor working conditions, in-human abuse, and fear of job loss. Since garment workers do not have much education and skills they have no other option but to work for the garment industry and suffer in silence.
Pac Health Dialog 2006 Sep
PMID:Physical and psychological health problems of garment workers in the Fiji. 1818 92


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