Quality of life in chronic kidney disease: effects of treatment modality, depression, malnutrition and inflammation

In the present study, our aim is to investigate the effects of the treatment modality, depression, malnutrition and inflammation on quality of life (QoL) in chronic kidney disease (CKD). Twenty-six patients with CKD on conservative management, 68 patients on haemodialysis (HD), 47 patients on continuous ambulatory peritoneal dialysis (CAPD) and 66 healthy controls were enrolled in the study. QoL was measured by means of the Short Form-36 (SF-36) and subscale scores were calculated. All patients were evaluated for the presence of depression using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I Disorders - Clinician Version. The severity of depression was evaluated by means of the Beck Depression Inventory (BDI). Serum C-reactive protein (CRP), ferritin, albumin, haemoglobin and haematocrit (Hct) levels were measured. All the SF-36 subscale scores were lower in the patient groups compared with control group. The SF-36 scores were higher and BDI scores were lower in the CAPD group than CKD and HD groups. In patients with depression, all SF-36 subscale scores were lower than that of the patients without depression. There was a significant negative correlation between all the SF-36 subscale scores and the BDI scores. There was a significant positive correlation between the SF-36 physical and total summary scores and the Hct value and serum albumin levels, but an inverse correlation between the SF-36 physical, mental and total summary scores and the serum CRP level in the HD patients. The authors suggest that the treatment modality, depression, malnutrition and inflammation have an important role on QoL in CKD.     

Association of depression and anxiety with reduced quality of life in patients with predialysis chronic kidney disease

Aim: Although depression and anxiety are the most common psychological problems among dialysis patients, little is known about the association between depression, anxiety and quality of life (QOL) in patients with predialysis chronic kidney disease (CKD). Therefore, we assessed the prevalence of depression and anxiety, and their association with QOL in patients with predialysis CKD. Methods: Two hundred and eight predialysis patients (male 61.1%) with a mean age of 55.7 ± 13.7 years and an estimated glomerular filtration rate < 60 ml/min/1.73 m² were enrolled. Depression and anxiety were assessed with the Hospital Anxiety and Depression Scale. Patients with anxiety and depression scores ≥ 8 were diagnosed with anxiety and depression disorders respectively. The WHOQOL‐BREF questionnaire was used to assess patient QOL. Results: The prevalence of depression (47.1%) and anxiety (27.6%) did not differ across CKD stages. Depression correlated positively with age, employment, income, education, comorbidity index, haemoglobin level, albumin concentration and anxiety score, and negatively with all WHOQOL‐BREF domain scores. Anxiety correlated significantly with QOL, but not with socioeconomic factors. In a multiple regression analysis, haemoglobin level, anxiety and QOL were independent factors associated with depression. In a linear regression analysis, depression and anxiety independently correlated with QOL after we adjusted for age, alcohol use, employment, income, education, haemoglobin level and albumin concentration. Conclusions: Patients with predialysis CKD have a high prevalence of depression and anxiety, which are associated with reduced QOL. Early detection of depression and anxiety and active interventions should be considered to improve the QOL of these patients.     

Management of hypertension in CKD patients

The purpose of treatment for chronic kidney disease (CKD) is to preserve the renal function and to prevent the cardiovascular disease (CVD). CKD patients frequently present non-dipper and salt-sensitive type hypertension, which is a powerful predictor for both the CKD and CVD. Many previous clinical studies in CKD patients showed that appropriate blood pressure control was absolutely necessary to prevent the progression of CKD and development of CVD. From these studies, the target blood pressure for CKD patients is determined as less than 130/80 mmHg, if amount of urinary protein < 1 g/day, and 125/75 mmHg, if urinary protein > 1 g/day. Especially, blood pressure control using the RAS (renin-angiotensin system) inhibitor such as ARBs or ACEIs is superior to other classes of antihypertensive agents in reducing the amount of urinary protein and in preserving renal function. Thus, ARBs and/or ACEIs should be administered to CKD patients unless hyperkalemia or excessive increase in serum creatinine level is observed. Furthermore, hypertension in CKD patients is sometimes intractable and other classes of antihypertensive agents should be administered in addition to ARBs or ACEIs to obtain the target blood pressure.     

慢性肾脏病患者生活质量评估方法与影响因素的研究现状

慢性肾脏病(chronic kidney disease,CKD)是一类以肾功能进行性恶化为主要表现的、伴有全身多系统病变的疾病,具有发病率高、死亡率高的特点。CKD患者常受到疼痛、焦虑、并发症等困扰,生存质量差,给患者、家属、社会经济和公共卫生事业造成极大压力。目前,对CKD患者的生活质量评估以量表法最为常用,分为普适性量表和疾病特异性量表,各有优劣,临床常结合使用。影响CKD患者生活质量的因素较为复杂,包括社会人口学、疾病相关表现、并发症、治疗情况以及心理状态等方面。本文对CKD患者生活质量评估方法及影响因素进行综述。     

Clinical considerations and practical recommendations for the primary care practitioner in the management of anemia of chronic kidney disease

Anemia is prevalent in patients with chronic kidney disease (CKD) and is a risk factor for poor disease outcome. Anemia acts as a risk multiplier, significantly increasing the risk of death in anemic versus nonanemic CKD patients with similar comorbidities. Erythropoiesis-stimulating agents (ESA) are a mainstay for the treatment of anemia in renal patients on dialysis, but recent data suggests that earlier treatment of anemia in CKD may delay the onset of end-stage renal disease (ESRD) and decrease mortality. Nonetheless, anemia of CKD is under-recognized and undertreated during the period before initiation of dialysis, when anemia correction may have the greatest impact on disease outcome. This report describes anemia in CKD and its association with diabetes, cardiovascular disease, and poor disease outcome, and offers suggestions for the recognition and treatment of anemia of CKD in the primary care setting.     

Effects of statins on renal function

Patients with chronic kidney disease (CKD) are much more likely to die of cardiovascular disease than end-stage renal disease. Dyslipidemia is highly prevalent in patients with CKD and may contribute to the elevated cardiovascular risk as well as CKD progression. Statins are lipid-lowering drugs that appear to protect the kidneys via cholesterol reduction as well as noncholesterol-mediated mechanisms. Subgroup analyses of major clinical studies and meta-analyses of smaller trials indicate that statin therapy slows the decline of the glomerular filtration rate. Additionally, statins appear to reduce proteinuria in patients with CKD. Statins are well recognized to reduce cardiovascular morbidity and mortality in patients with and without documented cardiovascular disease and in certain high-risk populations, such as persons with diabetes mellitus. However, conclusive evidence for improved cardiovascular outcomes with statin therapy for CKD is not yet available. Several ongoing studies are evaluating the effect of statins on cardiovascular end points in patients with CKD and may provide data needed to support adjunctive use of these agents in this high-risk population.     

Psychostimulants for depression in the medically ill

Medically ill patients who show signs of depression may have problems with traditional antidepressant therapy, because of the side effect profile and the delayed onset of action of these agents. Psychostimulants such as methylphenidate and dextroamphetamine are another treatment option. The beneficial effects of these drugs are usually noted within 36 hours, and drug habituation is generally not a problem. The primary obstacle to the use of these agents for depression in medically ill patients is the hesitancy of physicians to prescribe them.     

Interventional revascularization for cardiovascular disease in patients with chronic kidney disease

Chronic kidney disease (CKD) is an independent risk factor for cardiac mortality. Accelerated atherosclerosis is frequently seen in patients with CKD. However, even in drug eluting stent era, higher restenosis rate after percutaneous coronary intervention (PCI) for coronary artery disease remains a clinical limitation in patients with CKD. Similar tendency is also seen when treated with endovascular therapy (EVT) for peripheral artery disease. Thus, management for atherosclerotic disease is very difficult in patients with CKD. Recent reports have shown that improvement of devices and/or intensive medical treatment may contribute better clinical outcomes after PCI or EVT in patients with CKD. In addition, inflammatory markers such as C-reactive protein may predict worse clinical outcomes including restenosis in such population.     

Antidiabetic medication use and prevalence of chronic kidney disease among patients with type 2 diabetes mellitus in the United States

Objectives: The aims of this study were to estimate the proportion of patients with type 2 diabetes mellitus (DM) in the United States with different stages of chronic kidney disease (CKD) and to describe glycemic control and antidiabetic drug use among them.Methods: Using data from the Fourth National Health and Nutrition Examination Survey (NHANES IV) for the years 1999 through 2004, we performed a crosssectional analysis of patients with type 2 DM aged ≥20 years at the time of the survey interview. CKD stages were categorized according to the classification system established by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative. Anti-diabetic medication use among these patients was described using self-reported survey responses as well as survey medication files.Results: A total of 1462 patients with type 2 DM were included in the analysis. Men and women constituted 48.3% and 51.7% of the study sample, respectively; 15.6% received a DM diagnosis <2 years ago, and 36.2% received their diagnosis >10 years ago. CKD was present in 39.7% of patients with DM. Mean (SE) glycosylated hemoglobin was lower in more advanced CKD stages, from stage 1 (8.35% [0.23%]) to combined stages 4 and 5 (6.63% [0.15%]). Based on the medication file data, the proportion of patients with CKD using 1 antidiabetic medication was higher as CKD progressed, from 36.3% at stage 1 to 62.9% at stages 4 and 5 (P = 0.007). By self-report, the proportion of patients with CKD using insulin alone was 6.7% at stage 1 and 38.8% at stages 4 and 5 (P < 0.001). The proportion of patients using oral antidiabetic agents alone was 69.0% at stage 1 and 43.4% at stages 4 and 5 (P < 0.001).Conclusions: Our results indicate that 39.7% of adult patients with type 2 DM in the United States had some degree of CKD, as measured in NHANES IV for the years 1999 through 2004. This finding reinforces the need to screen patients with type 2 DM for CKD and to prevent the cascade of events leading to nephropathy by implementing adequate glycemic and blood pressure controls, especially in the early stages of CKD. Our data also reinforce the need for developing more oral antidiabetic therapies for patients with advanced CKD and type 2 DM, because treatment options for this group are limited.     

尿毒症脑病的心理因素分析

目的探讨心理因素在尿毒症脑病发病过程中的作用。方法以首都医科大学宣武医院肾脏内科慢性肾脏病（CKD5期）患者为观察对象进行病例对照研究。采用症状自评量表（SCL-90）、抑郁自评量表（SDS）、焦虑自评量表（SAS）对患者的心理状况进行评估。选择其后发生尿毒症脑病者23名为病例组，未发生尿毒症脑病者23名为对照组。比较抑郁、焦虑等负性情绪表现在两组间的差异，探讨负性情绪在尿毒症脑病发病过程中的作用。结果病例组SCL-90总分及各症状因子分，SDS和SAS标准分均高于对照组（P〈0．01或P〈0．05）。病例组的SCL-90总分及躯体化、强迫、人际敏感、抑郁、焦虑、恐怖等6项症状因子阳性检出率，SDS评分阳性率和SAS评分阳性率均明显高于对照组（P〈0．01或P〈0．05），OR值3．56～7．39。结论抑郁、焦虑等负性情绪可能是尿毒症脑病发生的危险因素。     

欧洲五维健康量表在慢性肾脏病患者中的应用及其影响因素的研究

目的调查评估慢性’肾脏病（chronickidneydisease,CKD）患者健康相关的生活质量,并探讨可能影响CKD患者健康相关生活质量的因素。方法应用欧洲五维健康量表（TheEuroOolGroup’S5-domain31evelquestionnaire,EO-5D-3L）,对CKD患者进行问卷调查,同时收集被调查者一般信息及临床实验室检验结果,并采用相关性检验分析影响CKD患者健康相关的生活质量的因素。结果EQ-5D-3L中可视化评分（visualanaloguescale,VAS）得分情况与健康描述系统评估结果一致,且VAS得分与年龄、血肌酐（SCr）、尿素氮（BUN）、胱抑素C（CYSC）、血磷（P）、钙磷乘积（Ca·P）、铁蛋白、尿蛋白／尿肌酐呈负相关,与估算的肾小球滤过率（eGFR）、血红蛋白（Hb）、白蛋白（Alb）、载脂蛋白A1（ApoAl）呈正相关。结论本中心应用EQ-5D-3L进行的调查提示,CKD患者中女性更容易出现焦虑沮丧状态,肾功能情况、贫血及微炎症状态对患者生活质量的影响较为显著,也进一步验证这一简明易行的量表反映肾脏病患者的健康相关的生活质量的效能。     

Assessment for chronic kidney disease service in high-risk patients at community health clinics

BACKGROUND: Chronic kidney disease (CKD) poses significant public health concerns. Early identification and interventions can help prevent or slow progression to end-stage renal disease. OBJECTIVE: To characterize CKD in high-risk indigent patients in a primary care setting and evaluate opportunities for pharmacists to work collaboratively with physicians to improve medication use and CKD patient outcomes. METHODS: Medical records of 200 patients with diabetes mellitus and/or hypertension were reviewed by the clinical pharmacist. Estimated glomerular filtration rate (creatinine clearance [Cl(cr)]) and urinalysis were used to identify and stage CKD according to published guidelines. Glycosylated hemoglobin concentrations and blood pressures were recorded. The pharmacist evaluated medications for possible drug-related problems (DRPs), made therapeutic recommendations, and evaluated the acceptance rate by physicians. RESULTS: One hundred nineteen patients met inclusion criteria, and a total of 68.9% met CKD criteria: stage 1, 16.0%; stage 2, 20.2%; stage 3, 25.2%; stage 4, 1.7%; stage 5, 0.8%; and not stageable, 5.0%. A total of 381 DRPs were identified, averaging 3.2 (1.7) per patient (range 0-11). The number of DRPs correlated with Cl(cr) (r = -0.25; p = 0.007). Therapeutic recommendations included change of drug, dose and/or interval adjustment of the current drug, discontinuation of nonsteroidal antiinflammatory drugs, additional laboratory monitoring, meeting goal blood pressure and glycosylated hemoglobin, adding renoprotective drug and/or low-dose aspirin, and nephrologist referral. Fewer than half (40.9%) of the recommendations were accepted or accepted with modifications, and an approximately equal percentage were not accepted by the physicians. CONCLUSIONS: CKD prevalence was high among the patients evaluated here. New guidelines are available to assist in managing CKD ambulatory patients. Pharmacist collaboration with physicians may optimize CKD screening in high-risk patients and improve medication usage.     

Rationale and design of the Chronic Kidney Disease Antidepressant Sertraline Trial (CAST)

Major Depressive Disorder (MDD) affects one in five patients with Chronic Kidney Disease (CKD) and is an independent risk factor for hospitalization and death before and after dialysis initiation. However, it remains an under-recognized and under-treated problem, in part due to the lack of well-controlled studies that support or refute the efficacy and safety of antidepressant medications in CKD patients. Major trials of antidepressant treatment excluded patients with stages 3–5 CKD, precisely those at higher risk for both depression and increased mortality. The Chronic Kidney Disease Antidepressant Sertraline Trial (CAST) is a randomized, double-blinded, placebo-controlled trial of sertraline, a selective serotonin reuptake inhibitor (SSRI). It will enroll 200 adults with stages 3–5 CKD and MDD excluding kidney transplant and chronic dialysis patients. Sertraline will be administered at an initial dose of 50 mg once daily or matching placebo followed by a dose escalation strategy consisting of 50 mg increments at 2 week intervals (as tolerated) to a maximum dose of 200 mg. The primary outcome is improvement in depression symptom severity measured by the Quick Inventory of Depressive Symptomatology scale. Secondary outcomes include safety endpoints and improvement in quality of life. Changes in cognitive function, adherence to medications, nutritional status, inflammation, and platelet function will be explored as potential mechanisms by which depression may mediate poor outcomes. We discuss the rationale and design of the CAST study, the largest placebo-controlled trial aimed to establish safety and efficacy of a SSRI in the acute phase treatment of CKD patients with MDD.     

慢性肾病合并高血压临床分析(附348例报告)

[目的]探讨慢性肾病（CKD）合并高血压的临床特征和治疗情况.[方法]对本院肾病内科收治的CKD患者进行调查,统计伴有高血压的CKD患者的基本资料,对患者的临床特征和药物治疗进行总体分析.[结果]2008年1月至2011年1月间本院伴有高血压的CKD患者348例,占总肾病患者的48.9%（347/712）,CKD分期结果显示各期都有高血压患者,且慢性肾炎后期患者的高血压比例高于早期患者;对合并CKD的患者配合降压药物治疗后,患者血压得到有效控制,且患者24h尿蛋白、血肌酐值均明显降低（P＜0.01）,血白蛋白升高（P＜0.05）.[结论]高血压既是CKD的致病因素也是其治疗评价标准,有效控制CKD患者的血压有利于其肾病的治疗.     

Dyslipidemia as a therapeutic target for prevention of cardiovascular events and end-stage renal disease

Chronic kidney disease (CKD) is an important risk factor for end-stage renal disease (ESRD) and cardiovascular events as well. Early-onset and progressive atherosclerosis is common in patients with CKD, which is caused by varieties of factors including dyslipidemia. CKD-related dyslipidemia such as increased triglyceride-rich atherogenic lipoproteins such IDL, small dense LDL and low HDL associated with insulin resistance, oxidative stress, inflammation, and malnutrition co-existing dyslipidemia such as high LDL are both causetive for early-onset atherogenesis and, possibly progression of CKD, thus are the therapeutic targets in early intervention of CKD. Life-style modification aimed for both renoprotection and anti-dyslipidemia as well as medications for metabolic disorders in CKD patients such as Ca/P imbalance is crucial for correction of dyslipidemia, and also prevention of cardiovasclular events and ESRD in CKD patients. Among anti-dyslipidemic drugs, statin, so far, is only class of drug proved to be effective for such purpose on evidence-basis.     

Antidepressant Pharmacotherapy: Considerations for the Pain Clinician

Abstract: Antidepressant pharmacotherapy presents many challenges to clinicians dealing with patients suffering from chronic pain. Co-existent depression and pain continues to present clinicians with a plethora of difficult treatment selections. Treated in isolation, each of these disease states can prove difficult to treat. Collectively, depression and pain often present significantly more difficult challenges to the clinician. Antidepressants may be used as a primary treatment modality for depression in a patient dealing with chronic pain. At other times these agents may be used to treat certain specific chronic pain syndromes, possibly in the face of concomitant depression. Clinicians should be aware of the many peculiarities associated with this broad class of medications. Included in this review are considerations for drug selection, dose escalation, and common drug related problems (eg, adverse drug reactions). In addition, attention is paid to the appropriate selection of an agent for use in either the primary management of pain or depression.     

开展优质护理服务对慢性肾脏病患者心理障碍干预的影响

目的:探讨优质护理服务对慢性肾脏病(CKD)患者心理障碍干预的影响。方法:采用症状自评量表(SCL-90)对CKD患者入院时进行心理状态测定,对存在焦虑、抑郁情绪的96例患者按优质护理服务的标准开展心理疏导,出院时再次进行心理状态测定。结果:通过开展优质护理服务使患者焦虑抑郁情绪明显缓解,本组患者出院时SCL-90中抑郁与焦虑因子与入院时比较差异有统计学意义(P<0.05)。结论:开展优质护理服务能明显的缓解CKD患者的焦虑、抑郁情绪,提高患者的生活质量。     

Successful treatment of relapsed chronic lymphocytic leukemia with venetoclax in a patient with severe chronic kidney disease

Venetoclax is a promising new drug for relapsed or refractory chronic lymphocytic leukemia (CLL). However, venetoclax use had not been reported in severe chronic kidney disease (CKD) patients. We report the first case of relapsed CLL in a severe CKD patient that was successfully treated with venetoclax.     

Implications of using the MDRD or CKD‐EPI equation instead of the Cockcroft–Gault equation for estimating renal function and drug dosage adjustment in elderly patients

The objectives of this study were to compare the estimations of renal function obtained with six equations, including the Cockcroft–Gault (CG), Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD‐EPI) equations and to evaluate the implication of using other equations for drug dosing in elderly patients in place of CG. An observational prospective study was conducted over 6 months in two geriatric hospitals with inclusions of all hospitalized inpatients. A list of 36 drugs for which recommendations of dosage adjustment for renal function were mentioned in the manufacturer dosing guidelines was used to compare the implications of using the various equations for drug dosing. A total of 249 patients with a mean age of 83.6 years were included. Mean estimates of renal function from the CG, MDRD, and CKD‐EPI equations were 51.3 ± 23.5 mL/min, 72.2 ± 35.2, and 64.3 ± 22.5 mL/min/1.73 m², respectively (P < 0.001). Twenty percent of patients had at least one drug for which the dose was not appropriately adjusted to renal function. The use of the MDRD and CKD‐EPI equations in place of the CG equation was associated with dosage discrepancy in 20–25% of patients and 15% of drug orders, resulting in potential overdosage in 95% of cases. Use of MDRD or CKD‐EPI equations results in higher estimates of renal function and may have important implications for drug dosing decision and drug safety in elderly patients. The best way is to directly measure the drug effect or its concentration when it is possible to do so.