How baseline, new-onset, and persistent depressive symptoms are associated with cardiovascular and non-cardiovascular mortality in incident patients on chronic dialysis

AbstractObjectiveDepressive symptoms are associated with mortality among patients on chronic dialysis therapy. It is currently unknown how different courses of depressive symptoms are associated with both cardiovascular and non-cardiovascular mortality.MethodsIn a Dutch prospective nation-wide cohort study among incident patients on chronic dialysis, 1077 patients completed the Mental Health Inventory, both at 3 and 12months after starting dialysis. Cox regression models were used to calculate crude and adjusted hazard ratios (HRs) for mortality for patients with depressive symptoms at 3months only (baseline only), at 12months only (new-onset), and both at 3 and 12months (persistent), using patients without depressive symptoms at 3 and 12months as reference group.ResultsDepressive symptoms at baseline only seemed to be a strong marker for non-cardiovascular mortality (HRadj 1.91, 95% CI 1.26–2.90), whereas cardiovascular mortality was only moderately increased (HRadj 1.41, 95% CI 0.85–2.33). In contrast, new-onset depressive symptoms were moderately associated with both cardiovascular (HRadj 1.66, 95% CI 1.06–2.58) and non-cardiovascular mortality (HRadj 1.46, 95% CI 0.97–2.20). Among patients with persistent depressive symptoms, a poor survival was observed due to both cardiovascular (HRadj 2.14, 95% CI 1.42–3.24) and non-cardiovascular related mortality (HRadj 1.76, 95% CI 1.20–2.59).ConclusionThis study showed that different courses of depressive symptoms were associated with a poor survival after the start of dialysis. In particular, temporary depressive symptoms at the start of dialysis may be a strong marker for non-cardiovascular mortality, whereas persistent depressive symptoms were associated with both cardiovascular and non-cardiovascular mortality

Assessment of fluid status in peritoneal dialysis patients

Assessment of fluid status in peritoneal dialysis patients. Konings CJ, Kooman JP, Schonck M, Cox-Reijven PL, van Kreel B, Gladziwa U, Wirtz J, Gerlag PG, Hoorntje SJ, Wolters J, Heidendal GA, van der Sande FM, Leunissen KM. Department of Internal Medicine, University Hospital Maastricht, The Netherlands. [email protected] OBJECTIVES: To assess the influence of abnormalities in fluid status and body composition on agreement between multifrequency bioimpedance analysis (MF-BIA), segmental BIA (sigmaBIA), the Watson formula, and tracer dilution techniques. DESIGN: Cross-sectional. SETTING: Multicenter. PATIENTS: 40 patients (29 males, 11 females) on peritoneal dialysis (PD). MAIN OUTCOME MEASURES: Agreement between the various techniques used to assess total body water (TBW) [MF-BIA, deuterium oxide (D2O), and the Watson formula] and extracellular water (ECW) [MF-BIA, bromide dilution (NaBr), and sigmaBIA], also in relation to the relative magnitude of the body water compartments [ECW (NaBr):body weight (BW) and TBW (D2O):BW] and body composition (DEXA). Second, the relation between body water compartments with echocardiographic parameters. RESULTS: Wide limits of agreement were observed between tracer dilution techniques and MF-BIA [TBW (D2O - MF-BIA) 2.0 +/- 3.9 L; ECW (NaBr - MF-BIA) -2.8 +/- 3.9 L], which were related to the relative magnitude of the body water compartments: r = 0.70 for ECW and r = 0.40 for TBW. sigmaBIA did not improve the agreement [ECW (NaBr-sigmaBIA): 3.7 +/- 2.9 L]. Also, wide limits of agreement were observed between D2O and the Watson formula (-2.3 +/- 3.3 L). The difference between D2O and Watson was related to hydration state and to percentage of fat mass (r = 0.70 and r = -0.53, p < 0.05). Both ECW and TBW as assessed by BIA and tracer dilution were related to echocardiographic parameters. CONCLUSION: Wide limits of agreement were found between MF-BIA and sigmaBIA with dilution methods in PD patients, which were related to hydration state itself. The disagreement between the Watson formula and dilution methods was related to both hydration state and body composition

Serum Potassium and Mortality Risk in Hemodialysis Patients: A Cohort Study

Rationale & Objective: Both hypo- and hyperkalemia can cause fatal cardiac arrhythmias. Although predialysis serum potassium level is a known modifiable risk factor for death in patients receiving hemodialysis, especially for hypokalemia, this risk may be underestimated. Therefore, we investigated the relationship between predialysis serum potassium level and death in incident hemodialysis patients and whether there is an optimum level. Study Design: Prospective multicenter cohort study. Setting & Participants: 1,117 incident hemodialysis patients (aged >18 years) from the Netherlands Cooperative Study on the Adequacy of Dialysis-2 study were included and followed from their first hemodialysis treatment until death, transplantation, switch to peritoneal dialysis, or a maximum of 10 years. Exposure: Predialysis serum potassium levels were obtained every 6 months and divided into 6 categories: ≤4.0 mmol/L, >4.0 mmol/L to ≤4.5 mmol/L, >4.5 mmol/L to ≤5.0 mmol/L, >5.0 mmol/L to ≤5.5 mmol/L (reference), >5.5 mmol/L to ≤6.0 mmol/L, and >6.0 mmol/L. Outcomes: 6-month all-cause mortality. Analytical Approach: Cox proportional hazards and restricted cubic spline analyses with time-dependent predialysis serum potassium levels were used to calculate the adjusted HRs for death. Results: At baseline, the mean age of the patients was 63 years (standard deviation, 14 years), 58% were men, 26% smoked, 24% had diabetes, 32% had cardiovascular disease, the mean serum potassium level was 5.0 mmol/L (standard deviation, 0.8 mmol/L), 7% had a low subjective global assessment score, and the median residual kidney function was 3.5 mL/min/1.73 m2 (IQR, 1.4-4.8 mL/min/1.73 m2). During the 10-year follow-up, 555 (50%) deaths were observed. Multivariable adjusted HRs for death according to the 6 potassium categories were as follows: 1.42 (95% CI, 1.01-1.99), 1.09 (95% CI, 0.82-1.45), 1.21 (95% CI, 0.94-1.56), 1 (reference), 0.95 (95% CI, 0.71-1.28), and 1.32 (95% CI, 0.97-1.81). Limitations: Shorter intervals between potassium measurements would have allowed for more precise mortality risk estimations. Conclusions: We found a U-shaped relationship between serum potassium level and death in incident hemodialysis patients. A low predialysis serum potassium level was associated with a 1.4-fold stronger risk of death than the optimal level of approximately 5.1 mmol/L. These results may imply the cautious use of potassium-lowering therapy and a potassium-restricted diet in patients receiving hemodialysis

Agreement between different parameters of dialysis dose in achieving treatment targets: results from the NECOSAD study.

BACKGROUND: The recommended parameter of dialysis dose differs between K-DOQI and the European Best Practice Guidelines. It is not well known to what extent an agreement exists between the different parameters, nor if target and delivered dialysis dose are prescribed according to the urea reduction rate (URR), single-pool Kt/V (spKt/V) or equilibrated double-pool Kt/V (eKt/V) and which parameter is most strongly related to mortality. METHODS: In 830 haemodialysis patients from the NECOSAD cohort URR, spKt/V and eKt/V were calculated and compared according to a classification regarding the recommended treatment targets (70%, 1.4 and 1.2, respectively) as well as minimum delivered dialysis dose (65%, 1.2 and 1.05, respectively). Moreover, the relation between treatment dose and survival was assessed using Cox regression analysis. RESULTS: A spKt/V of >/=1.4 and URR >/=70% corresponded with eKt/V >/=1.20 (as reference method) in, respectively, 98.0 and 90.6% of patients. spKt/V of >/=1.2 and URR >/=65% corresponded with eKt/V >/=1.05 in, respectively, 95.5 and 91.2% of patients. Deviations from the reference method were significantly related to differences in urea distribution volume (spKt/V), treatment time (URR) and ultrafiltration volume (URR). The adjusted HR (95% CI) was 0.98 (0.96, 0.99) for URR, 0.51 (0.31, 0.84) for spKt/V and 0.46 (0.30, 0.80) for the eKt/V. CONCLUSION: The use of URR leads to larger disagreement with the reference method (eKt/V) treatment target as compared to spKt/V. Low urea distribution volume, short treatment time and low ultrafiltration volumes are predictive parameters for overestimation of dialysis dose when utilizing the alternative methods spKt/V and URR instead of eKt/V. Delivered eKt/V, spKt/V and URR were all positively related to survival

Patients' representations of their end-stage renal disease: relation with mortality

BACKGROUND: Self-regulation theory explains how patients' illness perceptions influence self-management behaviour (e.g. via adherence to treatment). Following these assumptions, we explored whether illness perceptions of ESRD-patients are related to mortality rates. METHODS: Illness perceptions of 182 patients participating in the NECOSAD-2 study in the period between December 2004 and June 2005 were assessed. Cox proportional hazard models were used to estimate whether subsequent all-cause mortality could be attributed to illness perception dimensions. RESULTS: One-third of the participants had died at the end of the follow-up. Mortality rates were higher among patients who believed that their treatment was less effective in controlling their disease (perceived treatment control; RR = 0.71, P = 0.028). This effect remained stable after adjusting for sociodemographic and clinical variables (RR = 0.65, P = 0.015). CONCLUSIONS: If we consider risk factors for mortality, we tend to rely on clinical parameters rather than on patients' representations of their illness. Nevertheless, results from the current exploration may suggest that addressing patients' personal beliefs regarding the effectiveness of treatment can provide a powerful tool for predicting and perhaps even enhancing surviva

Subjective global assessment of nutritional status is strongly associated with mortality in chronic dialysis patients

Background: The subjective global assessment of nutritional status (SGA) is used to assess the nutritional status of chronic dialysis patients, but longitudinal data in relation to mortality risk are lacking. - \ud \ud Objective: Our objective was to study the long-term and time-dependent associations of the SGA with mortality risk in chronic dialysis patients. - \ud \ud Design: In a prospective, longitudinal, observational, multicenter study of incident dialysis patients, the 7-point SGA [7 = normal nutritional status; 1 = severe protein-energy wasting (PEW)] was assessed 3 and 6 mo after the start of dialysis and subsequently every 6 mo during 7 y of follow-up. With Cox regression analysis, we calculated hazard ratios (HRs) of the baseline and time-dependent SGA measurements, adjusted for age, sex, treatment modality, primary kidney diseases, and comorbidity. - \ud \ud Results: In total, 1601 patients were included [mean (±SD) age: 59 ± 15 y; 61% men; 23% with moderate PEW (SGA4–5), and 5% with severe PEW (SGA1–3)]. There was a dose-dependent trend of the 7-point SGA with mortality. Compared with a normal nutritional status at baseline, SGA4–5 (HR: 1.6; 95% CI: 1.3, 1.9) and SGA1–3 (HR: 2.1; 95% CI: 1.5, 2.8) were associated with an increase in 7-y mortality. Time-dependently, these associations were stronger: SGA4–5 (HR: 2.1; 95% CI: 1.7, 2.5) and SGA1–3 (HR: 5.0; 95% CI: 3.8, 6.5). - \ud \ud Conclusions: In dialysis patients, PEW at baseline assessed with SGA was associated with a 2-fold increased mortality risk in 7 y of follow-up. Time-dependently, this association was even stronger, which indicated that PEW was associated with a remarkably high risk of short-term mortality. These data imply that the 7-point SGA may validly distinguish different degrees of PEW associated with increasing risks of mortality

Is the decline of renal function different before and after the start of dialysis?

The presence of glomerular filtration in dialysis patients is associated with improved survival and quality of life. This study explores the time course of the glomerular filtration rate (GFR) between 1 year before and 1 year after the start of haemodialysis (HD) and peritoneal dialysis (PD). This study included 1861 incident dialysis patients (NECOSAD cohort; 62 male, 60 15 years, 61 HD, GFR 5.2 3.6 mL/min/1.73 m(2)). A decline of the GFR was estimated using linear mixed-effects models adjusted for age, sex, primary kidney disease, cardiovascular disease and diabetes. The rate of decline was allowed to change at a certain point in time. The decline of the GFR attenuated from 0.53 mL/min/1.73 m(2)/month (95 CI: 0.58, 0.48) in the period before the start of dialysis to 0.12 (95 CI: 0.20, 0.04) at 24 months of dialysis in all patients. In HD, decline attenuated from 0.51 (95 CI: 0.57, 0.44) to 0.14 (95 CI: 0.26, 0.02); in PD from 0.55 (95 CI: 0.62, 0.48) to 0.11 (95 CI: 0.23, 0.01). In patients who started dialysis with a GFR equal/above median GFR at dialysis start, the decline attenuated (at 3 months) from 0.70 (95 CI: 0.78; 0.62) to 0.21 (95 CI: 0.36; 0.05). In patients who started dialysis with a GFR below median GFR at dialysis start, the decline attenuated (at 1 month) from 0.73 (95 CI: 0.88; 0.58) to 0.04 (95 CI: 0.27 , 0.19). The apparent decline of the GFR slows down after 24 months of dialysis. This decline was similar in HD and PD patients, although at a different level of GFR. Further studies are needed to examine explanations for this phenomenon

Vergleichende dreidimensionale Vokaltraktbildgebung mittels MRT beim Singen und Sprechen

Hintergrund: Die Magnetresonanztomographie (MRT) ist zur Darstellung des Vokaltraktes beim Singen und Sprechen etabliert, wobei viele Studien auf schnelle zweidimensionale Aufnahmen konzentriert sind. Zusätzlich ist jedoch auch eine dreidimensionale Bildgebung möglich. Durch diese können detailgetreue Modelle geschaffen werden, aus denen ein direkter Rückschluss auf die Vokaltraktresonanzen möglich ist.Material und Methoden: In der vorliegenden Studie wurden Vokaltraktmodelle mittels 3D MRT bei einem professionellen Tenor erstellt. Dafür phonierte der Sänger im MRT die Vokale /a/, /i/ und /u/ in seiner Sprechstimmlage (C3) in Sing- und Sprechstimmfunktion sowie in seiner hohen Singstimmfunktion oberhalb des Passaggios (A4). Aus dem gewonnenen Bildmaterial wurde jeweils der Vokaltrakt segmentiert, ein dreidimensionales Zahnmodell des Probanden anhand von anatomischen Landmarken eingefügt und mittels 3D Drucker ausgedruckt. Die gedruckten Modelle wurden nun durch Einfügen von Breitbandrauschen im Glottisbereich und Ableiten von Transferfunktionen vor der Mundöffnung akustisch analysiert und die Formantfrequenzen bestimmt.Ergebnisse: Vorläufige Ergebnisse zeigen deutliche Vokaltraktmodifikationen zwischen Sing- und Sprechstimme auf gleicher Tonhöhe, sowie für die hohe Singstimme in allen Vokalkonditionen. Insgesamt war der Vokaltrakt in der Singstimmfunktion länger als beim Sprechen und es zeigte sich der supralaryngeale Raum beim Singen vokalunabhängig erweitert. In der akustischen Analyse konnte eine Erhöhung der Formantfrequenzen mit Clusterbildung der Formanten 3-5 in der Singstimmfunktion ermittelt werden.Diskussion: Die Verlängerung des Vokaltraktes und Erweiterung des supralaryngealen Bereichs sind möglicherweise Mechanismen, welche für die Klangformung in der Singstimmfunktion von Bedeutung sind