Abstract
Background and objectives: Persons with ESRD identify non-disease-specific conditions as negatively affecting their quality of life. It is unknown how these non-ESRD-specific conditions correlate with each other and with ESRD-specific conditions such as anemia, renal osteodystrophy, dialysis access, and dialysis adequacy. The objectives of this study were to determine the prevalence and inter-relatedness of selected conditions among persons receiving hemodialysis and to analyze the relationship between non-ESRD-specific and ESRD-specific conditions.
Design, setting, participants, & measurements: This was an observational cohort study of persons with ESRD that included standardized assessments for pain, fatigue, depression, cognitive impairment, and impaired physical performance. The study was conducted at three dialysis clinics in one urban geographic area. Of the 134 persons who met exclusion criteria, 25 declined participation, yielding a sample size of 109.
Results: Pain was present in >81% of participants, fatigue and impaired physical performance in >60% participants, and cognitive impairment and depression in >25% of participants. Pain, fatigue, and depression were highly correlated, but had no correlation with use of a catheter for access, hemoglobin (Hgb), intact parathyroid hormone (iPTH), phosphorous, or Kt/V values outside of the range of guidelines. There was a modest correlation between cognitive function and both Hgb and iPTH.
Conclusions: Non-ESRD-specific conditions such as fatigue, pain, and depression are as prevalent as ESRD-specific conditions, and the magnitude of the correlations between the non-ESRD-specific conditions is greater than the correlations between non-ESRD-specific and ESRD-specific conditions. Current guidelines may be failing to address a substantial component of the disease burden for persons with ESRD.
The current standard of care for ESRD is based on disease-specific guidelines that address aspects of ESRD due directly to renal failure (e.g., dialysis, anemia, and renal osteodystrophy). However, the guidelines do not address the aspects of health that prior studies have shown to be most important for the quality of life of persons receiving dialysis. When asked what affects their quality of life, patients identified lack of energy, sleep disturbance, trouble concentrating, depressed mood, dizziness/imbalance, problems walking, weakness, and dependence on others among their primary problems (1–4). Effectively, the conditions that patients describe as affecting their quality of life are the medical problem list as prioritized by patients themselves. People with ESRD therefore have two problem lists: the ESRD-specific problem list due directly to renal failure, and a second non-ESRD-specific patient-generated problem list composed of the conditions affecting patients’ day-to-day quality of life.
The non-ESRD-specific burden of disease has been described in previous studies measuring the prevalence of individual conditions such as pain, depression, fatigue, cognitive impairment, and impaired physical function in the ESRD population (4–10). Although those conditions have been shown in older populations without ESRD to be inter-related (11–16), this relationship has not been fully elucidated in the ESRD population. Additionally, the relationship between the non-ESRD-specific and ESRD-specific conditions has not been described. For example, although the relationships between quality of life and ESRD-specific conditions such as anemia are well described (17), as are the relationships between quality of life and non-ESRD-specific conditions such as depression, the relationship between anemia and depression in the ESRD population is unknown. Understanding the relationships between and among conditions both specific and nonspecific to ESRD will help focus clinical resources and future research on areas of convergence.
The purpose of this cross-sectional study was to (1) describe the prevalence and inter-relatedness of selected non-ESRD-specific conditions among persons receiving hemodialysis, and (2) analyze the relationship between the non-ESRD-specific conditions and ESRD-specific conditions addressed by clinical guidelines.
Materials and Methods
Participants and Setting
All patients meeting inclusion criteria at three hemodialysis clinics caring for most patients receiving dialysis in one urban geographic area were invited to participate. Inclusion criteria included being English-speaking, age 45 yr or older, and treated with hemodialysis >90 d. Although patients with cognitive impairment were not excluded from participation, the study participants included only one patient who required proxy consent because of the inability to provide informed consent.
The study was conducted at the West Haven VA Medical Center in West Haven, Connecticut, and DaVita dialysis clinics in New Haven and Branford, Connecticut, between September 2006 and April 2007.
This study was approved by the Human Subjects Subcommittee at the West Haven VA Medical Center, the Human Investigation Committee at Yale University School of Medicine, and DaVita Clinical Research. Participants or their proxies signed written informed consents.
Selection and Assessment of Non-ESRD-Specific Conditions
The problems reported by patients receiving dialysis are generally conceptualized as either symptoms (e.g., fatigue, weakness, pain) or separate diseases (e.g., depression and dementia). With considerable overlap among them, they can be considered more broadly as health conditions (18). We included five conditions that were selected because of their individual prevalence, potential prevention or treatment, feasibility of assessment, and effect on quality of life for patients in previous studies (1–4). The conditions were: impaired physical performance, depression, pain, fatigue, and cognitive impairment.
We used decision rules to select instruments for identification of conditions. First, the gold standard for diagnosis of each condition was identified. Second, if administration of the gold standard was not feasible because of the length of the test or because a specialist was required to administer it, instruments with sensitivity and specificity >90% referent to the gold standard were considered as possible alternatives. Third, when there was overlap of symptoms caused by ESRD and the condition to be assessed, instruments validated for use in the population with ESRD were given preference. We used clinically established cutoffs for each of the instruments to define the conditions as either present or absent in addition to using the full range of scores to reflect the severity of each condition.
The Short Physical Performance Battery (SPPB) was used to measure physical performance (see Appendix). Impaired physical performance was defined as a score ≤9. The nine-item Patient Health Questionnaire (PHQ-9) was used to identify depression (see Appendix). Depression was defined as a score ≥10. The 15-item McGill Pain Questionnaire–Short Form (MPQ) was used to identify pain (see Appendix). Presence of pain was defined as a score >0. The nine-item Brief Fatigue Inventory (BFI) was used to identify fatigue (see Appendix). Presence of fatigue was defined as a score >0 on the interference scale. Two instruments were used to identify cognitive impairment: the 30-item Mini Mental State Exam (MMSE) and the 25-item Executive Interview (EXIT25). We used both tests of cognitive function because the MMSE does not include tests of executive function necessary for decision-making and judgment. Cognitive impairment was defined as a score ≤24 on the MMSE and/or a score ≥15 on the EXIT25. Because the PHQ-9, MPQ, and BFI have not been validated for patients with moderate to severe cognitive impairment, testing of the patient for whom proxy consent was necessary was limited to physical performance and cognitive function.
Selection of ESRD-Specific Conditions
We included measures of four aspects of ESRD-specific management for which the widely accepted National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines are available: anemia (17), renal osteodystrophy (19), adequacy of hemodialysis (20), and vascular access for hemodialysis (21). Other aspects of care that affect the health and quality of life of people with ESRD such as intradialytic hypotension and interdialytic weight gain may also be associated with the non-ESRD-specific conditions studied, but the KDOQI™ guidelines do not give parameters for these management issues.
Process of assessments
In order to ensure that the two researchers administering the previously validated instruments were doing so in a similar fashion, the instruments were administered by both of the two researchers to five participants on the same day. The ratings of the researchers, using continuous scores, were compared using intra-class correlation coefficients (ICC). There was 100% agreement for the SPPB (ICC not calculable). The ICCs for the PHQ-9, MPQ, BFI, MMSE, and EXIT25 were .90, .77, .61, .94, and .93, respectively.
Data Collection
All assessments were performed midweek by one of two trained personnel at the same point in the treatment cycle for all patients. Assessments were not performed during the first treatment of the week to avoid possible uremic effects of the long weekend without dialysis (e.g. symptoms potentially worse prior to the first treatment of the week compared with later in the week). Assessments were not performed during the final treatments of the week because it was infeasible for the researchers to perform assessments on Saturdays. Physical performance was assessed before starting that day's hemodialysis treatment to minimize the effects of treatment itself on physical performance, such as orthostasis resulting from ultrafiltration. The remainder of the assessment was performed after the dialysis treatment was underway. Participants provided self-reports of their sociodemographic status and activities of daily living with proxy responses for these data for the one respondent who required proxy consent. Comorbid conditions, laboratory values, and type of access for and adequacy of dialysis (Kt/V) were determined by chart review. Measurements used were those most proximal to the study assessment.
Statistical Analyses
We utilized proportions to examine the prevalence of each of the non-ESRD-specific conditions defined as present or absent in the population as a whole and in the population stratified by age <60 yr or age ≥60 yr. A Pearson's correlation matrix was created using continuous scores from the assessment tools for each of the non-ESRD-specific conditions. To determine co-occurrence simultaneously considering all non-ESRD-specific conditions, we assessed the continuous measures of the conditions using principal components of their correlation matrix to identify groupings of co-occurring conditions. These groupings were supported by a supplementary analysis with oblique principal components. We retained the two principal components with eigenvalues >1. To assess the relationship between non-ESRD-specific conditions and ESRD-specific measures, we created a Kendall's Tau b correlation matrix. We used continuous measures of the non-ESRD-specific conditions because scores of the instruments are designed to progress in a linear, ordinal fashion. For ESRD-specific conditions, however, both the lowest and highest values of the laboratory data represent pathology and the optimal values according to the guidelines are in the middle of the spectrum. For example, a very low intact parathyroid hormone (iPTH) value may represent adynamic bone disease and a very high iPTH value may represent secondary hyperparathyroidism. Because classification of most of the ESRD-specific risk factors is nonlinear, binary indicator variables were created for the ESRD-specific conditions on the basis of KDOQI guidelines. The variable was considered present if guidelines were not met: hemoglobin (Hgb) <11 or >13 g/dl (17); iPTH <150 or >300 pg/ml (19); serum phosphorous <3.5 or >5.5 mg/dl (19); Kt/V <1.2 (20); and chronic dialysis access via catheter rather than fistula or graft (21). Although there are both lower and upper limits to the guideline for optimal Hgb level in anemia management, the literature indicates that there may be some quality of life benefit at or beyond the upper limit of current guidelines (17). We therefore made an a priori decision to also compare a continuous measure of Hgb with the non-ESRD-specific conditions. All analyses were performed using SAS statistical software, version 9.1.3, in which statistical significance was based on P values ≤0.05.
Results
Participants
A total of 193 patients received treatment at one of the three dialysis clinics during the 28-wk study period. Of the 193, a total of 59 patients met exclusion criteria because of age <45 yr (n = 35), insufficient English skills (n = 11), treatment with dialysis <90 d (n = 4), or illness/hospitalization (n = 9). Of the 134 eligible patients, 25 declined participation, yielding a sample size of 109 (participation rate 81%). Full testing was completed for 106 participants and 3 received partial testing. The average age of participants was 61 ± 10 yr (Table 1). Almost one-third of participants (32%) needed assistance with at least one activity of daily living, such as bathing or dressing themselves.
Table 1.
Description of 109 participants
| Characteristic | n = 109 |
|---|---|
| Age (yr ± SD) | 61 ± 10 |
| Age range (yr) | 41 to 85 |
| Male, n (%) | 71 (65) |
| Hispanic, n (%) | 8 (7) |
| Race, n (%) | |
| black | 67 (61) |
| white | 41 (38) |
| other | 1 (1) |
| Married, n (%) | 38 (35) |
| Residence, n (%) | |
| Non-age-restricted housing | 83 (76) |
| Age-restricted housing | 12 (11) |
| Nursing home | 14 (13) |
| Living alone, n (%) | 26 (24) |
| ≥12th grade education, n (%) | 74 (68) |
| Impairment of one or more activities of daily living, n (%) | 35 (32) |
| Comorbidities, n (%) | |
| hypertension | 94 (87) |
| atherosclerotic heart disease | 61 (57) |
| diabetes | 50 (46) |
| peripheral vascular disease | 17 (16) |
| amputations | 13 (12) |
| cancer other than skin cancer | 13 (12) |
| stroke | 13 (12) |
| hepatitis C | 13 (12) |
| HIV | 9 (8) |
| Chronic obstructive pulmonary disease | 8 (7) |
| Number of comorbidities per participanta | |
| 1 | 18 (17) |
| 2 to 3 | 67 (62) |
| ≥4 | 23 (21) |
| Hemoglobin (g/dl ± SD) | 12.5 (1.4) |
| Intact parathyroid hormone (pg/ml ± SD) | 278 (217) |
| Serum phosphorous (mg/dl ± SD) | 5.3 (1.9) |
| Kt/V | 1.6 (0.4) |
| Dialysis access via catheter | 31 (28) |
| Values meeting guidelines n (%) | |
| Hemoglobin | 55 (50) |
| Parathyroid hormone | 34 (31) |
| Phosphorous | 48 (44) |
| Kt/V | 100 (95) |
Numbers do not sum to 109 because of missing data.
Prevalence of Selected Non-ESRD Specific Conditions
Pain and fatigue were present in 81 and 69% of participants, respectively (Table 2). Physical performance was impaired in 61% of participants. More than one-third of participants had cognitive impairment (38%). One-quarter (27%) of participants had depression. The prevalence of these medical conditions was not restricted to older participants: of participants younger than 60 yr, 85% had pain, 74% had fatigue, 48% had impaired physical performance, 30% had cognitive impairment, and 22% had depression.
Table 2.
Prevalence of selected non-ESRD-specific conditions in patients receiving dialysis
| Condition | All Subjects (n = 109) n (%) | Age <60 (n = 58) n (%) | Age 60+ (n = 51) n (%) |
|---|---|---|---|
| Impaired physical performancea | 66 (61) | 28 (48) | 38 (76) |
| Depressionb | 29 (27) | 13 (22) | 16 (31) |
| Painb | 87 (81) | 49 (85) | 38 (76) |
| Fatigueb | 75 (69) | 43 (74) | 32 (64) |
| Cognitive impairmenta | 41 (38) | 17 (30) | 24 (47) |
One participant declined testing for physical performance and one patient declined testing for cognition.
One participant required a proxy for consent so that only physical performance and cognition were tested.
Number of Non-ESRD Specific Conditions per Patient
Of the five non-ESRD-specific conditions studied, the average number (95% confidence interval) of conditions per participant was 2.8 (2.5, 3.0); 57% (48%, 66%) of participants had three or more conditions (Table 3). Only four (4%) participants had none of the conditions.
Table 3.
Of the five conditions tested, number of non-ESRD-specific conditions among individual participants
| Count of Conditions Within Individual Participants | (n = 106)a Number of Individual Participants with Count of Non-ESRD-Specific Conditions n (column %)b |
|---|---|
| Five | 6 (6) |
| Four | 24 (23) |
| Three | 30 (28) |
| Two | 35 (33) |
| One | 7 (7) |
| Zero | 4 (4) |
One participant declined testing for physical performance and one other participant declined testing for cognition. One participant required a proxy for consent so only physical performance and cognition were tested. Number of conditions is not presented for these three participants.
Because of rounding, percentages do not sum to 100%.
Co-Occurrence of Non-ESRD-Specific Conditions
Principal components analysis revealed two groupings of non-ESRD-specific medical conditions with eigenvalues >1. These two groupings collectively accounted for 64% of variability in the sample. On the basis of the loadings of the individual conditions, the groupings were: (1) depression, pain, and fatigue; and (2) physical performance and both measures of cognition—MMSE score and EXIT25 score (Table 4).
Table 4.
Principal components analysis of non-ESRD-specific conditionsa
| Non-ESRD-Specific Conditions | First Grouping Factor Loadings | Second Grouping Factor Loadings |
|---|---|---|
| Physical performance (higher indicates better physical performance) | −0.14b | 0.42 |
| Depression (higher indicates more depressive symptoms) | 0.58 | −0.08 |
| Pain (higher indicates more pain) | 0.55 | 0.02 |
| Fatigue (higher indicates more fatigue) | 0.57 | −0.04 |
| Cognition (MMSE; higher indicates better cognition) | 0.10 | 0.64 |
| Cognition (EXIT25; higher indicates more impairment) | −0.08 | −0.63 |
MMSE, Mini Mental State Exam; EXIT25, Executive Interview.
Bold font indicates factor loadings clinically interpreted as groupings of co-occurring conditions.
Correlations between Conditions
Depression was positively correlated with pain and fatigue (r = 0.368 and 0.439, respectively; P < 0.0001), which were also positively correlated (r = 0.401, P < 0.0001). Depression, pain, and fatigue were not correlated with any of the ESRD-specific conditions (Table 5). Hgb values outside of KDOQI guidelines were positively correlated with better cognition as measured by MMSE scores (r = 0.160, P = 0.05). Hgb as a continuous variable showed stronger positive correlation with rising MMSE score (r = 0.257, P = 0.007). iPTH values outside of KDOQI guidelines were negatively correlated with better cognition as measured by both MMSE (r = −0.158, P = 0.05), in which higher scores reflect more cognitive capability, and EXIT25 scores (r = 0.185, P = 0.02), in which higher scores indicate less cognitive capability. There was no correlation between Hgb and EXIT25 score. The continuous variable for Hgb was also correlated with physical performance (r = 0.193, P = 0.05) and pain (r = 0.204, P = 0.03).
Table 5.
Kendall's tau b correlations between non-ESRD-specific conditions and ESRD-specific conditions as defined by meeting Kidney Disease Outcomes Quality Initiative (KDOQI) guidelinesa
| ESRD-Specific Conditions as Defined by KDOQI Guidelines | Non-ESRD-Specific Conditions
|
|||||
|---|---|---|---|---|---|---|
| Physical Performance (higher is better) | Depression (higher is worse) | Pain (higher is worse) | Fatigue (higher is worse) | Cognition Based on MMSE (higher is better) | Cognition Based on EXIT25 (higher is worse) | |
| Hgb <11 or >13 g/dl | r = 0.024,P = 0.77 | r = 0.089, P = 0.28 | r = 0.088, P = 0.28 | r = 0.055, P = 0.50 | r = 0.160,P = 0.05 | r = 0.039, P = 0.63 |
| iPTH <150 or >300 pg/dl | r = 0.133, P = 0.11 | r = 0.004, P = 0.97 | r = −0.097, P = 0.24 | r = 0.031, P = 0.70 | r = -0.158, P = 0.05 | r = 0.185, P = 0.02 |
| Phosphorus <3.5 or >5.5 mg/dl | r = 0.004, P = 0.95 | r = −0.014, P = 0.89 | r = −0.084, P = 0.31 | r = −0.007, P = 0.93 | r = −0.037, P = 0.65 | r = 0.034, P = 0.68 |
| Kt/V < 1.2 | r = 0.078, P = 0.35 | r = 0.051, P = 0.54 | r = 0.080, P = 0.33 | r = 0.084, P = 0.32 | r = −0.117, P = 0.16 | r = 0.126, P = 0.13 |
| Use of catheter for dialysis access | r = −0.142, P = 0.09 | r = 0.150, P = 0.07 | r = 0.152, P = 0.06 | r = 0.040, P = 0.63 | r = 0.080, P = 0.33 | r = 0.004, P = 0.96 |
Hgb, hemoglobin; iPTH, intact parathyroid hormone.
bBold font indicates significance at P ≤ 0.05.
Discussion
In this cohort of 109 persons receiving hemodialysis, the prevalence of impaired physical performance, depression, pain, fatigue, and cognitive impairment was high among older and younger persons, and conditions frequently co-occurred. Although correlations between depression, pain, and fatigue were statistically significant, they were not correlated with ESRD-specific conditions such as anemia, adequacy of dialysis, type of dialysis access, or renal osteodystrophy. Cognition was correlated with both Hgb and iPTH outside of the range of guidelines, but the magnitude of those correlations was not as great as the correlations between non-ESRD-specific conditions. The finding that 90% of participants in this study had two or more of the five non-ESRD-specific conditions studied, which were not associated with the ESRD-specific conditions, suggests that current disease management guidelines for the treatment of patients with ESRD are failing to address a major component of the disease burden of these patients. Clinicians will need to incorporate conditions such as cognition, physical performance, pain, fatigue, and depression into active problem lists if they are to address the problems that most concern their patients.
Our study confirms the results of prior studies of the prevalence of symptoms in persons treated with hemodialysis. Weisbord et al. (8) found the prevalence of “feeling tired or lack of energy” to be 69%, equal to the prevalence of fatigue in this study. Similarly, the two studies found the prevalence of physical pain of any etiology to be >85% and 81% respectively, and depression to be 26% and 27% respectively. Results for depression are further confirmed by multiple prior studies in which the prevalence of depression was from 20 to 30% (10,22,23). Impaired physical performance as measured by gait speed and sit-to-stand testing as in this study has also been quantified in other populations with ESRD (6). Using both the MMSE and an additional measure of executive function, we found that 38% of our population had cognitive impairment. Similarly, a prior study of cognitive impairment using solely the MMSE found a prevalence of 32% (24). None of the prior studies above measured all the selected non-ESRD-specific conditions together as we did in this study.
The grouping of depression, fatigue, and pain found in this study is similar to that of Weisbord et al. (8), which found that depressive symptoms were significantly associated with lack of energy and bone/joint pain, and “symptom cluster” studies performed among patients with cancer (11). Going beyond asking patients about subjective symptoms by adding objective measurements of not only depression but also physical and cognitive performance, this study extends the work of Weisbord et al. This is necessary because patients requiring dialysis reported that it is not only psychosocial symptoms such as depression that affect quality of life, but also problems walking and concentrating (1–4). Additionally, other studies have shown for older persons without ESRD that mobility impairment, depression (12,13), pain (14), and cognitive impairment (15,25) are shared risk factors for functional disability and falls. Older age, cognitive impairment, mobility impairment, and functional impairment are all risk factors for falls and functional decline (16). It is concerning that these risk factors are present for so many persons treated with hemodialysis who are not chronologically old.
With such strong correlations between pairings of depression, pain, and fatigue, it is notable that the ESRD-specific conditions were not correlated with them. The continuous measure of Hgb did correlate with pain, but not depression or fatigue. The ESRD-specific conditions Hgb and iPTH did correlate with cognition, but the magnitude of these relationships is not as great as the relationships between non-ESRD-specific conditions.
With its high rates of participation and completion of assessments, this study demonstrates the feasibility of evaluating multiple conditions in depth using tools that can be utilized in the context of busy dialysis clinics and without fatiguing the persons undergoing dialysis treatment. Approaches to diagnosis and treatment of these conditions as part of the hemodialysis experience are necessary. Our study builds upon earlier work which tended to use either a check list consisting of single-item symptoms, such as fatigue and pain, using instruments such as the Dialysis Symptoms Index (8) or specialized instruments to measure a single condition in great detail (5,7). Cognition has been measured during dialysis treatment in some studies using only the MMSE (24), an instrument that identifies some, but not all aspects of cognitive impairment. Alternately, cognition has been measured between dialysis treatments using a battery of neuropsychiatric tests (5) which, although very sensitive measures, are infeasible for adminstration by clinicians during the dialysis treatment. By using the EXIT25 in addition to the MMSE, we were able to capture executive dysfunction, a facet of cognition associated with the ability to independently perform instrumental activities of daily living (26). The high rate of completion of the SPPB, a test of physical performance that has been shown to be predictive of mortality and nursing home placement (27), stands in contrast to prior studies utilizing alternative physical performance measures, which had substantially higher rates of incomplete assessments (28,29).
Studies have demonstrated the effectiveness of treatments for several of the conditions, including impaired physical function (6,30), pain (31), and depression (32,33). The co-occurrence of multiple conditions would appear to be a formidable barrier to their successful treatment because of the need for many interventions. However, this study found that the five non-ESRD-specific conditions studied are inter-related. Considering groupings of conditions may provide a treatment approach that modifies multiple conditions simultaneously. For example, although the etiology of fatigue may be difficult to elucidate, considering its frequent co-occurrence with pain and depression may be a useful starting point for patient care and future research.
The study has several limitations. First, it is possible that the inter-relatedness of certain of the non-ESRD-specific conditions we included was inflated by the nature of their assessment. For example, correlation between depression and fatigue may have occurred because each is included in the instrument used to identify the other. To minimize this measurement effect, we used an instrument for measuring not just whether fatigue is present or absent, but, more specifically, whether fatigue alone interferes with daily activities. Additionally, as demonstrated by our results, fatigue and depression do not always coexist, suggesting that the two instruments were accurately assessing and differentiating between different conditions. Second, several of the instruments we used cannot provide such depth of information as that gained from the gold standards for diagnosis, such as the MMSE plus EXIT25 compared with a neuropsychiatric interview. Nonetheless, all of the instruments used have been validated and have reasonable sensitivity and specificity. Third, ESRD-specific conditions were chosen based on whether a commonly used guideline was available regarding management of that condition. Definitions of ESRD-specific conditions were based on whether guidelines were met. The guidelines are neither perfect nor permanent, but they are based on the scientific evidence available as interpreted by experts with thorough knowledge of the conditions. Fourth, there were numerous non-ESRD-specific and ESRD-specific conditions that were potential candidates for inclusion in the study. We focused on the conditions that best fit our inclusion criteria; however, others may be highly prevalent and also inter-related to the conditions included in the study presented here. The number of variables included in the study was limited by the sample size. Finally, our study was performed at most, but not all, of the clinics providing hemodialysis treatment in this geographical region, and non-English speaking patients were excluded. Our study population therefore does not represent the entire population of eligible patients in the region.
Depression, pain, fatigue, cognitive impairment, and impaired physical function are as prevalent in the ESRD population as are ESRD-specific conditions outside of the recommended range of guidelines for management of anemia, renal osteodystrophy, hyperphosphatemia, and use of a catheter for hemodialysis access. Although depression, pain, and fatigue are inter-related, they are not correlated with the ESRD-specific conditions we studied. There are correlations between cognition and both Hgb and iPTH outside of the range of guidelines, but the magnitude of those relationships is not as great as the relationships between non-ESRD-specific conditions. The lack of strong correlation between the non-ESRD-specific conditions and ESRD-specific quality indicators suggests that high-quality ESRD care as it is currently conceived will not ameliorate these other conditions. Considering associations among conditions may provide a new perspective on both ESRD-specific and non-ESRD-specific conditions and ultimately a treatment approach that simultaneously modifies multiple conditions. Finally, this study underscores the importance of diagnosing and treating non-ESRD-specific conditions to improve the health and quality of life of persons with ESRD.
Disclosures
None.
Acknowledgments
This study was supported by a grant from the John A. Hartford Foundation for Excellence in Aging at Yale and by the Claude D. Pepper Older Americans Independence Center at Yale. Dr. Leinau was a Robert Wood Johnson Clinical Scholar supported by the Robert Wood Johnson Foundation during the time this work was conducted. Dr. Fried is supported by K24 AG028443.
We are grateful to Sandra Ginter, RN, for administering the instruments with such care and respect for the patients and staff of the dialysis clinics.
Appendix
SPPB
The SPPB consists of three timed tests: (1) walking 10 m; (2) standing from a seated position five times, as fast as possible; and (3) standing with feet together then in tandem.
PHQ-9
Over the last 2 wk, how often have you been bothered by any of the following problems?
Possible responses: Not at all, several days, more than half the days, or nearly every day
Little interest or pleasure in doing things.
Feeling down, depressed, or hopeless.
Trouble falling or staying asleep, or sleeping too much.
Feeling tired or having little energy.
Poor appetite or overeating.
Feeling bad about yourself, or that you are a failure or have let yourself or your family down.
Trouble concentrating on things, such as reading the newspaper or watching television.
Moving or speaking so slowly that other people could have noticed. Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual.
Thoughts that you would be better off dead, or of hurting yourself in some way.
MPQ Short Form
We are interested in the type of pain you have experienced over the past 2 wk.
Have you had pain in the past 2 wk? (If answer is no, total score = 0)
I am going to read you some words that may describe the kind of pain you have. Please tell me the degree of pain you have had in the past 2 wk.
Possible responses: none, mild, moderate, or severe
To what degrees is your pain (a) throbbing, (b) shooting, (c) stabbing, (d) sharp, (e) cramping, (f) gnawing, (g) hot-burning, (h) aching, (i) heavy, (j) tender, (k) splitting, (l) tiring-exhausting, (m) sickening, (n) fearful, (o) cruel-punishing?
BFI
Throughout our lives, most of us have times when we feel very tired or fatigued. Have you felt unusually tired or fatigued in the past week? (If answer is no, total score = 0)
Each question on the following interference subscale is answered on a Likert scale from 0 to 10, with 0 indicating “does not interfere” and 10 indicating “completely interferes.”
During the past 24 h, how has pain interfered with your:
(a) general activity, (b) mood, (c) walking activity, (d) normal work (including both work outside of the home and daily chores), (e) relations with other people, (f) enjoyment of life?
Published online ahead of print. Publication date available at www.cjasn.org.
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