Nutritional Status and Depression, Sleep Disorder, and Quality of Life in Hemodialysis Patients

doi:10.1053/j.jrn.2007.08.008

Journal of Renal Nutrition

Volume 17, Issue 6, November 2007, Pages 381-388

https://doi.org/10.1053/j.jrn.2007.08.008 Get rights and content

Objective

The malnutrition-inflammation score (MIS) is a scoring system that measures malnutrition and inflammation. We sought to explore its associations with depression, sleep disturbance, and quality of life.

Design

This was a cross-sectional study.

Setting

This study took place at the Baskent University Outpatient Hemodialysis Unit (Ankara, Turkey).

Patients

We enrolled 67 hemodialysis patients (male/female, 34/33; age, 47.7 ± 11.4 years [mean ± SD]; hemodialysis duration, 103.7 ± 59.1 months [mean ± SD]).

Intervention

We retrospectively recorded patients' monthly clinical and laboratory findings from the previous 6 months. The same physician calculated MIS scores. We interviewed all patients, and each completed a Beck Depression Inventory (BDI) assessment. We used the Pittsburgh Sleep Quality Index (PSQI) to assess quality of sleep, and the Medical Outcomes Study 36-item short form (SF-36) questionnaire to evaluate health-related quality of life.

Main Outcome Measures

The main outcome measures involved the univariate and multivariate relationships of the MIS with BDI, PSQI, and SF-36.

Results

Patients with PSQI scores of ≤5 (“good sleepers”) had lower MIS scores than did poor sleepers (6.8 ± 2.5 vs. 8.8 ± 3.2, P < .05). Patients with moderate-to-severe depression (BDI score ≥19) had higher MIS scores (9.0 ± 3.2 vs. 6.5 ± 2.5, P = .005) and higher PSQI scores (7.6 ± 2.1 vs. 4.7 ± 1.8, P = .001), compared with patients with BDI scores <19. Increased MIS scores were correlated with increased comorbidity (P = .01) and poor SF-36 scores (P = .009).

Conclusion

Increased MIS is significantly associated with the presence of depression, sleep disorders, and poor quality of life. This close relationship may help establish the MIS as an important determinant of the increased morbidity and mortality of hemodialysis patients.

Section snippets

Materials and Methods

We enrolled 67 patients (age, 47.7 ± 11.4 years [mean ± SD]; 34 men, 33 women; duration of HD, 103.7 ± 59.1 months [mean ± SD]) who were on chronic maintenance HD at Baskent University Hospital (Ankara, Turkey). All patients had negligible residual renal function, and had been undergoing dialysis with a biocompatible membrane such as hemophane or polysulfone three times each week, 4 hr each time, and had been doing so for at least 12 months. We excluded patients who did not fill out

Results

Table 1 shows the demographic, clinical, and laboratory data of the 67 HD patients. Men comprised 51% of the study population. The mean MIS score was 7.7 ± 3.0 (range, 3-16).

The PSQI score ranged from 1 to 12, and 30 patients (42.5%) were poor sleepers (PSQI >5). We divided patients into two groups according to PSQI score: good sleepers (PSQI ≤5) and poor sleepers (PSQI >5). Table 2 shows the characteristics of each group. Compared with good sleepers, poor sleepers had lower serum albumin (38.0

Discussion

In our patients, the mean MIS value was 7.7 ± 3.0, and our results show that higher MIS values were associated with the presence of moderate-to-severe depression, poor quality of sleep, and poor quality of life.

In our study, the prevalence of poor sleep quality was 42.5%, comparable with the 45% to 80% prevalence of sleep complaints in HD patients reported in previous studies.7, 12, 30 Numerous factors probably contribute to the high prevalence of sleep problems in HD patients, including

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Severity of protein-energy wasting and obesity are independently related with poor quality of life in peritoneal dialysis patients
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Protein-energy wasting (PEW) and poor health-related quality of life (HRQoL) are independently associated with morbi-mortality in continuous ambulatory peritoneal dialysis (CAPD). PEW may reduce HRQoL; however, we hypothesized HRQoL is affected differentially by PEW degrees or by individual criteria of nutritional status.
To evaluate HRQoL according to PEW severity and nutritional status indicators in CAPD.
This is a cross-sectional study in 151 patients. Subjective global assessment (SGA) was employed, and nutritional status classified as normal, mild-moderate PEW, and severe PEW. HRQoL was evaluated using Kidney Disease Quality of Life Short Form™, including physical (PCS), mental (MCS) and kidney disease (KDCS) components, and their subscales. Dietary intake, anthropometric and biochemical variables were measured.
Forty-six percent of patients were well-nourished, 44% had mild-moderate PEW, and 10% severe PEW. Compared with well-nourished patients, those with mild-moderate (p = 0.06) and severe (p = 0.005) PEW had lower HRQoL score [68 (52–75), 55 (45–72), 46 (43–58), respectively]. PCS, MCS, and KDCS and their subscales had lower values as PEW was more severe. Patients with obesity and hypoalbuminemia had significantly lower HRQoL overall and component scores than their counterparts. Dietary intake was not associated with quality of life. In multivariate analysis obesity, PEW (by SGA), hypoalbuminemia, and low educational level predicted poor HRQoL (χ² 58.2, p < 0.0001).
As conclusion, PEW severity was related with worse HRQoL, either as overall score or in every component or subscale in CAPD patients. Poor HRQoL was predicted independently by PEW severity and obesity; additional predictors were hypoalbuminemia and low education.
El desgaste proteico-energético (DEP) y la mala calidad de vida relacionada con la salud (CVRS) se asocian de forma independiente con la morbimortalidad en diálisis peritoneal continua ambulatoria (DPCA). El DEP puede reducir la CVRS; sin embargo, planteamos la hipótesis de que la CVRS se ve afectada de forma independiente por los grados de DEP o por los criterios individuales del estado nutricional.
Evaluar la CVRS de acuerdo a la gravedad de la DEP e indicadores del estado nutricional en DPCA.
Este es un estudio transversal en 151 pacientes. Se empleó la evaluación global subjetiva (EGS) y el estado nutricional se clasificó como normal, DEP leve-moderada y DEP grave. La CVRS se evaluó mediante el uso del cuestionario Kidney Disease Quality of Life Short Form™, incluidos los componentes físicos (PCS), mentales (MCS) y de enfermedad renal (KDCS) y sus subescalas. Se midieron la ingesta dietética, las variables antropométricas y bioquímicas.
El 46% de los pacientes tenía un estado nutricional normal, el 44% tenía DEP leve-moderada y el 10% DEP grave. En comparación con los pacientes bien nutridos, aquellos con DEP leve-moderada (p = 0,06) y grave (p = 0,005) tenían una puntuación de CVRS más baja (68 [52-75], 55 [45-72], 46 [43-58], respectivamente). Igualmente, la PCS, MCS y KDCS y sus subescalas tuvieron valores más bajos, conforme la DEP fue más severa. Los pacientes con obesidad e hipoalbuminemia tenían puntuaciones de CVRS general y de sus componentes significativamente más bajas que sus contrapartes. La ingesta dietética no se asoció con la calidad de vida. En el análisis multivariado la obesidad, el DEP (por EGS), la hipoalbuminemia y el bajo nivel educativo predijeron una mala CVRS (χ² 58,2; p < 0,0001).
En conclusión, la gravedad del DEP se relacionó con una peor CVRS, ya sea como puntuación global o en cada componente o subescala de los pacientes con DPCA. La mala CVRS se predijo de forma independiente por la gravedad del DEP y la obesidad; predictores adicionales fueron hipoalbuminemia y la baja educación.
Differences and Effects of Metabolic Fate of Individual Amino Acid Loss in High-Efficiency Hemodialysis and Hemodiafiltration
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Citation Excerpt :
This study shows how at the time of recruitment patients were already affected by a state of malnutrition/inflammation typical of the terminal stages of uremia in patients on dialysis.38 Indeed, this serious metabolic situation represents a key component of the so-called “malnutrition-inflammatory complex syndrome”39,40 linked in patients on dialysis to a reduced quality of life, increased number of hospitalizations, higher incidence of coronary heart disease and depression, and an increased mortality rate.41-45 Malnutrition initially presents as a somatic protein type with the onset of sarcopenia.
The objective of the study was to quantify the loss and arterial blood concentration of the three main classes of amino acids (AAs)—nonessential amino acids (NEAAs), essential amino acids (EAAs), and branched-chain amino acids—as resulting from high-efficiency hemodialysis (HED) and hemodiafiltration (HDF). We moreover aimed to identify the different fates and metabolic effects manifested in patients undergoing hemodialysis and the consequences on body composition and influence of nutritional decline into protein energy wasting.
Identical dialysis monitors, membranes, and dialysate/infusate were used to ensure consistency. Ten patients were recruited and randomized to receive treatment with on-line modern HED and HDF. Arterial plasma concentrations of individual AAs were compared in healthy volunteers and patients undergoing hemodialysis, and AA levels outflowing from the dialyzer were evaluated. Baseline AA plasma levels of patients undergoing hemodialysis were compared with findings obtained 1 year later.
A severe loss of AA with HED/HDF was confirmed: a marked loss of total AAs (5 g/session) was detected, corresponding to more than 65% of all AAs. With regard to individual AAs, glutamine displayed a consistent increase (+150%), whereas all other AAs decreased after 12 months of HD/HDF. Only a few AAs, such as proline, cysteine, and histidine maintained normal levels. The most severe metabolic consequences may result from losses of EAAs such as valine, leucine, and histidine and from NEAAs including proline, cysteine, and glutamic acid eliciting the onset of hypercatabolism threatening muscle mass loss.
Dialysis losses, together with the effect of chronic uremia, resulted in a reduction of fundamental EAAs and NEAAs, which progressively led our patients after 12 months to a deterioration of lean mass toward sarcopenia. Therefore, the reintroduction of a correctly balanced AA supplementation in patients undergoing HD to prevent or halt decline of hypercatabolism into cachexia is recommended.
Predictors of nutritional and inflammation risk in hemodialysis patients
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Malnutrition and chronic inflammation are prevalent complications in hemodialysis (HD) patients. Different nutritional assessment tools are used to identify patients at risk. A composite and comprehensive malnutrition inflammation score (MIS) has been correlated with morbidity and mortality, and appears to be a robust and quantitative tool.
Determine malnutrition risk profile in a sample of portuguese HD patients; determine the association of clinical and laboratory factors with MIS, and the impact of each parameter on MIS.
We performed, between September 15th of 2015 and January 31st of 2016, a cross sectional analysis of 2975 patients, representing 25% of portuguese HD patients. 59% were men (66.7 ± 14.8 years); 31% diabetic; 79% and 21% performed, respectively, high-flux HD and HDF. A MIS >5 was considered to indicate higher risk and was present in 1489 patients (50%). Amongst all parameters, comorbilities/dialysis vintage, transferrin, functional capacity, changes in body weight and decreased fat stores showed the higher impact, while albumin had one of the lowest impact on the nutritional risk.
Higher age (>75 years, OR 1.71, p < 0.001), diabetes (OR 1.25, p = 0.026), lower P levels (OR 1.57,p = 0.001), higher Ca levels (OR 1.51, p < 0.001), higher ERI (OR 1.05, p < 0.001), higher Kt/V (OR 2.14, p < 0.001) and higher CRP (OR 1.01, p < 0.001) were independently associated with a higher risk of MIS>5; higher nPNA (OR 0.29, p < 0.001) and higher Pcreat (OR 0.88, p < 0.001) were associated with a risk reduction of MIS>5 (95% CI).
Routine clinical and analytic parameters were found to be associated with MIS range that might indicate higher risk, and may represent a simple alert sign for the need of further assessments.
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Citation Excerpt :
In this regard, nutritional considerations are safe and inexpensive approaches that can use to improve the sleep status of patients. Bilgic Akgul et al. were concluded sleep disorders are correlated with patients' nutritional status [16]. Foods containing tryptophan, serotonin and melatonin may have beneficial effects on the improving patients' sleep status [17,18].
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A clinical trial study (registered under IRCT.ir with identifier no. IRCT201309285134N7) was conducted with 68 hospitalized patients with the acute coronary syndrome in the coronary care unit of a referral hospital in Semnan, Iran. After hospitalization of patients and selected eligible patients, sleep status of them was measured by Richards–Campbell Sleep Questionnaire in range of 0 to 100 score. Then patients were divided into the intervention and control groups randomly. Patients in the intervention group were received milk-honey mixture twice a day for three days. The control group patients were received routine care. In the third day, sleep quality of patients in the two groups was measured again. Finally, the data were analyzed by descriptive and inferential statistics.
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The study purpose was to explore the relationship between nutritional status, as measured by Subjective Global Assessment (SGA), and Health Related Quality of Life measured using the Nutrition Specific Quality of Life (NS-QoL), tool among participants on maintenance hemodialysis (MHD). The study aim was to determine if NS-QoL may be an adjuvant tool for detecting changes in nutritional status among patients on MHD.
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Statistical tests were conducted to determine the relationship between key demographic characteristics (age, sex, dialysis vintage, gender, and ethnicity) and SGA and NS-QoL. Spearman's correlation examined the relationship between the independent variable, SGA and the dependent variable, NS-QoL. A univariate general linear model was conducted to adjust for confounding variables.
The relationship between overall SGA score and composite NS-QoL score.
The sample consisted of 85 men (58.6%), with a mean age of 55.3 ± 11.9 years, who were largely African–American (84.1%) and non-Hispanic (77.2%). Mean SGA score was 5.5 ± 1.0, and the mean NS-QoL composite score was 9.51 ± 3.77. No key demographic characteristics had a statistically significant relationship with SGA, whereas sex (P < .001) and race (P = .015) both had statistically significant relationships with NSQoL. After adjusting for the variables of race and sex, NS-QoL score was positively correlated with SGA composite score (P = .042); as NS-QoL score increased so did the SGA score.
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Original ResearchNutritional Status and Depression, Sleep Disorder, and Quality of Life in Hemodialysis Patients

Objective

Design

Setting

Patients

Intervention

Main Outcome Measures

Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Am J Kidney Dis

Am J Kidney Dis

J Ren Nutr

Am J Kidney Dis

Am J Kidney Dis

Kidney Int

Kidney Int

Kidney Int

Am J Kidney Dis

Am J Med Sci

Prog Neuropsychopharmacol Biol Psychiatry

Am J Med

Psychiatry Res

Kidney Int

Kidney Int

Prog Neuropsychopharmacol Biol Psychiatry

Gen Hosp Psychiatry

Am J Clin Nutr

Patient perception of distress associated with hemodialysis—a state survey

J Am Assoc Nephrol Nurses Tech

Depression, anxiety and adjustment in renal replacement therapy: a quality of life assessment

Clin Nephrol

Nocturnal sleep, daytime sleepiness, and quality of life in stable patients on hemodialysis

Health Qual Life Outcomes

Original Research
Nutritional Status and Depression, Sleep Disorder, and Quality of Life in Hemodialysis Patients