Treatment of steriod resistant nephrotic syndrome in children

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Slide 1 : Depression, Quality of Life and Malnutrition-Inflammation Scores in Haemodialysis Patients Salwa Ibrahim MD MRCP , Omima El Salamony MD Departments of Medicine and Public Health , Cairo University, Egypt
Slide 2 : Introduction-1 Depression is identified as the most common psychiatric illness in patients with end stage renal disease Boulware and colleagues reported a prevalence of depressive symptoms of 19-24% in the Choice for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) study Depression was associated with hospitalization in a substantial proportion of patients participating in the US ESRD Medicare program Lopes et al, 2002 showed, using data from the large Dialysis Outcomes and Practice Patterns Study (DOPPS), that a diagnosis of depression was associated with increased morbidity and mortality in an incident and prevalent population
Slide 3 : Introduction-2 Another marker of poor outcome among dialysis patients is impaired health related quality of life (HRQOL) HRQOL may also be affected by the clinical manifestations of the disease, the side effects of treatment and relationships of the patients with family members and care providers Arogundade and colleagues, 2005 reported significantly lower quality of life scores in a group of 68 Egyptian haemodialysis patients as compared to emotionally related kidney transplant recipients
Slide 4 : Aim Of The Study The aim of this cross-sectional study was to assess the prevalence of depressive symptoms and quality of life status among a group of chronic hemodialysis patients in order to identify those at high risk of poor outcome We also examined the relationship between depressive scores on the one hand and patients’ social demographic profile, dialysis adequacy, symptoms severity, haemoglobin, serum chemistry, malnutrition-inflammation complex syndrome (MICS) components, and QoL scores on the other hand
Slide 5 : Study Population 60 chronic haemodialysis patients participated in the study. They were on thrice weekly dialysis sessions at the Kasr El-Aini Nephrology and Dialysis centre, Cairo University Hospital. Detailed clinical and demographic data were obtained including history of DM, aetiology of ESRD, duration on RRT, marital status, education level, employment and history of prior renal transplant. Their case records were reviewed to obtain monthly laboratory results including haemoglobin (HB), urea reduction ratio (URR), serum albumin, total iron binding capacity (TIBC), serum calcium, phosphorus and creatinine.
Slide 6 : Survey Instruments Depression scoring We used the Beck Depression Inventory (BDI) to assess the presence and severity of depression. The BDI is a 21-item, patient–related scale that has been validated for depression assessment in hemodialysis patients Scores can range from 0 to 63; depression was diagnosed in the current study based on BDI score > 15
Slide 7 : Quality of life questionnaire The SF-36 questionnaire was used to assess quality of life in the study group It measures eight different dimensions of health: physical function and role limitations related to physical problems, bodily pain, vitality, general health perception, social function, role limitations due to emotional problems, and mental health Scores were assembled using the Likert method for summated ratings and the raw scores were transformed into 0-100 scales The scales of SF-36 were summarized into two dimensions. The first five scales make up the physical health dimension, and the last five form the mental health dimension
Slide 8 : Dialysis Symptoms Index (DSI) DSI was utilized to assess symptoms’ severity. The DSI is comprised of 28 items, each of which targets a specific physical or emotional symptom. Patients were asked to describe the presence of each symptom at any time during the previous 7 days, ranking was carried out using Likert scale( 1=Not at all bothersome to 5= bothers very much) Total symptom burden score was formulated by totalling the symptoms scores reported for each patient. The minimum possible score was 0 if none of these symptoms was present and the maximum potential score was 140 if all of the symptoms had a severity score 5
Slide 9 : Malnutrition Inflammation Score (MIS) The MIS consists of four sections (nutritional history, physical examination, body mass index (BMI), and laboratory values) The history section includes 5 components adopted from SGA form (weight change in the past 6 months, Dietary intake, GI symptoms, Functional capacity, Comorbidities includes dialysis vintage) Physical examination section includes assessment of body fat stores, and muscle wasting. Each scores 0-3 representing normal to severe changes. The BMI is graded in four levels, 0-3, representing BMI >20, 18-19.99, 16-17.99, and less than 16 kg/m2 Laboratory values include serum albumin, score 0 for albumin > 4 g/dl, 1 indicates albumin level 3.5-3.9 g/dl, 2 for 3-3.4 g/dl, 3 means <3 g/dl, and serum total iron binding capacity (TIBC), score 0 >250 mg/dl, 1 for 200-249 mg/dl, 2 for 150-199 mg/dl and score 3 for TIBC less than 150 mg/dl
Slide 10 : Statistics Clinical and demographic variables were described using mean, standard deviation (SD) for continuous variables, and percentages and frequencies for categorical variables Pearson correlation was used to test the relationship between BDI values, QOL scores and other demographic variables. The Frequency table was used to test the frequencies of categorical parameters such as gender, marital status, occupation, and education levels within different BDI scores. Linear regression analysis was used to estimate associations between baseline patient characteristics and BDI and QOL scores. P values of less than 0.05 were taken as statistically significant.
Slide 11 : Results Mean age was 46.13+16.55 years (range 22-77), they consisted of 31 males and 29 females. The duration of RRT was 67.03+56.09 months Twenty patients (33.33%) had BDI score > 15. Two patients (3.33%) had QOL total score less than 50, 8 patients (13.33%) had a score in the range of 50-60, 30 patients (50%) had a score range of 60-70, 12 patients (20%) had a score of 70-80, 8 patients (13.3%) had a score range 80-90 and non scored > than 90 Patients with BDI scores >15 had significantly lower total QOL scores and mental component scores (P=0.01)
Slide 12 : Results Sixty percent of patients with BDI scores > 15 are either single/widowed compared to those with BDI <15 Correlation and regression analysis did not show a significant relation between gender and both QOL and depressive scores (P>0.05) The mean BDI score of un-employed patients was significantly higher than employed patients (13.03+6.27 vs. 8.50+3.51, P=0.03) Patients with depression symptoms had higher MIS and DSI levels than those without depression symptoms, but the differences were not statistically significant (P=0.06 and 0.07 respectively)
Slide 13 : Results There was significant negative correlation between age and F-36 scores (P<0.05) Symptom severity burden and MIS showed significant positive correlations with BDI scores (P<0.05) and significant negative correlations with F-36 scores (P<0.05) Depression scores showed a highly significant inverse correlation with QOL total scores (R=-0.659, P=0.000) Neither age, BMI,URR, haemoglobin, blood urea and serum creatinine, calcium, phosphorus and albumin were predictable of BDI scores on regression analysis (P>0.05)
Slide 14 : Table-1
Slide 15 : Correlation between BDI and F36 Scores P=0.002
Slide 16 : Correlation between BDI and DSI Scores P=0.003
Slide 17 : Correlation between BDI and MIS Scores P=0.027
Slide 18 : Impact of Employment on BDI P=0.03
Slide 19 : Conclusion-1 Our results revealed high prevalence of depression among chronic hemodialysis patients that is not recognized by the treating physicians 20 patients (33.33%) had BDI scores >15 suggestive of symptomatic depression 40 patients (66.66%) had QOL scores of < 70, which reflects considerable impairment to their daily physical and/or social activities The difference in prevalence of depression between European patients and our study group may reflect the differences in age (mean age of patients surveyed in the current study was 46.13+16.55 years compared to 60.0+15.3 years in the DOPPS study)
Slide 20 : Conclusion-2 Based on our findings, we propose the routine use of simple screening tools like BDI, F36 and MIS to identify vulnerable patients who have poor quality of life and/or depression symptoms Further longitudinal studies are needed to examine whether depression and poor quality of life are associated with increased morbidity and/or mortality risks among middle aged ESRD in our region.
Slide 21 : References Boulware LE, Liu Y, Fink NE, Coresh J, Ford DE, Klag MJ, Powe NR. Temporal relation among depression symptoms, cardiovascular disease event, and mortality in end-stage renal disease: Contribution of reverse causality. Clin J Am Soc Nephrol 2006; 1: 496-504 Lopes AA, Bragg J, Young E, Goodkin D, Mapes D, Combe C, Piera L, Held P, Gillespie B, Port FK. Dialysis Outcomes and Practice Patterns Study (DOPPS): Depression as a predictor of mortality and hospitalization among hemodialysis patients in the United States and Europe. Kidney Int 2002; 62: 199-207 Arogundade F, Abd-Essamie M, Barsoum R. Health-Related Quality of Life in Emotionally Related Kidney Transplantation: Deductions from a Comparative Study. Saudi J Kidney Dis Transplant 2005; 16(3):311-320 Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36):1. Conceptual framework and item selection. Med Care 1992; 30: 473-483 Weisbord SD, Fried LF, Unruh ML, Kimmel PL, Switzer GE, Fine MJ, Arnold RM: Associations of race with depression and symptoms in patients on maintenance haemodialysis. Nephrol Dial Transplant 2007; 22: 203-208 Kalantar-Zadeh K, Kopple JD, Block G, Humphreys M: A malnutrition-inflammation score is correlated with morbidity and mortality in maintenance hemodialysis patients. Am J Kid Dis 2001; 38: 1251-1263.
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