Annotated Abstracts of Journal Articles
2014, 3rd Quarter
Annotations by Paula Zimbrean, MD, FAPM and Marta Novak, MD, PhD
Also of interest:
3. Setting Research Priorities for Patients on or Nearing Dialysis
ANNOTATION (Zimbrean & Novak)
The Findings: Antidepressants, neuroleptics, antihistamines, and antiemetics with dopamine blockade are associated with increased prevalence of Restless Legs Syndrome (RLS) in patients with End Stage Renal disease (ESRD). For antidepressants and antipsychotics, this association remains significant (p<0001) even after adjusting for the timing of the prescription to the diagnosis of RLS.
Strengths and Weaknesses: This was a case-control study of the US national registry of ESRD, which included 16,165 ESRD patients (3234 cases; 12,931 age-, sex-, and race-matched controls). As the others correctly point out, the study has the limitations inherent of a disease registry, which are relying on diagnosis made on insurance claims and not knowing if patients actually ingested the prescribed medications. In addition, specific groups include medications with varied structure and mechanism of action.
Relevance: For the psychiatrist prescribing psychotropic medications to patients with ESRD, this study provides important information to take into consideration when calculating the risk/benefit ratio of antidepressants/antipsychotics. At minimum this study emphasizes the need to screen for RLS prior to the treatment, and to monitor for RLS during the treatment with antidepressants/antipsychotics.
Objective: The objective of this study was to determine the association between the usage of four classes of “at-risk” medications (antidepressants, neuroleptics, antihistamines, and antiemetics with dopamine blockade) and restless legs syndrome (RLS) in dialysis patients within the United States Renal Data System (USRDS).
Methods: This was a case-control design within a national (United States) patient registry of all patients with end-stage renal disease (ESRD) in the USRDS anytime during the period of 1 October 2006 to 31 December 2010, inclusive. A total of 16,165 ESRD patients (3234 cases; 12,931 age-, sex-, and race-matched controls) were studied.
Results: All four classes of “at-risk” medications see widespread use among patients in the USRDS. All were associated with increased odds of an RLS diagnosis (range of odds ratios, 1.47-2.28; all p?<?0.0001) during the period of observation. Results were unchanged when controlling for time on hemodialysis. Usage of more than one class of medication increased the odds for having RLS.
Conclusions: ESRD patients often receive medication intended for relief of conditions associated with their disease, such as depression and psychological issues, pruritus, and gastroparesis; however, such medications may increase the risk of RLS. Given the high prevalence of RLS in ESRD patients, these medications should only be used when their benefits clearly outweigh the risk of development of the troubling and distressing symptoms of RLS.
ANNOTATION (Zimbrean & Novak)
The Finding: This is a cross-sectional study of 336 patients on hemodialysis in 26 dialysis centers across Maryland. Despite the fact that kidney transplantation has superior results compared to other treatments in end stage kidney disease, many potentially eligible patients are not referred for transplant evaluations. This paper explores the beliefs that may interfere with ESKD patients pursuing transplantation. Patients with high level of health-related concerns or psychosocial concerns were less likely to achieve ATT.
Strengths and Weaknesses: The strength of the study results from the high number of patients spread out to more than 20 dialysis centers, which suggests the potential for generalizability of the findings.The weaknesses of the study consist in the cross-sectional design which does not allow an understanding of how these beliefs evolve in time.
Relevance: For the psychosomatic medicine practitioner working with patients with end stage kidney disease, this article suggests that exploring psychosocial concerns about transplantation of patients on dialysis may increase the rate of referral for kidney transplantation and thus to a better quality of life.
Background and Objectives: Disparities in kidney transplantation remain; one mechanism for disparities in access to transplantation (ATT) may be patient-perceived concerns about pursuing transplantation. This study sought to characterize prevalence of patient-perceived concerns, explore interrelationships between concerns, determine patient characteristics associated with concerns, and assess the effect of concerns on ATT.
Design, Setting, Participants, & Measurements: Prevalences of 12 patient-perceived concerns about pursuing transplantation were determined among 348 adults who recently initiated dialysis, recruited from 26 free-standing dialysis centers around Baltimore, Maryland (January 2009-March 2012). Using variable reduction techniques, concerns were clustered into two categories (health-related and psychosocial) and quantified with scale scores. Associations between patient characteristics and concerns were estimated using modified Poisson regression. Associations between concerns and ATT were estimated using Cox models.
Results: The most frequently cited patient-perceived concerns were that participants felt they were doing fine on dialysis (68.4%) and felt uncomfortable asking someone to donate a kidney (29.9%). Older age was independently associated with having high health-related (adjusted relative risk, 1.35 [95% confidence interval, 1.20 to 1.51], for every 5 years older for those =60 years) or psychosocial (1.15 [1.00 to 1.31], for every 5 years older for those aged =60 years) concerns, as was being a woman (1.72 [1.21 to 2.43] and 1.55 [1.09 to 2.20]), having less education (1.59 [1.08 to 2.35] and 1.77 [1.17 to 2.68], comparing postsecondary education to grade school or less), and having more comorbidities (1.18 [1.08 to 1.30] and 1.18 [1.07 to 1.29], per one comorbidity increase). Having never seen a nephrologist before dialysis initiation was associated with high psychosocial concerns (1.48 [1.01 to 2.18]). Those with high health-related (0.37 [0.16 to 0.87]) or psychosocial (0.47 [0.23 to 0.95]) concerns were less likely to achieve ATT (median follow-up time 2.2 years; interquartile range, 1.6-3.2).
Conclusions: Patient-perceived concerns about pursuing kidney transplantation are highly prevalent, particularly among older adults and women. Reducing these concerns may help decrease disparities in ATT.
ANNOTATION (Zimbrean & Novak)
This paper reports the results of a survey of Canadian patients with end stage kidney disease, their caregivers and medical staff, regarding the perceived top research priorities for patients with ESRD. For psychiatrists it is important to note that depression is included among the first 10 topics considered to be the most important research subjects for end stage kidney disease
With increasing emphasis among health care providers and funders on patient-centered care, it follows that patients and their caregivers should be included when priorities for research are being established. This study sought to identify the most important unanswered questions about the management of kidney failure from the perspective of adult patients on or nearing dialysis, their caregivers, and the health care professionals who care for these patients. Research uncertainties were identified through a national Canadian survey of adult patients on or nearing dialysis, their caregivers, and health care professionals. Uncertainties were refined by a steering committee that included patients, caregivers, researchers, and clinicians to assemble a short-list of the top 30 uncertainties. Thirty-four people (11 patients; five caregivers; eight physicians; six nurses; and one social worker, pharmacist, physiotherapist, and dietitian each) from across Canada subsequently participated in a workshop to determine the top 10 research questions. In total, 1570 usable research uncertainties were received from 317 respondents to the survey. Among these, 259 unique uncertainties were identified; after ranking, these were reduced to a short-list of 30 uncertainties. During the in-person workshop, the top 10 research uncertainties were identified, which included questions about enhanced communication among patients and providers, dialysis modality options, itching, access to kidney transplantation, heart health, dietary restrictions, depression, and vascular access. These can be used alongside the results of other research priority-setting exercises to guide researchers in designing future studies and inform health care funders.