Abstract
The Effect of Social Support and Coping Style on Depression in Patients on Continuous Ambulatory Peritoneal Dialysis
Objective: To explore the effect of social support and coping style on depression in patients (pts) on continuous ambulatory peritoneal dialysis (CAPD).
Methods: The study recruited 200 pts on PD therapy for more than 3 months. The Beck Depression Inventory II (BDI-II), Social Support Rating Scale (SSRS), Medical Coping Modes Questionnaire (MCMQ), and Chinese version of the Short-Form Health Survey (SF-36) were used to evaluate depression, social support, coping style, and quality of life (QOL) respectively.
Results: Among 191 CAPD pts analyzed (mean age: 49.5 ± 15.7 years; 107 men, 84 women; median duration of PD: 15 months), 65 had depression (BDI-II score: 23.8 ± 8.4). Depression score and QOL were strongly negatively correlated (r = –0.557, p = 0.000). In pts with depression as compared with those without, the average score for social support was much lower, as were total score (37.87 ± 7.22 vs. 42.07 ± 7.46), objective social support (8.61 ± 2.46 vs. 9.58 ± 2.79), subjective support (22.34 ± 4.84 vs. 24.78 ± 4.88), and utilization of social support (6.92 ± 1.83 vs 7.70 ± 1.95)—all p < 0.05. Among coping styles, the depression and non depression pts showed significant differences in “confrontive” and “resignation” styles (18.82 ± 3.77 vs. 17.20 ± 3.96 and 10.36 ± 3.51 vs. 12.92 ± 2.47 respectively, p < 0.05). However, the groups showed no significant difference in “avoidance” (p > 0.05). In pts with depression as compared with those without, the QOL results such as total score (44.9 ± 14.0 vs. 64.7 ± 14.2), physical component summary score (36.2 ± 8.9 vs. 43.0 ± 6.3), and mental component summary score (37.8 ± 8.8 vs. 47.0 ± 8.9) were significantly lower (p < 0.001). There was a positive correlation between depression and average social support scores, including objective social support, subjective support, and utilization of social support (r = –0.280, –0.175, –0.240, and –0.25 respectively; p = 0.000). A similar result was also seen between depression and “confrontive” coping style scores (r = –0.180, p = 0.012). In contrast, there was a significant negative correlation and a significant positive correlation between depression and “resignation” coping style scores (r = 0.482, p = 0.000).
Conclusions: Depression was highly prevalent in CAPD pts, significantly affecting their QOL. Better social support and a suitable coping style such as “confrontive” are necessary for preventing and relieving depression and improving QOL.
Pre-implantation of Tenckhoff Catheter with Stepwise Initiation of Peritoneal Dialysis Reduces Length of Hospitalization and Medical Expenses
Objectives: Traditionally, peritoneal catheters have been implanted immediately before the start of dialysis, which increases hospitalization days and medical costs. The present study compared medical expenses and outcomes for patients with advanced chronic kidney disease (CKD) under a new plan of pre-implantation of a Tenckhoff catheter and stepwise initiation of dialysis as compared with the traditional plan of Tenckhoff catheter implantation at dialysis start.
Methods: The study enrolled advanced CKD patients receiving either the new plan of catheter pre-implantation or the traditional plan for peritoneal dialysis (PD) in one medical center during 1 December 2006 to 31 May 2009. The timing for catheter pre-implantation was an estimated glomerular filtration rate below 15 mL/min/1.73 m2 in diabetic patients and below 10 mL/min/1.73 m2 in nondiabetic patients. The timing for initiating PD therapy was decided by the nephrologists in charge.
Results: During the study period, 66 patients (mean age: 47 ± 13 years; 31 men, 35 women) received Tenckhoff catheters. Of these, 33 (mean age: 50 ± 12 years; 17 men, 16 women) underwent catheter pre-implantation. The age, sex, education status, underlying diseases, and follow-up periods after dialysis were not different between the two groups. Levels of blood urea nitrogen, serum creatinine, phosphate, and triglycerides were lower and serum albumin was higher in patients undergoing pre-implantation. Medical expenses were significantly less (US$810 ± $118 vs. US$2167 ± $1522, p < 0.001) and length of hospitalization was significantly shorter (3.6 ± 0.9 days vs. 15.8 ± 9.3 days, p < 0.001) in patients receiving pre-implantation. No problems in wound healing and only 1 catheter failure at dialysis initiation occurred in the pre-implantation group. There was no significant difference in drop-out rate between the two groups (7/33 traditional vs. 4/33 pre-implantation).
Conclusions: CKD patients receiving catheter pre-implantation for PD have lower medical expenses and shorter hospitalization. Catheter pre-implantation should therefore be considered to reduce medical costs and ensure better outcomes in PD patients.
Applying a Hierarchical Management Approach to Manage Peritoneal Dialysis (PD) Patients in a Fast-Expanding PD Program
Objective: Peritoneal dialysis (PD) is a home-based treatment for end-stage renal disease, and patient empowerment is one of the key factors for success of the program. However, because of the health care reimbursement policy in China, PD is in general a cost program for a renal clinic, and therefore limited human resources are assigned to the PD program as compared with the hemodialysis program. This paper presents a hierarchical management approach for managing an ever-growing number PD patients while economizing on nursing staff.
Methods: We have been applying a hierarchical management approach by which each primary PD nurse cares for a group of PD patients (1 nurse to 60 – 70 patients). All patients are graded into one of three different levels based on their self efficacy. About 10% of the patients were graded into level 1 and managed with a case-management approach (sick patients); 30% were graded into level 2 and managed with a disease-management approach (patients with risks of comorbidities); and 60% were graded into level 3 and managed with a population-management approach (stable patients). This approach has been explored and used in a group of patients averaging 60 in number over a 2-year duration.
Results: Since 2007, the number of PD patients in our program has grown from 200 to more than 400, while the number of primary nurses has remained at 6. By applying the hierarchical management approach, all primary nurses were able not only to take care of busy patient management, but also to participate in heavy professional training and clinical research. The overall quality of the program has been continuously improving despite the huge workload: uncontrolled hypertension accounted for 20% – 30%; anemia, 30%; hyperphosphatemia, 20%; and malnutrition, 20%. Serum albumin averaged 39 g/L, and the peritonitis incidence reached 1 episode in 67 patient–months. The satisfaction of the patients with regard to their therapy is high, and quality of life and rehabilitation status have been continuously improving.
Conclusions: Our results show that despite ever-increasing patient numbers and limited human resources, a PD program can maintain good quality of care with implementation of a hierarchical management approach.
Collaborative Multicenter Research into Quality of Life on Continuous Ambulatory Peritoneal Dialysis (PD) Treatment and Automated PD Treatment
Introduction and Aims: Taking the respective characteristics of continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) into account is important when choosing between these peritoneal dialysis (PD) treatments. However, very few controlled studies of quality of life (QOL) for both treatments have been described. The present study thus investigated the differences exerted by CAPD and APD treatment on the physical and mental aspects of patient (pt) life and the relationships between QOL and background variables.
Methods: Subjects were 81 CAPD pts and 82 APD pts from the participating facilities. The Short-Form 36-Item Health Survey (SF-36) and a QOL survey created for this study and using questions relating to PD treatment modality were administered, and the results were analyzed. Serum albumin and serum urea nitrogen, hemoglobin, and urinary output levels were also evaluated.
Results: No significant differences in SF-36 or QOL scores were seen between the CAPD and APD groups at each facility and overall. Among the PD treatment–related question items, no significant differences were seen in reduction in daytime activity time and inconvenience of securing a place to change bags, but the QOL score for these items tended to be higher in the APD group than in the CAPD group. The APD group described significantly more difficulty than did the CAPD group in bag changing and in handling instruments. The groups showed no difference in QOL score for sleep difficulties; inconvenience of traveling, bathing, and showering; discomfort of daytime dialysate retention; and inconvenience of bag exchange times. In the subgroup of pts 65 years of age, the APD group reported significantly more difficulty than did the CAPD group in bag changing and handling instruments. Regarding relationships between SF-36 outcomes and background variables, employment status, higher urine output, and higher serum albumin were, for the most part, significantly associated with increased QOL.
Conclusions: APD treatment facilitates bag exchange times and securing a place to change bags for non elderly pts, but APD instruments need improvement to be more easy to handle for elderly pts.
Psychosocial Status Rather than Educational Background Significantly Affects the Quality of Dietary Records in Continuous Ambulatory Peritoneal Dialysis Patients
Objective: Dietary records are an essential part of achieving peritoneal dialysis adequacy. However, because of the cumbersome work, it may not be easy to get accurate records from patients. In the present study, we investigated the factors that possibly affect the recording of dietary records by patients.
Methods: The study included 166 clinically stable peritoneal dialysis patients who visited monthly at our peritoneal dialysis clinic. All patients are required to hand in a dietary record each time they visit the clinic. The quality of the dietary records during a 6-month period was evaluated by a dedicated dietician and graded into four different levels (1 = best quality, 4 = worst quality). We analyzed and compared patient characteristics, nutrition status, psychosocial status, quality of life, and economic status between the various groups.
Results: There were 19, 41, 74, and 32 patients in the level 1, 2, 3, and 4 groups. The age of the patients was 64.42 ± 15.39 years, 61.54 ± 13.39 years, 60.31 ± 15.31 years, and 56.72 ± 17.32 years from level 1 to level 4 respectively. The dietary energy and protein intakes were significantly higher in level 1 patients than in patients in the other groups. From level 1 to level 4 respectively, the daily energy intake was 27.55 ± 6.72 kcal/kg, 23.65 ± 5.61 kcal/kg, 22.38 ± 5.69 kcal/kg, and 23.72 ± 9.85 kcal/kg, and the daily protein intake was 0.93 ± 0.26 g/kg, 0.74 ± 0.19 g/kg, 0.67 ± 0.18 g/kg, and 0.76±0.38 g/kg. Depression and anxiety scores were both significantly higher in level 3 and 4 patients than in level 1 and 2 patients. However, there were no significant differences in education background, blood chemistry, quality of life, economic status, and nutrition status between the various groups.
Conclusions: Our results suggest that the quality of the dietary record may be affected by psychosocial status, but not by educational background in the patients. Psychosocial consultation may be necessary to help patients who return inappropriate dietary records.