Original Paper Received: December 16, 2013 Accepted: March 31, 2014 Published online: October 2, 2014
Blood Purif 2014;38:46–54 DOI: 10.1159/000362669
Cancer Patients under Maintenance Hemodialysis: Relationship between Quality of Life, Depression, Sleep Quality and Malnutrition-Inflammation Score Juliana Ramiro Luna Castro a Geraldo B. Silva Junior b André Ferrer Carvalho a Thomas N. Hyphantis d Luiza de Andrade Braga Farias c Alexandre B. Libório a Elizabeth F. Daher a
a Post-Graduation Program in Medical Sciences, Federal University of Ceará, b School of Medicine, Master in Collective Health, Health Sciences Center, University of Fortaleza, c UNIFOR, Universidade de Fortaleza, Fortaleza, Ceará, Brazil; d Department of Psychiatry, Medical School, University of Ioaninna, Ioaninna, Greece
Key Words Cancer · Hemodialysis · Quality of life · Depression · Sleep quality · Malnutrition-inflammation score
Abstract Background: The kidney is one major organ affected by cancer and its associated therapies. The aim of this study was to compare the levels of depression, quality of life and sleep quality in hemodialysis patients with or without cancer, and to analyze the associations with the malnutrition-inflammation score (MIS). Patients and Methods: In this cross-sectional study, 40 cancer patients under hemodialysis and 44 patients under hemodialysis without cancer who served as the control group were included. Participants underwent structured interviews to investigate depression, quality of life, sleep quality and restless legs syndrome. Results: Hemodialysis patients with cancer had a greater depression score (16.5 ± 4.8 vs. 10.8 ± 5.2, p < 0.001). Patients had similar physical and mental composite quality of life scores. Patients under hemodialysis with cancer had poor quality of sleep (mean score 8.8 ± 3.5 vs. 6.4 ± 4.1, p = 0.011) and a higher prevalence of restless leg syndrome (55.9 vs. 25.7%, p =
© 2014 S. Karger AG, Basel 0253–5068/14/0381–0046$39.50/0 E-Mail [email protected] www.karger.com/bpu
0.011). These features were associated with MIS in patients without cancer but not in patients with cancer. Conclusion: Cancer patients undergoing hemodialysis present a higher prevalence of depression, poor quality of life, sleep disorders; however, associations of these features with MIS are different in hemodialysis patients with or without cancer. These findings can change the clinical approach to these pa© 2014 S. Karger AG, Basel tients.
Introduction
Cancer treatment has significantly improved over the past years; thus, an increased number of patients with cancer survive and live with the residual effects of their cancer and its associated treatment [1]. The kidney is one major organ affected by cancer and its associated therapies. Tumor infiltration, obstructive nephropathy and chemotherapies nephrotoxicity are some ways in which cancer can affect the kidney function [2]. Patients who have cancer are more susceptible to develop chronic kidney disease requiring dialysis treatment [3]. Dra. Elizabeth De Francisco Daher 1198, Vicente Linhares Street Aldeota Fortaleza, Ceará (Brazil) E-Mail ef.daher @ uol.com.br
Hemodialysis patients are at greater risk of developing malnutrition and persistent systemic inflammation. These abnormalities frequently coexist comprising the malnutrition-inflammation score (MIS). MIS is associated with disease outcomes, such as health-related quality of life (HRQoL) and sleep quality and mortality in hemodialysis patients [4–6]. It is well established that patients undergoing dialysis have a poor HRQoL, a high prevalence of sleep disturbances and high malnutrition-inflammation scores [7, 8]. Inflammation appears to play a crucial role in determining HRQoL in cancer patients and are reported to predict mortality and hospitalization in maintenance haemodialysis [9–12]. The presence and interactions of these two chronic conditions (cancer and dialysis-dependent chronic kidney disease) are likely to negatively impact the emotional and psychological well-being of patients [7, 8]. Despite the growing prevalence of cancer among patients under maintenance hemodialysis, no study has so far assessed HRQoL, depression and sleep disturbances in this special group of patients. Moreover, the restless legs syndrome (RLS) is a disorder of sensory-motor character. It has been described to affect between 5% and 10% of the dialysis population and that is associated with sleep disturbances that may be harmful to the quality of life of patients on dialysis treatment [13]. The RLS evaluation becomes important in this study because it interferes negatively with the overall result of HRQoL and quality of sleep. Therefore, the aims of the present study, was to compare HRQoL, levels of depression, sleep quality and RLS of hemodialysis patients with or without cancer and to analyze associations with MIS.
HRQoL and depression assessment. The validated Brazilian population version of the Short Form-36 (SF-36) questionnaire was used. This scale covers eight domains, four physical and four emotional ones. Each domain is scored on a scale of 0–100, with a higher score representing better HRQoL. These scales are aggregated into a physical composite score (PCS) and a mental composite score (MCS) [14]. Depression was evaluated with the validated Brazilian population version of the 17-item Hamilton depression rating scale (HAMD) [15]. The questionnaire has a scale that classifies degrees of depression according to these criteria: score lower than 6 – without mood swings/normal; from 7 to 17 – slightly depressed; from 18 to 24 – moderately depressed; above 25 – seriously depressed. RLS was investigated according to the criteria of the International RLS Study Group (IRLSG) [16]. This scale has been validated for Brazilian patients [17]. Sleep quality was evaluated by the Pittsburgh Sleep Quality Index (PSQI) [18]. This scale has seven components, each one dealing with a major aspect of sleep based on the quality, latency, duration and effectiveness of sleep, use of medicines and somnolence. Individuals with a PSQI score >6 were considered poor sleepers. The MIS has 4 sections (nutritional history, physical examination, BMI, and laboratory values) and 10 components. Each component has 4 levels of severity, from 0 (normal) to 3 (severely abnormal). The sum of all 10 MIS components range from 0 (normal) to 30 (severely malnourished); a higher score reflects a more severe degree of malnutrition and inflammation (table 1). The 5 nutritional history-based components include weight change, dietary intake, gastrointestinal symptoms, functional capacity, and comorbid conditions. In the present study, dialysis vintage was not included in the comorbidity component. The 2 physical examination components consist of assessment of subcutaneous body fat and signs of muscle wasting. In addition to the foregoing 7 subjective global assessment of nutrition-based components, the 3 MIS-unique sections include BMI (>20, 18– 19.99, 16–17.99, and
Blood Purif 2014;38:46–54 DOI: 10.1159/000362669
Cancer Patients under Maintenance Hemodialysis: Relationship between Quality of Life, Depression, Sleep Quality and Malnutrition-Inflammation Score Juliana Ramiro Luna Castro a Geraldo B. Silva Junior b André Ferrer Carvalho a Thomas N. Hyphantis d Luiza de Andrade Braga Farias c Alexandre B. Libório a Elizabeth F. Daher a
a Post-Graduation Program in Medical Sciences, Federal University of Ceará, b School of Medicine, Master in Collective Health, Health Sciences Center, University of Fortaleza, c UNIFOR, Universidade de Fortaleza, Fortaleza, Ceará, Brazil; d Department of Psychiatry, Medical School, University of Ioaninna, Ioaninna, Greece
Key Words Cancer · Hemodialysis · Quality of life · Depression · Sleep quality · Malnutrition-inflammation score
Abstract Background: The kidney is one major organ affected by cancer and its associated therapies. The aim of this study was to compare the levels of depression, quality of life and sleep quality in hemodialysis patients with or without cancer, and to analyze the associations with the malnutrition-inflammation score (MIS). Patients and Methods: In this cross-sectional study, 40 cancer patients under hemodialysis and 44 patients under hemodialysis without cancer who served as the control group were included. Participants underwent structured interviews to investigate depression, quality of life, sleep quality and restless legs syndrome. Results: Hemodialysis patients with cancer had a greater depression score (16.5 ± 4.8 vs. 10.8 ± 5.2, p < 0.001). Patients had similar physical and mental composite quality of life scores. Patients under hemodialysis with cancer had poor quality of sleep (mean score 8.8 ± 3.5 vs. 6.4 ± 4.1, p = 0.011) and a higher prevalence of restless leg syndrome (55.9 vs. 25.7%, p =
© 2014 S. Karger AG, Basel 0253–5068/14/0381–0046$39.50/0 E-Mail [email protected] www.karger.com/bpu
0.011). These features were associated with MIS in patients without cancer but not in patients with cancer. Conclusion: Cancer patients undergoing hemodialysis present a higher prevalence of depression, poor quality of life, sleep disorders; however, associations of these features with MIS are different in hemodialysis patients with or without cancer. These findings can change the clinical approach to these pa© 2014 S. Karger AG, Basel tients.
Introduction
Cancer treatment has significantly improved over the past years; thus, an increased number of patients with cancer survive and live with the residual effects of their cancer and its associated treatment [1]. The kidney is one major organ affected by cancer and its associated therapies. Tumor infiltration, obstructive nephropathy and chemotherapies nephrotoxicity are some ways in which cancer can affect the kidney function [2]. Patients who have cancer are more susceptible to develop chronic kidney disease requiring dialysis treatment [3]. Dra. Elizabeth De Francisco Daher 1198, Vicente Linhares Street Aldeota Fortaleza, Ceará (Brazil) E-Mail ef.daher @ uol.com.br
Hemodialysis patients are at greater risk of developing malnutrition and persistent systemic inflammation. These abnormalities frequently coexist comprising the malnutrition-inflammation score (MIS). MIS is associated with disease outcomes, such as health-related quality of life (HRQoL) and sleep quality and mortality in hemodialysis patients [4–6]. It is well established that patients undergoing dialysis have a poor HRQoL, a high prevalence of sleep disturbances and high malnutrition-inflammation scores [7, 8]. Inflammation appears to play a crucial role in determining HRQoL in cancer patients and are reported to predict mortality and hospitalization in maintenance haemodialysis [9–12]. The presence and interactions of these two chronic conditions (cancer and dialysis-dependent chronic kidney disease) are likely to negatively impact the emotional and psychological well-being of patients [7, 8]. Despite the growing prevalence of cancer among patients under maintenance hemodialysis, no study has so far assessed HRQoL, depression and sleep disturbances in this special group of patients. Moreover, the restless legs syndrome (RLS) is a disorder of sensory-motor character. It has been described to affect between 5% and 10% of the dialysis population and that is associated with sleep disturbances that may be harmful to the quality of life of patients on dialysis treatment [13]. The RLS evaluation becomes important in this study because it interferes negatively with the overall result of HRQoL and quality of sleep. Therefore, the aims of the present study, was to compare HRQoL, levels of depression, sleep quality and RLS of hemodialysis patients with or without cancer and to analyze associations with MIS.
HRQoL and depression assessment. The validated Brazilian population version of the Short Form-36 (SF-36) questionnaire was used. This scale covers eight domains, four physical and four emotional ones. Each domain is scored on a scale of 0–100, with a higher score representing better HRQoL. These scales are aggregated into a physical composite score (PCS) and a mental composite score (MCS) [14]. Depression was evaluated with the validated Brazilian population version of the 17-item Hamilton depression rating scale (HAMD) [15]. The questionnaire has a scale that classifies degrees of depression according to these criteria: score lower than 6 – without mood swings/normal; from 7 to 17 – slightly depressed; from 18 to 24 – moderately depressed; above 25 – seriously depressed. RLS was investigated according to the criteria of the International RLS Study Group (IRLSG) [16]. This scale has been validated for Brazilian patients [17]. Sleep quality was evaluated by the Pittsburgh Sleep Quality Index (PSQI) [18]. This scale has seven components, each one dealing with a major aspect of sleep based on the quality, latency, duration and effectiveness of sleep, use of medicines and somnolence. Individuals with a PSQI score >6 were considered poor sleepers. The MIS has 4 sections (nutritional history, physical examination, BMI, and laboratory values) and 10 components. Each component has 4 levels of severity, from 0 (normal) to 3 (severely abnormal). The sum of all 10 MIS components range from 0 (normal) to 30 (severely malnourished); a higher score reflects a more severe degree of malnutrition and inflammation (table 1). The 5 nutritional history-based components include weight change, dietary intake, gastrointestinal symptoms, functional capacity, and comorbid conditions. In the present study, dialysis vintage was not included in the comorbidity component. The 2 physical examination components consist of assessment of subcutaneous body fat and signs of muscle wasting. In addition to the foregoing 7 subjective global assessment of nutrition-based components, the 3 MIS-unique sections include BMI (>20, 18– 19.99, 16–17.99, and
