End – Stage Renal Disease (ESRD) – Diversity, Mental Health Conditions, Social and Economic Impact (part 2)

Diversity and Difference in Practice

Culture, age, sexual orientation, socio-economic status and gender all must be taken into consideration when working with patients suffering from ESRD. The African-American population is four times as likely to develop ESRD compared to Caucasian individuals suffering from the same condition (Atkinson, Neu, Fivush, & Frankenfield, 2008) (Crews et al., 2010). Additionally, African-Americans have poorer intermediate outcomes when compared to Caucasians. In reference to gender, previous research shows that the outcomes for women diagnosed with ESRD are also generally poorer compared to males, especially when it comes to anemia and nutrition (Atkinson et al., 2008). If patients fail to meet their targeted goals (hemoglobin goals in particular), their risk of hospitalization and mortality rates has been shown to steadily increase (Atkinson et al., 2008).

In reference to age, research has found that African American children struggle more to reach the desired hemoglobin goals compared to Caucasian children (Atkinson et al., 2008). Additionally, the effects of low socio-economic status has been linked to African-American patients, but not Caucasian patients (Crews et al., 2010). Access to medical treatment should also be taken into consideration. Patients diagnosed with End-Stage Renal Disease have legitimate concerns when it comes to meeting Medicare Part D coverage and the gap that exists when it comes to the purchasing of dialysis related medications (Kovacs, Perkins, Nuschke, & Carroll, 2012). Since 2010 Medicare Plan D is structured in such a way as to pay for at least 75% of the first $2,830, and 95 % of the medications exceeding $6,440 in cost (Kovacs et al., 2012).  The plan however provides no cost coverage for expenses that fall in-between the lower and higher spending limits. Not having access to medications due to the inability to afford them financially leads half of the studied participants in Kovacs et al.’s (2012) study to discontinue taking their medications altogether.  Vocational status has been found to have an impact in reference to patients’ adjustment and coping with ESRD (Billington et al., 2008)

Mental Health Conditions and ESRD

Individuals diagnosed with ESRD are treated by an interdisciplinary team to address the issues and concerns that have. Generally, a two-fold approach is needed in order to assist clients with their physical condition as well as evaluate any potential concerns relating to their mental condition. According to Cukor (2007), patients diagnosed with ESRD receive limited psychiatric services. Billington et al. (2008) report that ESRD clients often struggle with anxiety and depression. Research shows that 20 to 30% of patients diagnosed with ESRD suffer from depression (Cukor, 2007). Depression is the second most common co-morbid disorder with ESRD patients, second only to hypertension (Cukor, 2007).

Anti-depressants are an option and even though they are safe enough for ESRD clients, medical professionals and patients themselves are generally apprehensive to add depression medications to their course of treatment (Cukor, 2007). New Selective Serotonin Reuptake Inhibitors (SSRI) have shown less aversive side effects when treating depression, however they may influence some uremic symptoms (Chilcot, Wellsted, & Farrington, 2010). Patients are generally hesitant to take anti-depressants for fear of the side effects and potential interactions with the variety of drugs they are already taking (Duarte, Miyazaki, Blay, & Sesso, 2009)

A variety of evidence-based interventions have been attempted throughout the years with the renal population. Cognitive-behavioral therapy (CBT) has been established as the leading therapeutic intervention with clients who suffer from ESRD (Duarte et al., 2009). Clients with a depressed mood typically exhibit an avoidant behavior; they lose interest in doing things and their treatment compliance decrease (Duarte et al., 2009). According to Cukor (2007), CBT is an effective approach with the ESRD clients as it attempts to address and minimize the issues they are facing, doing so in an efficient, time-limited manner.

The goal of CBT with patients diagnosed with ESRD is to assist them in modifying the activities they previously enjoyed (Cukor, 2007). Cukor (2007) reports that clients often held the negative belief that depression comes with ESRD and is “part of the package”. This view is not only erroneous but also exemplifies the dysfunctional thinking that is prevalent within this population. Cukor (2007). The CBT approach helps patients to identify this negative thought pattern and make appropriate and healthy changes in their behavior.

A study performed by Cukor (2007) shows significant reductions in the depressed mood of patients who underwent 15 weeks of individual CBT sessions. The study aimed to address the restructuring of clients’ negative thought process as well promoting behavioral activation (Cukor, 2007). The results were significant, not only at the end of the 15 week treatment program (there was a 10 point decrease on Beck Depression Inventory), but after a three month follow up the results remained steady and even dropped slightly (Cukor, 2007).

Research has also shown that joining a peer support group has been very helpful for patients suffering from ESRD. Hughes, Wood and Smith (2009) report that patients benefit greatly when they can be a part of a group where they can interact and learn about their kidney disease. Invariably the patient also gains strength from this interaction. Research performed by Patel et al., (2005) with Canadian participants show a 4.6 month delay prior to the initiation of renal replacement therapy when a social support intervention was implemented.

Although evidence-based practice is very important, timing is also key. Research has shown that the most suitable time for a psychosocial intervention is during the actual hemodialysis treatment for those patients receiving in-center dialysis (Cukor, 2007). Since hemodialysis lasts on average four hours per treatment, a portion of this time can be allocated for psychosocial interventions.

Being diagnosed with ESRD is a traumatic and often scary experience regardless of the individual’s cultural background. It should be noted that CBT has been the primary choice of treatment not only in the United States, but also in Brazil and even Taiwan (Duarte et al., 2009). For instance, renal patients in Brazil have shown significant improvement in their depressive symptoms after months three and nine when compared to the control group (Duarte et al., 2009). A study conducted in Taiwan shows that through CBT sessions ESRD patients were able to improve the quality of their sleep (Duarte et al., 2009). Hence, this treatment modality has shown effectiveness not only in the Western world, but also in countries where the quality of live and patients’ socio-economic status differs significantly when compared to the United States.

 Social and economic impact

When healthcare access is limited, health disparities will be imminent (Williams, 2015). Research has established that African-American individuals are less likely to have access to medical insurance which in turn leads to less access to qualified medical care (Williams, 2015). According to Williams (2015). This inadequate access to care has been linked to an increased probability of developing chronic kidney disease. Moreover, low socio-economic status in addition to increased costs and the manner in which ESRD rapidly develops have all been attributed to delayed referrals to nephrologists (Williams, 2015).

As Nicholas, Kalantar-Zadeh and Norris (2015) reports; diabetes and hypertension are the main risk factors associated with chronic kidney disease which is believed to be attributable to ethical, racial and gender differences. In recent years however, SES has shown to have a greater influence with ESRD. For instance, a study evaluating almost 80,000 Caucasian and African-American participants found that those who made less than $15,000 a year had a 50% chance of developing ESRD (Nicholas et al., 2015). This number was 3.5 times greater for the African-American participants (Nicholas et al., 2015).

In addition to low SES, homelessness is another factor associated with developing ESRD (Nicholas et al., 2015). A study examining 15,000 individuals living in urban areas with mostly SES found that 858 of them were homeless, with high depression and rampant substance abuse. (Nicholas et al., 2015). After a three year follow up and thorough research it was determined that they had a 28% probability of acquiring ESRD and dying (Nicholas et al., 2015).

Lack of insurance is another independent risk factor that contributes to the development of ESRD especially in the low-income populations (Nicholas et al., 2015). Additionally, having health insurance does not necessarily ensure that all medical costs will be covered. For instance, Williams (2015) argues that a high deductible and high premiums are significant concerns for low-income individuals.

Individuals who are undocumented and who do not meet the eligibility criteria to enroll in a public health care exchange program generally do not have access to quality medical care (Williams, 2015). Data suggests that foreign-born residents living in the Unites states are three times as likely to not have access to insurance compared to United States residents (Williams, 2015). The same author reports that Medicaid eligibility criteria varies from state to state with foreign born residents having risk factors for ESRD and other health related disorders (Williams, 2015).

 

References:

Atkinson, M. A., Neu, A. M., Fivush, B. A., & Frankenfield, D. L. (2008). Disparate outcomes in pediatric peritoneal dialysis patients by gender/race in the End-Stage Renal Disease Clinical Performance Measures project. Pediatric Nephrology, 23(8), 1331-1338. doi:10.1007/s00467-008-0832-z

Billington, E., Simpson, J., Unwin, J., Bray, D., & Giles, D. (2008). Does hope predict adjustment to end-stage renal failure and consequent dialysis?. British Journal Of Health Psychology, 13(4), 683-699. doi:10.1348/135910707X248959

Blake, A., Toker, S., Dickerman, R., & Dunn, E. (2002). Trauma management in the end-stage renal disease patient. The American Surgeon, 68(5), 425.

Brown, E. A., & Johansson, L. (2011). Epidemiology and management of end-stage renal disease in the elderly. Nature Reviews Nephrology, (10), 591.

Chilcot, J., Wellsted, D., & Farrington, K. (2010). Depression in End-Stage Renal Disease: Current Advances and Research. Seminars In Dialysis, (1), 74.

Crews, D. C., Charles, R. F., Evans, M. K., Zonderman, A. B., & Powe, N. R. (2010). Original Investigation: Poverty, Race, and CKD in a Racially and Socioeconomically Diverse Urban Population. American Journal Of Kidney Diseases, 55992-1000. doi:10.1053/j.ajkd.2009.12.032

Cukor, D. P. (2007). Use of CBT to Treat Depression Among Patients on Hemodialysis. Psychiatric Services, (5), 711. doi:10.1176/ps.2007.58.5.711

Duarte, P. S., Miyazaki, M. C., Blay, S. L., & Sesso, R. (2009). Cognitive–behavioral group therapy is an effective treatment for major depression in hemodialysis patients. Kidney International, 76(4), 414-421. doi:10.1038/ki.2009.156

Hackett, A. S., & Watnick, S. G. (2007). Withdrawal from Dialysis in End-Stage Renal Disease: Medical, Social, and Psychological Issues. Seminars In Dialysis, 20(1), 86-90. doi:10.1111/j.1525-139X.2007.00249.x

Hughes, J., Wood, E., & Smith, G. (2009). Exploring kidney patients’ experiences of receiving individual peer support. Health Expectations: An International Journal Of Public Participation In Health Care & Health Policy, 12(4), 396-406. doi:10.1111/j.1369-7625.2009.00568.x

Jansen, D. L., Heijmans, M., Rijken, M., & Kaptein, A. A. (2011). The development of and first experiences with a behavioural self-regulation intervention for end-stage renal disease patients and their partners. Journal Of Health Psychology, 16(2), 274-283. doi:10.1177/1359105310372976

Kovacs, P. p., Perkins, N., Nuschke, E., & Carroll, N. (2012). How End-Stage Renal Disease Patients Manage the Medicare Part D Coverage Gap. Health & Social Work, 37(4), 225-233

Low, J., Smith, G., Burns, A., & Jones, L. (2008). The impact of end-stage kidney disease (ESKD) on close persons: a literature review. NDT Plus, 1(2), 67-79. doi:10.1093/ndt-plus/sfm046

Nicholas, D. B., Picone, G., & Selkirk, E. K. (2011). The lived experiences of children and adolescents with end-stage renal disease. Qualitative Health Research, 21(2), 162-173. doi:10.1177/1049732310382789

Nicholas, S. B., Kalantar-Zadeh, K., & Norris, K. C. (2015). Article: Socioeconomic Disparities in Chronic Kidney Disease. Advances In Chronic Kidney Disease, 22(Socioeconomics, Disparities, and the Kidney), 6-15. doi:10.1053/j.ackd.2014.07.002

Patel, S. S., Peterson, R. A., & Kimmel, P. L. (2005). The Impact of Social Support on End-Stage Renal Disease. Seminars In Dialysis, 18(2), 98-102. doi:10.1111/j.1525-139X.2005.18203.x

Wells, J. R., & Anderson, S. T. (2011). Self-Efficacy and Social Support in African Americans diagnosed with End Stage Renal Disease. ABNF Journal, 22(1), 9-12 4p.

Wells, J. R., & Walker, C. A. (2012). Factors Influencing Adherence in African Americans with End Stage Renal Disease. Journal Of Theory Construction & Testing, 16(2), 52-56.

Williams, A. W. (2015). Article: Health Policy, Disparities, and the Kidney. Advances In Chronic Kidney Disease, 22(Socioeconomics, Disparities, and the Kidney), 54-59. doi:10.1053/j.ackd.2014.06.002

End-Stage Renal Disease (ESRD) – Diagnoses, Progression and Treatment (part 1)

Brief Epidemiology of End- Stage Renal Disease (ESRD)

End-stage renal disease (ESRD) is the final stage of kidney failure that affects at least 230,000 individuals in the United States (Blake, Toker, Dickerman & Dunn, 2002). Some of the primary causes of ESRD include diabetes (34.47%), hypertension (25.1%), glomerulonephritis (16.4%), Cystic Kidney (4.69%) and 16.39% are due to unknown or miscellaneous causes (National Kidney Foundation, 2016). With older age additional age-related comorbid diseases also come into play (Brown and Johansson, 2011).

Disease progression and treatment

ESRD is the final stage of kidney failure. There are two types of ESRD treatment: dialysis and kidney transplant. Dialysis treatments consist of the removal of toxins and extra fluid from the body (Billington, Simpson, Unwin, Bray, & Giles, 2008). The NKF (2016) reports that more than 193,000 patients currently living in the United States have had a kidney transplant. Although a kidney transplant is the most desired type of Replacement Real Therapy (RRT), kidney transplant donors are generally limited with the organs typically “reserved” for the healthies of ESRD individuals (Billington et al., 2008).  To add to that, there is also a very high rate of transplant failure averaging 61% (Billington et al., 2008).

Since obtaining a kidney transplant is not a viable options for all patients, a hemodialysis treatment have been one of the most commonly used approaches for individuals diagnosed with ESRD to maintain their conditions over time (Billington et al., 2008).  The National Institute of Diabetes and Digestive and Kidney Disease (2016) reports that from the 398,861 patients who suffer from ESRD, the vast majority undergo hemodialysis (HD) treatments at a clinic as compared to those who employ peritoneal dialysis (PD) and home HD treatments combined. Brown and Johansson (2011) bring attention to the fact that even though the default treatment approach to chronic kidney disease is an in-center hemodialysis treatment, research has found that peritoneal dialysis has shown better results especially with the elderly population. Patients who are under peritoneal dialysis are able to travel, they are able to have their treatments at their convenience in their own home, and they skip the trips to the hemodialysis clinics and generally enjoy an active social life (Brown & Johansson, 2011).

Patel, Peterson and Kimmel (2005) described the limitations that patients undergoing hemodialysis treatments experience. For instance, patients are unable to work and travel, and they also have limited interactions with family and friends (Patel, Peterson &Kimmel, 2005). Additionally, the same authors also point to correlations between social support, depression and mortality rates, and the patient’s compliance with their medical treatment (Patel, Peterson & Kimmel, 2005). Wells and Anderson (2011) argue that ESRD clients whose results rate high on social support and self-efficacy have the potential to improve their health outcomes and are better able to cope with the stressors caused by ESRD. When it comes to ESRD, compliance with treatment is indeed crucial (Wells & Walker, 2012). Research shows that older adults tend to be more adherent to treatments especially regarding intradialytic weigh gain (IDWG) and potassium levels (Wells & Walker, 2012).  

Knowledge of human behavior and the social environment

When clients are diagnosed with ESRD there are typically in shock and denial. Being diagnosed with a ESRD is a traumatic experience, there’s no question about it. Individuals are already in frail conditions, and admit that thoughts about possible death plagued them for a while. Feelings of hopelessness and helplessness for a long period of time after the initial discovery are also common. It is not surprising to hear that during that stage, patients feel drained from the constant worry about their future, children and loss of job income.

As typically occurs with patients who have been diagnosed with a debilitating condition, once the shock and denial phase passes, clients are able to adjust their life to a point where they are able to accept their situation. From not wanting to discuss their hemodialysis treatments with friends or family, a topic already addressed by Nicholas, Picone and Selkirk’s study (2011), patients do overcome their feelings of fear and hopelessness. Some of them even become advocates, able to encourage and motivate patients who are newly diagnosed with ESRD.

It is not uncommon for patients to give up their businesses or leave work as the disease makes it impossible for them to perform daily tasks. The three hemodialysis’ treatments per week are very exhausting, with clients feeling extremely sick and unable to cope not only with the treatment itself, but also with the dietary and fluid restrictions. And in fact, ESRD is a brutal disease leaving patients wondering if they would be better off without treatment. Hackett and Watnick (2007) report that the third leading cause for mortality in the dialysis population has been found to be the withdrawal from medical treatment. This holds true for some patients who report that at times they did not believe they could make it and has had to “lean on” their families for courage and support. 

Theoretical framework for those individuals diagnosed with ESRD

The self-regulation theory is based on the famous Leventhal’s Common Sense Model (CSM). According to Jansen, Heijmans, Rijken and Kaptein (2011) when people are faced with a health related threat, they make cognitive representations relating to that threat. These cognitive schemas include several categories such as the name and related symptoms of the illness; what causes the disease and how long it would last, and what the personal consequences would be for both the individual and his or her mate (Jansen et al., 2011). The cognitive schemas created by patients influence how they will be able to cope with the illness not only psychologically but also emotionally. 

According to the Self-Determination theory (SDT), individuals function at their prime level when autonomy drives them to fulfil desired goals and it also brings psychological health (Jansen et al., 2011).  When an individual’s sense of autonomy is being deprived, feelings of loss and low-self-esteem come in to play and their self-worth being questioned (Jansen et al., 2011).  Autonomy is an important factor when dealing with patients on dialysis. Research has found that patients on dialysis feel limited autonomy due to the fact that they do not have the freedom to engage in activities they would like to do because of their condition (Jansen et al., 2011).  Indeed, hemodialysis treatments are not only time consuming (4 hours treatments, three times per week) but also lead to patients feeling drained and washed out with little energy to stay active.

Social support is critical, when patients feel supported by family and friends they generally are more adherent to their dialysis treatment, which in turn may stimulate their sense of autonomy and self-worth (Jansen et al., 2011).  Having a healthy support system is indeed important. Low, Smith, Burns, and Jones, (2008) draw the parallel that even though it is known that caretakers who are in a healthy state of mind positively affect patients suffering from ESRD, little to no research has been done to address this relationship.

The final theory that helps us to better understand patients suffering from ESRD is the Social Learning theory by Bandura. This theory is based on the foundational strategies of self-efficacy and expectation of outcomes (Jansen et al., 2011). Patients have the potential to change negative thought patterns and maladaptive behaviors by using modeling, self-monitoring skills and problem-solving techniques (Jansen et al., 2011). This is especially crucial for ESRD patients in areas such as finding a job and feeling productive.  

For this and more information regarding dealing with ESRD, please stay tuned. Part 2 will be posted next week. 

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References

Atkinson, M. A., Neu, A. M., Fivush, B. A., & Frankenfield, D. L. (2008). Disparate outcomes in pediatric peritoneal dialysis patients by gender/race in the End-Stage Renal Disease Clinical Performance Measures project. Pediatric Nephrology, 23(8), 1331-1338. doi:10.1007/s00467-008-0832-z

Billington, E., Simpson, J., Unwin, J., Bray, D., & Giles, D. (2008). Does hope predict adjustment to end-stage renal failure and consequent dialysis?. British Journal Of Health Psychology, 13(4), 683-699. doi:10.1348/135910707X248959

Blake, A., Toker, S., Dickerman, R., & Dunn, E. (2002). Trauma management in the end-stage renal disease patient. The American Surgeon, 68(5), 425.

Brown, E. A., & Johansson, L. (2011). Epidemiology and management of end-stage renal disease in the elderly. Nature Reviews Nephrology, (10), 591.

Chilcot, J., Wellsted, D., & Farrington, K. (2010). Depression in End-Stage Renal Disease: Current Advances and Research. Seminars In Dialysis, (1), 74.

Crews, D. C., Charles, R. F., Evans, M. K., Zonderman, A. B., & Powe, N. R. (2010). Original Investigation: Poverty, Race, and CKD in a Racially and Socioeconomically Diverse Urban Population. American Journal Of Kidney Diseases, 55992-1000. doi:10.1053/j.ajkd.2009.12.032

Cukor, D. P. (2007). Use of CBT to Treat Depression Among Patients on Hemodialysis. Psychiatric Services, (5), 711. doi:10.1176/ps.2007.58.5.711

Duarte, P. S., Miyazaki, M. C., Blay, S. L., & Sesso, R. (2009). Cognitive–behavioral group therapy is an effective treatment for major depression in hemodialysis patients. Kidney International, 76(4), 414-421. doi:10.1038/ki.2009.156

Hackett, A. S., & Watnick, S. G. (2007). Withdrawal from Dialysis in End-Stage Renal Disease: Medical, Social, and Psychological Issues. Seminars In Dialysis, 20(1), 86-90. doi:10.1111/j.1525-139X.2007.00249.x

Hughes, J., Wood, E., & Smith, G. (2009). Exploring kidney patients’ experiences of receiving individual peer support. Health Expectations: An International Journal Of Public Participation In Health Care & Health Policy, 12(4), 396-406. doi:10.1111/j.1369-7625.2009.00568.x

Jansen, D. L., Heijmans, M., Rijken, M., & Kaptein, A. A. (2011). The development of and first experiences with a behavioural self-regulation intervention for end-stage renal disease patients and their partners. Journal Of Health Psychology, 16(2), 274-283. doi:10.1177/1359105310372976

Kovacs, P. p., Perkins, N., Nuschke, E., & Carroll, N. (2012). How End-Stage Renal Disease Patients Manage the Medicare Part D Coverage Gap. Health & Social Work, 37(4), 225-233

Low, J., Smith, G., Burns, A., & Jones, L. (2008). The impact of end-stage kidney disease (ESKD) on close persons: a literature review. NDT Plus, 1(2), 67-79. doi:10.1093/ndt-plus/sfm046

Nicholas, D. B., Picone, G., & Selkirk, E. K. (2011). The lived experiences of children and adolescents with end-stage renal disease. Qualitative Health Research, 21(2), 162-173. doi:10.1177/1049732310382789

Nicholas, S. B., Kalantar-Zadeh, K., & Norris, K. C. (2015). Article: Socioeconomic Disparities in Chronic Kidney Disease. Advances In Chronic Kidney Disease, 22(Socioeconomics, Disparities, and the Kidney), 6-15. doi:10.1053/j.ackd.2014.07.002

Patel, S. S., Peterson, R. A., & Kimmel, P. L. (2005). The Impact of Social Support on End-Stage Renal Disease. Seminars In Dialysis, 18(2), 98-102. doi:10.1111/j.1525-139X.2005.18203.x

Wells, J. R., & Anderson, S. T. (2011). Self-Efficacy and Social Support in African Americans diagnosed with End Stage Renal Disease. ABNF Journal, 22(1), 9-12 4p.

Wells, J. R., & Walker, C. A. (2012). Factors Influencing Adherence in African Americans with End Stage Renal Disease. Journal Of Theory Construction & Testing, 16(2), 52-56.

Williams, A. W. (2015). Article: Health Policy, Disparities, and the Kidney. Advances In Chronic Kidney Disease, 22(Socioeconomics, Disparities, and the Kidney), 54-59. doi:10.1053/j.ackd.2014.06.002