Disappointment at proposed changes to chronic kidney disease quality standards

Here we quote a news item from the British Kidney Patients Association

We regularly work with the National Institute of Health and social Care Excellence (NICE) to add the perspective and views of kidney patients into their work. In 2011, the first ever CKD Quality Standards were produced, outlining markers of good quality for kidney care, including support for the patient’s mental as well as physical well-being, and recommending that a care planning discussion about treatment is held between the patient and doctor or nurse.

In 2017, NICE is reviewing the standards and have just put forward a proposal (external link). We're surprised to see that most of the standards have been removed and while we are all in favour of simplification we do not believe that removing the need for psycho-social support, or for a care planning discussion is the right thing to do for kidney patients.

We have made it clear that we want some of the previous standards to be retained and have worked closely with our colleagues in the Renal Association, British Renal Society, Renal Psychology Group and the renal services Clinical Reference group and they have also expressed these concerns in their responses to NICE.

We believe that people should be given information that’s appropriate for their kidney disease, and that the way in which they will be cared for should be documented and agreed with them. This standard should therefore remain. Furthermore we would like the standard recommending that “People with kidney failure have access to psychosocial support (which may include support with personal, family, financial, employment and/or social needs)” to be retained. Through our own work we fund much of this type of vital support for patients, yet NICE states that “the previous recommended quality standards are no longer considered national priorities for improvement but may still be useful at a local level”. This gives a disappointing and inaccurate message that these are not important for kidney patients. Something we know just simply isn’t true.

Antidepressants, Exercise, and Dialysis Patients

Having chronic kidney failure and being on dialysis is definitely depressing. But efforts to get these patients on antidepressants often fail, according to research published online in the Clinical Journal of the American Society of Nephrology.

Of 101 patients followed for ≤12 months, 39 met criteria for depression (Patient Health Questionnaire 9 score ≥10 on one or more assessments). These 39 patients had depression on 147 of 373 (39%) monthly assessments. At 103 of these 147 (70%) assessments, patients were receiving antidepressant therapy, and at 51 of 70 (70%) assessments, patients did not accept nurses’ recommendations to intensify treatment. At 44 assessments, patients with depression were not receiving antidepressant therapy, and in 40 (91%) instances, they did not accept recommendations to start treatment. The primary reason that patients refused the recommendations was attribution of their depression to an acute event, chronic illness, or dialysis (57%). In 11 of 18 (61%) instances in which patients accepted the recommendation, renal providers were unwilling to provide treatment.

Patients on chronic hemodialysis with depression are frequently not interested in modifying or initiating antidepressant treatment, commonly attributing their depression to a recent acute event, chronic illness, or dialysis. Renal providers are often unwilling to modify or initiate antidepressant therapy. Future efforts to improve depression management will need to address these patients- and provider-level obstacles to providing such care.

Interestingly, a second paper appeared in the very next issue of the journal, saying lower physical activity and depression are associated with hospitalization and shorter survival in CKD !

Physical activity or exercise training helps improve muscle strength and physical and mental function, including benefits on depressive symptoms, which affects at least 20%–30% of patients receiving maintenance hemodialysis (MD). Depression contributes to low quality of life and restricted living among patients with CKD. Thus, exercise can be an interesting intervention to reduce depression and hospitalization and improve quality of life in these patients. Physical activity is defined as any bodily movement produced by skeletal muscles that results in energy expenditure.

Overall, is exercise beneficial to patients with CKD? The answer is yes. Both physical activity and exercise are associated with improved outcomes in these patients. Although a limited number of studies have been reported, all differing by protocol, they show that aerobic and resistance training can improve physical functioning, quality of life, depressive symptoms, survival, or hospitalization