|Year : 2018 | Volume
| Issue : 2 | Page : 73-75
Consultation liaison with nephrology
Neena S Sawant
Department of Psychiatry, Seth GSMC and KEM Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||30-Nov-2018|
Neena S Sawant
Department of Psychiatry, Seth GSMC and KEM Hospital, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sawant NS. Consultation liaison with nephrology. Ann Indian Psychiatry 2018;2:73-5
A psychiatrist usually has a liaison with the nephrologist on various occasions, more often when the patient has gone into delirium while undergoing dialysis or if the patient has been diagnosed with kidney disease and is unable to cope with a history of treatment nonadherence or more commonly for a pre-organ transplant fitness.
Chronic kidney disease (CKD) is currently a growing global health problem with increasing incidence and prevalence and a huge burden on health-care services. Although renal diseases may have an acute onset, it is the chronic progressive course that worsens the prognosis and health-care costs. Chronic renal failure is an irreversible and progressive kidney failure where the body is unable to maintain the metabolic and electrolytic balance which then results in complications such as uremia, metabolic acidosis, anemia, electrolyte imbalances, and endocrine disorders. The most common causes of CKD worldwide include diabetes, hypertension, glomerulonephritis, and polycystic kidney disease.
Although longitudinal studies from India are not available, with the increase in the prevalence of diabetes and hypertension estimated by 2030, there would be a distinct rise in CKD.,
Apart from this several other factors, which can cause a significant rise in CKD, include as follows:
- Birth weight of around 2.5 kg
- Hypovitaminosis A with other nutritional deficiencies during pregnancy. This may cause smaller kidney volume at birth and a lower estimated glomerular filtration rate
- Consanguinity which still exists in India leading to several genetic diseases and a high risk for congenital anomalies of the kidney and urinary tract and obstructive or reflux nephropathy
- Social and environmental factors such as poverty, poor sanitation, high prevalence of air, water and soil pollution, overcrowding, and poor health facilities in towns/rural places
- Widely prevalent alternative medicine practices in which there is use of known and unknown nephrotoxins such as heavy metals and plant toxins which often lead to glomerular and interstitial kidney diseases.
In India, there are reports of CKD of unknown etiology in some parts of the states of Andhra Pradesh, Odisha, and Goa which are a chronic interstitial nephropathy with insidious onset and slow progression. All these factors will impact the prevalence and outcomes of CKD in future.
Despite this growing problem, the number of CKD patients seeking psychiatric assessment is mostly for pre-organ transplant fitness. Some of the patients may have a neuropsychiatric manifestation with agitation and confusion, during dialysis when the psychiatrist would be called for an emergency consult. Very few patients of CKD come forth for the stress, they are undergoing as most accept it as a part of their life. The treatment of CKD also involves a massive lifestyle change as compared to other chronic illnesses, and hence, the patient is at risk to develop comorbidities.
| Stressors|| |
The various stressors seen in patients of CKD include:,
- Knowledge of the illness
- Prognosis of the underlying condition
- Treatment options
- Stress of undergoing dialysis
- Medications and their effects/side effects
- Maintaining the nephrogenic diet
- Caregiver burnout and burden
- Financial burden
- Lack of social support
- Changes in social and marital relationships
- Uncertainty about future
- Difficulty in maintaining employment
- No leisure time
- No vacation for self and family due to the treatment regime
- Fear of disability/death
- Regular emergency hospital admissions
- Sometimes dependence on artificial kidney machines
- Dependence on health professionals.
Patients try to cope with all these issues, but due to their continuous nature, lack of communication of their complaints to the treating physician and lack of awareness about psychopathology in CKD by the treating doctor may result in worsening of the existing psychopathology or lead to newer psychiatric disorders.
| Psychiatric Disorders in CKD|| |
The most common causes for delirium in renal failure include uremia, aluminum toxicity, electrolyte disturbances, acid-base disorders, and dialysis disequilibrium syndrome (DDS). DDS is caused by a sudden correction in azotemia and a consequent change in pH and osmotic pressure. It is characterized by headaches, nausea, cramps, delirium, epileptic seizures, and coma. It usually sets in 3–4 h after the start of dialysis and lasts for nearly 8–48 h even after the end of dialysis.
Uremia is a syndrome due to the accumulation of nitrogen compounds. Apart from the symptoms of delirium, the patient has an altered state of consciousness leading to coma. Fluctuating clinical signs with headache, visual disturbances, tremor, multifocal myoclonus, and epileptic seizures are frequently present.
Patients of CKD can develop dementia due to underlying comorbidities of diabetes and hypertension, but there is another condition which can cause cognitive deficits. A progressive neurological syndrome called “dialysis dementia” has been established in those patients on dialysis for more than a year. This syndrome is characterized by dysarthria, dysphagia, and global dementia with a risk of death in 6–12 months if not treated properly. The most widely accepted pathophysiology of dialysis dementia revolves around toxicity of the aluminum salts found in dialysis fluids. Currently, the use of preventive measures such as discontinuation of the use of aluminum salts in dialysis fluids has now led to a significant reduction in the number of cases.
Several researchers have found depression to be the most common psychopathology in CKD patients with a meta-analysis finding the prevalence to be around 20%. Patients on hemodialysis showed a higher prevalence of nearly 44.8%., A study by Kumar et al. published in this issue has reported a higher prevalence of about 61% depression in males >80 years of age which adds to the information on the recent trends of psychopathology in Indian patients suffering from renal disease. However, many cases may be undiagnosed and untreated. This could be because the somatic complaints of depression would be missed for the anorexia, lassitude, and sleep disorders due to CKD itself. Hence, it is important to ask for the sadness of mood, hopelessness, helplessness, and suicidal ideations. Sometimes, patients may miss dialysis sessions and may binge on potassium-rich foods and could also be actively suicidal due to their emotional state. Hence, these symptoms should be evaluated. In general, selective serotonin reuptake inhibitors are preferred, but patients should be watched for signs of toxicity. Cognitive behavior therapy has also been found useful for symptom profile and improving patient adherence to treatment.
The symptoms of anxiety such as breathlessness, palpitations, intense worrying, panicky feeling, and chest pain are commonly seen in patients of CKD and those undergoing dialysis. Studies have reported the prevalence to be around 28%–45% with mostly the anxiety being untreated. Due to chronicity of the illness, many patients accept anxiety as a part of life. The treatment of anxiety and acute panic states can be done by giving benzodiazepines such as lorazepam or oxazepam, but caution has to be administered as they have a tendency to cause dependence and may also cause a delirium-like picture. Sometimes, insomnia may be severe, and so zolpidem and zaleplon have also been considered.
Although research studying personality dysfunctions in CKD is limited, a study by Koutsopoulou et al. found that patients who on dialysis exhibited traits of alexithymia, neuroticism, introversion, and psychotism. Organ transplant centers globally have reported the incidence of personality disorders to be around 10%–26% with borderline personality disorders carrying a high risk of posttransplant noncompliance and strained social relationships.,
Fatigue is one of the most common symptoms seen in 50% of adults and 25% of children and adolescents with CKD. Fatigue develops due to the circulating endotoxins, inflammatory cytokines, and increased oxidative stress. Fatigue is also a symptom of depression, sleep disturbance, and poor quality of life.
Moreover, fatigue has also been established as a predictor for cardiovascular events, independently from other known risk factors. Hence, it is necessary that correction of anemia and treatment of the underlying depression is carried out to improve the prognosis.
Some cases of CKD, especially those due to genetic causes, could have comorbid intellectual disability. Although there is no treatment of the same, it could hinder the organ transplant process as some transplant centers in the US do consider an IQ 70–90 and IQ <70, respectively, as an absolute contraindication for transplantation.
There is a high prevalence of substance use disorders, especially nicotine and alcohol among patients in liver organ transplant centers. Not many studies on substance use in kidney diseases are there. There are centers which debate on doing an organ transplant in cases of substance use as there is a high risk of posttransplant substance relapse resulting in direct damage to transplanted organ, decreased efficacy of ongoing medical treatment, increased risk for cancer, and nonadherence to treatment which finally result in death.
Role of the psychiatrist in renal transplant
Today organ transplant centers have a multidisciplinary team for assessment for fitness for transplant surgery. The psychiatrist is a part of the team, and it is mandatory for every patient to be assessed before the transplant surgery. The patient may be taken up for cadaver or live donor transplant. Hence, both the recipient and donor undergo assessment for psychopathology, coping and understanding the psychosocial problems and financial constraints. The psychiatrist evaluates for the ability of the patient to provide informed consent, to collaborate with the transplant team and adhere to treatment, to maintain abstinence from substance use problem, and to maintain healthy behaviors for better transplant outcomes.
Psychological testing is also done by some centers in most of the cases. If the donor or recipient has any psychiatric disorder, then they need to be treated as an untreated psychiatric disorder could worsen in the postoperative phase and have an impact on treatment adherence. An early diagnosis and intervention for psychopathology help in improving the posttransplant outcome.
| Conclusions|| |
In India, the facilities for dialysis and renal transplant are not available everywhere. Hence, patients have to travel to cities. Awareness about CKD is lacking among physicians and general public due to which the global burden is on the increase. CKD prevention and delaying progression by timely interventions are the need, with improving cadaveric organ donation in the country. Improving consultation-liaison and having private and government partnerships for organ sharing would definitely help to reduce the gap between donor need and availability.
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