Anxiety, depression and emotional profile in renal transplant recipients and healthy subjects: a comparative study.

BACKGROUND: Renal transplantation is a well established treatment for end-stage renal disease. However, recipients have been shown to develop emotional distress and affective disorders, such as anxiety and depression, associated with a compromised quality of life. Some accounts report an improvement of affective disorders after transplantation, others draw opposite conclusion. METHODS: The present cross-sectional study selected 42 transplant recipients and 42 control subjects matched for gender, age, educational background, and marital status. Symptoms of anxiety, depression and general emotional profiles were compared using the Zung Self-Rating Anxiety Scale, the Beck Depression Inventory (BDI), and the Affective Neuroscience Personality Scale (ANPS), a self-report inventory that evaluates 6 neurally based affective tendencies: seeking, caring, and playfulness (positive affects) and fear, anger, and sadness (negative affects). RESULTS: No significant differences were observed between transplanted patients and controls in scores for anxiety and depression, as evaluated with Zung and BDI scales. However, transplanted patients scored significantly lower than control subjects in fear and anger scales and in general negative emotions. Transplant recipients did not display any symptom of anxiety or depression, however, a significant reduction in negative affect, evaluated through the ANPS scale revealed psychological distress. CONCLUSIONS: These findings suggest that affective profile in transplanted patients should be more extensively examined to review all facets in their mental and emotional assessment, especially regarding the role played by this emotional pattern in complying with medical treatment, which is well known to be a clinically critical feature of these patients.

[Should dialysis be for all? Yes indeed!]. / Ma la dialisi deve essere per tutti? Certo che si'!

Clinically compromised patients who must undergo chronic dialysis are, in general, at risk because the procedure can be difficult to perform and give poor results in terms of survival and of rehabilitation. However, it is dialysis of the very elderly which is routinely characterized by misgivings about the indication for and limits of the technique. Patients older than 75 years of age currently represent more than 35% of the population that begin dialysis in most European registries. In our center at least 30 very old patients begin dialysis every year, which represents 45% of the total incident patients. About 30% of these patients, because of severe physical and/or mental disability, often associated with a situation of social deprivation, rarely achieve true clinical stability and depend upon outside caregivers in order to survive. The treatment of these patients strains the resources of the health and social structure, as well as the Nephrology Division, whose organization can be disrupted by their urgent needs, such as hospitalization, transportation, convalescent care, etc. Despite these difficulties and a mean survival of only 28 months, the global clinical conditions of patients older than 75 years of age are not much different than patients in the age bracket of 65 to 75 years. In fact, excluding patients older than 85 years of age (a category which geriatricians consider separately), the survival and rehabilitation of the very elderly appear similar to those of patients 65 to 75 years of age. Many of the clinical problems of the dialyzed elderly, such as sensory, mental and functional impairment, are the result of advanced age per se rather than of uremia or of dialysis. Therefore, ethical considerations of dialysis and of health maintenance in the very elderly are similar to those presented by patients who are afflicted by other serious diseases such as cancer, heart failure, or extensive stroke. As a result of modern technology and the advancement of our clinical knowledge, it is difficult to conceive of a true motive to not dialyze a patient--whether very elderly or any other patient in critical conditions--except in situations of futility or the impossibility to attain a reasonable quality of life. Thus, the true nature of the debate regarding the indications or the limits of dialysis in developed countries is not economic, technical nor clinical, but ethical. The challenge for the Nephrologist is to balance the need to alleviate human suffering and the institutional support that society can offer, which is the "bottom line" which unifies dialysis for the very elderly with every other therapy which prolongs life in tenuous conditions.

[Frail elderly in hemodialysis]. / L'anziano fragile in dialisi.

A new category of patients aged >75 yrs, namely the elderly, is now being freely admitted to hemodialysis (HD) and this category is becoming predominant. The absence of systematic studies makes this patient category almost indistinguishable from other categories, even though its peculiarity is now evident. At least 30-40% of individuals in this age bracket are expected to be dependent and/or frail, but the incidence of frailty is likely to be higher in the elderly undergoing HD. Due to severe physical and/or mental impairment and often because of strong social hardships, these patients rarely experience clinical stability and are dependent on third parties for their survival. Their care produces complex problems for welfare services and this has proved responsible for modifying the organization of renal care units. These repeated patient admissions to hospital are filling nephrology facilities, and the dialysis management -- mainly concerning outpatients -- requires a much greater use of facilities and staff than normal if compared to average dialysis patients. In 112 elderly patients consecutively admitted to the dialysis program over a period of 10 yrs, we identified 35 dependent or frail patients (31.2%), even taking into consideration only extreme degrees of infirmity. Dependence proved to be the only clinical parameter associated with survival (mortality at 6 months 23.6 vs. 10.6%, p<0.01; Kaplan-Meier survival curves, p<0.03 log-rank test), while comorbidities -- in particular cardiovascular -- that usually affect dialysis mortality rates, did not seem to be discriminating risk factors in the elderly. More precisely, with the confirmation of these data through wider case studies, the idea will be reinforced that, also in dialysis, the elderly must be constantly monitored for dependence and frailty, as is the case in any exclusively geriatric field. Prevention, as well as a therapeutic approach specifically modeled on these conditions, could help to improve the prognosis of this patient category, which is particularly difficult to deal with and is becoming predominant in dialysis units.

[An atypical presentation of a case of Horton's giant-cell arteritis]. / L'atipica presentazione di un caso di arterite gigantocellulare di Horton.

Horton giant cell arteritis can present with an atypical clinical picture that often resembles other diseases. In the case described below, the patient initially demonstrated clinical and laboratory evidence of a Candida albicans sepsis, and therefore we started antimycotic treatment with amphotericin B. Because of an adverse reaction to that drug, we added parenteral steroids before every administration of the antimycotic which led to an unexpected improvement of symptoms. This result caused us to reconsider some clinical aspects that could have been interpreted also as vasculitis, in particular for a giant cell arteritis: throbbing temporal headache, diffuse weakness, important rise in ESR, myoarthralgias. We performed a biopsy of the temporal artery that confirmed our diagnosis.