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Focus on the impact of new onset end stage renal disease on quality of life--case report.

INTRODUCTION

Glomerular diseases affect population of age 20 to 40 years but also elder ages [1]. The immunosuppressive treatment and lifestyle modifications affect more the Health Related Quality of Life (HRQoL) [2, 3]. Beyond lower HRQoL, the status of ill individual and feeling as a burden to family leads to depression. The connection between HRQoL and depressions has been established before [4].

The health-related quality of life (HRQoL) is an integrated concept that includes emotional, mental, physical and social function ing scales. It focuses on the impact of health status on quality of life, measuring the effects of chronic illness, treatments, and short and long-term disabilities [5].

The purpose of this article is to present the evolution of a patient until the correct diagnosis is established and adequate treatment is applied with favourable evolution, both physical and mental (documented by HRQoL, score SF-36 and depression score HAMD).

CASE REPORT

A 38 years old female presents with fatigue, fever (37.8-38.5 degrees), weight loss (four kg in two months), and articular pain (fist, elbow, and knee) especially during morning. She also experienced adynamia, fatigue, myalgias and slight depression.

Her family history is unremarkable. She only drinks socially and does not smoke. The personal pathological history is insignificant.

Clinical examination:

At clinical examination, patient looks ill, febrile (38,2[degrees]C) having a facial erythema appeared after return from the seaside two weeks ago and for this reason the patient gave no importance to it.

She complains about leg oedema appeared for couple of months but it was considered because of chronic venous insufficiency. She has diffuse abdominal pain. Liver dimensions were slightly increased (two cm bellow costal arch). There were no abnormalities detected in heart, lungs and central nervous system (CNS).

BMI = 19.49 kg/m2; Pulse = 116 beats/ min, regular; BP = 140/70 mmHg, equal in both arms.

At this point we are in front of a young depressive patient, having a febrile syndrome, legs oedema and nonspecific skin and digestive symptoms.

Paraclinical explorations were performed in order to narrow the correct diagnosis. It was requested also a psychiatric consult and psychological support.

A complete blood count was performed that showed:

--Normochromic anaemia Hb = 9.2 g/dl; Ht = 29.4 %

--Leukopenia with lymphopenia: leukocytes = 3500/mmc, lymphocytes = 1800/mmc

--Thrombopenia = 121000/mmc

Inflammatory syndrome: ESR = 92 mm/ 1 hour

Liver cytolysis: ASAT = 192 IU/l; ALAT = 216 IU/l, bilirubin (total = 1.54 mg/dl, direct = 1.12 mg/dl)

Viral markers for hepatitis B and C-negative

Blood Urea Nitrogen (BUN) = 82 mg/dl; Creatinine = 2.9 mg/dl;

Glomerular Filtration Rate (GFR) = 20 mL/min/1.73 [m.sup.2] (calculated using 2009 CKD-EPI creatinine equation, which is recommended by the KDIGO Clinical Practice Guidelines for Management of Chronic Kidney Disease); This value set the patient in stage 4 kidney disease (severe decrease in GFR).

Blood gases: pH = 7.22; CO2 = 31 mmHg; HC[O.sub.3.sup.-] = 14; this correspond to partly compensated metabolic acidosis

Urinalysis--proteinuria 1.9 g/24 hours; hematuria, hematic casts; uroculture--negative

EKG: sinus tachycardia 106/min; QRS axis = 49[degrees], no signs of ischemia

Chest X-ray: normal

Abdominal ultrasound: Liver steatosis (right liver lobe = 164 mm); normal gallbladder, no stones; both kidneys with slightly decreased cortical-medullare differentiation but normal dimensions (Right kidney: 106/53 mm, Left kidney: 110/ 65 mm)

Cardiac ultrasound--Normal cardiac chamber dimensions; no motion abnormalities; ejection fraction = 64 %

At this point we face a young patient with both emotional and complex physical disorders: fever, oedema, liver and kidney failure, normochromic anemia, leukopenia with lymphopenia, thrombopenia, nonspecific inflammatory syndrome. This aggregation of nonspecific clinical and paraclinical disorders without an infection trigger leads to suspicion of an immune disease.

Differential diagnosis includes:

--Systemic Lupus Erythematosus (SLE)

--Antiphospholipid Syndrome

--Autoimmune Hepatobilliary Disease

--Hepatitis (viral, drugs, Reye syndrome)

--Hemopathies

--Infective Endocarditis

--Polymyositis

--Rheumatoid Arthritis

--Sjogren Syndrome

--Undifferentiated Connective-Tissue Disease

An extended ANA profile [6] was done in order to help differentiate the autoimmune disorder. The complete profile includes antibodies for: U1-nRNP, SS-A, Ro-52, SS-B, Scl-70, Pm-Scl, Jo-1, Centromere B, PCNA, anti-dsDNA, nucleosomes, histones, ribosomal P Protein, AMA M2). W2 From these antibodies, the test was positive for: anti-dsDNA, nucleosomes, histones, ribosomal P Protein.

This immunologic test aggregated with clinical and paraclinical investigations sustained positive diagnosis of systemic lupus erythematous associated with lupus nephritis, liver cytolysis, anemia, leukopenia with lymphopenia, thrombopenia.

The diagnosis is confirmed also using the revised SLICC Classification Criteria for systemic lupus erythematosus (2012, revised in 2015). It requires at least four criteria (at least one clinical and one laboratory criteria) or biopsy proven lupus nephritis with positive ANA or anti-DNA [7, 8].

Clinical criteria

--Acute cutaneous lupus

--Chronic cutaneous lupus

--Oral or nasal ulcers

--Non scarring alopecia

--Arthritis

--Serositis

--Renal

--Neurological

--Hemolytic anemia

--Leukopenia

--Thrombocytopenia (< 100.000/[mm.sup.3])

Immunologic criteria

--ANA

--Anti-DNA

--Anti-Sm

--Antiphospholipid antibody

--Low complement (C3, C4, CH50)

--Direct Coombs' test (in the absence of hemolytic anemia)

TREATMENT

1. Pathogenic:

--methylprednisolone 1 g iv three days and after prednisone 1 mg/kg/day (for two weeks and thereafter decreased gradually)

--Hydroxychloroquine 200 mg twice a day

--Ibuprofen 400 mg bid

2. Symptomatic: correction of anaemia, acidosis, intravenous fluids, liver protection (arginine, silibinum)

3. Psychiatric support for depression and anxiety (tianeptine 12,5 mg bid) and psychological counselling

THE QUALITY OF LIFE QUESTIONNAIRE MOS-SF 36

MOS-SF-36, the Medical Outcome Study--Short Form 36, assesses the quality of life in eight dimensions: physical function, physical role, bodily pain, general health, vitality, social function, emotional role and mental health. There are four physical and four emotional dimensions. Each dimension has a scale from zero to 100, the highest score meaning a better situation [9].

The interpretation can be done on each dimension or based on two overall scores: the physical component and the mental component [10].

1. The physical functioning scale--10 items;

2. The physical role functioning scale--4 items;

3. The social role functioning scale--2 items;

4. The bodily pain scale--2 items;

5. The mental health scale--5 items;

6. The emotional role functioning scale 3 items;

7. The vitality scale--4 items;

8. The general health perceptions scale--5 items.

SCORING AND INTERPRETATION

Patient was evaluated at admission and discharge from the hospital. It was applied the quality of life questionnaire MOS-SF 36 validated for Romania. Depression was evaluated using the 17 items Hamilton depression score (HAMD) [11]. The HAMD questionnaire has a scale showing the depression severity: less than 6--normal, from 7 to 17 slight depression, from 18 to 24 moderate depression and over 25 severe depression [12].

Both scores were calculated at the beginning and at the end of hospitalizations period. Scores showed an improvement of quality of life (both physical and mental states) and also a significand decrease in depression score.
Score                              Admission   Discharge

Physical health composite score        65         80
Mental health composite score          62         75
Hamilton depression Rating Scale       14         6


Evolution:

--favourable clinical evolution;

--good general state of health;

--no fever;

--cooperative, looking forward to improve her health.

The particularities of this case:

--complex clinical presentation mimics infectious, liver or systemic disease;

--association classical symptoms with altered mental state and depression;

--absence of hypertension.

CONCLUSIONS

Physical health composite score and mental health composite score showed an improvement of quality of life (both physical and mental states). It was also proved a significand decrease in depression score. The scores differences clearly states the efficiency of psychiatric therapy and psychological counselling. Depression has also been linked to increased disease-related morbidity and mortality [12]. For this reason the adherence to treatment is increased to patients who are motivated to fight with the disease compared with the ones who lost interest for themselves.

It is known that many chronic medical conditions can impair HRQoL and increase depression prevalence [13, 14, 15]. Also, disease duration and age are associated with depression [16]. It is important though that psychiatric support should be provided as soon as possible meanwhile other therapeutic procedures are done.

Further studies are needed on groups of patients with glomerular disease to correlate quality of life with different factors present or associated with kidney disease as proteinuria, eGFR (Glomerular Filtration Rate), hypertension, diabetes, steroid therapy.

Loredana TURICEANU--M. D., Ph. D. Student, Department of Morpho-Functional Sciences--Histology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania

Corina ALEXINSCHI--M. D., Iasi, Romania

Romeo P. DOBRIN--M. D., Ph. D., Senior Psychiatrist, "Socola" Institute of Psychiatry, Iasi, Romania

ACKNOWLEDGMENTS AND DISCLOSURE

The authors declare that they have no potential conflicts of interest to disclose.

REFERENCES

[1.] Malafronte, P., Mastroianni-Kirsztajn, G., Betonico, G. N., Romao, J. E., Jr., Alves, M. A., Carvalho, M. F., Viera Neto, O. M., Cadaval, R. A., Bergamo, R. R., Woronik, V., Sens, Y. A., Marrocos, M. S., Barros, R. T., Paulista Registry of glomerulonephritis: 5-year data report. Nephrol Dial Transplant 2006;21:3098-3105.

[2.] Mujais, S. K., Story, K., Brouillette, J., Takano, T., Soroka, S., Franek, C., Mendelssohn, D., Finkelstein, F. O., Health-related quality of life in CKD Patients: correlates and evolution over time. Clin J Am Soc Nephrol 2009;4:1293-1301.

[3.] Finkelstein, F. O., Wuerth, D., Finkelstein, S. H., Health related quality of life and the CKD patient: challenges for the nephrology community. Kidney lnt 2009;76:946-952.

[4.] Omachi, T. A., Katz, P. P., Yelin, E. H., Gregorich, S. E., Iribarren, C., Blanc, P. D., Eisner, M. D., Depression and health-related quality of life in chronic obstructive pulmonary disease. Am J Med 2009;122:778-15.

[5.] Bakas, T., McLennon, S. M., Carpenter, J. S., Buelow, J. M., Otte, J. L., Hanna, K. M., Ellett, M. L., Hadler, K. A., Welch, J. L., Systematic review of health-related quality of life models. Health Qual Life Outcomes 2012;10:134.

[6.] http://www.synevo.ro/profil-ana-extins-blot-u1-nrnp-ss-a-ro-52-ss-b-scl-70-pm-scl-jo-1-centromer-b-pcna-adn-dublu- catenar-nucleozomi-histone-proteina-p-ribozomal-ama-m2/

[7.] http://www.rheumtutor.com/2012-slicc-sle-criteria/

[8.] Petri, M. et al., Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum 2012;64:2677-2686.

[9.] Ware, J. E., Jr., Sherbourne, C. D., The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30:473-483.

[10.] Pelle, A. J., Kupper, N., Mols, F., de J. P., What is the use? Application of the short form (SF) questionnaires for the evaluation of treatment effects. Qual Life Res 2013;22:1225-1230.

[11.] Hamilton, M., A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56-62.

[12.] Hamilton, M., Rating depressive patients. J Clin Psychiatry 1980;41:21-24.

[13.] Faller, H., Stork, S., Schuler, M., Schowalter, M., Steinbuchel, T., Ertl, G., Angermann, C. E., Depression and disease severity as predictors of health-related quality of life in patients with chronic heart failure--a structural equation modeling approach. J Card Fail 2009;15:286-292.

[14.] Soni, R. K., Weisbord, S. D., Unruh, M. L., Health-related quality of life outcomes in Chronic kidney disease. Curr Opin Nephrol Hypertens 2010;19:153-159.

[15.] Palmer, S., Vecchio, M., Craig, J. C., Tonelli, M., Johnson, D. W., Nicolucci, A., Pellegrini, F., Saglimbene, V., Logroscino, G., Fishbane, S., Strippoli, G. F., Prevalence of depression in chronic kidney disease: systematic review and meta-analysis of observational studies. Kidney Int 2013;84:179-191.

[16.] Abdel-Kader, K., Unruh, M. L., Weisbord, S. D., Symptom Burden, Depression, and Quality of Life in Chronic and End-Stage Kidney Disease. Clin J Am Soc Nephrol 2009;4:1057-1064.

Correspondence:

Loredana TURICEANU Department of Morpho-Functional Sciences--Histology "Grigore T. Popa" University of Medicine and Pharmacy No. 16, Str. Universitatii, Iasi, zip code 700115, Romania

E-mail: turiceanu@yahoo.com

Submission: June, 26th, 2015

Admittance: August, 10th, 2015
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Article Details
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Title Annotation:Case Reports
Author:Turiceanu, Loredana; Alexinschi, Corina; Dobrin, Romeo P.
Publication:Bulletin of Integrative Psychiatry
Article Type:Report
Date:Sep 1, 2015
Words:1916
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