RENAL PSYCHOLOGISTS | Kidney Psychologist

EDUCATION FOR FUTURE NEPHROPSYCHOLOGISTS

Renal disease is a slowly evolving dynamic interplay between physiological, cognitive, and psychological changes and there is searing liability when ongoing medical treatment ignores the emotional dimensions of illness

WHY NEPHROPSYCHOLOGY? Renal patients experience co-occurring mental health conditions at higher rates than the general population. These occur during the early stages of the illness when early intervention can be preventative of poor renal outcomes. As the disease progresses, neglected mental health leads to treatment nonadherence and increased hospitalization, morbidity, and mortality. These results urge further development of the fields of nephropsychiatry and nephropsychology to intervene to decrease decline rate and improve outcomes for renal patients.

Integrating behavioral health with renal medicine will improve patient outcomes, reduce healthcare utilization, and the stigma associated with mental health care

COMMON MENTAL HEALTH EXPERIENCES IN CKD & ESRD:

1. Depression

2. Cognitive decline

3. Anxiety

4. Sleep disorders

5. Sexual dysfunction

6. High risk for suicide

7. Racial and SES inequality

8. High risk for iatrogenic trauma

ILLNESS STAGE PROPORTIONALLY CORRELATED WITH:

quality of life, cognitive changes, stress, psychological distress, emotional maladaptation

Stages of CKD

Stage 1 = eGFR 90 or higher and kidney damage (e.g. uACR 30 or higher) for 3 months or more

Stage 2 = eGFR 60-89 and kidney damage (e.g. uACR 30 or higher) for 3 months or more

Stage 3a = mild to moderate loss of kidney function (eGFR 45-59) for 3 months or more

Stage 3b = moderate to severe loss of kidney function (eGFR 30-44 for) 3 months or more

Stage 4 = severe loss of kidney function (eGFR 15-29) for 3 months or more

Stage 5 = kidney failure or ESRD (eGFR less than 15) for 3 months or more

THE NEED FOR CAREFUL DIFFERENTIAL DIAGNOSIS: The etiology of many psychological conditions in CKD/ESRD is unclear due to the many physiological changes that occur as kidney function declines. Depression in CKD is especially difficult to evaluate in the face of uncontrolled comorbid illnesses such as anemia or heart disease, and/or due to uremic symptoms, treatment side effects, and lack of consensus across research measures used to assess depression in renal patients. Physiological changes in CKD mimic key symptoms of a depressive disorder: fatigue, amotivation, apathy, retarded movements, changes in appetite, libido, and/or sleep, and difficulty with attention and memory, etc. Fatigue is highly prevalent across all populations of ESRD, including pre-dialysis and those with a stable kidney transplant. The extent to which fatigue is a result of physiological-based deficiencies in ESRD verses one of many symptoms of a depressive disorder, remains unclear. Uremia specifically challenges mental health assessment accuracy during later-stage CKD due to high symptom overlap with depression, cognitive impairments (CI), sleep disorders, sexual dysfunction, eating disorders, etc. While cognitive changes in renal disease are multifactorial and remain inconclusive, impairments are partially the result of the effects of the accumulation of neurotoxin due to uremia.

The presence of depression & suicidal ideation increases proportionally to kidney decline beginning during mild decline

INEQUALITY IN KIDNEY DISEASE: Risk of kidney failure is alarmingly higher in those from marginalized groups. Racial, ethnic, socioeconomic, and educational inequities pose barriers to equal medical care. Numerous desperate social determinants influence prevalence rates and predict progression of CKD including: food insecurity, lower income, poverty, stress, unemployment, underpaid employment, inadequate access to healthy food, poor housing, environmental toxins, pollution, residing in low income neighborhoods, discrimination, less access to medical care, inadequate social support, and poor health insurance coverage. These all limit equal access to healthcare interventions for minority populations in CKD/ESRD nationwide.

Mental Health Burdens Differ Depending on Renal Replacement Therapy Used. Each Option Presents Significant Challenges and Includes:

1. Hemodialysis

2. Peritoneal Dialysis

3. Kidney Transplant

4. Conservative Medical Management (CMM)

NEEDS FROM THE FIELD OF PSYCHOLOGY: Needs From Research Psychology: 1. Develop more accurate kidney specific assessment measures in research in the CKD/ESRD population. 2. Utilize these better adapted & consistent testing protocols for CKD studies 3. Conduct more well-run trials examining psychiatric & psychological treatment efficacy for renal patients. 4. Develop and test specific treatment protocols for group therapy for renal patients. Differentiate groups and protocols based on illness-stage and RRT method. Clinical Psychologists Can... 1. Conceptualize CKD/ESRD from a critical time-point & needs-based stage perspective. 2. Become educated about the physiological changes in renal disease as the stages progress & as a result of the physical demands of renal replacement therapy. 3. Understand the practical demands of each renal replacement therapy & the mounting practical burdens in renal disease as stages progress. 4. Conduct thorough and discerning differential diagnoses as symptoms change 5. Refer renal patients for baseline cognitive testing & thereafter as changes occur. 6. Encourage & help patients develop medical advocacy & effective communication skills with providers. 7. Use The Transtheoretical Model to assess change readiness. 8. Utilize Motivational Interviewing (MI) for treatment non-adherence, suicidal ideation, & other required behavioral changes to maintain health. 9. Treat ongoing distress associated with cultural views of illness & dependence, & any internalized bias. 10. Assess & treat ongoing medical or iatrogenic trauma. 11. Strengthen patient internal locus of control, disease-agency, & illness-management skills. 12. Continuously assess stage of grief & provide support for grieving losses, including helping patients process loss of foreclosures of life aspirations. 13. Assess how illness onset influences developmental life stage and vice versa. 14. Help patients integrate pre-illness identity with post-illness identity. 15. Assess & address any maladaptive illness beliefs that will lead to poor outcomes. 16. Help patients move towards illness acceptance at their own pace. 17. Strengthen patient tolerance for uncertainty. 18. Strengthen adaptive coping to protect against a disease that will require constant adjustments. 19. Encourage treatment equality across all patients & be aware of how systemic discrimination affects non-White patients and/or those with less financial resources. 20. Help patients process existential suffering leading to illness meaning-making. 21. Train other nephropsychologists.

There is increased need among the psychology field as a whole to understand the many psychological burdens of renal disease & how these burdens hasten illness progression & lead to poor patient outcomes

NEPHROPSYCHIATRY: Psychiatric treatment in renal patients is a distinct challenge due to changes in pharmacokinetics in drugs cleared by the kidneys and removal of these drugs by dialysis. A new subspecialty of psychiatry has emerged over the past decade with the aim of combining psychosomatic medicine with the psychiatric challenges seen in patients at all stages of CKD/ESRD, including those on renal replacement therapies (RRTs).

CRISIS TIME-POINTS DURING ILLNESS PROGRESSION

(not all time-points apply to all persons)

Time of diagnosis
Initiating dietary changes
Onset of noticeable physiological symptoms
Early end-stage due to the high decision-making burden of renal replacement therapy (RRT) and worsening physical symptoms (increased uremia)
Kidney transplant candidacy evaluations (Recommendations are given to those who do not meet criteria-which can be upsetting)
Placed on transplant waiting list
Pursue living donor transplant?
Dialysis education (hemodialysis or peritoneal)
Vascular access surgery for those pursuing dialysis
Dialysis initiation
Dialysis reality and lifestyle changes (the entire first year on dialysis is a time of crisis)
Transplant surgery
Post-transplant reality & adjustment (immunosuppressants can cause problematic mental health and cognitive side-effects)
Expressed desire to discontinue or not begin dialysis & pursue conservative medical management (CMM)

THERAPY STRATEGIES & PROTECTIVE FACTORS

ARTICLE & BOOK RECOMMENDATIONS

**All information presented above is the result of a critical analysis of the literature examining mental health through stages of renal disease, on methods of dialysis, and post-transplant. Paper is in peer review. Table of therapy strategies & protective factors attached above**