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ORIGINAL ARTICLE
Ahead of print publication  

Assessment of prevalence and risk factors of delirium in kidney disease patients undergoing renal dialysis: A prospective observational study


 Department of Psychiatry, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India

Date of Submission06-May-2022
Date of Decision11-May-2022
Date of Acceptance17-May-2022
Date of Web Publication19-Jan-2023

Correspondence Address:
Vishwas Shrishail Yadawad,
Department of Psychiatry, Jawaharlal Nehru Medical College, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_85_22

  Abstract 


Context: Studies have shown that delirium is common in intensive care unit settings, postsurgery, and in elderly. There are various predisposing risk factors for same. There is evidence of delirium occurring after dialysis. Aims: The aim of this study was to assess the prevalence and risk factor of delirium in kidney disease (both acute and chronic) patients undergoing dialysis. Settings and Design: A 1-year prospective observational study in a tertiary care hospital. Subjects and Methods: The study included admitted patients of kidney disease (acute and chronic) requiring dialysis, aged 18 years or more. All patients who were already in delirium before dialysis were excluded. Mental status examination was done, and Confusion Assessment Method (CAM) scale was applied on the included patients to make a diagnosis of delirium. Statistical Analysis Used: For risk factors, sociodemographic data, past history of delirium, number of dialysis received, and blood investigations were collected. P value for all parameters was calculated using Chi-square, Fisher's exact, and unpaired t-test. Results: The prevalence of delirium was 20% after dialysis. Risk factors identified were past history of delirium, >3 dialysis received, the presence of hypertension, increased urea, creatinine, hemoglobin, white blood cells levels, and increased LFT's (significant P value). Conclusions: The prevalence of delirium in dialysis group patients is high. There are multiple risk factors for same and can be predicted and taken care of to reduce the long-term consequences of delirium.

Keywords: Delirium, dialysis, prevalence, risk factors



How to cite this URL:
Chate SS, Yadawad VS, Patil S, Tekkalaki B, Mutalik PP. Assessment of prevalence and risk factors of delirium in kidney disease patients undergoing renal dialysis: A prospective observational study. Ann Indian Psychiatry [Epub ahead of print] [cited 2023 Feb 3]. Available from: https://www.anip.co.in/preprintarticle.asp?id=368087




  Introduction Top


Diseases of the renal system are a globally increasing cause of life impairment and death. Global burden of disease conducted a study in 2015 that found out that 1.2 million deaths, 19 million disability-adjusted life years, and 18 million years of life lost due to diseases of cardiovascular system are directly because of decreased glomerular filtration rate. Hence, it has a tremendous economic burden.[1] Most of the people with kidney disease will undergo dialysis. The process of dialysis itself predisposes for delirium.[2]

The typical features of delirium are acute alteration in both, the level of consciousness and cognition with specific decline in attention. It is dangerous and fatal but still reversible.[3] It ensues in a matter of hours to days and changes in severity.[4] Although delirious state is one of the independent predictor of high levels of mortality and elongated intensive care unit (ICU) and hospital stay in severely ill individuals getting mechanical ventilation; it continues to be an unrecognized condition because of deficiency in regular monitoring and misdiagnosis.[5] Even though the need of assessment, prevention, and treatment of delirious state has been identified by health-care worker, the implementation continues to be difficult.[6],[7] Multiple factors such as drug use, period of ICU hospitalization, substance use, and physical restraining are independent risk factors for delirious state.[8]

Patients who are having kidney disease (both acute and chronic) are also at risk for developing delirium due to various factors. Damage to the kidney is an underevaluated risk factor that is vital in the development of delirious and comatose state during critically diseased conditions. Patients suffering from acute kidney injury are at a higher risk of delirium. This has been shown by studies done in the past.[9] Yasui-Furukori et al. showed in their study that prevalence of delirium in hemodialysis is 15% and it increases the risk of mortality. It may be due to disbalances in electrolyte levels which occur postdialysis, and can be a cause of a phenomenon called dialysis disequilibrium syndrome, or due to surgical/medical factors.[10] However, there are not many studies about the prevalence of delirium in patients undergoing dialysis and the possible risk factors causing it. Hence, it is important to evaluate the prevalence of delirium and risk factors for delirium among patients undergoing hemodialysis so that preventive measures can be taken to overcome the problems of morbidity and mortality associated. The aim of the study was to (1) to estimate the prevalence of delirium in patients of kidney disease (both acute and chronic) undergoing renal dialysis and (2) to identify risk factors associated with causation of delirium in patients of kidney disease (acute and chronic) undergoing renal dialysis.

To our knowledge, there are no studies conducted for evaluation of delirium in kidney disease patients receiving dialysis in India or outside. This makes this study even more important.


  Subjects and Methods Top


This study was done in KLE's Dr. Prabhakar Kore Charitable Hospital and Research Centre, Belagavi. It was a 1-year cross-sectional study done from January 1, 2020 to December 30, 2020. Before commencement of the study, the ethical clearance was obtained from Institute of Ethics Committee, Jawaharlal Nehru Medical College, Belagavi, and this study was approved by Institutional Ethics Committee with reference number MDC/DOME/297 obtained on December 24, 2019.

All patients of age 18 years and above who were diagnosed with kidney disease (acute and chronic) and required renal dialysis were included in the study. Patient already in delirium before dialysis were excluded from the study. Sample size was calculated using the formula 4 pq/d2. The sample size came out to be 100. However, due to COVID-19 pandemic, only 75 samples could be included in the study.

Informed consent was taken from all these participants or from their relatives as per institutional ethics committee approval along with consent taken for participation in the study and publication of the scientific results/clinical information without revealing their identity, name, or initials. The patient is aware that though confidentiality would be maintained anonymity cannot be guaranteed. Sociodemographic data were recorded on a specially designed pro forma. Other history including the presence of hypertension/diabetes, number of dialysis received in the past, and past history of delirium were also obtained. Along with this, blood investigations were recorded which were already done before dialysis by the primary clinician under whom the admission was made. General physical examination was done. Patients were examined for delirium twice within 48 h after they had undergone dialysis. Based on mental status examination and application of Confusion Assessment Method (CAM), diagnosis of delirium was made.

After collecting all the samples, the data obtained were tabulated in Microsoft Excel sheet and subjected to appropriate statistical analyses. Descriptive data were presented as percentages and mean and standard deviation (SD) was calculated. The strength of association (P value) was calculated using Chi-square and Fisher's exact test for qualitative data, and using unpaired t test for quantitative data. Statistical significance was set at P ≤ 0.05. All tests were two-tailed.


  Results Top


[Table 1] shows that 47% of the samples were in the age group 41–60 years [Figure 1]a. The mean age was 55.413 (SD, 12.9). The majority of the patients were males constituting 68% whereas 32% were females [Figure 1]b. Employment status showed that 20% were homemakers whereas 19% were unemployed. Seventeen percent were farmer whereas another 17% were self-employed. Eleven percent were skilled whereas 9% had an unskilled job. Only 7% of the sample had professional employment. Eighty-seven percent of the samples were constituted by Hindu and the rest were Muslim.
Figure 1: Prevalence of delirium in patients on dialysis

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Table 1: Description of the sociodemographic variables of the study sample

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In the present study, as shown in [Figure 1], 15 out of 75 patients developed delirium that is the prevalence of delirium was 20%.

[Table 2] describes the result about risk factor for which Chi-square test was used. In our sample, 7 out of 29 individuals who were older than 60 years developed delirium. This was not found to be significant. Twelve out of 43 hypertensive individuals developed delirium which was found to be statistically significant (P = 0.0472). Although for diabetes, the result was not significant. ≥3 dialysis received in past was found to be significant as a risk factor (P = 0.0003), and in our study, 7 out of 12 individuals who had received three or more dialysis developed delirium. Past history of delirium was also found to be a significant risk factor as all patients who had past history of delirium developed delirium again in our assessment (P < 0.0001).
Table 2: Association of risk factors of delirium using Chi-square test

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[Table 3] describes all the parameters for which unpaired t test was used. In our sample, 13 out of 57 individuals who had serum urea levels >50 mg/dl developed delirium. This was not significant. However, increased creatinine as a risk factor was found to be significant (<0.0001) and 9 out 14 individuals having creatinine >10 mg/dl developed delirium. 5 out of 7 individuals (P = 0.0002) with severe anemia and 10 out of 22 individuals (P = 0.0004) with leukocytosis developed delirium after dialysis. For both severe anemia and leukocytosis, the result was found to be significant. When albumin and calcium were evaluated, none were found to be a significant risk factor. However, hyperbilirubinemia and increased liver enzymes (serum glutamic-oxaloacetic transaminase/serum glutamic-pyruvic transaminase) were found to be significant. Six out of 13 individuals with hyperbilirubinemia developed delirium (P = 0.0095), whereas 4 out of 8 individuals with increased liver enzymes developed delirium (P = 0.0248).
Table 3: Association of risk factors of delirium using Chi-square test

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  Discussion Top


Main objective of this study was to find out the prevalence of delirium in the patients undergoing dialysis for kidney diseases and to assess the risk factors for the causation of same. Out of 75 patients that were assessed on CAM twice within 48 h after dialysis, 15 were found to have delirium. The prevalence of delirium was found to be 20%. In the study done by Yasui-Furukori et al. in Japan, the prevalence of delirium after dialysis was found to be 15.4% among 338 patients undergoing dialysis which is comparable to our results.[10] A study done in PGI, Chandigarh, India, by Sharma et al. estimated the incidence and prevalence of delirium as 24.4% and 53.6%, respectively, among 140 patients.[11] This difference could be because different causes of admission in ICU such as trauma, surgical procedures, and requirement of ventilator support.

In our study, the risk factor which were found to be strongly associated with delirium were hypertension, three or more dialysis received, and past history of delirium. This finding was in consistent with the study done by Dubois et al. who concluded that hypertension is strongly linked with development of delirium.[12] There have been no studies which has assessed number of dialysis as a risk factor for delirium. In a study done by Kim et al.(2016), past history of delirium was not found to be a significant risk factor for delirium in surgical or medical patients.[13] Although there are not enough studies to assess past history of delirium as a risk factor. Further studies are needed to assess the same.

Other risk factors which were evaluated were the various blood investigations like. The ones which were found to significant are increased creatinine, severe anemia, leukocytosis, hyperbilirubinemia, and increased liver enzymes. This result was in accordance with a few studies in past. Increased creatinine level was found to be one of the independent risk factor for delirium after cardiac surgery according to a study done by Bakker et al.[14] The study done by Aldemir et al. found anemia, hyperbilirubinemia, and increased liver enzymes to be a predisposing risk factor for delirium.[15] Leukocytosis was also concluded to be a risk factor in the study done by Gravante et al.[16]

We expected hyponatremic patients to have higher prevalence of delirium but our results did not show so. This was inconsistent with previous studies. Other risk factors which were not significant in our study were uremia, serum potassium, serum albumin, and serum calcium levels.

This study was conducted as there are no data about the prevalence of delirium after dialysis or about its risk factors. Delirium after dialysis is an important adverse event as it increases mortality, morbidity, and hospital stay. Hence, if identified at the earliest and adequately addressed, the adverse consequences can be reduced.

Strengths of the study

  • To our best knowledge, this is the 1st study which evaluates the prevalence of delirium among patients on hemodialysis
  • The study evaluates role of multiple parameters including blood investigations and past history of delirium in causation of delirium which has not been done previously.


Limitations of the study

  • Sample size was less compared to other studies done for prevalence of delirium
  • Delirium is an acute and transient condition. Due to lack of efficient continuous monitoring, some cases might have been missed
  • Medication information for comorbid conditions was not collected.



  Conclusion Top


Chronic kidney disease is a major cause of disability. End-stage renal disease is mostly treated by renal replacement therapy which includes renal transplant and dialysis. Hemodialysis has a major side effect in the form of delirium which may increase mortality and lead to adverse neurocognitive disturbances in long term.

Our study showed that 20% of the patients receiving dialysis were found to have delirium within 48 h of receiving dialysis. The study established that delirium after dialysis is associated with hypertension, increased creatinine levels, increased hemoglobin and TLC, increased LFT's, and other factors such as past history of delirium and multiple dialysis received.

Due to the high possibility of delirium postdialysis, these patients should be frequently monitored and adequately treated to avoid long-term consequences of cognitive deficits, increased hospital stay, morbidity, and mortality.

Acknowledgment

We would like to acknowledge the contribution of Late. Dr. Divya Prakash for his tremendous efforts in bringing this article up for publication.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Luyckx VA, Tonelli M, Stanifer JW. The global burden of kidney disease and the sustainable development goals. Bull World Health Organ 2018;96:414-22D.  Back to cited text no. 1
    
2.
Arieff AI. Dialysis disequilibrium syndrome: Current concepts on pathogenesis and prevention. Kidney Int 1994;45:629-35.  Back to cited text no. 2
    
3.
World Health Organisation. ICD-10 Classifications of Mental and Behavioural Disorder: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization; 1992.  Back to cited text no. 3
    
4.
Brown TM, Boyle MF. Delirium.BMJ 2002;325:644-7. doi: 10.1136/bmj.325.7365.644. PMID: 12242179; PMCID: PMC1124165.  Back to cited text no. 4
    
5.
Kalabalik J, Brunetti L, El-Srougy R. Intensive care unit delirium: A review of the literature. J Pharm Pract 2014;27:195-207.  Back to cited text no. 5
    
6.
Özsaban A, Acaroglu R. Delirium assessment in intensive care units: Practices and perceptions of Turkish nurses. Nurs Crit Care 2016;21:271-8.  Back to cited text no. 6
    
7.
Saller T, V Dossow V, Hofmann-Kiefer K. Knowledge and implementation of the S3 guideline on delirium management in Germany. Anaesthesist 2016;65:755-62.  Back to cited text no. 7
    
8.
Pan Y, Yan J, Jiang Z, Luo J, Zhang J, Yang K. Incidence, risk factors, and cumulative risk of delirium among ICU patients: A case-control study. Int J Nurs Sci 2019;6:247-51. doi: 10.1016/j.ijnss.2019.05.008.  Back to cited text no. 8
    
9.
Siew ED, Fissell WH, Tripp CM, Blume JD, Wilson MD, Clark AJ, et al. Acute kidney injury as a risk factor for delirium and coma during critical illness. Am J Respir Crit Care Med 2017;195:1597-607.  Back to cited text no. 9
    
10.
Yasui-Furukori N, Tarakita N, Uematsu W, Saito H, Nakamura K, Ohyama C, et al. Delirium in hemodialysis predicts mortality: A single-center, long-term observational study. Neuropsychiatr Dis Treat 2017;13:3011-6.  Back to cited text no. 10
    
11.
Sharma A, Malhotra S, Grover S, Jindal SK. Incidence, prevalence, risk factor and outcome of delirium in intensive care unit: A study from India. Gen Hosp Psychiatry 2012;34:639-46. Available from: http://dx.doi.org/10.1016/j.genhosppsych. 2012.06.009. [Last accessed on 2021 Sep 06].  Back to cited text no. 11
    
12.
Dubois MJ, Bergeron N, Dumont M, Dial S, Skrobik Y. Delirium in an intensive care unit: A study of risk factors. Intensive Care Med 2001;27:1297-304.  Back to cited text no. 12
    
13.
Kim H, Chung S, Joo YH, Lee JS. The major risk factors for delirium in a clinical setting. Neuropsychiatr Dis Treat 2016;12:1787-93.  Back to cited text no. 13
    
14.
Bakker RC, Osse RJ, Tulen JH, Kappetein AP, Bogers AJ. Preoperative and operative predictors of delirium after cardiac surgery in elderly patients. Eur J Cardiothorac Surg 2012;41:544-9.  Back to cited text no. 14
    
15.
Aldemir M, Ozen S, Kara IH, Sir A, Baç B. Predisposing factors for delirium in the surgical intensive care unit. Crit Care 2001;5:265-70.  Back to cited text no. 15
    
16.
Gravante F, Giannarelli D, Pucci A, Gagliardi AM, Mitello L, Montagna A, et al. Prevalence and risk factors of delirium in the intensive care unit: An observational study. Nurs Crit Care 2021;26:156-65.  Back to cited text no. 16
    


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    Tables

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