Carl E H Siegert

St. Lucas Andreas Hospital, Amsterdamo, North Holland, Netherlands

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Publications (40)106.34 Total impact

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    ABSTRACT: Background In Western countries, black and Asian dialysis patients experience better survival compared with white patients. The aim of this study is to compare the survival of native Danish dialysis patients with that of dialysis patients originating from other countries and to explore the association between the duration of residence in Denmark before the start of dialysis and the mortality on dialysis. Methods We performed a population-wide national cohort study of incident chronic dialysis patients in Denmark (≥18 years old) who started dialysis between 1995 and 2010. Results In total, 8459 patients were native Danes, 344 originated from other Western countries, 79 from North Africa or West Asia, 173 from South or South-East Asia and 54 from sub-Saharan Africa. Native Danes were more likely to die on dialysis compared with the other groups (crude incidence rates for mortality: 234, 166, 96, 110 and 53 per 1000 person-years, respectively). Native Danes had greater hazard ratios (HRs) for mortality compared with the other groups {HRs for mortality adjusted for sociodemographic and clinical characteristics: 1.32 [95% confidence interval (CI) 1.14–1.54]; 2.22 [95% CI 1.51–3.23]; 1.79 [95% CI 1.41–2.27]; 2.00 [95% CI 1.10–3.57], respectively}. Compared with native Danes, adjusted HRs for mortality for Western immigrants living in Denmark for ≤10 years, >10 to ≤20 years and >20 years were 0.44 (95% CI 0.27–0.71), 0.56 (95% CI 0.39–0.82) and 0.86 (95% CI 0.70–1.04), respectively. For non-Western immigrants, these HRs were 0.42 (95% CI 0.27–0.67), 0.52 (95% CI 0.33–0.80) and 0.48 (95% CI 0.35–0.66), respectively. Conclusions Incident chronic dialysis patients in Denmark originating from countries other than Denmark have a better survival compared with native Danes. For Western immigrants, this survival benefit declines among those who have lived in Denmark longer. For non-Western immigrants, the survival benefit largely remains over time.
    No preview · Article · Oct 2015 · Nephrology Dialysis Transplantation
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    Wim L Loosman · Marcus A Rottier · Adriaan Honig · Carl E.H. Siegert
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    ABSTRACT: Background: Depressive symptoms have been reported to be associated with adverse clinical outcome in patients with chronic kidney disease (CKD) not on dialysis. This association has not been examined in Europe. Anxiety and depressive symptoms often co-occur. However, as yet there are no data concerning a possible association of anxiety symptoms with adverse clinical outcome. We examined the association of depressive and anxiety symptoms with adverse clinical outcome in Dutch CKD patients not on dialysis. Methods: In this 3-year follow-up prospective cohort study, CKD patients not on dialysis with an estimated glomerular filtration rate (eGFR) ≤ 35 ml/min/1.73 m(2) from an urban teaching hospital were selected. Symptoms of depression and anxiety were evaluated using the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI). Cox proportional hazards models were used to calculate hazard ratio's (HRs) with a composite event of death, initiation of dialysis, and hospitalization as outcome. HRs were adjusted for age, gender, diabetes, cardiovascular disease and eGFR. Results: Of 100 included CKD patients depressive and anxiety symptoms were present in 34 and 31 %, respectively. Adjusted HRs for the composite event for patients with depressive and anxiety symptoms were 2.0 (95 % confidence interval (CI) 1.2-3.5) and 1.6 (95 % CI 0.9-2.7), respectively. Twenty three patients had both depressive and anxiety symptoms of whom adjusted HRs were 2.2 (95 % CI 1.2-4.0) for a composite event. Conclusions: Depressive and anxiety symptoms are common in patients with CKD in The Netherlands. Depressive symptoms are associated with an increased risk of poor clinical outcome. Anxiety symptoms show a trend for an increased risk of poor clinical outcome. There seems to be no additive effect of anxiety symptoms in addition to depressive symptoms with regard to poor clinical outcome.
    Preview · Article · Sep 2015 · BMC Nephrology
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    ABSTRACT: Background Communication and documentation of medication-related information are needed to improve continuity of care. Objective To assess the completeness of medication-related information in discharge letters and post-discharge general practitioner (GP)-overviews. Setting A general teaching hospital in Amsterdam, the Netherlands. Method An observational study was performed. Patients from several departments were included after medication reconciliation at hospital discharge. In liaison with the resident and patient, a pharmacy team prepared a Transitional Pharmaceutical Care (TPC)-overview of current medications, including changes and allergies. The resident was instructed to download the TPC-overview into the discharge letter instead of typing a self-made medication list. Medication overviews were gathered from the GP 2 weeks after the handover of the discharge letter. The TPC-overview (gold standard) was compared with the information in the discharge letter and post-discharge GP-overviews regarding correct medications and allergies. Descriptive data analysis was used. Main outcome measure The number and percentage of complete medication-related information in the discharge letter and the GP-overview were compared to the TPC-overview. Results Ninety-nine patients were included. Medication-related information was complete in 62 (63 %) of 99 discharge letters. Sixteen of 99 GP-overviews (16 %) were complete. Communication of medication-related information increased documentation by the GP, but the medication history could still be incomplete, mainly regarding medication changes and allergies. Conclusions Medication-related information is lost in discharge letters and GP-overviews post-discharge despite in-hospital medication reconciliation. This could result in discontinuity of care.
    No preview · Article · Sep 2015
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    ABSTRACT: Objective: Among immigrant chronic dialysis patients, depressive and anxiety symptoms are common. We aimed to examine the association of acculturation, i.e. the adaptation of immigrants to a new cultural context, and depressive and anxiety symptoms in immigrant chronic dialysis patients. Methods: The DIVERS study is a prospective cohort study in five urban dialysis centers in the Netherlands. The association of five aspects of acculturation ("Skills", "Social integration", "Traditions", "Values and norms" and "Loss") and the presence of depressive and anxiety symptoms was determined using linear regression analyses, both univariate and multivariate. Results: A total of 249 immigrant chronic dialysis patients were included in the study. The overall prevalence of depressive and anxiety symptoms was 51% and 47%, respectively. "Skills" and "Loss" were significantly associated with the presence of depressive and anxiety symptoms, respectively ("Skills" β=0.34, CI: 0.11-0.58, and "Loss" β=0.19, CI: 0.01-0.37; "Skills" β=0.49, CI: 0.25-0.73, and "Loss" β=0.33, CI: 0.13-0.53). The associations were comparable after adjustment. No significant associations were found between the other subscales and depressive and anxiety symptoms. Conclusion: This study demonstrates that less skills for living in the Dutch society and more feelings of loss are associated with the presence of both depressive and anxiety symptoms in immigrant chronic dialysis patients.
    No preview · Article · Sep 2015 · General hospital psychiatry
  • Wietske M Lambers · Bastiaan Kraaijenbrink · Carl E H Siegert
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    ABSTRACT: - The refeeding syndrome may occur during reintroduction of carbohydrates in malnourished patients. This syndrome is characterized by reduced plasma electrolyte levels, hypophosphataemia being most prevalent. The symptoms can vary from minor symptoms to severe neurological or cardiac symptoms.- The pathophysiological mechanism comprises an increase in insulin levels, resulting in shifts of phosphate, potassium and magnesium into the intracellular environment, as well as fluid retention and relative deficiency of vitamin B1.- There is growing interest in the screening and treatment of patients with malnutrition, due to which the incidence of refeeding syndrome is probably increasing.- Currently, there is no single definition of this syndrome and therefore there is no solid scientific basis for screening and treatment. In this article we describe the rationale for screening and additional laboratory investigations.- A prospective, controlled trial is important to define the clinical relevance of the refeeding syndrome and optimize its treatment.
    No preview · Article · Apr 2015 · Nederlands tijdschrift voor geneeskunde
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    ABSTRACT: Short-Form 36 (SF-36) is a self-report health-related quality-of-life (HRQOL) questionnaire, widely used in dialysis patients. It consists of physical and mental component scores (PCS/MCS), ranging from 0 to 100. To improve efficiency, the Short-Form 12 (SF-12) was developed to reproduce PCS and MCS. We assessed the ability of SF-12 versus SF-36 to detect change over time, and the association of SF-12 versus SF-36 with short-term and long-term mortality in dialysis patients. Patients were selected from the Netherlands Cooperative Study on the Adequacy of Dialysis (N = 1379), a prospective follow-up study among incident dialysis patients (62.1% HD) who completed SF-36 measurements every 6 months. Changes in scores of SF-12 versus SF-36 were compared with intra-class correlation coefficients (ICCs). Subsequently, Bland-Altman plots were used to assess limits of agreement. Relationship with mortality was assessed with Cox models with and without a time-dependent variable, adjusted for age, sex, ethnicity, comorbidity and dialysis modality at baseline. ICC for change in scores was 0.90 for MCS and 0.84 for PCS. Mean difference was -0.1 and 0.2, respectively, and limits of agreement were -8.3 to 8.4 for MCS change in scores and -8.8 to 9.2 for PCS. Adjusted hazard ratio's for mortality per 5 units increment were 0.87 (95% CI: 0.84-0.91) for MCS12, 0.87 (95% CI: 0.84-0.90) for MCS36, 0.79 (95% CI: 0.76-0.83) for PCS12 and 0.75 (95% CI: 0.71-0.78) for PCS36. SF-12 can be used to detect change in HRQOL in cohort studies on dialysis patients. SF-12 and SF-36 were similarly associated with short-term and long-term mortality. However, the wide limits of agreement indicate that SF-12 and SF-36 can give different scores on the individual level, suggesting that for individual purposes SF-36 instead of SF-12 should be used. © The Author 2015. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
    No preview · Article · Mar 2015 · Nephrology Dialysis Transplantation
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    ABSTRACT: OBJECTIVE To assess the completeness of medication-related information in hospital discharge letters and in general practitioner (GP) overviews after discharge DESIGN Observational study METHODS Patients discharged from the departments of neurology, cardiology, pulmonology and internal medicine were included after medication reconciliation was performed by pharmaceutical consultants In liaison with the resident and the patient they made a transitional medication overview (TMO) that contained all pharmacotherapy and allergies The resident was urged to download the TMO information into the discharge letter to inform the GP However, the resident could include a self-made medication list instead The TMO information was considered the gold standard and was compared with the medication-related information in the collected discharge letters and GP overviews after discharge regarding correct medications and allergies Descriptive data analysis was used RESULTS 99 patients were included The resident had downloaded the TMO information in 71 discharge letters 172%) However, medication-related information was complete in 62 letters (63%) as residents adjusted the TMO information or included a self-made medication list which was incomplete Of GP overviews 16 (16%) were complete Communication of medication-related information increased documentation by the GP, but the medication history could still be incomplete, mainly regarding medication changes and allergies CONCLUSION Medication-related information is lost in discharge letters and GP overviews despite in-hospital medication reconciliation This may result in discontinuity of care More m-hospital training is needed and future studies should determine the effect of electronic infrastructures on improving information transfer and continuity of pharmaceutical care.
    No preview · Article · Dec 2014

  • No preview · Article · Oct 2014 · British Journal of Clinical Pharmacology
  • Jacob W Bosma · Jesse M Bijl · Carl E H Siegert · Wies L E Vasmel
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    ABSTRACT: Isolated angioedema may be the presenting symptom of acquired C1 inhibitor (C1-INH) deficiency. C1-INH deficiency is associated with lymphoproliferative disorders. Treatment of the underlying disease can result in a complete reversal of clinical and complement abnormalities. We describe a 41-year-old woman who was referred to our emergency department with recurrent episodes of isolated angioedema. Initially, her angioedema was linked to the use of angiotensin receptor blockers. However, after discontinuation of this drug angioedema recurred. Additional investigations revealed the presence of acquired C1-INH deficiency caused by an indolent non-Hodgkin's lymphoma. Treatment with rituximab resulted in complete clinical and biochemical remission of the acquired angioedema.
    No preview · Article · Mar 2014 · Nederlands tijdschrift voor geneeskunde
  • L Tonneijck · M Schouten · M C Weijmer · C E H Siegert
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    ABSTRACT: No abstract available.
    No preview · Article · Nov 2013 · The Netherlands Journal of Medicine
  • L L Snoeks · A C Ogilvie · E P van Haarst · C E H Siegert
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    ABSTRACT: Prostate cancer is one of the most common cancers in men. When metastasised (40% of patients), classic anti-androgen therapy is the first-line treatment. Usually, this treatment becomes ineffective when castration-resistant prostate cancer (CRPC) develops. Thus far, docetaxel was the only chemotherapeutic option that has shown to be able to extend overall survival and improve quality of life in these patients. Recently, cabazitaxel and abiraterone have shown significant survival benefits for patients progressive on or after docetaxel treatment, as did enzalutamide and radium-223. In North America, immune therapy (sipuleucel-T) became available for a subgroup of CRPC patients. These new treatment options will change the treatment paradigm of patients with metastatic castration resistant prostate cancer. A multidisciplinary approach by both medical oncologists and urologists seems mandatory.
    No preview · Article · Aug 2013 · The Netherlands Journal of Medicine
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    ABSTRACT: Studies performed in the United States showed that blacks progress from CKD to ESRD faster than do whites. Possible explanations are differences in health care system factors. This study investigated whether progression is also faster in a universal health care system, where all patients receive comparable care. Data from the PREdialysis PAtient REcord study, a multicenter follow-up study of patients with CKD who started predialysis care in The Netherlands (1999-2011), were analyzed. Time-dependent Cox proportional hazards models were used to estimate the hazard ratio (HR) for starting renal replacement therapy (RRT), and linear mixed models were used to compare renal function decline (RFD) between blacks and whites. To explore possible mechanisms, analyses were adjusted for patient characteristics. At initiation of predialysis care, blacks (n=49) were younger and had more diabetes mellitus, higher proteinuria levels, and a higher estimated GFR than whites (n=946). Median follow-up time in months was similar (blacks: 13.9 [boundaries of interquartile range (IQR), 5.3 to 19.5]; whites: 13.1 [IQR, 5.1 to 24.0]). For blacks compared with whites, the crude HR for starting RRT within the first 15 months was 0.86 (95% confidence interval [CI], 0.55 to 1.34) and from 15 months onward, 1.93 (95% CI, 1.02 to 3.68), which increased after adjustment. RFD was faster by 0.18 (95% CI, 0.05 to 0.32) ml/min per 1.73 m(2) per month in blacks compared with whites. Blacks receiving predialysis care in a universal health care system have faster disease progression than whites, suggesting that health care system factors have a less influential role than had been thought in explaining black-white differences.
    Preview · Article · Jul 2013 · Clinical Journal of the American Society of Nephrology
  • L Tonneijck · W W Fuijkschot · M Schouten · C E H Siegert
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    ABSTRACT: No abstract available.
    No preview · Article · Jun 2013 · The Netherlands Journal of Medicine
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    ABSTRACT: Objective Depressive symptoms are associated with mortality among patients on chronic dialysis therapy. It is currently unknown how different courses of depressive symptoms are associated with both cardiovascular and non-cardiovascular mortality.Methods In a Dutch prospective nation-wide cohort study among incident patients on chronic dialysis, 1077 patients completed the Mental Health Inventory, both at 3 and 12 months after starting dialysis. Cox regression models were used to calculate crude and adjusted hazard ratios (HRs) for mortality for patients with depressive symptoms at 3 months only (baseline only), at 12 months only (new-onset), and both at 3 and 12 months (persistent), using patients without depressive symptoms at 3 and 12 months as reference group.ResultsDepressive symptoms at baseline only seemed to be a strong marker for non-cardiovascular mortality (HRadj 1.91, 95% CI 1.26–2.90), whereas cardiovascular mortality was only moderately increased (HRadj 1.41, 95% CI 0.85–2.33). In contrast, new-onset depressive symptoms were moderately associated with both cardiovascular (HRadj 1.66, 95% CI 1.06–2.58) and non-cardiovascular mortality (HRadj 1.46, 95% CI 0.97–2.20). Among patients with persistent depressive symptoms, a poor survival was observed due to both cardiovascular (HRadj 2.14, 95% CI 1.42–3.24) and non-cardiovascular related mortality (HRadj 1.76, 95% CI 1.20–2.59).Conclusion This study showed that different courses of depressive symptoms were associated with a poor survival after the start of dialysis. In particular, temporary depressive symptoms at the start of dialysis may be a strong marker for non-cardiovascular mortality, whereas persistent depressive symptoms were associated with both cardiovascular and non-cardiovascular mortality.
    Preview · Article · Jun 2013 · Journal of psychosomatic research
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    ABSTRACT: Context: The supervision of specialty registrars during on-call shifts is essential to ensure the quality of both health care and medical education, but has been identified as a major novelty and stressor for new consultants in the transition from specialty training. There is a paucity of research on how consultants deal with their new supervisory roles and which factors influence this process. These issues are addressed in a prospective study designed to gather insights that can inform measures to ensure the provision of high-quality supervision and specialty training. Methods: A longitudinal qualitative study was performed in the Netherlands. Semi-structured interviews were conducted with new consultants. The study was guided by an interpretative phenomenological approach until saturation was reached. At 3-month intervals between July 2011 and March 2012, eight novice consultants in internal medicine were interviewed three times each about their supervisory role while on call. Interviews focused on their preparation for the role in training, the actions they took to master the role, and their progression over time. Results: Three interrelated domains of relevant factors emerged from the data: preparedness; personal characteristics, and contextual characteristics. Preparedness referred to the extent to which new consultants were prepared by training to take full responsibility for registrars' actions while supervising them from a distance. Personal characteristics, such as coping strategies and views on supervision, guided consultants' development as supervisors. Essential to this process were contextual characteristics, especially those concerning the extent to which the consultant knew the registrar, was familiar with departmental procedures, and had access to support from colleagues. Conclusions: New consultants should be prepared for their supervisory role by training and by being given a proper introduction to their workplace. The former requires progressive independence and exposure to supervisory tasks during specialty training; the latter requires an induction programme to enable new consultants to familiarise themselves with the departmental environment and the registrars they will be supervising.
    No preview · Article · Apr 2013 · Medical Education
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    ABSTRACT: Background: Insight into the transition from specialist registrar to hospital consultant is needed to better align specialty training with starting as a consultant and to facilitate this transition. Aims: This study investigates whether preparedness regarding medical and generic competencies, perceived intensity, and social support are associated with burnout among new consultants. Method: A population-based study among all 2643 new consultants in the Netherlands (all specialties) was conducted in June 2010. A questionnaire covering preparedness for practice, intensity of the transition, social support, and burnout was used. Structural equation modelling was used for statistical analysis. Results: Data from a third of the population were available (32% n = 840) (43% male/57% female). Preparation in generic competencies received lower ratings than in medical competencies. A total of 10% met the criteria for burnout and 18% scored high on the emotional exhaustion subscale. Perceived lack of preparation in generic competencies correlated with burnout (r = 0.15, p < 0.001). No such relation was found for medical competencies. Furthermore, social support protected against burnout. Conclusions: These findings illustrate the relevance of generic competencies for new hospital consultants. Furthermore, social support facilitates this intense and stressful stage within the medical career.
    No preview · Article · Mar 2013 · Medical Teacher
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    ABSTRACT: Background Patients with an elevated erythrocyte sedimentation rate (ESR) and non-specific symptoms often pose a diagnostic dilemma. PET/CT visualises infection, inflammation and malignancy, all of which may cause elevated ESR. Objectives To determine the contribution of 18F-fluorodeoxglucose positron emission tomography (PET/CT) in the diagnostic work-up of referred patients with an elevated ESR, in whom initial routine evaluation did not reveal a diagnosis, in order to detect large vessel vasculitis, among other diseases. Methods In a combined retrospective (A) and prospective (B) study PET/CT was performed in elderly patients (> 50 years of age) who presented with a significantly elevated ESR (≥ 50 mm/h) and non-specific complaints. In addition, a protocolised work-up (including chest X-ray, abdominal ultrasound and protein electrophoresis) was used in study B. In both studies, the final diagnosis was based on histology, clinical follow-up, response to therapy and/or additional imaging. Results In study A, 30 patients were included. PET/CT results suggested malignancy (8 patients), inflammatory disease (8 patients, including 5 with large-vessel vasculitis) and infection (3 patients). In 2 patients, non-specific abnormalities were found. Of the 21 patients with abnormal PET/CT results, final diagnoses were in accordance with PET/CT results in 12 patients (including 5 with large-vessel vasculitis). In 9 patients, abnormalities detected by PET/CT did not contribute to the final diagnosis. Two diagnoses (tendinitis and acute myeloid leukaemia) were established in 9 patients with a normal scan. In study B, 58 patients were included. PET/CT results suggested inflammatory disease (25 patients), particularly large-vessel vasculitis (14 cases), infection (5 patients) and malignancy (3 patients). 7 scans demonstrated non-specific abnormalities. Of the 40 patients with abnormal PET/CT results, final diagnoses were in accordance with PET/CT results in 22 patients (including 14 with large-vessel vasculitis). In 18 patients PET/CT abnormalities did not contribute to a final diagnosis. One final diagnosis (PMR) was established in 20 patients with a normal scan. Conclusions PET/CT may be of potential value in the diagnostic work-up of patients with non-specific complaints and an elevated ESR. In particular, large-vessel vasculitis appears to be a common finding. A normal PET/CT scan in these patients suggests that it is safe to follow a wait-and-see policy. Disclosure of Interest None Declared
    Full-text · Article · Mar 2013 · PLoS ONE
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    ABSTRACT: Introduction: Danish and Dutch new consultants' perceptions regarding the transition to consultant were compared to gain insight into this period, particularly the influence of contextual factors concerning the organisation of specialty training and health care therein. Preparation for medical and generic competencies, perceived intensity and burnout were compared. Additionally, effects of differences in working conditions and cultural dimensions were explored. Methods: All consultants registered in the Netherlands in 2007-2009 (n = 2643) and Denmark in 2007-2010 (n = 1336) received in June 2010 and April 2011, respectively, a survey about their preparation for medical and generic competencies, perceived intensity and burnout. Power analysis resulted in required sample sizes of 542. Descriptive statistics and independent t-tests were used for analysis. Results: Data were available of 792 new consultants in the Netherlands and 677 Danish new consultants. Compared to their Dutch counterparts, Danish consultants perceived specialty training and the transition less intensely, reported higher levels of preparation for generic competencies and scored lower on burnout. Conclusions: The importance of contextual aspects in the transition is underscored and shows that Denmark appears to succeed better in aligning training with practice. Regulations regarding working hours and progressive independence of trainees appear to facilitate the transition.
    No preview · Article · Mar 2013 · Medical Teacher
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    ABSTRACT: Familial LCAT deficiency (FLD) is a recessive lipid disorder ultimately leading to end-stage renal disease (ESRD). We present two brothers with considerable variation in the age at which they developed ESRD. Kidney biopsies revealed both tubular and glomerular pathology. To date, no causal therapy is available, yet enzyme replacement therapy is in development.
    No preview · Article · Feb 2013 · The Netherlands Journal of Medicine
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    ABSTRACT: Objective: Depressive symptoms seem to pose a risk factor for mortality among patients on dialysis. It is currently unknown whether the association is only short-lived and whether associations over time depend on specific causes of mortality. Methods: In a prospective nationwide cohort study, 1528 patients with end-stage renal disease starting on dialysis completed the Mental Health Inventory. Patients were observed up to 5 years or until the end of follow-up in April 2011. Cox regression analyses were used to calculate associations between depressive symptoms and short-term (0-6 months), medium-term (6-24 months), or long-term (24-60 months) cardiovascular and noncardiovascular mortality. Results: The adjusted hazard ratio (HR) was 1.43 (95% confidence interval [CI] = 1.08-1.88) for cardiovascular mortality and 2.07 (95% CI = 1.62-2.64) for noncardiovascular mortality. Depressive symptoms posed a strong risk factor for noncardiovascular mortality at the short term (HR = 2.82, 95% CI = 1.58-5.05), medium term (HR = 2.08, 95% CI = 1.40-3.09), and long term (HR = 1.84, 95% CI = 1.26-2.69), whereas the association between depressive symptoms and cardiovascular mortality was not observed during the first 6 months of follow-up (HR = 1.03, 95% CI = 0.49-2.15). Conclusions: Depressive symptoms at the start of dialysis therapy are associated with short-, medium-, and long-term mortality. The cause-specific mortality risk over time may help clinicians to understand multifactorial causes of the association between depressive symptoms and survival.
    No preview · Article · Oct 2012 · Psychosomatic Medicine

Publication Stats

490 Citations
106.34 Total Impact Points

Institutions

  • 2006-2015
    • St. Lucas Andreas Hospital
      Amsterdamo, North Holland, Netherlands
  • 2014
    • St. Antonius Ziekenhuis
      Nieuwegen, Utrecht, Netherlands
  • 2008
    • Academisch Medisch Centrum Universiteit van Amsterdam
      • Department of Clinical Epidemiology and Biostatistics
      Amsterdam, North Holland, Netherlands