The predictive value of self-report scales compared with physician diagnosis of depression in hemodialysis patients

Pharmacological treatment for mental health illnesses in adults receiving dialysis: A scoping review

BACKGROUND

Pharmacologic management of mental health illnesses in patients receiving dialysis is complex and lacking data.

OBJECTIVE

Our objective was to synthesize published data for the treatment of depression, bipolar and related disorders, schizophrenia or psychotic disorders, and anxiety disorders in adults receiving hemodialysis or peritoneal dialysis.

METHODS

We undertook a scoping review, searching the following databases: Medline, Embase, CINAHL, PsycINFO, Cochrane Library, Scopus, and Web of Science. Data on patients who received only short-term dialysis, a kidney transplant, or non-pharmacologic treatments were excluded.

RESULTS

Seventy-three articles were included: 41 focused on depression, 16 on bipolar disorder, 13 on schizophrenia and psychotic disorders, 1 on anxiety disorders, and 2 addressing multiple mental health illnesses. The majority of depression studies reported on selective serotonin reuptake inhibitors (SSRIs) as a treatment. Sertraline had the most supporting data with use of doses from 25 to 200 mg daily. Among the remaining SSRIs, escitalopram, citalopram, and fluoxetine were studied in controlled trials, whereas paroxetine and fluvoxamine were described in smaller reports and observational trials. There are limited published data on other classes of antidepressants and on pharmacological management of anxiety. Data on treatment for patients with bipolar disorder or schizophrenia and related disorders are limited to case reports.

CONCLUSION

Over half of the studies included were case reports, thus limiting conclusions. More robust data are required to establish effect sizes of pharmacological treatments prior to providing specific recommendations for their use in treating mental health illnesses in patients receiving dialysis.

Depressive Symptoms, Antidepressants, and Clinical Outcomes in Chronic Kidney Disease: Findings from the CRIC Study

Rationale & Objective

The extent to which depression affects the progression of chronic kidney disease (CKD) and leads to adverse clinical outcomes remains inadequately understood. We examined the association of depressive symptoms (DS) and antidepressant medication use on clinical outcomes in 4,839 adults with nondialysis CKD.

Study Design

Observational cohort study.

Setting and Participants

Adults with mild to moderate CKD who participated in the multicenter Chronic Renal Insufficiency Cohort Study (CRIC).

Exposure

The Beck Depression Inventory (BDI) was used to quantify DS. Antidepressant use was identified from medication bottles and prescription lists. Individual effects of DS and antidepressants were examined along with categorization as follows: (1) BDI <11 and no antidepressant use, (2) BDI <11 with antidepressant use, (3) BDI ≥11 and no antidepressant use, and (4) BDI ≥11 with antidepressant use.

Outcomes

CKD progression, incident cardiovascular disease composite, all-cause hospitalizations, and mortality.

Analytic Approach

Cox regression models were fitted for outcomes of CKD progression, incident cardiovascular disease, and all-cause mortality, whereas hospitalizations used Poisson regression.

Results

At baseline, 27.3% of participants had elevated DS, and 19.7% used antidepressants. Elevated DS at baseline were associated with significantly greater risk for an incident cardiovascular disease event, hospitalization, and all-cause mortality, but not CKD progression, adjusted for antidepressants. Antidepressant use was associated with higher risk for all-cause mortality and hospitalizations, after adjusting for DS. Compared to participants without elevated DS and not using antidepressants, the remaining groups (BDI <11 with antidepressants; BDI ≥11 and no antidepressants; BDI ≥11 with antidepressants) showed higher risks of hospitalization and all-cause mortality.

Limitations

Inability to infer causality among depressive symptoms, antidepressants, and outcomes. Additionally, the absence of nonpharmacological data, and required exploration of generalizability and alternative analytical approaches.

Conclusions

Elevated DS increased adverse outcome risk in nondialysis CKD, unattenuated by antidepressants. Additionally, investigation into the utilization and counterproductivity of antidepressants in this population is warranted.

Barriers and Facilitators to Exercise in Older Adults Awaiting Kidney Transplantation and Their Care Partners

Rationale & Objective

Despite guidelines calling to improve physical activity in older adults, and evidence suggesting that prekidney transplant physical function is highly associated with posttransplant outcomes, only a small percentage of older patients treated with dialysis are engaged in structured exercise. We sought to elucidate barriers and facilitators of exercise among older adults treated with dialysis awaiting transplant and their care partners.

Study Design

Individual, in-depth, cognitive interviews were conducted separately for patients and care partners through secure web-conferencing.

Setting & Participants

Twenty-three patients (≥50 years of age, treated with dialysis from the University of San Francisco kidney transplantation clinic, with a short physical performance battery of ≤10) and their care partners.

Analytical Approach

All audio interviews were transcribed verbatim. Three investigators independently coded data and performed qualitative thematic content. The interview guide was updated iteratively based on the Capability Opportunity Motivation Behavior model.

Results

Patients' median age was 60 years (57 ± 63.5) and care partners' median ages was 57 years (49.5 ± 65.5). Thirty-nine percent of patients and 78% of care partners were female, 39% of patients and 30% of care partners self-identified as African American, and 47% of dyads were spouse or partner relationships. Major themes for barriers to pretransplant exercise included lack of understanding of an appropriate regimen, physical impairments, dialysis schedules, and safety concerns. Major facilitators included having individualized or structured exercise programs, increasing social support for patients and care partners, and motivation to regain independence or functionality or to promote successful transplantation.

Limitations

Participants geographically limited to Northern California.

Conclusions

Although patients and care partners report numerous barriers to pretransplant exercise and activity, they also reported many facilitators. An individualized, structured, home-based exercise program could circumvent many of the reported barriers and allow older patients to improve pretransplant physical function.

Mortality, health-related quality of life, and depression symptoms in younger and older men and women undergoing hemodialysis

BACKGROUND AND OBJECTIVE

Some studies on maintenance hemodialysis (MHD) patients report a longer survival, albeit with poorer health-related quality of life (HRQoL), and more depression symptoms in women than in men. Whether these gender differences vary with age is uncertain. We tested the associations of gender with mortality, depression symptoms, and HRQoL in MHD patients of different age groups.

METHODS

We used data from 1504 adult MHD patients enrolled in the PROHEMO, a prospective cohort in Salvador, Brazil. The KDQOL-SF was used for the component summaries of the mental (MCS) and physical (PCS) HRQoL scales. Depression symptoms were assessed by the complete version of the Center for Epidemiological Studies Depression Screening Index (CES-D). To test for gender differences, extensively adjusted linear models were used for depression and HRQoL scores, and Cox models for death hazard ratio (HR).

RESULTS

Women reported worse HRQoL than men, particularly for ages ⩾60 years. In the age group ⩾60 years, the adjusted difference (AD) in score was -3.45; 95% CI: -6.81, -0.70 for MCS -3.16; -5.72, -0.60 for PCS. Older (⩾60 years) women also had more depression symptoms (AD 4.98; 2.33, 7.64). Mortality was slightly lower in women than in men with an adjusted HR of 0.89 (0.71, 1.11) and consistent across age categories.

CONCLUSIONS

In a sample of Brazilian MHD patients, women had a slightly lower mortality, albeit with more depression symptoms and poorer HRQoL than men, particularly among older patients. This study highlights the need to investigate gender inequalities for MHD patients across different cultures and populations.

Non-Pharmacological Interventions for Pain Management in Hemodialysis: A Narrative Review

This narrative review aims to summarize non-pharmacological interventions for pain management in hemodialysis patients, assessing their potential benefits and limitations in enhancing patient well-being and quality of life. We reviewed the current literature on five primary non-pharmacological interventions: acupuncture, cognitive behavioral therapy, relaxation techniques, virtual reality, and alternative methods such as transcutaneous electrical nerve stimulation, music therapy, and aromatherapy. We analyzed the evidence regarding their effectiveness, feasibility, and optimal implementation strategies. The existing evidence supports the potential benefits of these interventions in managing pain and improving the well-being of hemodialysis patients. However, further high-quality research is needed to confirm their effectiveness, establish implementation best practices, and assess their long-term impact on patient outcomes. Non-pharmacological interventions hold promise for pain management in hemodialysis patients. Additional research is required to optimize these interventions and validate their effectiveness, contributing to comprehensive pain management strategies for this vulnerable patient population.

Global research trends and mapping knowledge structure of depression in dialysis patients

BACKGROUND

Depression is one of the most common and important psychological issues faced by dialysis patients. It can make it more difficult for them to adhere to their treatment regimen, which, in turn, can worsen their physical symptoms and lead to poorer health outcomes.

AIM

To examine the evolution and growth of publications related to dialysis and depression. The objectives were to identify the number of publications, the top active countries, the contributed institutions, funding agencies and journals, as well as to perform citation and research theme analysis.

METHODS

The search was conducted using the Scopus database for publications related to dialysis and depression between 1970 and 2022. Subsequently, bibliometric analysis was carried out on the data obtained using VOSviewer software, version 1.6.9. This analysis included visualization analysis, co-occurrence analysis and examination of publication trends in dialysis and depression.

RESULTS

We identified 800 publications that met the search criteria. The number of publications related to dialysis and depression has increased significantly in the past two decades. The USA led the way with 144 publications, which is 18% of all publications on this topic. Turkey came second with 88 publications (11%), followed by China with 55 publications (6.88%) and Iran with 52 publications (6.5%). Analysis of the research theme identified three main clusters related to gender differences in prevalence, identification of depression as a risk factor, and effective interventions to relieve depression. Future research direction analysis shows a shift toward effective interventions to relieve depression in dialysis patients.

CONCLUSION

This study provides a comprehensive overview of growth, trends and research themes related to dialysis and depression that could help researchers identify gaps in the literature and develop future research.

Effects of Technology Assisted Stepped Collaborative Care Intervention to Improve Symptoms in Patients Undergoing Hemodialysis: The TĀCcare Randomized Clinical Trial

Importance

Patients with end-stage kidney disease (ESKD) undergoing long-term hemodialysis often experience a high burden of debilitating symptoms for which effective treatment options are limited.

Objective

To compare the effectiveness of a stepped collaborative care intervention vs attention control for reducing fatigue, pain, and depression among patients with ESKD undergoing long-term hemodialysis.

Design, Setting, and Participants

Technology Assisted Stepped Collaborative Care (TĀCcare) was a parallel-group, single-blinded, randomized clinical trial of adult (≥18 years) patients undergoing long-term hemodialysis and experiencing clinically significant levels of fatigue, pain, and/or depression for which they were considering treatment. The trial took place in 2 US states (New Mexico and Pennsylvania) from March 1, 2018, to June 31, 2022. Data analyses were performed from July 1, 2022, to April 10, 2023.

Interventions

The intervention group received 12 weekly sessions of cognitive behavioral therapy delivered via telehealth in the hemodialysis unit or patient home, and/or pharmacotherapy using a stepped approach in collaboration with dialysis and primary care teams. The attention control group received 6 telehealth sessions of health education.

Main Outcomes and Measures

The coprimary outcomes were changes in fatigue (measured using the Functional Assessment of Chronic Illness Therapy Fatigue), average pain severity (Brief Pain Inventory), and/or depression (Beck Depression Inventory-II) scores at 3 months. Patients were followed up for 12 months to assess maintenance of intervention effects.

Results

There were 160 participants (mean [SD] age, 58 [14] years; 72 [45%] women and 88 [55%] men; 21 [13%] American Indian, 45 [28%] Black, 28 [18%] Hispanic, and 83 [52%] White individuals) randomized, 83 to the intervention and 77 to the control group. In the intention-to-treat analyses, when compared with controls, patients in the intervention group experienced statistically and clinically significant reductions in fatigue (mean difference [md], 2.81; 95% CI, 0.86 to 4.75; P = .01) and pain severity (md, -0.96; 95% CI, -1.70 to -0.23; P = .02) at 3 months. These effects were sustained at 6 months (md, 3.73; 95% CI, 0.87 to 6.60; P = .03; and BPI, -1.49; 95% CI, -2.58 to -0.40; P = .02). Improvement in depression at 3 months was statistically significant but small (md -1.73; 95% CI, -3.18 to -0.28; P = .02). Adverse events were similar in both groups.

Conclusions and Relevance

This randomized clinical trial found that a technology assisted stepped collaborative care intervention delivered during hemodialysis led to modest but clinically meaningful improvements in fatigue and pain at 3 months vs the control group, with effects sustained until 6 months.

Trial Registration

ClinicalTrials.gov Identifier: NCT03440853.

Association between Depressive Symptom Trajectory and Chronic Kidney Disease Progression: Findings from the Chronic Renal Insufficiency Cohort Study

Key Points

Depressive symptoms are largely stable over time among individuals with mild-to-moderate CKD Low educational attainment, cigarette smoking, and poor quality of life are associated with persistent depressive symptoms Persistent depressive symptoms are associated with nonlinear and rapid decline in kidney function

Background

Although depression is highly prevalent among individuals with CKD, little is known about the course of depressive symptoms over time. We characterized trajectories of depressive symptoms and CKD progression and evaluated the association between depressive symptoms trajectory and CKD progression.

Methods

Two thousand three hundred sixty-one individuals with mild-to-moderate CKD enrolled in the Chronic Renal Insufficiency Cohort Study were analyzed. The Beck Depression Inventory (BDI) was used to assess depressive symptoms at baseline and biennially. Higher BDI scores indicate worse depressive symptoms. eGFR was calculated using the 2021 CKD-EPI equation. Group-based trajectory models were used to determine trajectories of BDI score and eGFR change over time. Multinomial logistic regression was used to examine factors associated with BDI trajectories and to evaluate the association of BDI trajectories with eGFR change.

Results

Over 8 years of follow-up, three patterns of depressive symptoms were identified: persistently low BDI score (57.7%), persistently moderate BDI score (33.1%), and persistently high BDI score (9.2%). Three eGFR trajectory groups were identified: nonlinear, rapid eGFR decline (21.5%); linear, expected eGFR decline (54.8%); and stable eGFR (23.7%). Predictors of persistently moderate and high BDI trajectories included low educational attainment, smoking, and poor quality of life. Compared with those with a persistently low BDI score, the odds for nonlinear, rapid eGFR decline were higher for those with persistently moderate BDI scores (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.04 to 2.03) and persistently high BDI scores (OR, 1.90; 95% CI, 1.02 to 3.56). No association between moderate BDI score and linear, expected eGFR decline was observed.

Conclusions

Depressive symptoms remained largely stable among individuals with mild-to-moderate CKD, and persistently moderate and high BDI scores were associated with nonlinear, rapid eGFR decline. Future work is needed to better understand the interplay between depression and CKD progression.

Association between sedentary behavior and depression in US adults with chronic kidney disease: NHANES 2007-2018

BACKGROUND

Depression increases the risk of adverse clinical outcomes in patients with chronic kidney disease. Physical activity has been shown to improve depressive symptoms in this population, but the relationship of sedentary behavior with depression has not been studied. In this study, we examined the relationship between sedentary behavior and depression in patients with chronic kidney disease.

METHODS

This cross-sectional study included 5,205 participants aged ≥ 18 years with chronic kidney disease participating in the 2007-2018 National Health and Nutrition Examination Survey. Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9). Recreation activity, work activity, walking or cycling for transportation, and sedentary behavior were measured using the Global Physical Activity Questionnaire. A series of weighted logistic regression models were used to investigate the aforementioned relationship.

RESULTS

The prevalence of depression among US adults with chronic kidney disease was 10.97% in our study. In addition, sedentary behavior was strongly associated with higher levels of depressive symptoms, as measured by the PHQ-9 (P < 0.001). In the fully adjusted model, we found that compared with participants who had shorter durations of sedentary behavior, participants who had the highest durations of sedentary behavior had 1.69 times (odd ratio 1.69, 95% confidence interval: 1.27, 2.24) greater risk of being clinically depressed. After adjusting for confounding factors, subgroup analyses showed that the association between sedentary behavior and depression still existed in all stratifications.

CONCLUSION

We found an association between longer duration of sedentary behavior and more severe depression in US adults with chronic kidney disease; however, prospective studies with larger sample sizes are still needed to confirm the effects of sedentary behavior on depression in the chronic kidney disease population.

Frailty as a dynamic process in a diverse cohort of older persons with dialysis-dependent CKD

This study examines frailty status evolution observed in a two-year follow-up of a cohort of older persons (age ≥65) with chronic kidney disease (CKD) undergoing maintenance hemodialysis (HD) treatment. Frailty, a geriatric syndrome that connotes a state of low physiologic reserve and vulnerability to stressors, is associated with increased risk for multiple adverse health outcomes in studies of persons with CKD as well as older persons in the general population. The Fried frailty index defines frailty as the presence of 3 or more of 5 indicators-recent unintentional weight loss, slowed gait speed, decreased muscle strength, self-reported exhaustion, and low physical activity. In the seminal work by Fried and colleagues, persons who were characterized by 1-2 of the Fried index criteria were termed "pre-frail" and considered at risk for subsequently becoming frail, potentially providing insight regarding intervention targets that might slow or prevent individuals' transition from pre-frail to frail status. Other less frequently studied types of transitions may also be informative, including "recovery or reversion" (improvement) by people whose longitudinal assessments indicate movement from frailty to prefrailty or robust, or from prefrailty to robust. These status changes are also a potential source of insights relevant for prevention or remediation of frailty, but research focusing on the various ways that individuals may transition between frailty states over time remains limited, and no previous research has examined varying patterns of frailty status evolution in an older cohort of persons with dialysis-dependent CKD. In a study cohort of dialysis-dependent older persons, we characterized patterns of frailty status evolution by age, sex, race/ethnicity, and treatment vintage; by longitudinal profiles of non-sedentary behavior; and by self-report indicators relevant for dimensions emphasized in the Age-Friendly 4Ms Health System (What Matters, Mobility, Mentation). Our study suggests that strategies to promote resiliency among older persons with dialysis-dependent CKD can be informed not only by frailty status transition that indicates improvement over time but also by older adults' maintenance of (stable) robust status over time, and we concur that inclusion of both frailty and resilience measures is needed in future longitudinal studies and clinical trials.

Weight change and risk of depression in patients with diabetic kidney disease: a nationwide population-based study

BACKGROUND

Several studies have reported that depression is prevalent in patients with diabetes or chronic kidney disease. However, the relationship between weight changes and the risk of depression has not been elucidated in patients with diabetic kidney disease (DKD).

METHODS

From the Korean National Health Insurance Service database, we selected 67,866 patients with DKD and body weight data from two consecutive health examinations with a 2-year interval between 2009 and 2012. Weight change over 2 years was categorized into five groups: ≥-10%, &lt;-10% to ≥-5%, &lt;-5% to &lt;5%, ≥5% to &lt;10%, and ≥10%. The occurrence of depression was monitored via the codes of International Statistical Classification of Diseases, 10th revision through the end of 2018.

RESULTS

During the 5.24-year follow-up, 17,023 patients with DKD developed depression. Weight change and the risk of depression had a U-shaped relationship: patients with ≥-10% weight change (hazard ratio [HR], 1.12) and those with ≥10% weight change (HR, 1.11) showed higher HRs for depression than those with &lt;-5% to &lt;5% weight change, even after adjusting for several confounding factors. In the subgroup analyses, the risk of depression tended to increase as weight gain or weight loss increased in all subgroups.

CONCLUSION

Both weight loss and weight gain increased the risk of depression in patients with DKD.

Emotional and cognitive changes in chronic kidney disease

Chronic kidney disease (CKD) leads to cognitive impairment and emotional changes. However, the precise mechanism underlying the crosstalk between the kidneys and the nervous system is not fully understood. Inflammation and cerebrovascular disease can influence the development of depression in CKD. CKD is one of the strongest risk factors for cognitive impairment. Moreover, cognitive impairment occurs in CKD as patients experience the dysregulation of several brain functional domains due to damage caused to multiple cortical regions and to subcortical modulatory neurons. The differences in structural brain changes between CKD and non-CKD dementia may be attributable to the different mechanisms that occur in CKD. The kidney and brain have similar anatomical vascular systems, which may be susceptible to traditional risk factors. Vascular factors are assumed to be involved in the development of cognitive impairment in patients with CKD. Vascular injury induces white matter lesions, silent infarction, and microbleeds. Uremic toxins may also be directly related to cognitive impairment in CKD. Many uremic toxins, such as indoxyl sulfate, are likely to have an impact on the central nervous system. Further studies are required to identify therapeutic targets to prevent changes in the brain in patients with CKD.

Psychiatric and substance use disorders in a predominately low-income, black sample in early midlife

Decades of research have documented elevated rates of psychopathology among individuals affected by poverty. However, many studies have relied on predominately White samples, and on brief symptom screening measures which may not fully capture the experiences of individuals of color (who are disproportionately affected by poverty in the United States.) The present study examines prevalence rates of probable major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder, substance use disorder, and alcohol use disorder in a predominately Black sample that grew up in urban poverty, utilizing structured neuropsychiatric interview methods. Data are drawn from a subsample of the Chicago Longitudinal Study (CLS), which has followed a large cohort for over four decades. Outcomes were assessed using the Mini International Neuropsychiatric Interview (M.I.N.I.) 7.0.2. Results indicate high probable rates of all measured outcomes, with notably high rates of substance use and alcohol use disorder compared to rates reported in previous national studies. Differences by sex and childhood neighborhood poverty, as well as significant comorbidity among psychiatric, substance and alcohol use disorders were also detected. Findings underscore an urgent need for community-based, culturally tailored prevention and intervention initiatives to support the mental health of individuals living in poverty. The high prevalence of psychiatric, substance and alcohol use disorders in this study likely reflect systematic inequities faced by low-income people of color in the United States. Future directions for research and practice are discussed.

Directly Observed Weekly Fluoxetine for Major Depressive Disorder Among Hemodialysis Patients: A Single-Arm Feasibility Trial

Rationale & Objective

Major depressive disorder (MDD) is common among hemodialysis patients, but treatment can add to their pill burden and may be limited by nonadherence. We sought to investigate the value of directly observed, once-weekly fluoxetine dosing in MDD.

Study Design

Feasibility trial of adult hemodialysis patients with untreated MDD. The diagnosis of MDD was determined using the Mini International Neuropsychiatric Interview.

Setting & Participants

16 patients at 15 hemodialysis facilities in Northeast Ohio.

Intervention

Patients were initially prescribed 20 mg of fluoxetine once daily for 2 weeks to assess their tolerance. The patients took this daily fluoxetine unobserved at home. They were then transitioned to 90 mg of fluoxetine once weekly for 10 weeks. The patients took this weekly fluoxetine during hemodialysis treatment and were observed by the study staff. The dose was increased to 180 mg once weekly among patients with an inadequate response based on the judgment of the prescribing clinician.

Outcomes

Mini International Neuropsychiatric Interview diagnosis of MDD at the end of the trial and changes in the Patient Health Questionnaire (PHQ-9) scores over 12 weeks.

Results

One patient withdrew from active treatment after 2 daily doses of 20 mg of fluoxetine because of side effects of stomach cramping, vomiting, dizziness, and lightheadedness but completed the baseline and final assessments. The remaining 15 patients received all scheduled weekly fluoxetine doses during the trial. At 12 weeks, 14 of 16 patients (87.5%) no longer met the criteria for MDD (P < 0.001). Among all participants, the mean PHQ-9 scores decreased from 11.3 to 6.6 (P = 0.002).

Limitations

Small sample size, modestly elevated baseline PHQ-9 scores, no comparison group, and short treatment duration.

Conclusions

Directly observed, once-weekly fluoxetine may be an effective and well-tolerated treatment option for hemodialysis patients. Future research should investigate longer-term health outcomes of weekly fluoxetine in this population and explore the feasibility of implementing this depression treatment model in routine clinical practice.

Trial Registration

This trial was registered at clinicaltrials.gov as NCT03390933.

Depressive Symptoms at Kidney Transplant Evaluation and Access to the Kidney Transplant Waitlist

Introduction

Depressive symptoms, even without a clinical diagnosis of depression, are common in kidney failure patients and may be a barrier to completing the complex process of kidney transplant (KT) evaluation. We assessed depressive symptom burden and association between depressive symptoms and access to KT waitlist by age.

Methods

In a prospective cohort of 3728 KT patients (aged 18–88 years), the Center for Epidemiologic Studies—Depression (CES-D) scale was used to measure depressive symptoms at evaluation. Depressive symptom severity was defined as follows: none: 0; minimal: 1 to 15; mild: 16 to 20; moderate: 21 to 25; severe: 26 to 60. Hazard ratios (HRs) of active listing within 1 year after evaluation were estimated using Cox proportional hazards models, adjusted for clinical and social factors.

Results

At evaluation, 85.8% of the patients reported at least minimal depressive symptoms; the proportion was lower among older patients: 18 to 29 years = 92.0%; 30 to 39 years = 88.3%; 40 to 49 years = 87.2%; 50 to 59 years = 87.0%; 60 to 69 years = 83.4%; and ≥70 years = 82.0%. Chance of active listing decreased with more severe depressive symptoms (log-rank, P < 0.001). After adjustment, every 5-point higher CES-D score (more depressive symptoms) was associated with a 13% lower chance of listing (HR = 0.87, 95% CI: 0.85–0.90); the strongest association was found among patients aged ≥70 years (adjusted HR [aHR] = 0.73, 95% CI: 0.62–0.86). Furthermore, minimal (HR = 0.69, 95% CI: 0.60–0.79), mild (HR = 0.57, 95% CI: 0.44–0.72), moderate (HR = 0.53, 95% CI: 0.39–0.71), and severe (HR = 0.44, 95% CI: 0.34–0.57) depressive symptoms were all associated with a lower chance of listing.

Conclusion

Older candidates were less likely to report depressive symptoms at KT evaluation. Regardless of age, candidates who did report depressive symptoms, and even minimal symptoms, had a lower chance of listing. Transplant centers should routinely screen patients for depressive symptoms and refer the affected patients to mental health services to improve access to KT.

Executive functions as a mediator of childhood maltreatment on adult psychopathology: A longitudinal mediation analysis comparing maltreatment factor models

BACKGROUND

Childhood maltreatment (CM), executive functions (EFs), and psychiatric disorders all correlate highly. Changes in EFs during adolescence related to CM present a possible mediating mechanism for the development of psychiatric disorders, yet no study has analyzed this longitudinally while comparing predictive capacity of different CM factor structures. We hypothesized that changes in EFs from adolescence to adulthood would mediate, in part, associations between CM, internalizing disorders (INT), and anti-social personality disorder (ASPD) while different subtypes of CM would differentially predict INT and ASPD.

OBJECTIVE

This study longitudinally examined the mediating effects of EFs on associations between CM, INT, and ASPD while comparing prediction of two CM factor structures.

PARTICIPANTS

High-risk subjects selected for drug use in adolescence (N = 658) from mean ages 16 to 23.

METHODS

A Bayesian structural equation model was deployed to analyze change in EFs as a mediator of the relationship between CM and adult INT and ASPD. CM was measured using two factor structures: a single overall factor and four correlated factors representing CM subtypes.

RESULTS

CM significantly predicted INT and ASPD but there was no evidence that the relationship was substantially mediated through EFs. High correlations among subtypes of CM limited the unique predictions of each subtype on INT and ASPD.

CONCLUSION

In this high-risk sample, the collinearity of CM subtypes obscured their predictions of outcome measures supporting the use of one CM factor. EFs did not significantly mediate associations between CM and psychiatric disorders, but further research on these relationships is warranted.

Depression in dialysis

PURPOSE OF REVIEW

The aim of this study was to examine updated prevalence rates, risk factors and the prognosis, diagnosis and treatments for depression among dialysis patients.

RECENT FINDINGS

Depression influences prognosis, complications, quality of life (QOL), treatment and costs for dialysis patients worldwide. Reported prevalence of depression is 13.1-76.3%; it is higher for dialysis than transplant and higher post than predialysis. Reported depression rates with peritoneal dialysis (PD) compared with in-centre haemodialysis (HD) are inconsistent. Related medical factors are known, but suspected associated patient characteristics including gender and race remain unexplored. Associations between depression in dialysis and QOL, mortality, pathophysiological mechanisms of increased mortality, infection and pathways of inflammation-mediated and psychosocial factors require clarification. Several depression screening instruments are validated for dialysis patients - the Structured Clinical Interview for DSM disorders (SCID) remains the gold standard - but authors suggest the diagnostic standard should be higher than for the general population. Short-term studies indicate nonpharmacological therapy achieves clinical effects for depression in dialysis patients, but research on long-term effects is needed.

SUMMARY

Depression management through early screening and continuous care models emphasizing dynamic relationships between healthcare teams, patients and families should be encouraged. Large-scale studies of short-term and long-term benefits of pharmacological and nonpharmacological depression management are warranted.

Effects of Nutritional Knowledge of Informal Caregivers on Depression and Metabolic Outcomes of Hemodialysis Patients

Chronic renal failure (CRF) makes significant changes in the life of patients and their families. A good family support has a positive effect on successful patients' adaptation to the treatment and compliance with dietary regimen. This study aimed to examine the effects of nutritional knowledge of informal caregivers on depression and metabolic outcomes of hemodialysis patients. This was a cross-sectional study conducted at Baskent University Hemodialysis Center with 116 hemodialysis patients and their informal caregivers. Findings revealed that the caregivers who were the couple of the patients had the highest nutritional knowledge level than the other caregivers (p < .05). The postgraduate caregivers were more likely to have high nutritional knowledge level than the others (p < .05). The inflammation marker of the patients was significantly lower in the group of caregivers with higher level (T3 group) of nutritional knowledge than the others (p < .05). The mean CES-D scores were also more likely to be low in T3 group than in the others (p < .05). These findings highlight that the nutritional knowledge of caregivers of hemodialysis patients may have an additional benefit on patients' nutritional management and metabolic outcomes.

How useful is the center for epidemiologic studies depression scale in screening for depression in adults? An updated systematic review and meta-analysis✰

This study analyzes the performance of the Center for Epidemiologic Studies Depression Scale (CES-D) to screen for major depressive disorder (MDD) in adults. We divided adults into three groups such as community-indwelling adults, patients with chronic diseases, and psychiatric patients. Electronic searches were performed on the MEDLINE, EMBASE, CINAHL, and PsycINFO database using the following keywords: depression, depressive disorder, major, and CES-D scale. The Quality Assessment of Diagnostic Accuracy Studies-2 was applied to assess the risk of bias in diagnostic studies. We reviewed 33 studies, including 18,271 adults that met the selection criteria. In meta-analysis, the pooled sensitivity was 0.86 on community-indwelling adults, 0.85 on patients with chronic diseases and 0.85 on psychiatric patients. The pooled specificity was 0.74, 0.84, and 0.88, respectively, and the summary receiver-operating characteristic curves were 0.88, 0.91, and 0.93, respectively. The RE correlation was a negative value (-0.394) only in patients with chronic diseases, showing no heterogeneity between studies. The CES-D, which has shown high diagnostic accuracy in adults, can be recommended for use as a first-stage screener for MDD. As a result, the early application of the CES-D can lead to disease prevention in adults at risk for depression.

Frequency of depressive symptoms in Syrian refugees and Turkish maintenance hemodialysis patients during COVID-19 pandemic

Introduction

Pneumonia of unknown cause was detected on 30 December 2019 in China. It was categorized as an outbreak and named as COVID-19 by the World Health Organization. The pandemic affects all people, but patient groups such as hemodialysis (HD) patients have been particularly affected. We do not know if refugees suffered more during the outbreak. In this study, we compared depressive symptom frequency between Syrian refugee HD patients and Turkish ones.

Methods

The study had a single-center, cross-sectional design. Demographic and clinical data were collected retrospectively from patients’ files containing details about past medical history, demographic variables and laboratory values. Validated Turkish and Arabic forms of Beck Depression Inventory (BDI) were used to assess depressive symptoms. BDI scores were compared according to nationality, demographic features and clinical data. A BDI score more than 14 was accepted as suspicion of depression.

Results

119 patients were enrolled in the study. After the exclusion of 22 patients, 75 Turkish and 22 Syrian patients were included for further analysis. The median BDI (interquartile range) score for Turkish and Syrian patients were 12 (7–23) and 19.5 (12.7–25.2), respectively (p = 0.03). Suspicion of depression was present at 42.7% of Turkish, and 72.7% of Syrian HD patients (p = 0.013). Regarding all patients, phosphorus level, Kt/V, and nationality were significantly different between patients with and without suspicion of depression (p = 0.023, 0.039, 0.013, respectively).

Conclusion

Syrian patients had higher BDI scores and more depressive symptoms than Turkish patients. Additional national measures for better integration and more mental support to Syrian HD patients are needed.

Hopelessness and Depression Predict Sarcopenia in Advanced CKD and Dialysis: A Multicenter Cohort Study

BACKGROUND/OBJECTIVES

Depression and hopelessness are frequently experienced in chronic kidney disease (CKD) and are generally associated with lessened physical activity. The aim of this study was to quantify the associations between sarcopenia as determined by SARC-F with both depression and hopelessness.

DESIGN AND SETTING

This multicenter cohort study involving cross-sectional and longitudinal analyses was conducted in a university hospital and four general hospitals, each with a nephrology center, in Japan.

PARTICIPANTS

Participants consisted of 314 CKD patients (mean age 67.6), some of whom were receiving dialysis (228, 73%).

MEASUREMENTS

The main exposures were depression, measured using the Center for Epidemiologic Studies Depression (CES-D) questionnaire, and hopelessness, measured using a recently developed 18-item health-related hope scale (HR-Hope). The outcomes were sarcopenia at baseline and one year after, measured using the SARC-F questionnaire. Logistic regression models were applied.

RESULTS

The cross-sectional and longitudinal analyses included 314 and 180 patients, respectively. Eighty-nine (28.3%) patients experienced sarcopenia at baseline, and 44 (24.4%) had sarcopenia at the one-year follow-up. More hopelessness (per 10-point lower, adjusted odds ratio [AOR]: 1.33, 95% confidence interval [95% CI] 1.12-1.58), depression (AOR: 1.87, 95% CI 1.003-3.49), age (per 10-year higher, AOR: 1.70, 95% CI 1.29-2.25), being female (AOR: 2.67, 95% CI 1.43-4.98), and undergoing hemodialysis (AOR, 2.92; 95% CI, 1.41-6.05) were associated with a higher likelihood of having baseline sarcopenia. More hopelessness (per 10-point lower, AOR: 1.69, 95% CI 1.14-2.51) and depression (AOR: 4.64, 95% CI: 1.33-16.2) were associated with a higher likelihood of having sarcopenia after one year.

CONCLUSIONS

Among patients with different stages of CKD, both hopelessness and depression predicted sarcopenia. Provision of antidepressant therapies or goal-oriented educational programs to alleviate depression or hopelessness can be useful options to prevent sarcopenia.

Higher dose weekly fluoxetine in hemodialysis patients: A case series report

OBJECTIVE

The antidepressant medication fluoxetine at 90 mg dosed weekly is as effective and safe as standard formulation fluoxetine 20 mg dosed daily in patients with major depressive disorder. Weekly fluoxetine has not been well studied in hemodialysis patients, and doses beyond 90 mg/week have not been described in this population. This case series, derived from a larger study on depression in hemodialysis patients, describes the use of weekly fluoxetine at dosages beyond 90 mg/week.

METHOD

Hemodialysis patients with depressive symptom severity scored ≥10 on the 9-item Patient Health Questionnaire and major depressive disorder confirmed with Mini International Neuropsychiatric Interview were initially prescribed daily fluoxetine for two weeks and then transitioned to weekly fluoxetine. Dosage titration was made at the discretion of the prescribing clinician. Fluoxetine was continued for a total of 12 weeks.

RESULTS

Four women, aged 24 to 65 years, on hemodialysis for 1 to 18 years, were started on weekly fluoxetine that was increased over several weeks up to 180 mg. Side effects included restlessness, dry mouth, sedation, and lightheadedness. Two patients ultimately had their weekly fluoxetine decreased back to 90 mg. However, all four continued weekly fluoxetine as part of poststudy aftercare and no longer met diagnostic criteria for major depressive disorder, current episode.

CONCLUSIONS

Weekly fluoxetine at doses of 180 mg may be a reasonable treatment consideration for hemodialysis patients who have partial or insufficient antidepressant response. Side effects may limit tolerance of the 180 mg dose in some individuals. Future research should investigate longer term health outcomes of weekly fluoxetine in this population.

Psychological Flexibility and Depression in Advanced CKD and Dialysis

Rationale & Objective

Depression is prevalent and highly associated with mortality among patients with chronic kidney disease (CKD). Psychological flexibility can be captured as acceptance in psychology, and its improvement by behavioral therapy is associated with reduced depression in some clinical settings. However, no study has been reported on patients with CKD. This study aimed to examine the association between psychological flexibility and depression in patients with CKD.

Study Design

Cohort study.

Setting & Participants

This multicenter study of 5 hospitals in Japan included patients with nondialysis stage 3-5 CKD or stage 5D CKD receiving hemodialysis or peritoneal dialysis.

Predictor

Psychological flexibility measured using the 7-item Acceptance and Action Questionnaire (AAQ-II).

Outcomes

The prevalence and incidence of depression after 1 year, which was defined by a score ≥ 16 points on the Center for Epidemiologic Studies Depression (CES-D) questionnaire.

Analytical Approach

Gamma regression was used in the examination of correlates of the psychological flexibility value. Modified Poisson regression models were fit for the prevalence and incidence of depression.

Results

The cross-sectional and longitudinal analyses included 433 and 191 patients, respectively. Lower (ie, worse) psychological flexibility levels were associated with hemodialysis and peritoneal dialysis. Higher (ie, better) psychological flexibility levels were associated with lower prevalence of depression (per 5-point increase; adjusted prevalence ratio, 0.75; 95% CI, 0.70-0.80) and lower incidence of depression (per 5-point increase; adjusted risk ratio, 0.72; 95% CI, 0.61-0.85).

Limitations

Depression was assessed using the CES-D questionnaire. Cultural differences may exist in the interpretation of AAQ-II scores.

Conclusions

Better psychological flexibility was associated with lower prevalence and incidence of depression in patients with CKD. Further studies are warranted to determine the possible prevention and treatment of depression by the development of behavioral interventions to improve psychological flexibility.

Depression Screening Tools for Patients with Kidney Failure: A Systematic Review

BACKGROUND AND OBJECTIVES

Patients with kidney failure experience depression at rates higher than the general population. Despite the Centers for Medicare and Medicaid Services' ESRD Quality Incentive Program requirements for routine depression screening for patients with kidney failure, no clear guidance exists.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

For this systematic review, we searched MEDLINE, PsycINFO, and other databases from inception to June 2020. Two investigators screened all abstracts and full text. We included studies assessing patients with kidney failure and compared a tool to a clinical interview or another validated tool (e.g., Beck Depression Inventory II). We abstracted data related to sensitivity and specificity, positive and negative predictive value, and the area under the curve. We evaluated the risk of bias using the Quality Assessment of Diagnostic Accuracy Studies 2.

RESULTS

A total of 16 studies evaluated the performance characteristics of depression assessment tools for patients with kidney failure. The Beck Depression Inventory II was by far the best studied. A wide range of thresholds were reported. Shorter tools in the public domain such as the Patient Health Questionnaire 9 and Geriatric Depression Scale 15 (adults over 60) performed well but were not well studied. Short tools such as the Beck Depression Inventory-Fast Screen may be a good option for an initial screen.

CONCLUSIONS

There is limited research evaluating the diagnostic accuracy of most screening tools for depression in patients with kidney failure, and existing studies may not be generalizable to US populations. Studies suffer from limitations related to methodology quality and/or reporting. Future research should target widely used, free tools such as the Patient Health Questionnaire 2 and the Patient Health Questionnaire 9.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Systematic Review Registration: PROSPERO CRD42020140227.

Pharmacologic and psychological interventions for depression treatment in patients with kidney disease

PURPOSE OF REVIEW

It remains controversial whether existing therapies, including pharmacologic and psychological interventions, are effective for treatment of depression in patients with chronic kidney disease (CKD) and end-stage kidney disease.

RECENT FINDINGS

Most studies of depression treatment were underpowered or uncontrolled. The CKD Antidepressant Sertraline Trial showed no benefit of a serotonin-selective reuptake inhibitor (SSRI), sertraline, over double-blind matched placebo for the treatment of depressive symptoms in patients with nondialysis CKD. A Trial of Sertraline vs. Cognitive Behavioral Therapy (CBT) for End-stage Renal Disease Patients with Depression showed improvement in depressive symptoms from baseline in both groups and a marginal benefit of sertraline over CBT that was of unclear clinical significance, given the lack of an active control group. SSRIs are associated with poor tolerability in clinical trials and serious adverse outcomes in large retrospective studies.

SUMMARY

Although the data do not support unlimited use of SSRIs in patients with CKD or end-stage kidney disease, it is reasonable to initiate a cautious trial of sertraline while closely monitoring for depressive symptom improvement and adverse effects. CBT is a low-risk, possibly effective intervention to treat major depressive disorder in patients with kidney disease who have access to such treatments.

Association of renal function and depressive symptoms: Evidence from the China health and retirement longitudinal study

AIM

We examined the association between kidney function and risks of depression in a nationally representative sample of community-dwelling older adults.

METHODS

Participants were a subset selected from the China Health and Retirement Longitudinal Study. Estimated glomerular filtration rate (eGFR) was calculated using chronic kidney disease epidemiology collaboration equations. Incident depression was defined by a score of 10 or higher on the 10-item Center for Epidemiologic Studies Depression Scale, use of antidepressant medications, or both, at the 2015 follow-up visit. Multiple linear regression analyses were used to examine the baseline eGFR and CESD-10 score during follow up. The associations between level of renal function at baseline and incident depression were assessed using multivariate logistic regression analysis.

RESULTS

Over a four-year follow-up period, 22.8% (N = 773) of the participants reported incident depression. After multivariate analysis, baseline eGFRcr and eGFRcr-cys were significantly associated with higher depression score during follow up. Coefficients and 95%CI for eGFRcr and eGFRcr-cys were - 0.041(-0.066 to -0.016) and - 0.028(-0.051 to -0.005), respectively. Using eGFRcr-cys, the crude odds ratio (OR) for incident depression in the 4th quartile group was 1.60 (95%CI 1.23-2.06) than that in the 1st quartile group, (p for trend <0.001). Fully adjustment for confounding factors did not attenuate but strengthened the association (OR 2.46, 95%CI 1.61-3.76).

CONCLUSIONS

Among community-dwelling older adults over most of the range in renal function, eGFR was significantly, independently, and associated with incident depression.

Comparison of intradialytic versus home-based exercise programs on physical functioning, physical activity level, adherence, and health-related quality of life: pilot study

Intradialytic exercise (ID) programs are effective and safe for hemodialysis (HD) patients to avoid functional deterioration. However, exercise is not routinely undertaken in most HD units, and we do not know if home-based (HB) programs are as effective as ID programs. The purpose of this study was to compare the effects of 16 weeks of ID exercise versus a HB exercise program for HD patients. A total of 46 patients were randomly assigned to the ID group (n = 24) or HB group (n = 22). They completed a 16-week combined exercise program 3 times/week. We measured physical activity level, physical functioning, depression level, and health-related quality of life at baseline and after 16 weeks. A significant time effect was found in both groups for the physical activity level (p = 0.012). There was also a significant group-time interaction effect for the one-leg standing test (OLST) (p = 0.049) and a significant time effect for the Short Physical Performance Battery (p = 0.013), timed up-and-go test (p = 0.005), sit-to-stand-10 (p = 0.027), right and left hand handgrip (p = 0.044, p < 0.001), one-heel left leg raise (p = 0.019), and 6-minute walking (p = 0.006), depression (p = 0.017). HRQoL remained unchanged. There was no difference between the two interventions on the tested outcomes (besides OLST). Both interventions were associated with positive changes of the physical activity levels and physical function.

Effects of Exercise Training Combined with Virtual Reality in Functionality and Health-Related Quality of Life of Patients on Hemodialysis

Objective: The progression of chronic kidney disease can directly affect patient's health-related quality of life (HRQoL). Exercise training is a good option to reverse the impacts caused by the disease. To escape from the monotonous routine and stimulate further practice, the therapist should consider making physical activity more playful. Using videogames during exercise training is possible to rehabilitate the patient aiming for fun beyond the organic condition. The present study aimed to evaluate the effects of exercise training combined with Virtual Reality (VR) in functionality and HRQoL of patients on hemodialysis. Materials and Methods: A randomized controlled study in which control group (n = 20) maintained only hemodialysis without any physical effort or intervention from the researchers and intervention group (n = 20) who performed endurance and strength physical exercises in combination with VR during hemodialysis for 12 weeks. All eligible patients underwent a familiarization of games and were evaluated by an investigator-blind for functional capacity, quality of life, and depressive symptoms. Functional capacity tests included walking speed, timed up and go (TUG), and Duke Activity Status Index (DASI). To evaluate a HRQoL, Kidney Disease and Quality-of-Life Short-Form (KDQOL-SF™, v. 1.3) was used and to investigate depressive symptoms, the Center for Epidemiological Scale-Depression. Paired sample t-tests were conducted to determine differences within each group. Repeated-measures analysis of variance (group vs. time) was used to assess group differences in our major outcomes. The level of significance was 5%. Results: The exercise improved functional capacity (TUG: P = 0.002, DASI: P < 0.001) and HRQoL in physical and specific domains: physical functioning (P = 0.047), role physical (P = 0.021), as well as in physical composite summary (P < 0.001) and effects of kidney disease (P = 0.013). There was no influence on depressive symptoms (P = 0.154). Conclusion: Physical training combined with VR improved functional capacity and some quality-of-life domains of hemodialysis patients.

Prevalence and associated factors of depressive symptoms among chronic kidney disease patients in China: Results from the Chinese Cohort Study of Chronic Kidney Disease (C-STRIDE)

OBJECTIVE

Depression is the most common mental disorder in patients with chronic kidney disease (CKD), and previous studies have found that: (a) depression can accelerate the progression of CKD; and (b) depression is an independent risk factor for hospitalization and death among patients with CKD. Therefore, the objective of the current study was to investigate the prevalence of depression in Chinese patients with CKD, and to identify variables associated with depression.

METHODS

The study analyzed baseline data from a multicenter prospective cohort study of Chinese patients with chronic kidney disease (the C-STRIDE study). In all, 2995 participants in CKD stages 1 to 4 who completed a survey of depressive symptoms were included in the analyses. Depressive symptoms were assessed by the Zung Self-Rating Depression Scale (ZSDS). A ZSDS ≥50 was used as the cut-off score for the presence of depressive symptoms. Multivariable logistic regression was used to identify variables associated with depression.

RESULTS

The mean estimated glomerular filtration rate (eGFR) in the study sample was 51.59±29.49 ml/min/1.73 m². The prevalence of depressive symptoms was 37.8% and increased significantly with CKD stage. Being female, a higher level of education, a low income, a larger economic impact of disease cost, comorbid cardiovascular disease, anemia, and impaired physical ability were independently associated with depressive symptoms.

CONCLUSION

Our study revealed that depressive symptoms were common among patients with CKD in China. Sociodemographic variables and the clinical characteristics of disease severity were strongly associated with depressive symptoms.

No association between low-dose reserpine use and depression in older hypertensive patient: result of a multicenter, cross-sectional study

Background

Reserpine is currently used by millions of Chinese hypertensive patients, in spite of the continued concern of its depressogenic effect, even when used in low dose. This study aimed to investigate the association between low-dose reserpine use and depression in older Chinese hypertensive patient.

Methods

In this cross-sectional, case-control study, we recruited patient aged 60 years or over who had regularly taken one or two tables of “compound reserpine and triamterene tablets (CRTTs)” for more than one year (reserpine user) from 26 community health centers located in 10 provinces in China. For each patient who took CRTTs, we selected an age (within five years) and sex matched hypertensive patient who had never taken any drugs containing reserpine (non-reserpine user) as control. Depressive symptoms were evaluated using a Chinese depression scale adapted from the Zung Self-Rating Depression Scale. Demographic, clinical data and laboratory examination results within six months were collected.

Results

From August 2018 to December 2018, 787 reserpine user and 787 non-reserpine user were recruited. The mean age of all study subjects was 70.3 years, with about equal numbers of males and females. The mean depression score was 40.4 in reserpine users and 40.6 in non-reserpine users (P = 0.7). The majority of study subject had a depression score < 53 (87.6% in reserpine users and 88.2% in non-reserpine users, respectively). There were no significant differences in the prevalence of mild, moderate or severe depression in reserpine users and non-reserpine users.

Conclusions

There is no association between low-dose reserpine use and depression in older hypertensive patient. The role of reserpine in the treatment and control of hypertension should be reconsidered; and further studies, especially randomized, controlled clinical trials to compare efficacy and safety of reserpine and other widely recommended anti-hypertensive agents are needed.

Prevalence and predictors of depression among hemodialysis patients: a prospective follow-up study

BACKGROUND

Even though depression is one of the most common psychiatric disorders, it is under-recognized in hemodialysis (HD) patients. Existing literature does not provide enough information on evaluation of predictors of depression among HD patients. The objective of the current study was to determine the prevalence and predictors of depression among HD patients.

METHODS

A multicenter prospective follow-up study. All eligible confirmed hypertensive HD patients who were consecutively enrolled for treatment at the study sites were included in the current study. HADS questionnaire was used to assess the depression level among study participants. Patients with physical and/or cognitive limitations that prevent them from being able to answer questions were excluded.

RESULTS

Two hundred twenty patients were judged eligible and completed questionnaire at the baseline visit. Subsequently, 216 and 213 patients completed questionnaire on second and final follow up respectively. The prevalence of depression among patients at baseline, 2nd visit and final visit was 71.3, 78.2 and 84.9% respectively. The results of regression analysis showed that treatment given to patients at non-governmental organizations (NGO's) running HD centers (OR = 0.347, p-value = 0.039) had statistically significant association with prevalence of depression at final visit.

CONCLUSIONS

Depression was prevalent in the current study participants. Negative association observed between depression and hemodialysis therapy at NGO's running centers signifies patients' satisfaction and better depression management practices at these centers.

Improved Detection and Evaluation of Depression in Patients with Chronic Kidney Disease: Validity and Reliability of Screening (PHQ-2) and Diagnostic (BDI-FS-Fr) Tests of Depression in Chronic Kidney Disease

Objective

Depression is underdiagnosed and thus undertreated. This study aimed to validate the French version of the PHQ-2 (Patient Health Questionnaire-2) and BDF-FS-Fr (Beck Depression Inventory-Fast Screen-France) on patients with chronic kidney disease (CKD) living in France.

Method

A cross-sectional study was conducted on 109 patients of the Centre universitaire de maladies rénales, Centre Hospi-talier Universitaire (CHU) de Caen (37 patients with CKD on pre-dialysis and grafting stage, 36 grafted patients, and 36 dialyzed patients).

Statistical Approach

Test parameters and statistical aspects of assessing diagnostic and screening tests were used, including knowledge of and ability to calculate, sensitivity, specificity, positive and negative predictive values, diagnostic odds ratios, and the use of ROC (receiver operating characteristic) curves.

Results

PHQ-2 and BDI-FS-Fr statistical parameters for depression tested very positively and had a satisfactory AUC (area under the curve). The PHQ-2 had a satisfactory AUC > 0.70, sensitivity > 0.60, and specificity > 0.80. The BDI-FS-Fr had a satisfactory area under the curve (0.859) with sensitivity (83%) and specificity (0.859); and internal consistency (α = 0.668). The PHQ-2 and BDI-FS-Fr showed good internal and external validity of structure, construct validity, criterion validity, discriminant validity, internal consistency, and factorial validity.

Conclusion

The French versions of the PHQ-2 and BDI-FS have highly favorable psychometric properties. These instruments are valid self-assessment tools for screening and evaluating depression, its intensity, and its evolution. The PHQ-2 and BDI-FS-Fr thus have very good psychometric properties and are useful tools for researchers and practitioners. Regarding clinical practice in the hospital, clinicians and nurses can use the PHQ-2 to screen quickly for depression during routine consultations, during hospitalization, and in dialysis centers. The 7 items of the BDI-FS-Fr enable us to assess the depressive state, thereby avoiding a false diagnosis of depression among CKD patients in a clinical setting.

Comparative Efficacy of Therapies for Treatment of Depression for Patients Undergoing Maintenance Hemodialysis: A Randomized Clinical Trial

BACKGROUND

Although depression is common among patients receiving maintenance hemodialysis, data on their acceptance of treatment and on the comparative efficacy of various therapies are limited.

OBJECTIVE

To determine the effect of an engagement interview on treatment acceptance (phase 1) and to compare the efficacy of cognitive behavioral therapy (CBT) versus sertraline (phase 2) for treating depression in patients receiving hemodialysis.

DESIGN

Multicenter, parallel-group, open-label, randomized controlled trial. (ClinicalTrials.gov: NCT02358343).

SETTING

41 dialysis facilities in 3 U.S. metropolitan areas.

PARTICIPANTS

Patients who had been receiving hemodialysis for at least 3 months and had a Beck Depression Inventory-II score of 15 or greater; 184 patients participated in phase 1, and 120 subsequently participated in phase 2.

INTERVENTION

Engagement interview versus control visit (phase 1) and 12 weeks of CBT delivered in the dialysis facility versus sertraline treatment (phase 2).

MEASUREMENTS

The primary outcome for phase 1 was the proportion of participants who started depression treatment within 28 days. For phase 2, the primary outcome was depressive symptoms measured by the Quick Inventory of Depressive Symptoms-Clinician-Rated (QIDS-C) at 12 weeks.

RESULTS

The proportion of participants who initiated treatment after the engagement or control visit did not differ (66% vs. 64%, respectively; P = 0.77; estimated risk difference, 2.1 [95% CI, -12.1 to 16.4]). Compared with CBT, sertraline treatment resulted in lower QIDS-C depression scores at 12 weeks (effect estimate, -1.84 [CI, -3.54 to -0.13]; P = 0.035). Adverse events were more frequent in the sertraline than the CBT group.

LIMITATION

No randomized comparison was made with no treatment, and persistence of treatment effect was not assessed.

CONCLUSION

An engagement interview with patients receiving maintenance hemodialysis had no effect on their acceptance of treatment for depression. After 12 weeks of treatment, depression scores were modestly better with sertraline treatment than with CBT.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute, Dialysis Clinic, Kidney Research Institute, and National Institute of Diabetes and Digestive and Kidney Diseases.

Pharmacokinetics of antidepressants in patients undergoing hemodialysis: a narrative literature review

We conducted a narrative literature review on studies that specifically addressed the pharmacokinetics of antidepressants in patients on hemodialysis. The search included the MEDLINE, LILACS, and Web of Knowledge databases and combined Medical Subject Headings and free-text search terms for chronic kidney disease, end-stage renal disease, renal replacement therapy, depression, and antidepressants; it was limited to studies conducted in humans, with no language or time constraints. The search yielded 212 studies. After screening titles and abstracts, 32 studies were read in full and 11 ultimately met the inclusion criteria and were included in the review. Most of the studies showed no difference in the pharmacokinetics of antidepressant drugs between patients with normal renal function and patients undergoing hemodialysis. However, studies with fluvoxamine and amitriptyline showed that variations in albumin levels might affect serum concentrations of these agents. The included studies have several limitations, and there are many obstacles to the adequate treatment of depression in patients undergoing hemodialysis. Further studies on this topic are needed to support proper treatment of these patients, improving their quality of life and reducing mortality.

Depressive symptoms, frailty, and mortality among dialysis patients

INTRODUCTION

Frailty and depression are highly prevalent in the dialysis population, but the association between them, the risk factors for their development, and their independent associations with mortality have not been studied.

METHODS

We examined 771 patients enrolled in the ACTIVE/ADIPOSE prevalent dialysis cohort study. Fried's frailty phenotype and the Center for Epidemiologic Studies Depression score were used to determine frailty and presence of depressive symptoms, respectively. We assessed the baseline association between frailty and depressive symptoms, whether one entity is a risk factor for development of the other, and associations between frailty and depressive symptoms with mortality.

FINDINGS

At baseline, 13.1% of our population screened positive for depressive symptoms, 21.8% met criteria for frailty, and 10.0% met criteria for both. During follow-up, 26.6% of our population developed frailty and 12.7% developed depressive symptoms. Using multivariable logistic regression, baseline depressive symptoms were associated with 2.14-fold higher odds of being frail at baseline (95% confidence interval [CI] 1.45-3.17) and with a 2.16-fold higher odds of incident frailty during follow-up (95% CI 1.22-3.82). However, baseline frailty was not associated with incident depressive symptoms. Frailty and depressive symptoms were independent predictors of mortality in time-varying survival analysis (meeting frailty criteria: hazard ratio [HR] 1.53, 95% CI 1.05-2.23; depressive symptoms: HR 2.21, 95% CI 1.50-3.25).

DISCUSSION

Frailty and depressive symptoms remained highly prevalent over time and were strongly associated with one another and independently associated with mortality among dialysis patients. Future studies should investigate whether interventions for depression could potentially mitigate the appearance of frailty and its associated poor outcomes.

Indole-3 acetic acid increased risk of impaired cognitive function in patients receiving hemodialysis

Patients receiving hemodialysis (HD) have a higher risk of cognitive impairment and dementia than the general population. The accumulation of uremic toxins in the brain causes uremic encephalopathy, however, limited data exists to elucidate the effect of protein-bound uremic toxins on cognitive function. Here we investigate the effect of indole-3 acetic acid (IAA) and hippuric acid (HA), two different protein-bound uremic toxins from amino acid derivatives, on cognitive function by Silico and in a clinical study. Prevalent HD patients were enrolled in two independent hospitals. Serum IAA and HA were measured using mass spectrometry. Cognitive performance was measured using Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and Cognitive Abilities Screening Instrument (CASI) by trained psychologists. Using silico data to predict the effect of blood-brain barrier penetration was performed. The silico data demonstrated that IAA and HA had positive blood-brain barrier penetration ability. Amongst the 230 HD patients, serum IAA was associated with poor MMSE score (β= -0.90, 95% CI -1.61 to -0.19) and poor CASI score (β= -3.29, 95% CI -5.69 to -0.88) in stepwise multiple linear regression analysis. In logistic regression model, Serum IAA was also associated with cognitive impairment based on MMSE definition (OR, 1.96, 95% CI 1.10, 3.5) and CASI definition (OR, 2.09, 95% CI 1.21, 3.61). There was no correlation between Serum HA levels and cognitive function status. In conclusion, IAA, not HA, was associated with cognitive impairment in HD patients. Further large scale and prospective studies are needed to confirm our findings.

Depressive Symptoms Associate With Race and All-Cause Mortality in Patients With CKD

INTRODUCTION

Depression is common but underrecognized in patients with chronic kidney disease (CKD), especially among racial/ethnic minorities. We examined the association between depressive symptoms and all-cause mortality (including deaths before and after end-stage renal disease [ESRD]) and whether antidepressant use impacts this association, overall, and by race/ethnicity.

METHODS

We ascertained whether the presence of depressive symptoms, defined by a Beck Depression Inventory II (BDI) score of >14 at cohort enrollment, was associated with all-cause mortality (before or after ESRD) among study participants of the Chronic Renal Insufficient Cohort (CRIC) overall and by race/ethnicity. Models were adjusted for socioeconomic factors, baseline CKD severity, time-updated comorbid conditions, and time-updated antidepressant use. Confirmatory analyses were performed among African American Study of Kidney Disease and Hypertension (AASK) participants.

RESULTS

Among 3739 CRIC participants, 16.3% had a baseline BDI of >14; 18.2% reported antidepressant use. Crude mortality rate was 3.16 per 100 person-years during 6.8 years of median follow-up. Baseline BDI >14 was independently associated with higher risk of all-cause mortality (adjusted hazard ratio [aHR]: 1.27; 95% confidence interval: 1.07-1.52) without attenuation by antidepressant use. Differences among white and black individuals were noted (Pinteraction= 0.02) but not among white versus Hispanic individuals (Pinteraction = 0.43) or black versus Hispanic individuals (Pinteraction = 0.22). Depressive symptoms were associated with higher mortality among white individuals (aHR: 1.66; 1.21-2.28), but not Hispanic individuals (aHR: 1.47; 0.95-2.28) or black individuals (aHR: 1.06; 0.82-1.37). Similar results were noted among 611 AASK participants (aHR: 0.99; 0.69-1.42).

CONCLUSIONS

The presence of depressive symptoms is a risk factor for all-cause mortality among patients with mild-moderate CKD, particularly among white individuals. Further studies are needed to understand the heterogeneity in the response to the presence of depressive symptoms by race.

Health Behaviors in Younger and Older Adults With CKD: Results From the CRIC Study

INTRODUCTION

A cornerstone of kidney disease management is participation in guideline-recommended health behaviors. However, the relationship of these health behaviors with outcomes, and the identification of barriers to health behavior engagement, have not been described among younger and older adults with chronic kidney disease.

METHODS

Data from a cohort study of 5499 individuals with chronic kidney disease was used to identify health behavior patterns with latent class analysis stratified by age <65 and ≥65 years. Cox models, stratified by diabetes, assessed the association of health behavior patterns with chronic kidney disease (CKD) progression, atherosclerotic events, and death. Logistic regression was used to assess for barriers to health behavior engagement.

RESULTS

Three health behavior patterns were identified: 1 "healthy" pattern, and 2 "less healthy" patterns comprising 1 pattern with more obesity and sedentary activity and 1 with more smoking and less obesity. Less healthy patterns were associated with an increased hazard of poor outcomes. Among participants <65 years of age, the less healthy patterns (vs. healthy pattern) was associated with an increased hazard of death in diabetic individuals (hazard ratio [HR] = 2.17, 95% confidence interval [CI] = 1.09-4.29; and HR = 2.50, 95% CI = 1.39-4.50) and cardiovascular events among nondiabetic individuals (HR = 1.49, 95% CI = 1.04-2.43; and HR = 2.97, 95% CI = 1.49-5.90). Individuals with the more obese/sedentary pattern had an increased risk of CKD progression in those who were diabetic (HR = 1.34, 95% CI = 1.13-1.59). Among older adults, the less healthy patterns were associated with increased risk of death (HR = 2.97, 95% CI = 1.43-6.19; and HR = 3.47, 95% CI = 1.48-8.11) in those who were nondiabetic. Potential barriers to recommended health behaviors include lower health literacy and self-efficacy.

CONCLUSION

Identifying health behavior patterns and barriers may help target high-risk groups for strategies to increase participation in health behaviors.

Higher Physical Activity Is Associated With Less Fatigue and Insomnia Among Patients on Hemodialysis

Introduction

Patients on hemodialysis experience a heavy burden of symptoms that may be related to the low levels of physical activity reported in this population. We hypothesized that physical activity would be inversely related to symptom severity and that depression might mediate this association.

Methods

We designed a cross-sectional study of 48 patients receiving hemodialysis at 3 San Francisco dialysis clinics. Physical activity was measured using pedometers and recorded within 1 week of symptom assessment. Symptoms were assessed using total symptom burden and severity on the Dialysis Symptom Index (DSI; burden 0–29, severity 0–145), individual symptoms on the DSI (0–5), Kidney Disease Quality of Life Vitality scores, (0–100), and the Center for Epidemiologic Study-Depression (0–60).

Results

Median daily step count was 2631 (25th, 75th percentile 1125, 5278). Seventy-three percent of patients reported fatigue. After adjustment for age, sex, diabetes, and serum albumin, physical activity was associated with 0.2 points lower fatigue severity per 1000 steps per day (95% confidence interval [CI] −0.3 to 0.0), P = 0.04. Physical activity was also associated with higher Vitality score (2.36 points per 1000 steps; 95% CI 0.07–4.65) and lower insomnia scores (−0.1 points per 1000 steps; 95% CI −0.3 to 0.0], P < 0.05) in our adjusted models. Physical activity was not associated with other symptoms.

Conclusion

Because the study was cross-sectional, we cannot determine whether physical activity lowers fatigue and insomnia or whether less insomnia and fatigue increase physical activity. However, interventions to increase physical activity should be considered alongside current strategies as a possible approach to managing fatigue and insomnia.

Rationale and design of technology assisted stepped collaborative care intervention to improve patient-centered outcomes in hemodialysis patients (TĀCcare trial)

Most hemodialysis (HD) patients experience symptoms of depression, pain and fatigue that impair their health-related quality of life (HRQOL) significantly. These symptoms are associated with increased hospitalization and mortality, mediated by behavioral factors (e.g. non-adherence to medication and dialysis) and biological factors (e.g. inflammatory cytokines). Prior interventions to alleviate symptoms and improve HRQOL showed limited effectiveness in HD patients and their effect on bio-behavioral mediators is lacking evidence. It is imperative to improve patient-centered dialysis care and to address call from Kidney Disease Improving Global Outcomes (KDIGO) guidelines for integration of symptom assessment and management in routine HD-care. Technology-Assisted stepped Collaborative Care (TĀCcare) is a multi-center randomized controlled trial (RCT) of 150 diverse HD patients from Pennsylvania and New Mexico, designed to compare the effectiveness of a 12-week stepped collaborative care intervention (cognitive behavioral therapy, CBT) with an attention control arm of technology-delivered health education. Collaborative care provides an integrated multi-disciplinary structured management plan. Furthermore, a stepped approach to pharmacotherapy and/or CBT allows for individualization of treatment according to patients' clinical status, preferences and treatment response. To simplify the delivery of CBT and to minimize patient and provider burden, we will use live video-conferencing with patients in dialysis units. We will examine the effect of these interventions on patient symptoms, HRQOL, treatment adherence and inflammatory biomarkers. This RCT tests a readily implementable intervention that can be integrated in routine HD-care and will generate novel and meaningful insights on strategies to alleviate common symptoms and improve HRQOL in HD.

Depressive symptoms, frailty, and adverse outcomes among kidney transplant recipients

Depressive symptoms and frailty are each independently associated with morbidity and mortality in kidney transplant (KT) recipients. We hypothesized that having both depressive symptoms and frailty would be synergistic and worse than the independent effect of each. In a multicenter cohort study of 773 KT recipients, we measured the Fried frailty phenotype and the modified 18-question Center for Epidemiologic Studies-Depression Scale (CES-D). Using adjusted Poisson regression and survival analysis, we tested whether depressive symptoms (CES-D score > 14) and frailty were associated with KT length of stay (LOS), death-censored graft failure (DCGF), and mortality. At KT admission, 10.0% of patients exhibited depressive symptoms, 16.3% were frail, and 3.6% had both. Recipients with depressive symptoms were more likely to be frail (aOR = 3.97, 95% CI: 2.28-6.91, P < 0.001). Recipients with both depressive symptoms and frailty had a 1.88 times (95% CI: 1.70-2.08, P < 0.001) longer LOS, 6.20-fold (95% CI:1.67-22.95, P < 0.01) increased risk of DCGF, and 2.62-fold (95% CI:1.03-6.70, P = 0.04) increased risk of mortality, compared to those who were nonfrail and without depressive symptoms. There was only evidence of synergistic effect of frailty and depressive symptoms on length of stay (P for interaction < 0.001). Interventions aimed at reducing pre-KT depressive symptoms and frailty should be explored for their impact on post-KT outcomes.

Beck Depression Inventory as a screening tool for depression in chronic haemodialysis patients

OBJECTIVES

To evaluate the psychometric properties of the Beck Depression Inventory (BDI) and Cognitive Depression Index (CDI) as a potential screening tool for major depression in haemodialysis (HD) patients.

METHODS

Forty-five HD patients completed both the BDI/CDI and diagnostic interview. The interview was conducted by two experienced clinicians and was based on DSM-IV criteria. The sensitivity, specificity and positive (PPV) and negative (NPV) predictive values were then calculated.

RESULTS

A diagnosis of depression was found in 6 of the 45 participants (13.3%). Optimal cut-offs were ≥18 for the BDI (sensitivity 1.0, specificity 0.90, PPV 0.60, NPV 1.0) and ≥11 for the CDI (sensitivity 1.0, specificity 0.92, PPV 0.67, NPV 1.0).

CONCLUSIONS

Both the BDI and CDI were shown to be acceptable screening tools for depression in this population of chronic HD patients. The recommended cut-off scores for both scales are higher than those suggested for the general population and slightly higher than previously found in the chronic kidney disease literature, suggesting that altered thresholds are required when using these screening tools amongst HD patients.