S. Susan Hedayati

Death or hospitalization of patients on chronic hemodialysis is associated with a physician-based diagnosis of depression

Depressive symptoms, assessed using a self-report type of questionnaire, have been associated with poor outcomes in dialysis patients. Here we determined if depressive disorders diagnosed by physicians are also associated with such outcomes. Ninety-eight consecutive patients on chronic hemodialysis underwent the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders administered by a physician. Depression was diagnosed in about a quarter of the patients. Associations adjusted for age, gender, race, time on dialysis and co-morbidity were determined using survival analysis. Using time to event (death or hospitalization) models of analysis the hazard ratios were 2.11 and 2.07 in unadjusted and adjusted models respectively. The finding of poor outcome using a formal structured physician interview suggests that a prospective study is needed to determine whether treatment of depression affects clinical outcomes.

A practical approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease

Depression is a common, under-recognized, and under-treated problem that is independently associated with increased morbidity and mortality in CKD patients. However, only a minority of CKD patients with depression are treated with antidepressant medications or nonpharmacologic therapy. Reasons for low treatment rates include a lack of properly controlled trials that support or refute efficacy and safety of various treatment regimens in CKD patients. The aim of this manuscript is to provide a comprehensive review of studies exploring depression treatment options in CKD. Observational studies as well as small trials suggest that certain serotonin-selective reuptake inhibitors may be safe to use in patients with advanced CKD and ESRD. These studies were limited by small sample sizes, lack of placebo control, and lack of formal assessment for depression diagnosis. Nonpharmacologic treatments were explored in selected ESRD samples. The most promising data were reported for frequent hemodialysis and cognitive behavioral therapy. Alternative proposed therapies include exercise training regimens, treatment of anxiety, and music therapy. Given the association of depression with cardiovascular events and mortality, and the excessive rates of cardiovascular death in CKD, it becomes imperative to not only investigate whether treatment of depression is efficacious, but also whether it would result in a reduction in morbidity and mortality in this patient population.

Prevalence of Major Depressive Episode in CKD

BACKGROUND Depression is prevalent in long-term dialysis patients and is associated with death and hospitalization. Whether depression is present through all chronic kidney disease (CKD) stages or appears after dialysis therapy initiation is not clear. We determined the prevalence of a major depressive episode and other psychiatric illnesses by using a structured gold-standard clinical interview and demographic and clinical variables associated with major depressive episode in patients with CKD. STUDY DESIGN Observational cross-sectional study using a Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition)-based structured interview administered by trained persons to 272 consecutive participants. Multivariable logistic regression was used to determine demographic and clinical variables associated with major depressive episode. SETTING & PARTICIPANTS Patients with stages 2 to 5 CKD not treated by using dialysis were consecutively approached and enrolled from a Veterans Affairs CKD clinic. PREDICTORS Demographic and clinical variables. OUTCOME Major depressive episode diagnosed by using a structured Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition)-based interview, the Mini International Neuropsychiatric Interview. RESULTS The cohort had a mean age of 64.5 +/- 12.0 years. Thirty-eight percent were African American, and 55% had diabetes mellitus. Percentages of patients with stages 2, 3, 4, and 5 CKD were 6%, 38%, 41%, and 14%, respectively. Mean hemoglobin level was 12.5 +/- 2.0 g/dL. The prevalence of a major depressive episode was 21% and did not vary significantly among different CKD stages. Variables associated with a major depressive episode were diabetes mellitus, comorbid psychiatric illness, and history of drug or alcohol abuse. LIMITATIONS Single-center study composed of primarily male veterans. CONCLUSIONS One in 5 patients with CKD had a major depressive episode. Patients with CKD should be screened routinely for depression given this high prevalence and the independent association of depression with poor outcomes in patients with end-stage renal disease receiving maintenance dialysis.

Association Between Major Depressive Episodes in Patients With Chronic Kidney Disease and Initiation of Dialysis, Hospitalization, or Death

CONTEXT Patients with chronic kidney disease (CKD) experience increased rates of hospitalization and death. Depressive disorders are associated with morbidity and mortality. Whether depression contributes to poor outcomes in patients with CKD not receiving dialysis is unknown. OBJECTIVE To determine whether the presence of a current major depressive episode (MDE) is associated with poorer outcomes in patients with CKD. DESIGN, SETTING, AND PATIENTS Prospective cohort study of 267 consecutively recruited outpatients with CKD (stages 2-5 and who were not receiving dialysis) at a VA medical center between May 2005 and November 2006 and followed up for 1 year. An MDE was diagnosed by blinded personnel using the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria. MAIN OUTCOME MEASURES The primary outcome was event-free survival defined as the composite of death, dialysis initiation, or hospitalization. Secondary outcomes included each of these events assessed separately. RESULTS Among 267 patients, 56 had a current MDE (21%) and 211 did not (79%). There were 127 composite events, 116 hospitalizations, 38 dialysis initiations, and 18 deaths. Events occurred more often in patients with an MDE compared with those without an MDE (61% vs 44%, respectively, P = .03). Four patients with missing dates of hospitalization were excluded from survival analyses. The mean (SD) time to the composite event was 206.5 (19.8) days (95% CI, 167.7-245.3 days) for those with an MDE compared with 273.3 (8.5) days (95% CI, 256.6-290.0 days) for those without an MDE (P = .003). The adjusted hazard ratio (HR) for the composite event for patients with an MDE was 1.86 (95% CI, 1.23-2.84). An MDE at baseline independently predicted progression to dialysis (HR, 3.51; 95% CI, 1.77-6.97) and hospitalization (HR, 1.90; 95% CI, 1.23-2.95). CONCLUSION The presence of an MDE was associated with an increased risk of poor outcomes in CKD patients who were not receiving dialysis, independent of comorbidities and kidney disease severity.

Epidemiology, Diagnosis, and Management of Depression in Patients With CKD

A 58-year-old Hispanic man who has been dialysis dependent for 2 years because of diabetic nephropathy reports depressive symptoms during dialysis rounds. For the past 6 weeks, he has had reduced energy and difficulty sleeping and concentrating. He reports a loss of interest in his usual hobbies and family activities and notes an increasing sense of feeling worthless and guilty. He denies suicidal ideation. Medical history includes diabetic retinopathy and neuropathy, coronary artery disease treated with 4-vessel coronary artery bypass grafting 3 years ago, ischemic cardiomyopathy with an ejection fraction of 30%, and cerebrovascular disease. His wife recently has been given a diagnosis of breast cancer. His medications are aspirin, metoprolol, lisinopril, simvastatin, sevelamer, and epoetin alfa. His blood pressure is 130/75 mm Hg, pulse is 65 beats/min, and cardiac and pulmonary examination results are unremarkable. He is interviewed by the social worker in the dialysis unit, who diagnoses clinical depression by using standard Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM IV) criteria. The patient refuses to discuss his problems with the social worker and declines further psychiatric evaluation. His nephrologist discusses a trial of antidepressant medication, but the patient refuses to use additional medication. During the next month, the patient presents with greater interdialytic weight gains and begins to come late for dialysis sessions. He then presents to a dialysis session reporting dyspnea and orthopnea and is found to have a 10-kg weight gain. On physical examination, blood pressure is 196/96 mm Hg and he has increased jugular venous pressure and bibasilar crackles. He is admitted to the hospital with a diagnosis of congestive heart failure.

Validation of Depression Screening Scales in Patients With CKD

BACKGROUND Depressive symptoms, assessed by using self-report scales, are present at a striking rate of 45% in patients with chronic kidney disease (CKD) at dialysis therapy initiation. These scales may emphasize somatic symptoms of anorexia, sleep disturbance, and fatigue, which may coexist with chronic disease symptoms and lead to overestimation of depression diagnosis. No study has validated these scales in patients with CKD before dialysis therapy initiation. STUDY DESIGN We conducted a diagnostic test study in participants with CKD to investigate the screening characteristics of 2 depression self-report scales against a gold-standard structured psychiatric interview. SETTING & PARTICIPANTS 272 consecutively recruited outpatients with stages 2 to 5 CKD not treated by dialysis were studied. INDEX TESTS The Beck Depression Inventory (BDI) and the 16-item Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR(16)) depression screening scales were administered to all participants. REFERENCE TEST A structured Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition)-based interview, the Mini International Neuropsychiatric Interview, was administered by trained persons blinded to self-report scale scores. RESULTS 57 of 272 (21%) patients had major depression according to the reference test. The best cutoff scores by means of receiver/responder operating characteristic curves to identify a major depressive episode were 11 for the BDI and 10 for the QIDS-SR(16). Sensitivities were 89% (95% confidence interval [CI], 78 to 96; BDI) and 91% (95% CI, 80 to 97; QIDS-SR(16)), whereas specificities were 88% (95% CI, 83 to 92; BDI) and 88% (95% CI, 83 to 92; QIDS-SR(16)). The positive and negative likelihood ratios for these cutoff scores were 7.6 and 0.1 (BDI) and 7.5 and 0.1 (QIDS-SR(16)). LIMITATIONS Single-center study and a sample not representative of US demographics. CONCLUSIONS We found that a BDI score of 11 or higher was a sensitive and specific cutoff value for identifying a major depressive episode in patients with CKD not on dialysis therapy. Both the BDI and QIDS-SR(16) are effective screening tools.

Central venous catheter-related bacteremia in chronic hemodialysis patients: epidemiology and evidence-based management.

Central venous catheter-related blood stream infection (CRBSI) is a major cause of morbidity and mortality in patients with end-stage renal disease treated with chronic hemodialysis. Risk factors include Staphylococcus aureus nasal colonization, longer duration of catheter use, previous bacteremia, older age, higher total intravenous iron dose, lower hemoglobin and serum albumin levels, diabetes mellitus and recent hospitalization. Symptoms that raise clinical suspicion of bacteremia in chronic hemodialysis patients are fevers and chills. When CRBSI is suspected, blood cultures should be obtained and empirical therapy with broad spectrum intravenous antibiotics initiated. The diagnosis of CRBSI is confirmed by isolation of the same microorganism from quantitative cultures of both the catheter and the peripheral blood of a patient that has clinical features of infection without any other apparent source. Gram-positive cocci, predominantly S. epidermidis and S. aureus, cause bacteremia in two-thirds of cases. Among the various approaches to management of CRBSI, removal and delayed replacement of the catheter, catheter exchange over a guidewire in selected patients, and the use of antimicrobial/citrate lock solutions have all been found to be promising for treatment and/or prevention; however, resolution of issues regarding selection, dose, duration and emergence of antibiotic-resistant organisms with chronic use of antibiotic lock solutions, as well as the safety of long-term use of trisodium citrate lock solutions, await further randomized, multicenter trials involving larger samples of hemodialysis patients.

Association between depression and death in people with CKD: A meta-analysis of cohort studies

BACKGROUND Depression occurs relatively commonly in people with chronic kidney disease (CKD), but it is uncertain whether depression is a risk factor for premature death in this population. Interventions to reduce mortality in CKD consistently have been ineffective and new strategies are needed. STUDY DESIGN Systematic review and meta-analysis of cohort studies. SETTING & POPULATION Adults with CKD. SELECTION CRITERIA FOR STUDIES Cohort studies identified in Ovid MEDLINE through week 3 December 2012 without language restriction. PREDICTOR Depression status as determined by physician diagnosis, clinical coding, or self-reported scales. SELECTION CRITERIA FOR STUDIES All-cause and cardiovascular mortality. Outcomes were summarized as relative risks (RRs) with 95% CIs using random-effects meta-analysis. RESULTS 22 studies (83,381 participants) comprising 12,063 cases of depression (mean prevalence, 27.4%; 95% CI, 20.0%-36.3%) with a follow-up of 3 months to 6.5 years were included. Methodological quality generally was good or fair. Depression consistently increased the risk of death from any cause (RR, 1.59; 95% CI, 1.35-1.87), but had less certain effects on cardiovascular mortality (RR, 1.88; 95% CI, 0.84-4.19). Associations for mortality were similar regardless of the diagnostic method used for depression, but were weaker in analyses controlled for preexisting cardiovascular disease (RR, 1.36; 95% CI, 1.23-1.50). LIMITATIONS Meta-analyses adjusting for antidepressant medication use were not possible, and data for kidney transplant recipients and individuals with earlier stages of CKD not treated with dialysis were limited. CONCLUSIONS Depression is associated with a substantially increased risk of death in people with CKD. Effective treatment for depression in people with CKD may reduce mortality.

Association of Urinary Sodium/Potassium Ratio with Blood Pressure: Sex and Racial Differences

BACKGROUND AND OBJECTIVES Previous studies reporting an association between high BP and high sodium and low potassium intake or urinary sodium/potassium ratio (U[Na(+)]/[K(+)]) primarily included white men and did not control for cardiovascular risk factors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This cross-sectional study investigated the association of U[Na(+)]/[K(+)] with BP in 3303 participants using robust linear regression. RESULTS Mean age was 43±10 years, 56% of participants were women, and 52% were African American. BP was higher in African Americans than in non-African Americans, 131/81±20/11 versus 120/76±16/9 mmHg (P<0.001). Mean U[Na(+)]/[K(+)] was 4.4±3.0 in African Americans and 4.1±2.5 in non-African Americans (P=0.002), with medians (interquartile ranges) of 3.7 (3.2) and 3.6 (2.8). Systolic BP increased by 1.6 mmHg (95% confidence interval, 1.0, 2.2) and diastolic BP by 1.0 mmHg (95% confidence interval, 0.6, 1.4) for each 3-unit increase in U[Na(+)]/[K(+)] (P<0.001 for both). This association remained significant after adjusting for diabetes mellitus, smoking, body mass index, total cholesterol, GFR, and urine albumin/creatinine ratio. There was no interaction between African-American race and U[Na(+)]/[K(+)], but for any given value of U[Na(+)]/[K(+)], both systolic BP and diastolic BP were higher in African Americans than in non-African Americans. The diastolic BP increase was higher in men than in women per 3-unit increase in U[Na(+)]/[K(+)] (1.6 versus 0.9 mmHg, interaction P=0.03). CONCLUSIONS Dietary Na(+) excess and K(+) deficiency may play an important role in the pathogenesis of hypertension independent of cardiovascular risk factors. This association may be more pronounced in men than in women.

Renal Replacement Therapy in the Elderly Population

ESRD has become an important problem for elderly patients. The segment of the ESRD population age 65 years or older has grown considerably, and this growth is expected to accelerate in coming years. Nephrologists caring for the elderly with advanced kidney disease will encounter patients with comorbid conditions common in younger patients, as well as physical, psychological, and social challenges that occur with increased frequency in the aging population. These challenging factors must be addressed to help inform decisions regarding the option to initiate dialysis, the choice of dialysis modality, whether to pursue kidney transplantation, and end-of-life care. This article will highlight some common problems encountered by elderly patients with ESRD and review data on the clinical outcomes of elderly patients treated with different modalities of dialysis, outcomes of kidney transplantation in the elderly, and nondialytic management of CKD stage 5.