Association between major depressive episodes in patients with chronic kidney disease and initiation of dialysis, hospitalization, or death

Abstract

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.

Figure 1

Description of Chronic Kidney Disease Cohort GFR indicates glomerular filtration rate; MINI, Mini International Neuropsychiatric Interview.

Figure 2

Survival Curves for Outcome Measures The composite event is defined as death, hospitalization, or maintenance dialysis initiation. Four patients with missing dates of hospitalization were excluded from the composite event and hospitalization models. One patient with missing event date was excluded from the dialysis model.

Figure 3

Adjusted Risks of Events Associated With Major Depressive Episode CI indicates confidence interval; CKD, chronic kidney disease; GFR, glomerular filtration rate.