Pre-ESRD Depression and Post-ESRD Mortality in Patients with Advanced CKD Transitioning to Dialysis

Abstract

Background and objectives: Depression in patients with nondialysis-dependent CKD is often undiagnosed, empirically overlooked, and associated with higher risk of death, progression to ESRD, and hospitalization. However, there is a paucity of evidence on the association between the presence of depression in patients with advanced nondialysis-dependent CKD and post-ESRD mortality, particularly among those in the transition period from late-stage nondialysis-dependent CKD to maintenance dialysis.

Design, setting, participants, & measurements: From a nation-wide cohort of 45,076 United States veterans who transitioned to ESRD over 4 contemporary years (November of 2007 to September of 2011), we identified 10,454 (23%) patients with a depression diagnosis during the predialysis period. We examined the association of pre-ESRD depression with all-cause mortality after transition to dialysis using Cox proportional hazards models adjusted for sociodemographics, comorbidities, and medications.

Results: Patients were 72±11 years old (mean±SD) and included 95% men, 66% patients with diabetes, and 23% blacks. The crude mortality rate was similar in patients with depression (289/1000 patient-years; 95% confidence interval, 282 to 297) versus patients without depression (286/1000 patient-years; 95% confidence interval, 282 to 290). Compared with patients without depression, patients with depression had a 6% higher all-cause mortality risk in the adjusted model (hazard ratio, 1.06; 95% confidence interval, 1.03 to 1.09). Similar results were found across all selected subgroups as well as in sensitivity analyses using alternate definitions of depression.

Conclusion: Pre-ESRD depression has a weak association with post-ESRD mortality in veterans transitioning to dialysis.

Keywords: African Americans; Comorbidity; Confidence Intervals; Disease Progression; Humans; Kidney Failure, Chronic; Male; Proportional Hazards Models; Renal Insufficiency, Chronic; Risk; Veterans; chronic kidney disease; depression; diabetes mellitus; end stage kidney disease; hospitalization; mortality; quality of life; renal dialysis; transition.

Graphical abstract

Figure 1.

Flow chart of the study population.

Figure 2.

Probability of all-cause mortality of patients with and without depression using different definitions of depression. (A) Depression defined only using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code is not associated with mortality. (B) Depression defined on the basis of the ICD-9-CM code and/or antidepressant medication, or on the basis of the ICD-9-CM code and/or antidepressant medication separated by treatment (C) is associated with higher mortality.

Figure 3.

Patients with depression experienced higher all-cause mortality risk across most examined subgroups. Model is adjusted for age, sex, race/ethnicity, marital status, comorbidities (dementia, myocardial infarction, congestive heart failure, peripheral vascular disease, connective tissue disease, lung disease, peptic ulcer disease, HIV, diabetes mellitus, stroke/paraplegia, liver disease, malignancy, and hypertension), type of vascular access (arteriovenous fistula, arteriovenous graft, or catheter), eGFR slope before ESRD initiation, post-traumatic stress disorder, substance abuse, numbers of mental health care and emergency department visits, and medications (phosphorous binder, active vitamin D, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, bicarbonate, β-blockers, calcium channel blockers, vasodilators, diuretics, statins, and erythropoietin stimulating agents). CHF, congestive heart failure; CVD, cerebrovascular disease.