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

Abstract

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.

Keywords: age; depressive symptoms; end-stage kidney disease; kidney transplantation; waitlisting.

Graphical abstract

Figure 1

Proportion of patients with mild or more severe depressive symptoms (CES-D ≥ 16) by age at kidney transplant evaluation (N = 3728). The CES-D score ranges from 0 to 60, with the higher score representing more severe depressive symptoms. Depressive symptom severity was categorized as follows: none (0 point), minimal (1–15 points), mild (16–20 points), moderate (21–25 points), and severe (26–60 points). Age was treated as a continuous variable at evaluation. Restricted cubic splines were used, and 95% CIs are depicted as the region between the dotted curves. CES-D, Center for Epidemiologic Studies—Depression.

Figure 2

Depressive symptom severity by age group among kidney transplant evaluation patients (N = 3728). The CES-D score ranges from 0 to 60. Depressive symptom severity was categorized as follows: none (0 point), minimal (1–15 points), mild (16–20 points), moderate (21–25 points), and severe (26–60 points). CES-D, Center for Epidemiologic Studies—Depression.

Figure 3

Unadjusted cumulative incidence of (a) any listing and (b) active listing for kidney transplant within 1 year after evaluation by depressive symptom severity among evaluation patients (N = 3728). The CES-D score ranges from 0 to 60. Depressive symptom severity was categorized as follows: none (0 point), minimal (1–15 points), mild (16–20 points), moderate (21–25 points), and severe (26–60 points). CES-D, Center for Epidemiologic Studies—Depression.

Figure 4

Impact of depressive symptoms on (a) chance of any listing and (b) chance of active listing for kidney transplant within 1 year after evaluation by age group using complete case analysis. The CES-D score ranges from 0 to 60, with the higher score representing more severe depressive symptoms. Adjusted HRs with 95% CIs were presented from adjusted Cox proportional hazards models adjusted for age group, sex, Black race, years on dialysis, BMI, smoking history, Charlson Comorbidity Index, education, marital status, employment, and neighborhood poverty level. BMI, body mass index; CES-D, Center for Epidemiologic Studies—Depression; HR, hazard ratio.