Original Investigation
Dialysis
Association Between Depression and Mortality in Patients Receiving Long-term Dialysis: A Systematic Review and Meta-analysis

https://doi.org/10.1053/j.ajkd.2013.08.024Get rights and content

Background

We aimed to systematically review and analyze the association between depression and mortality risk in adults with kidney failure treated by long-term dialysis.

Study Design

A systematic review and meta-analysis of observational studies.

Setting & Population

Patients receiving long-term dialysis.

Selection Criteria for Studies

Searching MEDLINE, EMBASE, and PsycINFO, we identified studies examining the relationship between depression, measured as depressive symptoms or clinical diagnosis, and mortality.

Predictor

Depression status as determined by physician diagnosis or self-reported scales.

Outcomes

Pooled adjusted HR and OR of depression for all-cause mortality.

Results

15 of 31 included studies showed a significant association between depression and mortality, including 5 of 6 studies with more than 6,000 participants. A significant link was established between the presence of depressive symptoms and mortality (HR, 1.51; 95% CI, 1.35-1.69; I2 = 40%) based on 12 studies reporting depressive symptoms using depression scales (N = 21,055; mean age, 57.6 years). After adjusting for potential publication bias, the presence of depressive symptoms remained a significant predictor of mortality (HR, 1.45; 95% CI, 1.27-1.65). In addition, combining across 6 studies reporting per-unit change in depression score (n = 7,857) resulted in a significant effect (HR per unit change in score, 1.04; 95% CI, 1.01-1.06; I2 = 74%).

Limitations

Depression or depressive symptoms were documented only from medical charts or a single self-report assessment. Included studies were heterogeneous because of variations in measurement methods, design, and analysis.

Conclusions

There is considerable between-study heterogeneity in reports of depressive symptoms in dialysis patients, likely caused by high variability in the way depressive symptoms are measured. However, the overall significant independent effect of depressive symptoms on survival of dialysis patients warrants studying the underlying mechanisms of this relationship and the potential benefits of interventions to improve depression on the outcomes.

Section snippets

Criteria for Selection of Studies

All observational studies published in either abstract or full form that included an assessment of the ability of depressive symptoms or clinical depression to predict mortality were included. Studies were included if they recruited adult participants 18 years or older who were receiving dialysis (hemodialysis and peritoneal dialysis modalities) as a long-term renal replacement therapy. Non-English articles were considered for inclusion provided that an abstract in English was available.

Search Results

The search yielded 2,528 records, of which 63 were potentially relevant. The κ index for agreement between the 2 reviewers was 0.96. The selected reports were screened for eligibility for inclusion. Authors were contacted for additional information; attempts were successful in 7 cases with additional data provided by authors. Thirty-two studies were excluded, and 31 articles were included for qualitative synthesis (Fig 1).

Table 1 is a summary of 31 studies included in the review (N = 67,075; mean

Discussion

Using meta-analytical techniques, we have shown an independent association between depression and increased mortality risk in the dialysis population. The magnitude of the increased risk was 1.5 times in the presence of depressive symptoms. This magnitude was slightly smaller when the risk of publication bias was incorporated using the trim-and-fill analysis. Studies with repeated measurements of depressive symptoms (longitudinal assessment) demonstrated a 1.66 times higher mortality risk with

Acknowledgements

We thank Dr Prakesh Shah for excellent guidance, and the authors of the reviewed publications who contributed to our work: Rasheed Balogun, Joseph Chilcot, Konstadina Griva, Eduardo Lacson, Rolf Peterson, Cheuk-Chun Szeto, Melissa Thong, and Tessa van den Beukel.

Support: None.

Financial Disclosure: The authors declare that they have no relevant financial interests.

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