Relation Between Depression, Some Laboratory Parameters, and Quality of Life in Hemodialysis Patients

Abstract

Depression is common in patients with end-stage renal disease (ESRD) and is associated with increased mortality and morbidity. Several investigators have estimated that depression occurs in about 20% to 30% of dialysis patients. The aim of this study was to investigate the relationship between depression, some laboratory parameters, and quality of life (QOL) in hemodialysis patients. Forty-three hemodialysis patients (mean age 40.5 ± 15.2; M = 28, F = 15) were included in the study. Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA), and short form with 36 (SF-36) were used for evaluation. Subsequently, patients were divided into two groups according to HAMD scores: group 1, those who had a low HAMD score (between 0 and 7), and group 2, those who had a high HAMD score (over 7). The two groups were compared in terms of anxiety scores, QOL scores, and some laboratory parameters. The group 2 patients (n = 21; M = 13, F = 8) had lower levels of hemoglobin than the group 1 patients (9.5 ± 1.7 vs. 10.7 ± 1.4 g/dL, respectively; p< 0.01). Group 2 patients also had lower SF-36 scores than group 1 patients (91.5 ± 21.3 vs. 74.9 ± 13.6, respectively; p = 0.03). On the contrary, the patients of group 2 had higher HAMA scores than group 1 patients (16.6 ± 6.9 vs. 6.3 ± 3.5, respectively; p< 0.01) and CRP level (10.7 ± 4.6 vs. 4.5 ± 3.8, respectively; p< 0.001). A significant correlation was found between depression scores and C-reactive protein (CRP) (r = 0.57, p< 0.001) and HAMA scores (r = − 0.43, p< 0.05). In contrast, a negative correlation was found between HAMD scores and albumin (r = − 0.43, p< 0.05), hemoglobin (r = − 0.38, p =0.015) and SF-36 scores (r = 0.39, p = 0.032). These findings demonstrate that there is a relationship among high depression score, low levels of hemoglobin and albumin, high CRP level, low SF-36 score, and high anxiety score. Evaluation of psychiatric status should be part of the care provided to hemodialysis patients.

• depression
• quality of life
• Hamilton anxiety
• laboratory parameters
• hemodialysis

Introduction

Chronic renal failure (CRF) patients have diminished quality of life (QOL) scores compared with healthy persons. CRF disease not only impacts patient survival, but also yields negative effects in daily life. Clinicians are concerned about the QOL of patients with chronic diseases beyond mere survival. Health-related QOL is a multidimensional, patient-centered, dynamic concept encompassing physical health and symptoms, functional status, mental well-being, and social functioning. Improving QOL is important in treating patients with end-stage renal disease (ESRD).[1&2] Depression is the most widely acknowledged psychosocial factor seen in patients with chronic kidney disease. Major depression occurs in 20% to 30% of patients facing impending dialysis. A low QOL score and depression are associated with higher comorbidity, anemia, poorer nutritional status, lower residual renal function, and increased hospitalization rates.[3-5] The aim of this study is to investigate the relationship between depression, some laboratory parameters, and QOL in patients with ESRD.

Material and Method

ESRD patients treated with hemodialysis (HD) at Yuzuncu Yil University Hospital and Van Yuksek İhtisas Hospital during January 2003 to August 2003 participated in this study. The study protocol was approved by the Ethics Committees of Yuzuncu Yil University. All the patients were routinely dialyzed two or three times a week, and all maintained a fractional urea clearance (Kt/V) greater than 1.1.

Criteria for the study include 1) age between 20 and 60 years, 2) being on HD for at least a year or longer, 3) being in a clinically stable condition, 4) being ambulant, and 5) being literate. The criteria excluded for the study were 1) evident cerebrovascular disease, 2) major psychiatric illness, and 3) major visual or hearing impairment.

After the QOL scales were assessed by an internist who was not informed about the laboratory parameters of the patients, blood tests were performed before starting HD to access the patients in the same predialysate weight-gained condition. Biochemical parameters were determined in the serum by routine colorimetric methods on a Roche modular autoanalyser (Roche modular autoanalyser, Tokyo, Japan). High sensitivity (hs) CRP were measured by using the commercial IMMULITE kits, which are solid-phase, two-site chemiluminescent immunometric assays (Immulite, DPC, USA). Complete blood counts were performed by using an automatic analyzer (STKS Coulter), and biochemical parameters were studied with a Technicon RA-XT auto analyzer in the biochemistry laboratory using the Biotrol commercial kits. Serum C-reactive protein (CRP) levels were measured by nephelometry (Dade Behring Gmbh). Kt/V was calculated according to Daugirdas.[6] The information obtained included social and professional situations, socioeconomic status, and educational levels.

The Medical Outcomes Study Short Form-36 (SF-36) consists of eight subscales to evaluate different domains of health-related quality-of-life (HRQOL): 1) physical functioning, 2) role limitations because of physical health problems, 3) bodily pain, 4) social functioning, 5) general mental health (psychological distress and well-being), 6) role limitations because of emotional problems, 7) vitality, and 8) general health perception. The total score varies between 0 and 100; higher scores represent better QOL. The validity and reliability of SF-36 for the Turkish population has also been demonstrated by Demirsoy.[7]

Turkish versions of the Hamilton Depression Scale (HAMD, range = 0–54 [maximally impaired]) and Hamilton Anxiety Scale (HAMA, range = 0–56 [maximally impaired]) were administered to assess symptoms of depression and anxiety. Subsequently, patients were divided into two groups according to HAMD scores: group 1, those who had low HAMD scores (between 0 and 7), and group 2, those who had a high HAMD score (over 7).Two groups were compared in terms of anxiety scores and QOL scores.[8]

Student's t test and chi-square tests were used for the statistical comparisons.

Results

Mean age of 43 dialysis patients was 33.2 ± 8.7 (range 24–45) years. All patients were on HD treatment twice (n = 5) or three times (n = 38) weekly. Duration of dialysis was 30 ± 17 (12–84) months. Among 43 patients, 35 patients (62.5%) used arterial-venous fistulae, and 8 patients (32.1%) used jugular catheter for HD. The causative disease of ESRD and patients characteristics is shown in Table 1.

Table 1. Patients' characteristics and causative disease of ESRD

	Total	Group 1	Group 2
Number	43	22	21
Age (years) (mean ± SD)	33.2 ± 8.7	34.2 ± 8.1	31.6 ± 8.2
Gender (M/F)	28/15	15/7	13/8
Body weight		66 ± 10	65 ± 11
Primary diagnosis
Glomerulonephritis	13	7	6
DM	13	6	7
Hypertensive nephropathy	7	4	3
Other	6	3	3
Unknown origin	4	2	2

Group 1 consisted of 22 patients with low HAMD scores (M = 15, F = 7); group 2 consisted of 21 patients with high HAMD scores (M = 13, F = 8). Group 2 patients had lower levels of hemoglobin than the group 1 patients (9.5 ± 1.7 vs. 10.7 ± 1.4 g/dL, respectively; p< 0.01). Group 2 patients also had lower SF-36 scores than group 1 (74.9 ± 13.6 vs. 91.5 ± 21.3, respectively; p = 0.03). On the contrary, the patients in group 2 had higher HAMA scores than group 1 patients (16.6 ± 6.9 vs. 6.3 ± 3.5, respectively; p< 0.01) and CRP levels (10.7 ± 4.6 vs. 4.5 ± 3.8, respectively; p< 0.001). The gender ratio was the same among both groups, and there was no statistical difference between the groups' terms of HD duration, cigarette smoking, education level, Kt/V, blood urea nitrogen, albumin, and creatinine (Table 2).

Table 2. Laboratory parameters of patients

Parameters	Group 1	Group 2	p
Hemoglobin	10.7 ± 1.4	9.5 ± 1.7	< 0.01
Creatinine	7.4 ± 2.1	6.9 ± 2.1	ns
Albumin	3.9 ± 0.5	3.5 ± 0.6	ns
CRP	4.5 ± 3.8	10.7 ± 4.6	< 0.001
Total cholesterol	164.7 ± 39.4	167 ± 38.5	ns

A significant correlation was found between depression scores and CRP (r = 0.57, p< 0.001) and HAMA scores (r = − 0.43, p< 0.05). However, a negative correlation was found between HAMD scores and albumin (Figure 1) (r = − 0.43, p< 0.05), hemoglobin (r = − 0.38, p = 0.015), and SF-36 scores (r = 0.39, p = 0.032).

Figure 1. Scatter between HAMD and CRP in hemodialysis patients.

Discussion

Depression is the most common psychological complication and may increase mortality in HD patients because it could be associated with poor oral intake and activation of proinflammatory cytokines that could further increase mortality by malnutrition.[9&10] Koo et al. suggested that in patients on HD therapy, depression was related closely to nutritional status and could be an independent risk factor for malnutrition.[11] A low QOL score and depression are associated with higher comorbidity, anemia, and poorer nutritional status. Increased depressive scores are predictive of an elevated peritonitis risk, perhaps due to decrease in immune defenses.[3] Our findings demonstrate that there is a relationship among high depression score and low albumin levels. In another study, 62 ESRD patients who underwent dialysis were interviewed and completed a Beck Depression Inventory assessment. Thirty-four patients who had criteria for major depressive disorder were selected to receive paroxetine 10 mg/day and psychotherapy for 8 weeks. This study shows that antidepressant medication with supportive psychotherapy successfully treats depression and improves nutritional status in HD patients with depression.[12]

Patients with ESRD often suffer from anemia due to erythropoietin deficiency. Partial correction of anemia with erythropoietin treatment has been shown to improve QOL physical exercise capacity[13] and ameliorate left ventricular hypertrophy,[14] an established risk factor for cardiovascular morbidity and mortality in ESRD.[15] Hans et al. showed beneficial effects of hemoglobin normalization on depression and QOL in HD patients.[10] More recent studies have also suggested additional benefits in QOL and safety with complete hemoglobin correction in both predialysis[16] and dialysis patients.[17&18] In our study, hemoglobin levels are lower in high HAMD score patients than in low HAMD score patients.

In response to internal stressors, such as infectious agents or a nonspecific form of tissue injury, secretion of CRP is primarily regulated by cytokines whose effects in turn are modified by other cytokines and by stress hormones such as cortisol, adrenocorticotropic hormone, and insulin.[19&20] However, production of cytokines and stress hormones may be altered in conditions other than inflammation or injury. There is now growing evidence that not only internal, but also external, mental challenges or affective states are associated with altered immune system parameters.[21] Miller et al. studied 50 subjects with major depression, but otherwise excellent health, and compared the levels of inflammatory markers with a demographically matched control group. They revealed significantly higher CRP and IL-6 levels among the depressed patients.[22] Ladwig et al. found that depressive mood was significantly associated with increased CRP in obese men.[23] Also, Ford et al. found that major depression was strongly associated with increased levels of CRP among 6914 (age, 18–39 years) healthy persons.[24] Hung et al. suggested that CRP levels are the most significant predictors of mortality in dialysis patients.[25] In our study, we found that CRP levels were associated with increased HAMD scores in HD patients. These findings show that there is a relationship between high depression score and CRP levels in HD patients. It may suggest that depression is important to comorbidity for HD patients and closely related to physical parameters of patients.

Conclusion

Our findings show that there is a relationship among high depression score, low levels of hemoglobin and albumin, high CRP level, low SF score, and high anxiety score. Evaluation of psychiatric status should be part of the care provided to HD patients.