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Revista de Psiquiatria do Rio Grande do Sul

Print version ISSN 0101-8108

Rev. psiquiatr. Rio Gd. Sul vol.26 no.3 Porto Alegre Sept./Dec. 2004 



The impact of depression and others psychosocial factors in the prognosis of chronic renal patients


El impacto de la depresión y otros factores psicosociales en el pronóstico de pacientes renales crónicos



Paulo Roberto ZimmermannI; Juliana Oliveira de CarvalhoII; Jair de Jesus MariIII

IProfessor, Department of Psychiatry and Forensic Medicine, PUCRS, Porto Alegre, Brazil
IIMedical student, PUCRS, Porto Alegre, Brazil
IIIProfessor, Department of Psychiatry, Universidade Federal de São Paulo, Brazil





The authors review the literature on depression and other psychosocial risk factors that may influence the evolution of patients with kidney disease. Studies addressing depression, age, gender, skin color, social support, and marital status/family support were included in the review. The study revealed that trials assessing these factors have not come to a consensus so far. Age seems to be a factor that interferes with disease evolution, but the papers examined did not include confounding factors. Some papers also showed strong evidence that gender is not associated with the evolution of these patients.

Keywords: Depression, psychosocial factors, nephrology, renal dialysis, kidney transplantation, peritoneal dialysis, CAPD.


Los autores realizaron una revisión bibliográfica sobre la depresión y otros factores psicosociales que podrían tener influencia en la evolución de los pacientes renales. Evaluaron trabajos relativos a depresión, edad, género, raza, soporte social y situación marital / soporte familiar. Al final, se demostró que no hay resultados definitivos en las investigaciones realizadas sobre estos factores. La edad parece ser un factor que influye en esta evolución, pero los factores de confusión no se contemplaron en los trabajos examinados. Además, aparecieron fuertes evidencias de que el género no estaría asociado a la evolución de estos pacientes.

Palabras clave: Depresión, factores psicosociales, nefrología, diálisis renal, trasplante de riñón, diálisis peritoneal ambulatoria continua.




The first three decades of dialysis were to increase the survival of patients. The challenge for the next 30 years will be to understand the association between psychosocial factors and patient outcome, which includes adjustment, compliance, morbidity and mortality.1 An immense quantity has already been learnt about the physiological reactions of dialysis patients. The field of stress has merely begun to make plausible connections between emotions and their biological mediators.2 These two statements of the position of a well-respected researcher into the area clearly show us the importance of the theme here proposed.

During the initial periods of dialysis use, all efforts were dedicated towards sustaining of life; since then highly significant progress has been made to this end, and, currently this is already being achieved in a more consistent manner. This being so space is opened up for other concerns, namely the issue of the emotional factors of these patients and concern with their quality of life. The majority of papers presented to date are studies of the associations between a number of different psychosocial factors and morbidity and mortality. Recently work has started to appear that has offered certain ideas about biological mediators to explain these associations.3 The factors that can most frequently influence the outcome of chronic renal patients can be divided into two groups: fixed factors, those that cannot be modified by the patient or physician and which include age, concomitant disease, sex and race and variable factors, those that can be modified and include depression, social support and marital status.1

The authors performed a search of PubMed, using the keywords "hemodialysis," "CAPD," "renal transplantation," "kidney transplantation," "depression," "quality of life" and "psychosocial factors." Priority was given to cohort studies, since they are most applicable to the current research article.




Findings relating to depression in this group of patients are still very contradictory. This may be due to a series of factors, such as highly varied populations, medical teams with different training and experience, non-homogenous criteria for depression diagnosis and different instruments for measurement, among other factors. One example of this can be found in the review paper by Kimmel et al.,4 who state that the prevalence of depression in these patients varies from 0 to 100%. In a different article, Kimmel2 states that the lifelong risk of major depression is 10 to 25% in women and 5 to 12% in men. In the same study, the author states that depression tends to diminish with age, but points out that this finding should be treated with a certain degree of caution because of the possibility of survivor bias, since, to the extent that the most depressed die, those with least or no depression survive. Deoreo,5 examining a group of 1,000 patients over 2 years, found a 25% prevalence of depression using the SF36 instrument, and Lopes et al.6 evaluated 5,256 patients at a number of different centers across the United States and in Europe, finding a 20% prevalence of depression. In extensive work that examined data from 176,368 patients from the records of American Medicare, it was observed that the records of 9% of the patients on hemodialysis exhibited some type of report of mental disease, and that, of these, 26% were depression and affective disorders.4

The etiology of depression is usually associated with some type of loss — and losses are normally numerous and long-lasting for patients with kidney disease. There is the lost renal function, the sense of well-being, the role within the family and at work, lost time, sources of financial resources and sexual function, among others. To this must be added characteristics of the patients' personalities, in addition to possible genetic predisposition towards depression.1

Work that has examined a possible association between depression and morbidity and mortality present results that are very often contradictory, as we shall see below. Some cohort studies have shown such an association: Devins et al.7 examined 97 patients using the Beck Depression Inventory (BDI) in a 46-month study and found an association between depression and mortality, a fact that was also confirmed by Wai et al.,8 who followed 285 patients for 18 months. Other studies have shown that there was no association between depression and mortality: Kimmel et al.,9 studying 295 patients for 26 months and measuring with the BDI, did not find any association, in common with Christensen et al.,10 who examined 84 patients for 3.5 years with a number of different measurements using the BDI, also did not find any association, even when they divided the BDI into its cognitive and a somatic components.

Lopes et al.,6 already cited above, found that depressed patients exhibited a relative risk of death of 1.23 and, furthermore, presented a relative risk of hospital admissions of 1.11 when compared with patients who were not depressed. Since the group of patients was very large (5,256) all of the results were significant from a statistical point of view. Data was corrected for country of origin. Assessing 174 patients in a 1-year cohort study, Kimmel et al.3 did not find any association between depression and mortality. In this research, the authors assessed the influence of the dyadic relationship between gender and depression on the outcome of these patients. This is a study that begins to investigate the relationship between emotions and biological mediators to the extent that it identifies that women on hemodialysis and with a good dyadic relationship present an elevated level of beta-endorphin, in contrast to what is observed with men. In this group interleukin-1 levels were not associated with any of the factors measured.

In another cohort study the same authors11 state that the effects of depression are of the same magnitude as medical risk factors for these patients. Studying 295 patients originating from three different clinics over 2 years, with depression measurements taken every 6 months with the BDI, they found that depression at the start of the experiment was not associated with mortality, but that permanent depression involved a relative risk of death of 1.24 (corrected for age, albumin, type of dialysis equipment and place of dialysis). After adjusting for time, an elevated BDI score is associated with a relative risk of 1.32, and, even if we use its cognitive component in isolation (CDI), this will be associated with a relative risk de 1.23.

The same study states that, stratifying the BDI results, those patients classified as presenting mild depression live longer than those classified as moderately or severely depressed. They also cite that any care program that is capable of reducing the average BDI by 8.1 points can increase these patients' survival by 32%.

Examining patients treated with continuous ambulatory peritoneal dialysis (CAPD), Finkelstein et al.12 found that elevated depression and anxiety were related with an increased incidence of peritonitis in these patients, i.e. with greater morbidity. Studying 88 kidney transplant patients, Akman et al.13 found that patients who had had transplantations had a lower prevalence of depression than did patients on waiting lists, and that these had lower rates than patients who had lost their grafts. These authors also reported that depression was inversely related to graft survival time, but that the statement should be treated with a certain caution since it is possible that the depression is a consequence of losing the graft and not the cause.

In work performed in Brazil, a review undertaken by Almeida & Meleiro14 states that the prevalence of depression is 5 to 25% when strict diagnosis criteria are used. Attempting to explain the consequences of depression in these patients, the authors state that it impacts on quality of life, suicide rates, compliance with treatment and mortality.

With respect of this, other authors15 claim that depression provokes a reduction in immunity, relaxation of personal care, reduced compliance with treatment and diets, intensification of both financial and professional problems and, finally, a greater possibility of comorbidity with alcohol or drug abuse or dependency.

In work performed in Porto Alegre with 41 patients on hemodialysis, Duarte et al.16 found prevalence rates of 24.39% for major depression, 12.9% for major depressive disorder in remission, 9.76% for minor depressive disorder in partial remission and, finally, 12.9% for dysthymia.


All of the papers reviewed showed that there was a direct association between age and mortality.5,7-10,17 Factors related to age that could be responsible for this are not hard to identify: to the extent that age increases a series of factors occur concomitantly: a greater chance of comorbidity, a greater incidence of depression, a variety of losses (whether of spouses, social support or economic capacity), the process of aging itself and others. This being so, the statement that increasing age is associated with increased mortality should be looked at with caution since this association may be due to the sum of all these factors and not specifically to age. We should, perhaps, develop future research to correct for these facts. In a cohort study, Devins et al.7 evaluated 97 patients on hemodialysis, continuous ambulatory peritoneal dialysis and with transplants for 4 years. The authors found that age and number of comorbid conditions were directly associated with patient survival.

Kimmel et al.9 studied the outcome of 295 patients over 26 months, with assessments every 6 months, and were able to observe that the only factors linked to mortality were age and disease severity. In an older work, published in 1981 by Wai et al.,8 285 patients were followed in 14 different hospitals for 18 months. The authors related that psychological factors did not only appear to interfere with these patients' adjustment, but also to contribute to self-destructive behavior. They too found that there was an association between age and mortality. In a review article, Valderrabano et al.17 found work that reported the same association between age and mortality. Furthermore, they also described increased age being associated with reduced patient quality of life, in particular with respect of physical aspects. Notwithstanding, they observed that it is possible that, for older patients, the impact of a terminal kidney disease is less severe than for younger people, because they have a greater capacity to deal with the limitations imposed by the disease. The impact, for example, of three weekly hemodialysis sessions to a retired person is less than to someone who is engaged in productive activity.

Christensen et al.10 examined 84 patients in a 3.5 year cohort study and found that age was related with observed mortality over the period. An interesting study published by Kutner et al.18 describes the follow-up of a group of 287 senior patients (over 60 years old) for 12 years. The study found that in this age group, the age factor was not associated with mortality. Deoreo5 conducted a 2-year study of a group of 1,000 patients and described a positive association between age, number of hospital admissions and mortality. One additional finding was that younger patients more often missed one or more hemodialysis sessions per month.


The majority of work that has investigated a possible association between gender and mortality indicate that there is no association. The same authors cited above, Devins et al.,7 and Deoreo,5 state that this association does not exist. Valderrabano et al.17 describe studies that demonstrate that women exhibit worse quality of life indices (morbidity) than men, suggesting that may occur as a result of the loss of their social roles and the greater incidence of depression in this group. Leggat et al.,19 when studying compliance to treatment, which influences outcome for these patients, found that, within a group of 6,251 patients, gender did not influence the patients' compliance; this allows us to suggest, in consequence, that it did not influence mortality. An association between gender and mortality was found in work by Kutner et al.,18 who examined 287 patients aged over 60 years and found that men died more than women over a 2 year period. This result maybe expresses the reality that women live longer than men, and not specifically a fact related to gender and renal patients.


A possible association between race and morbidity and mortality is highly complex. Perneger et al.,20 in an interesting study, state that the differences in state of health between different races may be caused, at least in part, by issues of socioeconomic status. The continue by claiming that a minority race may have genetic characteristics that predispose it to a given disease or outcome. Additionally, minority races frequently have lower socioeconomic status, which can mean that the types of jobs that members of that race obtain are of an inferior level, exposing them to greater risks. Furthermore, socioeconomic difficulties can also lead to limitations to health service access, which reduces the prevention of diseases or their control once they have set in. Despite this, the research that the same author conducted with 716 patients and 361 controls in Maryland, found that African Americans presented an odds ratio of 5.5 for mortality, even after correction for socioeconomic variables.

Leggat et al.,19 examined a group of 6,251 patients, perceiving that African American patients had a greater possibility of missing hemodialysis sessions or interrupting them earlier when compared with white patients. Contradictorily, the authors state that these patients have a lower chance of dying on hemodialysis than do white patients. Valderrabano et al.17 cite studies that describe that African American patients on hemodialysis progress better than do whites. In addition to this, citing work by Welch & Austin, they claim that the quality of life of African American patients undergoing hemodialysis is comparable with that of white patients and the authors believe that race need not be monitored for these patients. Similarly, a number of different works,7,10,11,13,18,21-23 when describing the demographic characteristics of the patients studied do not give race as a parameter.

Social support

One definition for social support could be that the individual feels themselves to be part of a network of affect, mutual help and obligations.1 Kimmel, in another paper,2 suggests that the social support perceived and received from friends is related to attendance at hemodialysis sessions, i.e. compliance to the treatment. Furthermore, when describing the social support that the patient receives from their family members, the author points out that this contributes positively to their outcome, but that the patient is a huge source of stress for the family. The author states that differences in social support may be implicated in the differences in mortality rates between countries, groups or treatment centers and possibly contribute to the different rates of adhesion to treatment.

Shidler et al.,24 studying 50 patients with chronic renal failure (creatinine clearance below 80), proffer the idea that social support has an action similar to a buffer, in other words, it does not offer a larger protective action in situations of mild stress, but prevents or reduces the negative effects of elevated stress. In work already cited, Kimmel et al.,3 studying 174 patients on hemodialysis, found that social support is linked to increased survival among these patients.

Marital/family support

The approach to this variable is profoundly related with the previous one since the family, or relationship in a couple, is most often included in the support network of these patients. Examining 84 patients receiving hemodialysis in a 3.5 year cohort study, Christensen et al.,10 using the Family Environment Scale (FES), which measures cohesion, expressiveness and conflict, found that family support is related to patient survival. They point out that an increase of 1 point in this scale contributes to a 13% reduction in mortality in the group. Those patients who were at one standard deviation above the mean were defined as having high family support, and those at on deviation below the mean as having low family support. The authors found that, over 5 years, there was a three times difference in mortality: 18% of the patients with high support had died in contrast with 52% of those with low support. Additionally, the authors state that these differences were not cause by compliance problems, since values for urea and creatinine were no different between the groups.

Steidl et al.,25 examined the families of 33 patients on dialysis, finding that family functioning with respect of coalition of family members, respect for individuality in the context of intimacy and warm and optimistic affective interactions are related to better medical conditions. Furthermore, the authors state that limitations imposed by the disease also influence the family. In a study of kidney transplantation patients, Akman et al.13 report that a lower percentage of depression was observed among married patients, suggesting that they adapt more rapidly to the situation, having better support.

Devins et al.,7 studied a group of 97 patients on hemodialysis, CAPD and post-transplantation for 46 months, did not find an association between marital status and mortality. Amplifying the influence of the disease on the family a little further still, Kimmel2 states that family roles are changed when the disease has onset and that, in addition to this the common sexual alterations generate a variety of sentiments, which should be managed. The study also reports that if the marital relationship is good then there will be an increase in patient health. The same author, studying dyadic relationships in these patients, found that women who presented values one standard deviation from the mean on the Dyadic Adjustment Scale exhibited a 50% reduced risk of mortality and that a reduction in score negativity on the same scale was associated with a 60% reduction of risk. These findings were not reproduced with male patients.



As was demonstrated throughout the review, there are no conclusive results on the influence of emotional factors on morbidity and mortality of these patients, but certain statements can be made.

The influence of depression on the outcome of these patients is the factor that has been most studied. The results are not yet conclusive, but there is a tendency towards a direct association between depression, morbidity and mortality in this group of patients. Due to the possibility of treating these disorders avoiding the possible severe consequences to patient outcome, the authors believe that it is important for further studies to be performed in this area, which would make it possible to achieve a greater degree of certainty about the true influence of depression on chronic renal patients.

There is agreement across all of the studies reviewed, with a single exception,18 that age is directly related to mortality. However, the studies did not correct the results obtained with respect of other variables with elevated incidence rates in this group of patients, such as increased comorbidity, increased depression, reduced social support through lost spouses, etc. In other words, it is not clear whether age is responsible for increased mortality or some other factor related to it.

With respect of gender, the studies indicated a strong tendency in the direction of the non-existence of an association with morbidity or mortality.

With respect of race, results are contradictory, with the tendency being that race does not influence the morbidity or mortality of these patients. Furthermore, results that were possibly positive may have been affected by other factors linked with the race of patients. Many of the studies reviewed did not mention the race of their patients among their demographic characteristics.

Social and family support appear to be inversely related to morbidity and mortality, and, once more, other factors amply involved in social support may be responsible for these results.

As this was not a meta-analysis, the results should be treated with some caution since they are not uniform due to different populations, diagnostic criteria, follow-up periods, etc.

Finally, there is a need for better controlled, longitudinal studies with well-defined methodologies larger groups of patients longer observation periods so that more valid results can be obtained.



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Correspondence to
Paulo Roberto Zimmermann
Rua Carvalho Monteiro, 257/301 — Bela Vista
CEP 90470-100 — Porto Alegre — RS — Brazil

Received on September 14, 2004.
Revised on November 16, 2004.
Accepted on November 25, 2004.



The present study was carried out at Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil.

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