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Depressive symptoms and kidney transplant outcome
Depressive Symptoms and Kidney Transplant Outcome G. Rocha, C.E. Poli de Figueiredo, D. d’Avila, and D. Saitovitch
D
EPRESSION is a condition prevalent among patients with end-stage renal disease undergoing replacement therapy. It has also been increasingly recognized among kidney transplant recipients.1 It reduces self-esteem, leads to noncompliance with therapy, and eventually may lead to death.2 It has been previously demonstrated that patients on dialysis may present with moderate to severe depression, while individuals submitted to a successful kidney transplant are less prone to develop major symptoms of depression.3 It has also been shown that most dialysis patients, whose depression scores, assessed by de Beck Depression Inventory (BDI) are equal to or greater than 14 (evaluated as depressed) will die within 2 years, while the majority of those with scores under 10 (not depressed individuals) will survive longer, and either change modality of dialysis (to CAPD) or receive a kidney transplant. The current investigation studied in depth the relationship between depression and patient and graft outcome at our institution.
patients in group 1 (36%) and 11 in group 2 (28%) presented with chronic allograft nephropathy (NS); two patients in group 1 (8%) and 1 in group 2 (2.5%) died with a functioning graft (NS). Furthermore, overall “negative results” (by adding all the events listed as negative outcome) were significantly more frequent in depressed patients (60% and 31% for groups 1 and 2, respectively).
PATIENTS AND METHODS
CONCLUSIONS
Sixty-four recipients of a first successful kidney transplant were surveyed during a 4-month period at the Transplant Outpatients Clinic of Sa˜o Lucas Hospital, Porto Alegre. They were submitted to the BDI and divided into two groups, according to the scores obtained: group 1, with scores ⱖ10 (depressed patients, n ⫽ 25), and group 2, with scores ⬍10 (not depressed patients, n ⫽ 39). These patients were followed for up to 36 months. The groups did not differ with regards to demographic or major baseline clinical variables. The only clinical variable achieving statistical significance between the two groups was the presence of delayed graft function, that occurred more frequently in group 1 (33% versus 22%, P ⫽ .05). For the assessment of outcome, occurrence of negative results was the study endpoint. Chronic allograft nephropathy (by graft biopsy evidence, serum creatinine over 1.8 mg/dL for at least 6 months, and proteinuria above 0.5 g/d), return to dialysis, or death with a functioning graft were defined as negative outcomes of a kidney graft. Chi-square and Fisher exact tests were used for statistical analysis.
An association between moderate to severe depression and negative outcomes in kidney transplant recipients is suggested. We might speculate that a less than well-functioning graft is perceived as a potentially health-threatening situation, adversely impacting affection expression and perception of overall quality of life. Alternatively, depressed patients may become less compliant with therapy.
RESULTS
During the follow-up period, four patients in group 1 (16%) and none in group 2 returned to dialysis (P ⫽ .02); 9
0041-1345/01/$–see front matter PII S0041-1345(01)02476-9 3424
DISCUSSION
During the observation period, more patients in group 1 presented negative outcomes— death, evidence of chronic allograft nephropathy, or return to dialysis—than patients in group 2. This finding may point to a possible association between the perception of a threatening, and negatively evolving illness, acting on affection expression. However, it was not possible to rule out that individuals with depressive symptoms before being submitted to a kidney transplant are those more prone to be nonadherent to therapy.
REFERENCES 1. O’Donnel K, Chung JY: Psychother Psychosom 66:38, 1997 2. Frazier P, Davis-Ali ASH, Dahl KE: Clin Transplant 8:550, 1994 3. Zimmermann P, Poli de Figueiredo CE: Clin Nephrol (in press) From the Divisions of Nephrology and Psychiatry, Sa˜o Lucas Hospital, Pontificia Universidade Cato´lica do Rio Grande do Sul, Porto Alegre, Brazil. Address reprint requests to G. Rocha, Hospital Sao Lucas da Puc-Hemodialise, Av. Ipirauga GA 6690, 90000 Porto Alegre RS, Brazil.
© 2001 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 33, 3424 (2001)
D
EPRESSION is a condition prevalent among patients with end-stage renal disease undergoing replacement therapy. It has also been increasingly recognized among kidney transplant recipients.1 It reduces self-esteem, leads to noncompliance with therapy, and eventually may lead to death.2 It has been previously demonstrated that patients on dialysis may present with moderate to severe depression, while individuals submitted to a successful kidney transplant are less prone to develop major symptoms of depression.3 It has also been shown that most dialysis patients, whose depression scores, assessed by de Beck Depression Inventory (BDI) are equal to or greater than 14 (evaluated as depressed) will die within 2 years, while the majority of those with scores under 10 (not depressed individuals) will survive longer, and either change modality of dialysis (to CAPD) or receive a kidney transplant. The current investigation studied in depth the relationship between depression and patient and graft outcome at our institution.
patients in group 1 (36%) and 11 in group 2 (28%) presented with chronic allograft nephropathy (NS); two patients in group 1 (8%) and 1 in group 2 (2.5%) died with a functioning graft (NS). Furthermore, overall “negative results” (by adding all the events listed as negative outcome) were significantly more frequent in depressed patients (60% and 31% for groups 1 and 2, respectively).
PATIENTS AND METHODS
CONCLUSIONS
Sixty-four recipients of a first successful kidney transplant were surveyed during a 4-month period at the Transplant Outpatients Clinic of Sa˜o Lucas Hospital, Porto Alegre. They were submitted to the BDI and divided into two groups, according to the scores obtained: group 1, with scores ⱖ10 (depressed patients, n ⫽ 25), and group 2, with scores ⬍10 (not depressed patients, n ⫽ 39). These patients were followed for up to 36 months. The groups did not differ with regards to demographic or major baseline clinical variables. The only clinical variable achieving statistical significance between the two groups was the presence of delayed graft function, that occurred more frequently in group 1 (33% versus 22%, P ⫽ .05). For the assessment of outcome, occurrence of negative results was the study endpoint. Chronic allograft nephropathy (by graft biopsy evidence, serum creatinine over 1.8 mg/dL for at least 6 months, and proteinuria above 0.5 g/d), return to dialysis, or death with a functioning graft were defined as negative outcomes of a kidney graft. Chi-square and Fisher exact tests were used for statistical analysis.
An association between moderate to severe depression and negative outcomes in kidney transplant recipients is suggested. We might speculate that a less than well-functioning graft is perceived as a potentially health-threatening situation, adversely impacting affection expression and perception of overall quality of life. Alternatively, depressed patients may become less compliant with therapy.
RESULTS
During the follow-up period, four patients in group 1 (16%) and none in group 2 returned to dialysis (P ⫽ .02); 9
0041-1345/01/$–see front matter PII S0041-1345(01)02476-9 3424
DISCUSSION
During the observation period, more patients in group 1 presented negative outcomes— death, evidence of chronic allograft nephropathy, or return to dialysis—than patients in group 2. This finding may point to a possible association between the perception of a threatening, and negatively evolving illness, acting on affection expression. However, it was not possible to rule out that individuals with depressive symptoms before being submitted to a kidney transplant are those more prone to be nonadherent to therapy.
REFERENCES 1. O’Donnel K, Chung JY: Psychother Psychosom 66:38, 1997 2. Frazier P, Davis-Ali ASH, Dahl KE: Clin Transplant 8:550, 1994 3. Zimmermann P, Poli de Figueiredo CE: Clin Nephrol (in press) From the Divisions of Nephrology and Psychiatry, Sa˜o Lucas Hospital, Pontificia Universidade Cato´lica do Rio Grande do Sul, Porto Alegre, Brazil. Address reprint requests to G. Rocha, Hospital Sao Lucas da Puc-Hemodialise, Av. Ipirauga GA 6690, 90000 Porto Alegre RS, Brazil.
© 2001 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 33, 3424 (2001)