Evaluation of depression, quality of life and malnutrition–inflammation scores in haemodialysis patients: a cross-sectional analysis

Sir,

Depression is the most common psychiatric illness in patients with end-stage renal disease (ESRD), and has been associated with increased risk of death, cardiovascular events and hospitalization in a substantial proportion of patients [1–3]. Impaired quality of life (QoL) has been reported in dialysis patients and is a marker of poor outcome [4]. We assessed the prevalence of depression and QoL status among a cohort of 60 chronic haemodialysis patients, between June and August 2007. Their mean age was 46.13 ± 16.55 years, with a range of 22–77 years. They consisted of 31 males and 29 females (P = 0.91). The duration of RRT was 67.03 ± 56.09 months. They were on three times weekly dialysis at the Kasr El-Aini Nephrology and Dialysis Centre, Cairo University Hospital. We explored the relationship between depressive symptoms and poor QoL on the one hand and socio-demographic profile, dialysis adequacy, laboratory parameters and malnutrition–inflammation score (MIS) on the other. The MIS consists of four sections [nutritional history, physical examination, body mass index (BMI) and laboratory values] [5]. We used the Beck Depression Inventory (BDI) to assess the severity of depression [6] and SF-36 questionnaire to assess QoL in the study group [7].

Fig. 1

Correlation between BDI and MIS in all study subjects (R² = 0.163, P = 0.02).

Table 1

Patient characteristics and their association with BDI scores >15 (^*P < 0.05)

	BDI > 15 (N = 20)	BDI < 15 (N = 40)	P-value
Age	49 ± 19.64	44.7 ± 15.12	0.27
Gender (M/F)	6/14	16/14	0.02*
Duration of dialysis (months)	63.5 ± 51.43	68.8 ± 59.49	0.40
BMI (kg/m2)	23.51 ± 5.55	24.49 ± 4.73	0.11
Education
Primary	20%	20%	0.50
Secondary/tertiary	50%	45%	0.45
Higher education	10%	25%	0.02*
Uneducated	20%	10%	0.07
History of transplant	0/20	1/40	0.43
Diabetes mellitus	10%	10%	0.50
Marital status
Single	30%	20%	0.07
Divorced	0%	15%	0.02*
Widowed	30%	5%	0.01*
Married	40%	60%	0.01*
Employment
Employed	0%	20%	0.04*
Unemployed	100%	80%	0.04*
Malnutrition–inflammation score (MIS)	9.8 ± 3.25	7.55 ± 4.63	0.06
Serum albumin (g/dl)	3.78 ± 0.47	3.82 ± 0.45	0.40
Haemoglobin (g/dl)	9.18 ± 1.26	9.47 ± 1.78	0.30
Urea reduction ratio (URR)	66.2 ± 7.25	66.65 ± 4.93	0.43
Blood urea (mg/dl)	162.10 ± 38.56	164.18 ± 40.10	0.41
Serum creatinine (mg/dl)	7.30 ± 2.02	8.89 ± 3.15	0.39
Serum calcium (mg/dl)	8.79 ± 0.59	8.71 ± 0.69	0.48
Serum phosphorus (mg/dl)	5.52 ± 1.03	5.44 ± 1.20	0.47
F-36 total scores	58.94 ± 13.09	69.90 ± 9.63	0.01*
F-36 mental component	59.54 ± 13.70	71.39 ± 9.85	0.01*
F-36 physical component	58.92 ± 13.57	66.76 ± 11.10	0.06

We found a high prevalence of depressive symptoms in this cohort as 20 patients (33.33%) had BDI score ≥15. Fourteen patients with BDI scores ≥15 were females (P = 0.02). Patients with BDI scores ≥15 had significantly lower total QoL scores and mental component scores (P = 0.01). Employment was found to significantly affect BDI scores; all patients with BDI scores ≥15 were unemployed (Table 1). The mean BDI score of unemployed patients was significantly higher than employed patients (13.03 ± 6.27 versus 8.50 ± 3.51, P = 0.03). Widowed patients had significantly higher BDI and lower F-36 scores compared to single, married and divorced patients (P < 0.05). Patients with BDI scores ≥15 had higher MIS values, although the difference was not statistically significant (P = 0.06). MIS showed significant positive correlations with BDI scores (P < 0.05) (Figure 1) and significant negative correlations with F-36 scores (P < 0.05). Neither age, BMI, MIS, dialysis adequacy, haemoglobin, blood urea and serum creatinine, calcium, phosphorus and albumin were predictors of BDI scores on regression analysis (P > 0.05).

The prevalence of depression in the current study was higher than that previously reported in the DOPPS study (20%) [8] and the CHOICE study (19–24%), respectively [9]. The difference in prevalence of depression between European, American patients and our study group may reflect the differences in age (mean age of patients surveyed in the current study was 46.13 ± 16.55 years compared to 60.0 ± 15.3 years in the DOPPS study). Previous studies have shown a lower prevalence of depression among older people [8,10]. Development of ESRD in middle age usually leads to a severe disruption of patients’ physical and social activities, with consequent psychological distress and poor QoL. These findings highlight the impact of the malnutrition–inflammation complex (MIC) on the quality of patients’ life and their mental health. MIC occurs commonly in maintenance haemodialysis patients and correlates with increased morbidity and mortality [5]. Serum albumin, however, did not correlate with BDI scores in our study; this could be explained by the near normal serum albumin levels in our study group (3.83 ± 0.45 g/dl). Based on our findings, we propose the routine use of simple screening tools like BDI, MIS and F-36 form to identify patients at high risk for hospitalization and poor outcome. Such vulnerable patients should receive more counselling, social support and specialist referral for treatment of depression.

Conflict of interest statement. None declared.

© Oxford University Press 2008