DEPRESSION AND COGNITIVE FUNCTION IMPAIRMENT IN PATIENTS UNDERGOING HEMODIALYSIS

ABOUT AUTHORS:
Vishal V. Timaliya*, Prof.Mital v. Dalal
Gujarat Technical University
*vishal.vishal.timaniya@gmail.com

ABSTRACT
The main objectives of this study were the prevalence of depression and cognitive function impairments in patients undergoing hemodialysis.
An observational study performed on 60 patients with CKD stage IV and V undergoing hemodialysis two or three times in a week and CKD stage I to III without hemodialysis. Depressive symptomatology, defined by a Center for Epidemiological Studies Depression Scale (CES-D) score of 16 or higher and cognitive function measured by Mini Mental State Examination (MMSE) questionnaire. All data was analyzed by MS excel and Graph pad Prism 5.0.

There were 60 participants enrolled in this study, 50 participants of CKD 4 to 5 stage treat with hemodialysis and 10 participants of CKD 1 to 3 stage treat without hemodialysis. We found that 37 out of 50 patients (74%) had a burden of depressive symptoms. Expectedly, the prevalence of depression was higher in the 50–60 age group and was found to be positively correlated with age in general. From our study, it was found that more depressive symptoms were found in patients with lower education as compared to patients with graduation or above. The positive correlation between duration of dialysis both depression and cognitive function. Diabetes and hypertension are primary causes of ESRD and diabetes patients were more depressed than hypertension patients.
From the present study, it can be concluded that there is a high prevalence of depression in ESRD patients receiving hemodialysis, particularly those taking it for a longer duration. We found that a mild positive correlation between cognitive function and depression. Future studies with neuroimaging may be done to explore the etiology of concurrent depression and cognitive function impairment.

REFERENCE ID: PHARMATUTOR-ART-1759

1. INTRODUCTION
End stage renal disease occurs when the kidney are no longer able to function at a level that is necessary for day-to-day life. It usually occurs when chronic kidney failure has progressed to the point where kidney function is less than 10% of normal function. When healthy, the kidneys maintain the body's internal equilibrium of water and minerals (sodium, potassium, chloride, calcium, phosphorus, magnesium, and sulfate). Those acidic metabolism end products that the body can’t get rid of via respiration are also excreted through the kidneys. The kidneys also function as a part of the endocrine system producing erythropoietin and calcitriol. Erythropoietin is involved in the production of red blood cells and calcitriol plays a role in bone formation.⁽¹⁾Hemodialysis is a method for removing waste product such as potassium and urea, and excess water from blood.Dialysis is an imperfect treatment to replace kidney function because it does not correct the endocrine functions of the kidney.⁽²⁾

Chronic kidney disease (CKD) and end-stage renal disease (ESRD) have become worldwide public health problems.India gets 1.5 lake patients with kidney failures every year and a majority of them die within five years due to the acute shortage of dialysis units in the country.⁽³⁾Many of these individuals are on long-term hemodialysis and suffer from relatively poor physical health. These conditions increase patient morbidity and mortality risks and put major economic strain on the health-care systems.⁽⁴⁾Patients with ESRD on dialysis experience a broad range of symptoms some with potentially negative effect on functioning and well being of patient. Dialysis affects the quality of life leading to time limitation in activities and high level of disability and impairment in functioning statues and psychological aspects. ⁽⁵⁾

Numerous studies have documented that quality of life in patients undergoing dialysis therapy is significantly impaired.⁽⁶⁾ Poor mental health which includes depressive symptoms and depression is a major health problem and most frequent group of psychological problem in hemodialysis patients.⁽⁷⁾ Recent study reported that among hemodialysis patients those with depressive symptoms were high risk of death and high risk of hospitalization and had high rates of dialysis withdrawal than those without depressive symptoms.⁽⁸⁾ Similarly, cognitive impairment is associated with negative outcomes, including non-adherence to drug treatment and increased costs of care.Mild cognitive impairment is likely under-diagnosed but highly prevalent in individuals with end-stage renal disease.⁽⁹⁾

The KDQOL-CF is a poor determinant of neurocognitive performance in hemodialysis patients, with limited sensitivity. To assess cognitive impairment in hemodialysis patients, better screening tests are essential.⁽¹⁰⁾

Depression is common in patients with end-stage renal disease and has been linked to increased mortality. Screening for depression in the general medical population remains controversial. However, given the high prevalence of depression and its significant impact on morbidity and mortality, a strong case for depression screening in patients with end-stage renal disease can be made.There are limited data on the treatment of depression in this patient population.Larger randomized, controlled clinical trials are needed to determine the optimal approach to treatment of depression in patients with ESRD.⁽¹¹⁾

The World Health Organization predicts that by the year 2020, major depression will be the second most disabling condition worldwide, measured in disability-adjusted life years. ⁽¹²⁾ A study based on the World Health Organization’s World Mental Health Survey Initiative has said that India has the highest rate of major depression in the world.The depression is highest among Indians, indicators of state of mental dis balances and state of mental dis-balances which heavily depends on ones way of thinking on the issues of social, political, economical and cultural happenings. ⁽¹³⁾

Depression and cognitive impairment are prevalent in patients with kidney disease. Estimated rates of clinical depression among hemodialysis patients range from 20 to 30% with as many as 42% of hemodialysis patients exhibiting some form of depressive affect. ⁽¹⁴⁾ Depression has significant effects on both individual patient well-being as well as delivery of medical care. Hemodialysis patients with depression have a lower quality of life, more functional impairments, a greater occurrence of co-morbid conditions and psychopathology, lower adherence to drug treatment, and an increased likelihood of long-term body pain. ⁽¹⁵⁾ Many women on dialysis for kidney failure may suffer sexual problems, according to a new observational study from Italy. highly frequent condition of female sexual dysfunction in women on dialysis; this deserves attention and further study. ⁽¹⁶⁾

The lack of routine depression screening among the hemodialysis (HD) population may contribute to depression being under-recognized. While screening patients could be beneficial, the optimum screening procedure remains unclear. One method would be to screen HD patients while they receive their treatment. ⁽¹⁷⁾

The best treatment for depression in dialysis patients is unknown. However, treatment may lead to improved rates of depression and may improve overall outcomes in a population with exceedingly low survival. Further research is needed to assess the effects of treating depressive symptoms and cognitive performance in dialysis patients.⁽¹⁸⁾

2. AIM AND OBJECTIVES

AIM:-
To study the prevalence of depression and cognitive function impairment in patients undergoing hemodialysis.

OBJECTIVES:-
A) Primary objectives:-
1) To assess occurrence of depression in patients undergoing hemodialysis.
2) To assess occurrence of cognitive function impairment in patients undergoing hemodialysis.
B) Secondary Objectives:-
1) To identify the complications after hemodialysis.
2) To evaluate relationship between depression and cognitive function impairment in patients undergoing hemodialysis.
3) To identify causes of End Stage Renal Disease (ESRD) in patients undergoing hemodialysis.
4) To compare depression rate in patients CKD stage (1 to 3) without hemodialysis and CKD stage (4 to 5) with hemodialysis.

4. METHODOLOGY

4.1) Study design & Study site:-
An observational study performed on 60 patients with CKD stage IV and V undergoing hemodialysis two or three times in a week and CKD stage I to III without hemodialysis at HCG Medisurge Hospital, Ahmedabad and L.J. Haria Rotary Hospital, Vapi between January to April 2012.

4.2) Patient Data collection:-
Sociodemographic and clinical data, including a review of medical records collected for all patients enrolled in the study. The data collection had been done by using Case Report Form (CRF) as shown in appendix -1. The CRF had been designed to provide detailed information such as name, age, sex, blood pressure, family history duration of dialysis, complications and co morbid diseases. It also includes record of biochemical parameters such as serum creatinine, BUN, Serum electrolytes, CBC report, and other reports whichever were available.

4.3) Inclusion criteria:-

Age between 18-65 years old.
Patients undergoing hemodialysis for at least 3 months.
Patient willing to provide informed consent.
Patient having chronic co-morbid condition like cardiovascular disorder, kidney stone, and diabetes- mellitus can also be enrolled.

4.4) Exclusion criteria:-

Female subjects who are pregnant.
Patients having a history of psychiatric disorder or cognitive function impairment prior to start of hemodialysis.
Patients participating in any other clinical study.
Patients unable to read and write.
Patients having terminal condition like cancer or any other diseases leading to impaired CNS function.

4.5) Withdrawal of participation from study:-

Subjects may voluntarily withdraw consent at any time for any reason.
If investigator considers patient unfit for continuous in the study.
If the subject is discharged from the hospital and transferred to another facility or hospital for further treatment.

4.6) Instruments used for assessment of Depression and Cognitive function:-
4.6.1) Depression screening performed by using the Center for Epidemiological Studies Depression Scale (CES-D). The CES-D is a validated self-reporting Questionnaire composed of 20 questions and maximum score is 60. If CES-D score is 16 or higher indicates patients suffering from depressive symptoms.⁽⁵⁷⁾

4.6.2) Mini mental state examination (MMSE) which is used to systematically asses mental status. It is based on 11 questions that test five areas of cognitive function. The five sections of the test are divided as follows: orientation, registration, attention and calculation. The maximum score is 30 and if a score is 23 or lower, it indicates cognitive impairment.⁽⁵⁸⁾

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4.7) Data Analysis:-
All data was analyzed by using software such as MS excel, prism graph pad version 5.0. Similarly, Characteristics of participants with and without depression were also compared. Correlation coefficient was used to evaluate the correlation between depressive symptoms and cognitive performance with cognitive outcomes being the raw scores on cognitive tests.

4.8) Ethics:-
The study was performed in accordance with the ethical standards of the ICMR and Good Clinical Practice guidelines. Approval for study had been obtained from the human ethics committee at the HCG Medisurge Hospital. All the patients received verbal and written information and they had been obtained informed consent before their inclusion in the study.

7. CONCLUSION

From the present study, it can be concluded that there is a high prevalence of depression in ESRD patients receiving hemodialysis, particularly those taking it for a longer duration.
In our study population, diabetes and hypertension were the more common causes of ESRD. Expectedly, the prevalence of depression was higher in the 50–60 age group and was found to be positively correlated with age in general.
It was found that patients with higher depression scores had poor cognitive function particularly in attention, listening and answering, when compared to non-depressed patients (CES-D<16). This data suggests a mild positive correlation between cognitive function and depression.

Future studies with greater number of patients are required to determine the relationship between depression and cognitive function in patients undergoing hemodialysis which would help in ascertaining the role of pharmacological therapy. Additionally, neuroimaging studies may be done to explore the etiology of concurrent depression and cognitive function impairment.

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