Factors associated with depression in patients undergoing hemodialysis in a Peruvian hospital

Stress, anxiety, and depression have been correlated with increased morbidity and mortality across various illnesses. In this context, the healthcare system recognizes that chronic kidney disease (CKD), like other medical conditions, is linked to psychiatric disorders. CKD not only manifests physically but also emotionally, giving rise to negative affectivity, emotional discomfort, and a predisposition to experience adverse emotions such as disgust, anxiety, sadness, anger, guilt, fear, dissatisfaction with oneself, and a negative assessment of the situation. This symptomatology predicts a greater propensity for somatic complaints, the development of mental disorders, and other physical conditions. Anxiety and depression, in particular, are identified as factors that can accentuate and complicate the progression of the disease, interfering with both its treatment and the perception of symptoms (3).

Patients experiencing irreversible loss of kidney function, clinically termed chronic kidney failure (CKD) or chronic kidney disease (CKD), undergo notable alterations in various aspects of their lives, including the physical, biological, psychological, family, and social domains. Among these alterations, depressive and anxious symptoms stand out, emerging as responses to the crisis and part of the coping process against the disease and its treatments. Chronic renal failure is the primary reaction to the adversities arising from kidney disease and its treatments, scoring notably higher than the general population, as indicated by studies such as Pérez-Domínguez et al. (2012). This disorder not only impacts daily life but significantly affects the quality of life of those affected, revealing a substantial prevalence in this context.

Depression, closely linked to the appearance of feelings of loss experienced by many kidney failure patients, manifests as a response to the loss of autonomy, the deterioration of physical performance, and the alteration of family and work roles. Despite being the most common psychological problem among people with chronic kidney disease (CKD), the second psychological profile most associated with CKD is anxiety, serving as a warning response of the body in situations implying danger, threat, or novelty. However, when anxiety persists without the presence of danger or cannot be faced, it becomes pathological, distorting the patient's behavior and affecting their relationship with healthcare personnel, family, and even compliance with medical prescriptions. Moreover, experiencing either of these two psychological disorders in the early stages of CKD predicts a high risk of mortality in patients in more advanced stages of kidney disorder. Despite technological advances reducing mortality in CKD patients, the presence of depression and anxiety increases suicide risks (4).

Dialysis, a therapeutic procedure designed to remove toxic substances from the blood, is carried out through hemodialysis (HD). In this treatment, the patient's blood circulates through a machine that dialyses it, leading it from an artery to a dialysis filter where toxic substances diffuse into the dialysis fluid. The purified blood returns to the body through a channeled vein. HD, a process lasting around 4 hours, is performed two or three times a week. Additionally, this treatment involves daily intake of numerous medications and adherence to a diet restricted in liquids and foods. Patients undergoing this procedure often experience different levels of emotional disturbances, such as anxiety and depression, linked to organic symptoms, the limitations imposed by chronic kidney failure (CKD), and hemodialysis treatment. The intensity of these emotional reactions varies between patients, depending on how they cognitively evaluate the impact of kidney disease and HD on their living conditions, and is also related to individual abilities to adapt to the condition of dependence on the hemodialysis program.

An analytical case-control study was carried out at the Ramiro Prialé Prialé National Hospital, located in the city of Huancayo, during the year 2022. This study included patients over 18 years of age who attended the Nephrology service to receive treatment in the Hemodialysis Unit, all diagnosed with End Chronic Renal Disease (ESRD). Inclusion criteria were established that included patients who signed a complete informed consent, those diagnosed with terminal stage V CKD, who demonstrated lucidity and a good state of consciousness, and who were able to respond to a survey in person. Patients with Acute Kidney Injury (AKI), those without defined stage V chronic kidney disease, hospitalized patients, those who did not complete the survey or completed it incorrectly, as well as those who started hemodialysis treatment 2 months ago were excluded. The complete sample of patients with CKD of the corresponding stage was obtained from the Nephrology Unit, totaling 170 patients, with 85 cases and 85 controls. A case was defined as the patient with CKD on hemodialysis and the controls were patients with CKD but without hemodialysis. Main sociodemographic data were collected (age, sex), levels of depression (absence, mild, moderate, severe, extremely severe), educational level (elementary, secondary, university, technical, none), marital status (single, married, separated, divorced, widowed), employment status (worker, unemployed), pathological history (diabetes, high blood pressure), physical activity, sleep quality and duration of hemodialysis treatment (months, years). The study was carried out through observation, analysis and application of surveys using documentary instruments such as questionnaires and tests of depression, anxiety and stress scales (DASS-21). These instruments were approved by three specialist doctors from the Department of Nephrology and Psychiatry. Data were collected from the medical records, verifying the inclusion and exclusion criteria, assigning a patient code to each documentary instrument according to the clinical history. These codes were known only to the main authors of the study to maintain confidentiality as established in the informed consent provided to the patients. Data were analyzed using Excel and STATA V.17.0 software. Descriptive statistics were applied, measures of central tendency for numerical variables and absolute and relative frequencies for non-numeric variables, expressed in percentages. A bivariate analysis of the qualitative variables was carried out using the Chi Square test. In addition, it is planned to perform a multivariate analysis using logistic regression, with a 95% confidence interval and considering a p value <= 0.05 as statistically significant. In this case-control design, the corresponding Odds Ratio (OR) were calculated. The present study has the approval of the ethics committee of the Continental University and the Institutional Ethics committee of the Junín Social Security Network of EsSalud, obtaining its approval following the guidelines established by both committees in order to strictly respect the privacy of each patient because it is sensitive information and is protected by law.

An analytical case-control study was conducted at the Ramiro Prialé Prialé National Hospital in the city of Huancayo during the year 2022. The study focused on patients aged 18 and above who sought treatment at the Nephrology service in the Hemodialysis Unit, all of whom were diagnosed with End-Stage Chronic Renal Disease (ESRD). Inclusion criteria were defined to encompass patients who provided complete informed consent, those diagnosed with terminal stage V CKD, exhibiting lucidity and good consciousness, and capable of responding to an in-person survey. Exclusion criteria involved patients with Acute Kidney Injury (AKI), those without a defined stage V chronic kidney disease, hospitalized individuals, those who did not complete or incorrectly completed the survey, and those who initiated hemodialysis treatment two months ago. The complete sample of patients with CKD of the corresponding stage was derived from the Nephrology Unit, totaling 170 patients, with 85 cases and 85 controls. A case was identified as a patient with CKD on hemodialysis, while controls were patients with CKD but without hemodialysis.

Key sociodemographic data, including age, sex, levels of depression (ranging from absence to extremely severe), educational level (elementary, secondary, university, technical, none), marital status (single, married, separated, divorced, widowed), employment status (worker, unemployed), pathological history (diabetes, high blood pressure), physical activity, sleep quality, and duration of hemodialysis treatment (in months and years) were collected.

The study employed observation, analysis, and survey application, utilizing documentary instruments such as questionnaires and tests of depression, anxiety, and stress scales (DASS-21). These instruments were approved by three specialist doctors from the Department of Nephrology and Psychiatry. Data were extracted from medical records, ensuring adherence to inclusion and exclusion criteria, with each documentary instrument assigned a patient code according to the clinical history. These codes were known only to the main authors of the study to uphold confidentiality, as specified in the informed consent provided to the patients.

Data were analyzed using Excel and STATA V.17.0 software. Descriptive statistics, including measures of central tendency for numerical variables and absolute and relative frequencies for non-numeric variables expressed in percentages, were applied. A bivariate analysis of qualitative variables was conducted using the Chi Square test. Additionally, a planned multivariate analysis using logistic regression with a 95% confidence interval and considering a p-value <= 0.05 as statistically significant was outlined. In this case-control design, Odds Ratios (OR) were calculated.

The study received approval from the ethics committee of the Continental University and the Institutional Ethics committee of the Junín Social Security Network of EsSalud. Approval adhered to the guidelines established by both committees, ensuring strict respect for patient privacy due to the sensitivity of the information, protected by law.

 Table 1. Characteristics of HNRPP hemodialysis patients.

Education plays a fundamental role in the health-disease process, serving as a tool for individuals to comprehend the world around them. The study focused on a population primarily covered by the social system, with the majority having at least secondary education, enabling their entry into the workforce. In comparison to other studies, 81.2% of patients in this study had at least secondary education, a higher percentage than the 72.5% reported for patients on hemodialysis in industrialized countries (7).

Among the cases in the study, 53% exhibited depression, with 9.4% having mild depression, 27% moderate depression, 7% severe depression, and 9.4% extreme depression. In contrast, 16% of controls showed depression, with 8% having mild depression, 4% moderate, and 4% extreme. The study suggests that hemodialysis is a risk factor for depression. The overall population studied showed a depression prevalence of 41.7%, higher than the 27.7% reported in a study in Mexico (8).

Depression was diagnosed using the Hamilton Scale, categorizing it into various levels. The study revealed that physical activity was present in 55.3% of cases, while anxiety was found in 34.1% of patients, demonstrating a significant association with the presence of depression in the total population studied. The study also explored the impact of physical activity, anxiety, and depression on health-related quality of life in patients with end-stage renal disease (ESRD) undergoing hemodialysis treatment. The findings indicated that anxiety was present in 57.6% of cases and 34.1% of controls, with a significant association with depression. The absence of physical activity was associated with 44.7%, and its presence with 55.3%, reinforcing the link between physical activity, anxiety, and depression in CKD patients undergoing hemodialysis. These results align with previous studies emphasizing the importance of addressing mental health aspects in these patients (11).

Comparing findings with another study, the prevalence of depression in this study was 53%, which contrasts with the reported 22.5% in a previous study. Those diagnosed with depression in this study exhibited lower scores in quality of life, highlighting the impact on well-being. Additionally, depression was linked to lower albumin levels and higher parathormone levels (13).

The study also explored the relationship between sleep quality and depression in hemodialysis patients. It revealed that 53% of patients had depression related to poor sleep quality, showing a significant correlation. This result concurs with an earlier study where insomnia was prevalent in 82.14% of hemodialysis patients, and a positive correlation was found between Pittsburgh Test scores and anxiety and depression levels. This suggests a need to address sleep habits in the education of hemodialysis patients and improve the detection and specialized treatment of anxiety and depression (14).

In conclusion, the study identified significant associations between physical activity, sleep quality, anxiety, and stress with the presence of depression in hemodialysis patients. The multivariate model highlighted additional factors such as age, education level, marital status, and falling asleep as significant contributors to depression in this population. The findings underscore the importance of addressing mental health and sleep-related aspects in the care and education of hemodialysis patients.