HIDDEN IN PLAIN SIGHT: PSYCHOLOGICAL DISTRESS AND SYMPTOM BURDEN IN CHRONIC HEMODIALYSIS PATIENTS IN PARAGUAY

Chronic kidney disease patients on maintenance hemodialysis (HD) often endure a high burden of physical symptoms and impaired quality of life, which contributes to significant psychological distress[1]. These patients commonly experience numerous dialysis-related symptoms (e.g. pain, fatigue, pruritus) that substantially affect daily functioning[2]. It is well recognized that anxiety and depression are prevalent in the end-stage renal disease (ESRD) population, far higher than in the general public. Meta-analyses indicate that roughly one-third of HD patients have depressive symptoms on average[3], although reported prevalence rates vary widely across studies. For instance, some cross-sectional studies have found extraordinarily high depression rates, with up to 83% of HD patients exhibiting depressive symptoms[4], whereas other cohorts report much lower prevalence on the order of 20–25%[5]. One multicenter Saudi Arabian study found that about half of patients on HD had at least mild to moderate depression[6]. Anxiety symptoms are similarly common in this population: in a single-center analysis, 56% of HD patients had an anxiety disorder diagnosis[7], though another study observed clinically significant anxiety in roughly 20–40% of cases[5]. Co-morbidity of anxiety and depression is frequent, with about one-quarter of patients in some samples experiencing both conditions simultaneously[7]. Discrepancies in prevalence estimates stem from differences in assessment tools (clinical interviews vs. questionnaires) and patient sociocultural contexts. Nevertheless, the overall evidence underscores that a large proportion of HD patients suffer from psychological distress.

Certain demographic and clinical factors have been associated with elevated psychological burden in dialysis populations. In some studies, depression has been reported as more prevalent among male HD patients[8], although more commonly female sex is identified as a risk factor for anxiety and depression[9]. Older age has shown significant association with higher depression scores in dialysis patients[9], while younger patients may experience different stressors. Low education level, unemployment, and low income have also been linked to worse depression scores in this population[10]. Importantly, many somatic symptoms of ESRD (such as fatigue, sleep disturbance, and pain) overlap with or contribute to depressive symptomatology[11]. This overlap often leads to under-recognition of depression by healthcare providers, as physical symptoms may be attributed solely to uremia or dialysis rather than to an underlying mood disorder[12]. Untreated anxiety and depression in dialysis patients are concerning because they are associated with poor outcomes, including reduced treatment adherence, higher hospitalization rates, and impaired functional status[13]. In fact, depression has been identified as an independent risk factor for increased mortality in maintenance dialysis patients[14]. Given this impact, there is a compelling need to routinely screen and manage psychological conditions in the dialysis unit setting.

The present study aims to examine the prevalence of anxiety and depression in a cohort of maintenance hemodialysis patients and to evaluate their association with patients’ symptom burden. We used the Hospital Anxiety and Depression Scale (HADS) to assess psychological distress and the Dialysis Symptom Index (DSI) to quantify the burden of common dialysis-related symptoms. We hypothesized that rates of anxiety and depression would be high in our HD population and that greater symptom burden would correlate with more severe anxiety/depression. Our findings highlight the importance of an integrated approach to dialysis care that addresses both physical symptoms and mental health.

Study Design and Participants: We conducted a cross-sectional observational study of adult patients receiving maintenance hemodialysis at a single center. Inclusion criteria were age ≥18, ESRD on HD for at least 3 months, and ability to provide informed consent. Patients with acute psychiatric emergencies or cognitive impairment precluding questionnaire completion were excluded. A total of 37 patients were enrolled (after excluding those who did not meet criteria or declined participation). This sample size represents the dialysis unit census during the study period (year 2025).

Assessments: Demographic and clinical data were obtained from medical records and patient interviews, including age, sex, dialysis vintage (time on HD in months), and comorbidities. Comorbidity burden was quantified using the Charlson Comorbidity Index. Each participant completed the Hospital Anxiety and Depression Scale (HADS) – a 14-item self-report questionnaire designed to screen for anxiety (7 items) and depression (7 items) in medically ill patients. HADS yields an Anxiety subscale score (HADS-A) and Depression subscale score (HADS-D), each ranging from 0 to 21 (higher scores indicate greater symptomatology). We applied standard cut-offs for HADS scores: 0–7 = normal, 8–10 = borderline, ≥11 = clinically significant case. Anxiety or depression “caseness” was defined as a subscale score ≥11 on HADS, consistent with probable disorder.

Symptom burden was measured using the Dialysis Symptom Index (DSI), which assesses the presence and severity of 30 common symptoms experienced by dialysis patients[15]. The DSI asks patients to rate whether they have experienced each symptom in the past week and, if so, how bothersome it is, typically on a Likert scale. For this study, we used the total number of symptoms endorsed (DSI symptom count) and the DSI total score (sum of severity ratings) as measures of overall symptom burden. The DSI is a validated instrument in the dialysis population[15], capturing a broad range of physical and emotional symptoms related to ESRD and its treatment.

Procedure: After obtaining written informed consent, patients were administered the HADS and DSI questionnaires during their routine dialysis sessions (either self-completed or via interviewer for those with visual or literacy limitations). Clinical and laboratory data were recorded from charts. The study followed the principles of the Declaration of Helsinki and was approved by the local institutional ethics committee.

Statistical Analysis: We summarized patient characteristics using mean ± standard deviation (SD) or median (range) for continuous variables and proportions for categorical variables. Prevalence of anxiety and depression was calculated as the percentage of patients with HADS-A and HADS-D scores ≥8 (borderline or above) and ≥11 (clinical case). We evaluated correlations between HADS scores and DSI scores using Pearson’s correlation coefficient. Group comparisons (e.g. by sex or median split of symptom burden) were performed with t-tests or nonparametric equivalents as appropriate. A two-sided p<0.05 was considered statistically significant. Data analysis was conducted with Python’s pandas and SciPy libraries.

A total of 37 HD patients were analyzed. The mean age was 53.2 ± 15.3 years (median 57, range 20–81 years), and 62% were male. The median dialysis vintage was 59 months (approximately 5 years on HD), with a range from 4 to 126 months. Comorbidity burden was moderate: the median Charlson Comorbidity Index was 2 (range 2–4). Table 1 summarizes the demographic and clinical characteristics of the sample. Notably, the cohort was relatively evenly distributed in middle and older age groups, and all patients had at least one or more comorbid conditions (the Charlson index minimum was 2 by design, given ESRD is a major comorbidity itself).

Table 1. Patient Baseline Characteristics

All patients were receiving thrice-weekly in-center HD. The most common comorbid illnesses were hypertension (in 81% of patients) and diabetes mellitus (54%), reflecting typical ESRD demographics. There was one patient with missing sex designation in records (treated as unspecified sex in analysis). No significant differences in age or comorbidity were observed between male and female patients.Self-reported anxiety and depression symptoms were highly prevalent in this cohort. The mean HADS-Anxiety (HADS-A) score was 13.1 ± 4.3, and the mean HADS-Depression (HADS-D) score was 11.5 ± 3.4 (Table 2). The majority of patients scored above the conventional cut-off for clinically significant psychological symptoms: 30 out of 37 patients (81.1%) had HADS-A ≥11, indicating significant anxiety, and 29 patients (78.4%) had HADS-D ≥11, indicating significant depression. Even using a more inclusive threshold (HADS ≥8 points), fully 94.6% of the sample had at least borderline abnormal anxiety and the same percentage (94.6%) had at least borderline depressive symptoms. In practical terms, almost every patient reported experiencing some degree of anxiety or depressive mood, and roughly four in five met criteria for probable clinical anxiety or depression. Figure 1 illustrates the distribution of overall psychological distress (HADS total scores) in relation to symptom burden.

Table 2. Psychological Symptom Scores and Dialysis Symptom Burden

As shown in Table 2, the median anxiety score was 14, well above the clinical threshold, and the median depression score was 12. Out of 37 patients, only two patients had HADS scores in the normal range for both anxiety and depression; all others had at least borderline or higher symptom levels. When examining overlap, 28 patients (75.7%) met criteria for both significant anxiety and depression concurrently. Only one patient had high depression without high anxiety, and two had high anxiety without high depression – underscoring that these conditions largely co-occurred in this group. There were no statistically significant differences in mean HADS scores by sex, although females showed a trend toward higher anxiety scores than males (mean HADS-A 15.2 vs 12.5) in our sample. Older patients (age >60) had slightly higher depression scores on average than younger patients, but the difference did not reach significance in this modest sample (median HADS-D 13 vs 11, p=0.18).

Patients reported a wide range of physical and emotional symptoms on the Dialysis Symptom Index. The mean number of symptoms endorsed was 12.8 (out of 30), with a median of 13 symptoms per patient. The total DSI severity score (which sums the ratings for all symptoms, maximum possible 150) averaged 30.2 ± 15.2. This indicates a substantial symptom burden in general, although there was broad variability between individuals (the total symptom count ranged from 0 symptoms in one patient to 28 symptoms in the most symptomatic patient). The most commonly reported symptoms (present in >50% of patients) included fatigue (reported by 86% of patients), dry skin/itching (76%), muscle cramps (68%), poor appetite (65%), and trouble sleeping (62%). Notably, symptoms such as anxiety and depressed mood were also queried in the DSI and were reported by 60% and 57% of patients, respectively, aligning with the HADS findings. In patients with clinically significant depression (HADS-D ≥11), the DSI symptom count was higher (mean 15 symptoms) compared to those with lower depression scores (mean 7 symptoms), reflecting a greater symptom burden among the depressed group. A similar pattern was observed for anxiety.

There was a strong positive correlation between the total number of dialysis symptoms and the severity of anxiety/depression. The Pearson correlation between DSI total score and HADS total score was r = 0.65 (p<0.001). In particular, higher DSI scores were moderately correlated with higher HADS-Anxiety scores (r = 0.68) and with higher HADS-Depression scores (r = 0.55). Figure 1 displays a scatter plot of the relationship between overall HADS psychological distress scores and DSI symptom burden scores. Patients with low symptom burden (toward the left of the graph) tended to have lower anxiety/depression scores, whereas those reporting many or severe symptoms showed correspondingly higher HADS scores. This correlation suggests that patients who feel worse physically are also more likely to experience emotional distress.

Beyond simple correlation, we examined specific symptoms in relation to mood scores. Notably, fatigue/energy loss was nearly ubiquitous among patients with depression – consistent with fatigue being one of the most common symptoms associated with depression in CKD[16]. Patients who reported pruritus (itching), another frequent uremic symptom, had significantly higher mean HADS-D scores than those without itching (13.0 vs 9.8, p=0.01), aligning with recent findings that severe pruritus is an independent predictor of depressive symptoms in HD patients[17]. Similarly, those with severe sleep difficulties tended to have higher anxiety scores, though this did not reach statistical significance in our sample. These observations reinforce the interplay between physical symptom severity and psychological well-being in dialysis patients.

Our study demonstrates that the vast majority of patients on maintenance hemodialysis in our unit experience significant symptoms of anxiety and depression, and that greater dialysis symptom burden is strongly correlated with worse psychological distress. These results shine a spotlight on the often underappreciated mental health challenges faced by ESRD patients. Routine screening and timely intervention for anxiety and depression in dialysis settings are imperative. Multidisciplinary efforts – including optimal symptom management, psychosocial support, and possibly psychiatric treatment – should be integrated into standard nephrology care to improve patients’ overall well-being. Addressing mental health is not only vital for quality of life, but it may also enhance clinical outcomes such as adherence and survival in this vulnerable population. Dialysis providers and caregivers must remain vigilant to patients’ emotional needs and facilitate access to mental health services. Our findings add to the call for holistic care in nephrology: treat the kidney, but also treat the mind. Future research with larger samples should explore interventions to reduce symptom burden and psychological distress, and determine if such interventions can indeed translate into better long-term outcomes for dialysis patients. Early identification and management of psychological distress in ESRD will ultimately contribute to more humanistic and effective care for those on dialysis.