Pendekatan Interdisipliner pasien Dialisis Pengambilan Keputusan pada Pasien CKD Dengan Depresi

1. An Interdisciplinary Approach to Dialysis
Decision-Making in the CKD Patient With Depression
Jane O. Schell, Renee Bova-Collis, and Nwamaka D. Eneanya
Depression and depressive symptoms are common in advanced kidney disease and are associated with poor outcomes. For
those with CKD not on dialysis, depression may influence how patients cope and prepare for their disease and its management,
including decisions about dialysis treatment. Patient self-reported scales exist to better identify depression; how to incorporate
these scales into clinical practice and assist with treatment decision-making is less clear. We present a case-based discussion of
depressive symptoms in patients with advanced kidney disease not on dialysis. We highlight the contribution of underlying so-
matic and psychosocial factors in the assessment and management of depression. We further define the role of the interdisci-
plinary care team, including palliative care and hospice medicine, to assist with symptom management and end-of-life care for
CKD patients with depression.
Q 2014 by the National Kidney Foundation, Inc. All rights reserved.
Key Words: Chronic kidney disease, Depression, Interdisciplinary team, Palliative care, End of life
Case
J.K. is a 68-year-old man with Stage 3B CKD attrib-
uted to longstanding diabetes and hypertension.
Kidney replacement options were discussed in the
past, and he had planned to prepare for dialysis
when the time came. Two months ago, he suffered
critical ischemia of the left foot resulting in amputa-
tion. During his hospitalization, his serum creatinine
worsened to 3.4. mg/dL and an estimated glomerular
filtration rate (eGFR) of 16 mL/minute. He is less
interactive than usual. His daughter shares her
concern that J.K. has been more withdrawn and
less interested in activities he previously enjoyed
for the past 6 weeks. He describes his appetite as
poor and has lost 20 lb since his hospitalization.
When the nephrologist asks J.K. his thoughts on
preparation for dialysis, J.K. responds, “Is dialysis
really worth it?”
Introduction
Depression is common in CKD, and it may hinder how
patients view and plan for their kidney disease manage-
ment. Depressed patients with kidney disease are at risk
for making poor decisions, which can potentially lead to
worsening symptoms, reduced life satisfaction, and poor
physical health.1
Depression can affect how dialysis de-
cisions are made and has been associated with increased
withdrawal from treatment.2
Patients faced with dialysis
decisions and for whom depression is suspected warrant
comprehensive assessment and management of depres-
sion before decisions about dialysis can be made.
The diagnosis of depression can be challenging. These
patients experience a high burden of somatic and psycho-
logical symptoms associated with advanced kidney dis-
ease that may overlap with those of depression.3-5
Somatic symptoms include fatigue, decreased mood,
and sleep disorders, to name a few.6,7
These same
symptoms may also result from progression of coexisting
conditions such as end organ failure (eg, lung, heart
disease) or general functional decline (eg, dementia,
frailty).8
The kidney care team is tasked with determining
whether these symptoms are a result of progressive end or-
gan illness or are due to depression. Understanding the
underlying cause of the symptoms can better guide assess-
ment and management (Fig. 1).
When depression is suspected, the kidney care team
must adopt a comprehensive care approach with resources
to screen for depression, provide support to patients and
families, and refer the patient to appropriate services
including mental health and palliative care. The initial
step in the evaluation of a patient suspected of depressive
symptoms involves exploring and attending to the pa-
tient's concerns and perceptions. Through exploration of
patient concerns and perceptions, members of the kidney
care team gain an understanding of the somatic and psy-
chosocial factors that may be contributing to depression.
In certain patients who are declining from advanced kid-
ney disease or coexisting conditions, dialysis may not be
elected even with treatment of depression.9,10
In these
instances, the hoped-for benefits of dialysis are out-
weighed by the potential burdens that accompany the
treatment. Conservative management with palliative
care can provide care with a focus on symptom control
and quality of life.
Depression in CKD
For a diagnosis of depression, low mood or anhedonia
(lack of pleasure in activities) must also be present in
From Renal-Electrolyte Division, Section of Palliative Care and Medical
Ethics, University of Pittsburgh School of Medicine, University of Pittsburgh
Medical Center, Pittsburgh, PA; Mid-Atlantic Renal Coalition, Richmond,
VA; and Division of Nephrology, Massachusetts General Hospital, Harvard
Medical School, Boston, MA.
Financial Disclosure: The authors declare that they have no relevant finan-
cial interests.
Address correspondence to Jane O. Schell, MD, Division of Renal-
Electrolyte, Section of Palliative Care and Medical Ethics, University of Pitts-
burgh School of Medicine, UPMC Montefiore Suite 933W, 200 Lothrop Street,
Pittsburgh, PA 15213. E-mail: schelljo@upmc.edu
Ó 2014 by the National Kidney Foundation, Inc. All rights reserved.
1548-5595/$36.00
http://dx.doi.org/10.1053/j.ackd.2014.03.012
Advances in Chronic Kidney Disease, Vol 21, No 4 (July), 2014: pp 385-391 385

2. addition to the associated symptoms. A major depressive
episode (MDE) requires that 5 of 9 symptoms be present
during the same 2-week period (Table 1).11
Less severe
forms of depression exist and deserve attention because
they can lead to major depression and contribute to
morbidity.
Depression is common in patients with CKD, with rates 4
times that of the general population.12
Approximately 1 in
5 patients with CKD can experience a MDE before initia-
tion of dialysis.13
Most studies have focused on depression
in patients on dialysis; however, increasing data suggest
that the prevalence is similar in CKD patients not on dial-
ysis. The point prevalence of depression and depressive
symptoms in kidney disease varies between 15% and
50%.14,15
In a recent meta-analysis, this variability in
depression depended on the population studied, the stage
of CKD, and the methods used to assess depression, specif-
ically self-rating vs structured interview,16
However when
assessed using a structured clinical interview, Hedayati
and colleagues found that 1 in 5 patients with CKD had
depression, suggesting that the actual rates of depression
are high.15
In patients on long-term dialysis, depression has been
associated with adverse out-
comes such as nonadherence,
increased hospitalization and
health-care utilization, and
all-cause death.13,17-20
Within
the CKD population not on
dialysis, the rate of de-
pression and its implica-
tions on health outcomes
are similar. In a Taiwanese
cohort, the presence of high
depressive symptoms, as
determined by self-reported
surveys, was associated with
an increased risk of progres-
sion to ESRD or death and
first hospitalization.21
Whether the high depressive symp-
toms are causative or merely represent a marker for overall
clinical decline is less clear. However, the results remained
significant after adjustment for comorbidities, suggesting
an independent association of depression with poor out-
comes. Within this cohort, high depressive symptoms
were also linked to kidney function decline. In the Chronic
Renal Insufficiency Cohort (CRIC) study and the
Hispanic-CRIC study, lower levels of kidney function and
higher levels of albuminuria were associated independently
with higher odds of elevated depressive symptoms.22
For
every 10-mL/min decrease in eGFR, the odds of elevated
depressive symptoms increased by 10%.
It is important to note that depression has been associ-
ated with poor outcomes at the time of dialysis initiation.
Heyadati and colleagues examined the association of
MDE using physician interview and outcomes in a Veter-
ans' Administration CKD cohort.13
Patients with CKD
and MDE had almost twice the risk of being hospitalized
and 3 times the risk of dialysis initiation within 1 year
compared with those without MDE. This association
remained significant after adjustment for comorbidities
and risk factors. These results underscore the need for ac-
curate assessment and treatment of depression in
advanced kidney disease, especially in those starting dial-
ysis.
Risk factors for depression in CKD patients include fe-
male sex, presence of diabetes, underlying psychiatric
illness, and alcohol or substance abuse.21,23
In the
CRIC and Hispanic-CRIC study, compared with non-
Hispanic Whites, non-Hispanic Blacks and Hispanics
had 1.5-fold greater odds of elevated depressive symp-
toms and had at least 50% lower odds of antidepressant
use.16
Depression Evaluation and the Role of the Social
Worker
The nephrologist becomes concerned that J.K. may
be suffering from depression. J.K. denies having
a prior diagnosis of depression or depressive
disorder in the past. His daughter describes her
father as a “go-getter” and someone who especi-
ally enjoyed visiting
with his family and
grandchildren. Lately,
he has preferred to
stay at home and
avoids social gather-
ings. The nephrologist
asks the patient and
his daughter to meet
with the clinic social
worker. The patient
scores 13 out of 21 on
the Beck Depression
Index (BDI), support-
ing a diagnosis of
MDE. J.K. is referred to mental health for further
assessment and management.
For the kidney provider who suspects depression, open
communication and access to interdisciplinary resources
are key components to appropriate management. Mem-
bers of the kidney care team, in particular social workers,
have a unique role in the care of the CKD patients with
depression. Patients with kidney disease often must adjust
to and cope with living with chronic illness and the effect it
has on their experience.24
This process of adaptation af-
fects multiple components of a patient's life, including
one's identity, independence, and support.25
Acute
stressors and poor support have also been associated
with psychological outcomes such as depression.26
Mem-
bers of the kidney care team can provide support, educa-
tion, and resources to counter and respond to these
needs, thereby helping patients and family members better
adjust and prepare for their disease trajectory. In partic-
ular, the masters-prepared social worker has demon-
strated competencies in counseling as well as behavioral
and social systems knowledge that can be applied to offer
CLINICAL SUMMARY
The prevalence of depression in CKD patients is
approximately 20%.
Depression can affect how patients make decisions about
dialysis.
The kidney care team can use self-reported scales to iden-
tify and manage CKD patients with depression.
Palliative care can assist the kidney care team with the
management of depression, address treatment decision-
making, and outline advance care planning in patients
with CKD and depression.
Schell et al386

3. support, assistance in care decisions, and evaluation of
symptoms.
Screening Tools
The gold standard diagnosis of depression requires a
clinical interview performed by trained mental health
professionals. For the kidney care team, the use
of self-reported screening tools has been studied and
validated in the kidney disease population. The diag-
nosis is confirmed using a structured interview per-
formed by a member of the kidney care team or, if
necessary, by a mental health professional, especially if
there are concerns for suicidal ideation or other psychi-
atric illnesses.
The use of self-reported tools has been validated in the
dialysis and CKD population. In the dialysis population,
Watnik and colleagues measured depression in a dialysis
population using the 21-item BDI and the Patient Health
Questionnaire-9 compared with the gold standard struc-
tured clinical interview.27
Twenty-six percent of the
cohort was diagnosed with a depressive disorder. The
cutoff score for depression using the BDI was 14 to 16
for ESRD patients compared with 10 for the general pop-
ulation. The increased cutoff was attributed to the
increased number of somatic symptoms experienced by
patients on dialysis independent of depressive symp-
toms. Both self-reported tools performed well as
screening tools with sensitivities of 91% and 92% and
specificities of 86% and 92% for the BDI and Patient
Health Questionnaire-9, respectively.
In patients with CKD not on dialysis, Hedayati and
colleagues investigated the BDI and the 16 Quick Inven-
tory Depressive Symptoms Scale of Self-Report (QID-
SR16) against the gold standard clinical interview in
272 patients with a mean eGFR of 31.4 mL/minute.28
The best diagnostic accuracy for each measure was a
cutoff score of 11 for the BDI and 10 for the QID-SR16,
with sensitivities of 89% and 91% and specificities of
88% and 88%, respectively. The positive and negative
likelihood ratios for the cutoff scores were 7.6 and 0.1,
respectively, for BDI and 7.5 and 0.1, respectively, for
QID-SR16. These results suggest that either the BDI or
QID-SR16 can be used reliably as a screening tool for
depression.
Table 1. DSM-5 Criteria for Major Depressive Episode11
Low mood or anhedonia plus $5 of 9 of the following symp-
toms in the same 2-wk period must be present:
1. Depressed mood
2. Loss of interest or pleasure
3. Appetite disturbance
4. Sleep disturbance
5. Psychomotor agitation or retardation
6. Fatigue or tiredness
7. Worthlessness, feeling like a burden, or guilty
8. Difficulty concentrating
9. Recurring thoughts of death or suicide
DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition.
Figure 1. Influence of somatic and psychosocial symptoms and depression on outcomes in CKD.
Depression in CKD 387

4. Treatment
Treatment for depression may include pharmacologic and
nonpharmacologic options that can be tailored based on
the individual patient's needs and the resources available
to the kidney care team. The use of pharmacologic treat-
ment has not been clearly supported in the literature,
and their use can be associated with adverse complications
for patients with advanced kidney disease.23,29
On the basis
of the limited studies performed in patients with kidney
disease, selective serotonin reuptake inhibitors are
thought to be relatively safe with advanced CKD with
fewer side effects.30,31
If medications are started, then
they must be dosed for kidney impairment and
monitored closely for the occurrence of side effects.
Given the limited efficacy and potential harm associated
with pharmacologic treatments, nonpharmacologic inter-
ventions have been explored with promising results.
Most data come from studies of patients with depression
undergoing dialysis. For example, alterations in dialysis
treatment regimens have been associated with improve-
ment in depressive symptoms and postdialysis recovery
time.32
Cognitive behavioral therapy, an interactive ther-
apy that incorporates techniques that reinforce logical
thinking and refocuses negative thoughts and behaviors,
has been associated with improved depression scores. A
recent study of cognitive behavioral therapy administered
to patients undergoing hemodialysis was associated with
statistically significant reductions in depression scores,
improved quality of life, and decreased interdialytic
weight gain compared with the wait-list control group.33
In addition, appropriate assessment and management of
symptoms such as pain and anxiety may also indirectly
improve depressive symptoms.
Approach to the Management of Depression in CKD
Despite data suggesting a high prevalence of depression,
only a small percentage of patients receive treatment.22,34
These treatment patterns reflect a lack of clinical
guidelines and practice patterns for depression
management in advanced kidney disease. In the dialysis
population, experts recommend routine screening given
the high prevalence of depression and its effect on
patient outcomes.35,36
A previously published algorithm
in patients with kidney disease provides a patient-
centered approach to depression management that is
based on screening results and associated symptoms.35
The kidney care team can then devise a treatment plan
tailored to the unique experience and needs of the patient.
Patients should ideally have symptoms reassessed period-
ically for evidence of a successful treatment plan and
improved depressive symptoms. Data suggest that the
timing and rate of improvements after initiation of an anti-
depressant can vary with some patients, demonstrating ev-
idence of improvement within 1 week of treatment.37,38
Treatment of depressive symptoms may not affect the
overall disease trajectory in patients who are experiencing
decline either due to advanced kidney disease or
coexisting conditions. It is reasonable to discuss the overall
goals of care and whether dialysis would meaningfully
provide benefit.
Dialysis Decision-Making, Symptom
Management, and the Role of Palliative Care
J.K. was diagnosed with depression and started on
an antidepressant. The interdisciplinary team fol-
lowed the patient's progress closely. After 3 months,
J.K. became more interactive and his appetite
improved. However, his clinical status worsened
with 2 subsequent hospitalizations for infection and
pain related to his amputated foot. He had been
living on and off in a skilled nursing home and
requiring assistance with activities of daily living.
The clinic social worker alongside the kidney care
team discussed whether or not to prepare for dialysis
given his clinical status and treatment for depression.
During a family meeting, J.K. outlined his goals of
living independently and not being dependent on
others. He shared his worries that these goals are
less likely to occur and that he is declining. When
the social worker asked about the kinds of care J.K.
wished to avoid, he shared a desire not to go back
to the hospital even if that meant he would not
receive life-prolonging therapies. He ultimately elec-
ted not to start dialysis and instead favored conserva-
tive management with a focus on comfort and
symptoms.
Palliative care is an interdisciplinary care team made up
of physicians, nurses and nurse aids, chaplains, and social
workers with the goal of addressing patients with needs.
These services include symptom management, psychoso-
cial support, communication and advance care planning,
treatment decision-making, and hospice and bereavement
services (Table 2).39,40
Palliative care is person- and family-
centered care that optimizes quality of life by anticipating,
preventing, and treating suffering.41
Palliative care meets
the needs of a patient at different points of the disease tra-
jectory with the flexibility to respond to unexpected or
acute changes in health status.
Table 2. Palliative Care Services for the Declining Patient With CKD
Symptom management:
Escalating/refractory symptoms (ie, pain, nausea, pruritus)
Complex pharmacologic regimens
Psychological distress and illness (ie, depression, insomnia,
anxiety, grief)
Psychosocial support:
Family/caregiver support
Communication and advance care planning:
Prognostic discussions
Living will completion and health-care proxy designation
Reassessment of goals of care
Transitions of care and shared decision-making:
Initiation of time-limited trial of renal replacement therapy
Withdrawal of renal replacement therapy
Conservative management (“No dialysis” treatment option)
Hospice education and referral
Bereavement support
Schell et al388

5. Treatment Decision-Making
Many patients with advanced kidney disease have under-
lying comorbidities and functional impairments that limit
the hoped-for benefits of dialysis. Often the potential ben-
efits of dialysis come at the risk of increased interface with
the health-care system, such as travel time to dialysis, pro-
cedures to maintain dialysis access, and unanticipated
hospitalizations.42,43
To better guide decision-making, it
is helpful for the kidney care team members to gain a sense
of the patient's overall goals and values to determine if
dialysis aligns with these goals and values.44
For some pa-
tients, with adequate treatment of depression, dialysis falls
short of achieving important patient goals, such as living
independently or the ability to enjoy certain activities,
and it may encourage outcomes wished to be avoided,
such as hospitalization or living in a skilled nursing facil-
ity. Palliative care can assist with goals-of-care discussions,
especially when prognostic uncertainty or concerns about
the patient's treatment preferences exist.
A communication framework using open-ended ques-
tions to explore and understand these big-picture goals
and values can better guide treatment decision-making
discussions (Table 2). By gaining an understanding of a pa-
tient's hopes and concerns for the future, the kidney pro-
vider has a better sense of whether dialysis will
meaningfully assist with these goals. These conversations
are emotion-provoking often bringing up feared topics
such as prognosis and uncertainty. Similar to the skills pro-
viders use to elicit relevant medical data, specific skills are
necessary to respond to and explore emotional data. The
NURSE acronym (Name the emotion, Understand
the emotion, Respect the patient, Support the patient,
Explore the emotion) is a helpful communication tool
for responding to emotion (Table 3).45
Responding to pa-
tient emotion assists with coping and builds trust.46
The life expectancy for patients with many comorbidities
is often limited whether or not dialysis is elected. By dis-
cussing patients' overall goals and values, the kidney
care team has the opportunity to engage in timely discus-
sions of advance care planning to outline care preferences
at end of life.47
Data suggest patients want to discuss these
topics and that the care provider initiate these discus-
sions.48-50
Patients who have had timely discussions of
end of life are more likely to receive care consistent with
their care preferences, and family members are less likely
to suffer psychological distress after their loved one's
death.51
Symptom Management
Early integration of palliative care with standard clinical
practice has been associated with clinical benefits.52
Temel
and colleagues demonstrated that integration of palliative
care with standard oncologic care (as opposed to standard
oncologic care alone) resulted in higher quality of life and
increased survival in patients with new diagnoses of met-
astatic non-small-cell lung cancer.53
Tailoring palliative
care to the needs of a patient throughout their disease spec-
trum remains a critical step in optimizing care for patients
with CKD. For these patients who are dying, depression
can significantly affect the quality of life by taking away
hope, sense of peace, and meaning.54
Untreated depres-
sion also makes the effective treatment of pain and other
symptoms more difficult.55
Because patients may be reluc-
tant to report depressive symptoms to medical personnel,
palliative care may assist with routine assessment for
depression and depressive symptoms over the kidney dis-
ease course.54
End of Life and Bereavement
Patients with kidney disease are less likely to use hospice
services at end of life.56
Instead, these patients experience
a high intensity of care at the end of life compared with
those with other life-limiting illnesses.57
Factors explaining
the underutilization of hospice include patient-level fac-
tors, nephrologist referral patterns, and hospice eligibility
in patients with kidney disease. However, timely hospice
referral can improve the end-of-life experience for patients
with kidney disease. Dialysis patients who receive hospice
are less like to receive intensive therapies at end of life and
more likely to die at home.56
Hospice can also assist with managing symptoms at
end of life in patients either on dialysis or managed conser-
vatively. Murtagh and colleagues measured symptom
prevalence and severity in the last month of life for
patients undergoing conservative management.58
Patients
Table 3. Communication Framework for Treatment Decision-Making Based on Patient Goals and Values43
Communication Tools Potential Communication Statements
Open-ended questions to explore goals and values:
Current experience “What has life been like these past months?”
Hopes for the future “When you think about the future, what is most important to you?”
“As we think about how to care for you, what kinds of things should we focus on?”
Concerns for the future “As you think about the future, what concerns do you have?”
“When it comes to the kinds of care you receive, are there situations you hope to
avoid (such as going to the hospital, undergoing CPR)?
Responding to emotion:
Name the emotion “I can see this has been difficult.”
Understand the emotion “This has been a tough time for you.”
Respect (praise) the patient “I can tell you’ve put a lot of thought into this decision.”
Support the patient “We will be here for you no matter what we decide today.”
Explore the emotion “Tell me what worries you most about not doing dialysis.”
CPR, cardiopulmonary resuscitation.
Depression in CKD 389

6. reported physical and psychological symptoms, including
feeling worried, sad, and nervous. It is important to note
that conservatively managed kidney patients experienced
higher overall symptom burden in the last month of life
compared with patients with advanced cancer in the last
month of life. These findings highlight the need for timely
hospice referral in this patient population.
Most end-of-life symptoms in kidney disease come from
patients and their families who have received and/or with-
drawn from dialysis. For instance, Cohen and colleagues
surveyed families of patients who were on dialysis within
6 to 10 weeks of their deaths.59
Most deaths took place in
institutions such as hospitals or nursing homes. Most fam-
ilies believed their loves ones had peaceful deaths. The
most common distressing symptom was pain; patients
had significantly less likelihood of having pain in the last
week of life if they died at home compared with those
who died in institutions. Likewise, Phillips and colleagues
investigated the effect of dialysis discontinuation on
families within 5 years of death.60
The main patient
symptoms reported by families during the last week of
life include confusion, agitation or restlessness, and/or
significant pain.
Conclusion
Patients with advanced CKD encounter significant symp-
toms throughout the kidney disease course. Physical and
psychological symptoms are prevalent and can negatively
affect clinical outcomes and patient experience. Depres-
sion is understudied in CKD patients; however, its pres-
ence is associated with poor outcomes and it affects
treatment decision-making. Depression can best be ad-
dressed through an interdisciplinary approach incorpo-
rating the skill sets of the kidney care team and referral
to services such as mental health and palliative care
when appropriate. Palliative care services can provide a
layer of support to provide assistance with treatment
decision-making, ongoing symptom assessment, and
management and care at the end of life.
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