Depression, anxiety and reduced quality of life in predialysis: differences across the CKD stages?

Abstract

Recently, we read with great interest the article by Lee et al. entitled ‘Association of depression and anxiety with reduced quality of life in patients with predialysis chronic kidney disease’ published in April 2013 in The International Journal of Clinical Practice 1. As the authors said, depression and anxiety were related to impaired quality of life (QOL), and the prevalence of anxiety and depression did not differ significantly across the chronic kidney disease (CKD) stages. However, the QOL between different stages in advanced CKD remain unclear in this article. Previous longitudinal studies showed that serum creatinine or estimated glomerular filtration rate (eGFR) was associated with QOL. The Modification in Diet in Renal Disease Study in a cohort of patients with moderate to severe CKD found decreased renal function was associated with psychological distress and impaired health-related QOL 2. Okubo's account of a 3-year follow-up study in Japan showed that the health-related QOL at stages 4–5 were significantly lower than at stages 1–2 3. Nevertheless, few cross-sectional studies measured QOL between different stages of moderate to advanced CKD although sufficient data are available to evaluate. Although psychological distress is a mirror of decreased QOL, the specific status of QOL is important for planning proper treatment strategies. So we suggest that QOL between different CKD stages should be mentioned in the study. The authors indicated that there were no association between depression or anxiety and the stages of CKD. However, patients with CKD face several challenges that increase the likelihood of developing anxiety or depression. As these challenges change with the decreasing renal function, the management may not invariable. These challenges include specific symptoms caused by CKD or the patient's treatment; diet prescription and water restriction; fear of disability, morbidity and shortened life span; worry about the burden on family and so on 4, 5. Theoretically, therapies for anxiety and depression include medications on CKD or specific symptoms caused by CKD; reduced-doses of anxiolytics and antidepressants adjusted by eGFR; proper psychological therapy and alternative medicine 5. Surprisingly, only few data exist on the effective and safety of these therapies. Further research may emphasise on how to improve depression and anxiety and enhance QOL in patients with different stages of CKD. Another considerable question is that the abbreviated version of the World Health Organization Quality of Life assessment instrument (WHOQOL-BREF) was used to assess the patients' subjective QOL. WHOQOL-BREF is a generic instrument and widely used in patients with CKD. However, the use of a disease-specific instrument along with the generic instrument selected in each case is recommended by the majority of experts. The specific instrument is more effective than the generic instrument, and the generic instrument allows different diseases or patients and general population to be compared 6-8. There is not a specific instrument for non-dialytic therapy. Nevertheless, patients with predialysis CKD also have high prevalence of psychological and physical impairment, and the early detection and active interventions are in urgent need. Along with better understanding of the problems with advanced CKD patients, the time to develop a new specific instrument for predialysis CKD population has truly arrived. None.