Older kidney transplant candidates unlikely to report depressive symptoms at evaluation
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Older adults are less likely to report depressive symptoms compared with younger adults at evaluations for kidney transplants, according to data published in Kidney International Reports.
Further, investigators found patients of any age who report any degree of depressive symptoms are unlikely to achieve kidney transplant listing.
“Although extensive research sheds light on the high burden and poor clinical outcomes of depressive symptoms in dialysis population, it is unclear whether kidney failure patients who present depressive symptoms have obstacles in seeking kidney transplant,” Xiaomeng Chen, MSPH, from the department of surgery at Johns Hopkins University School of Medicine in Maryland, and colleagues wrote. They added, “The goals of this study included: 1) to evaluate the severity of depressive symptoms by age, 2) to identify risk factors of depressive symptoms and 3) to estimate the association of depressive symptom severity with kidney transplant listing among adults of all ages being evaluated for kidney transplant.”
In a prospective cohort study, researchers evaluated 3,879 adults with kidney failure. At the time of the study, all patients were being examined for kidney transplants at Johns Hopkins Hospital.
Using the Center for Epidemiologic Studies-Depression (CES-D) scale, researchers measured self-reported depressive symptoms at kidney transplant evaluation, considering depressive symptom severity as: none (0), minimal (1 to 15), mild (16 to 20), moderate (21 to 25) and severe (26 to 60).
Adjusting for clinical and social factors, researchers conducted Cox proportional hazards models to determine the hazard ratios of active transplant listing within a year of evaluation. Researchers followed patients until their first listing, administrative censoring on March 2, 2011, or 1 year following evaluation.
Among the 3,879 patients, 3,728 were included in the final analyses (median age was 56 years; 40.7% were women; 46.7% were Black; 70.6% received dialysis). At evaluation, 85.8% of patients reported depressive symptoms, and reported symptoms declined with age (18-29 years old=92%; 30-39 years old=88.3%; 40-49 years old=87.2%; 50-59 years old=87%; 60-69 years old=83.4%; and 70 years old=82%). Older adults were less likely to report depressive symptoms compared with younger patients.
Analyses revealed a patient’s chance of active listing decreased as the patient reported more severe depressive symptoms. Specifically, every five-point higher CES-D score reported correlated with a 13% lower chance of listing.
“Our findings indicate that despite the relatively lower burden of depressive symptoms, older kidney failure patients with higher CES-D scores may be more vulnerable to limited access to kidney transplant,” Chen and colleagues wrote. “Therefore, there is a need to routinely screen for depressive symptoms among kidney failure patients to improve their access to kidney transplant.”
Perspective
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Charlie Thomas, LCSW, ACSW, FNKF
Depression is serious among all individuals, but particularly among kidney transplant candidates because, as this study reports, some symptoms can keep a candidate off the list.
At the transplant center I work for, we calculate similar scores to the ones used in the study. We also ask candidates about a potential history of suicidal thoughts, suicidal plans and suicidal attempts; of course, those who have attempted suicide are scored with the most severe depression symptoms. So, depending on the severity, we will trigger a referral to our transplant psychiatrist to further evaluation. We're fortunate that we have access to one, and many major transplant centers do not have a dedicated psychiatrist. Once the patient is found to be higher risk due to depression, they are referred to community mental health services and welcome to return to the transplant center in 6 months or so to be revaluated for listing. If they’ve taken the recommended steps to improve their mental health, such as adhered to medication or participated in therapy, we would lean favorably toward selection.
So, as the study suggests, it is possible for patients with even severe depression symptoms to be added to the kidney transplant list if they can improve their mental health. While the study is correct in the suggestion that transplant centers can refer patients for help, it does not clarify who would be responsible for managing that part of the evaluation. Perhaps it would depend on the transplant center.
In response to the rest of the findings, I believe older adults are less likely to report depression symptoms at evaluation because they perceive those symptoms differently than those who haven’t lived as long. For a healthy individual in their 30s who is still able to participate in physical activities, like playing with their kids or skiing or backpacking, they will feel a larger loss when they’re put on dialysis than an older adult who already stopped participating in those actives. If we look at Erickson’s developmental stages, we can see that aging is somewhat of a reorganization of your life. I think that older people, in general, are probably in more of a position to cope with going on dialysis and making some choices about transplant than younger adults.
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