OVERVIEW

Depression and Kidney Transplantation

Joseph Chilcot,1,4 Benjamin Walter Jack Spencer,2 Hannah Maple,3 and Nizam Mamode3
While kidney transplantation offers several advantages in terms of improved clinical outcomes and quality of life
compared to dialysis modalities, depressive symptoms are still present in approximately 25% of patients, rates
comparable to that of the hemodialysis population. Correlates of depressive symptoms include marital status, income,
kidney function, history of affective illness, malnutrition, and inflammation. Depressive symptoms are also associated
with poor outcomes following kidney transplantation including nonadherence to immunosuppressant medication,
graft failure, and all-cause mortality. Efforts to detect and treat depression should be a priority if one is to improve
treatment adherence, quality of life, and outcomes in transplant recipients.
Keywords: Depression, Kidney transplantation, Renal transplantation, Kidney transplant, Transplant, Outcomes.
(Transplantation 2014;97: 717Y721)

t is well documented that end-stage renal disease (ESRD)

patients experience high levels of depression with approximately 20% to 30% suffering from depressive symptoms
(1Y3). When compared with dialysis modalities, kidney transplantation is associated with improved clinical outcomes (4),
better quality of life (5), and lower rates of psychiatric morbidity (6, 7). Despite this, transplantation requires psychological adjustment and comes with its own treatment challenges.
This can produce problematic feelings such as fear, guilt,
and global distress. Depression is likely to be the most common psychological complaint in kidney transplant recipients
and is the focus of this review. Specifically, this article describes
the estimated prevalence, correlates, and consequences of depression in this setting, and evaluates treatment options.

Prevalence Rates of Depression in Kidney

Transplant Patients
Prevalence rates for depression in renal patients vary as
a product of the assessment undertaken (1, 8). As discussed
elsewhere, the assessment of depression is complicated in
kidney disease patients, partly as a result of overlapping physical symptoms between renal insufficiency and the features of
The authors declare no funding or conflicts of interest.
1
Health Psychology Section, Psychology Department, Institute of Psychiatry, Kings College London, UK.
2
Department of Psychological Medicine, Institute of Psychiatry, Kings
College London, UK.
3
Department of Transplantation, Guys Hospital, London, UK.
4
Address correspondence to: Joseph Chilcot, Ph.D., Health Psychology
Section, Psychology Department, Institute of Psychiatry, Kings College
London, 5th floor Bermondsey Wing, Guys Hospital Campus, London
Bridge, London, SE1 9RT, UK.
E-mail: joseph.chilcot@kcl.ac.uk
All authors contributed to the reviewing of references, and the writing and
editing of this article.
Received 30 August 2013. Revision requested 3 October 2013.
Accepted 21 October 2013.
Copyright * 2014 by Lippincott Williams & Wilkins
ISSN: 0041-1337/14/9707-717
DOI: 10.1097/01.TP.0000438212.72960.ae

Transplantation

& Volume 97, Number 7, April 15, 2014

depression, such as lethargy (2, 9, 10). Screening approaches

that utilize standardized questionnaires with predetermined
cutoff scores often inflate estimated prevalence rates, with
diagnostic approaches (i.e., clinical interviews) often attenuating these estimates (8). Several screening and severity measures have been used to evaluate depression symptoms in
kidney transplant patients, and these include the Hospital
Anxiety Depression Scale (11), Beck Depression Inventory
(BDI) (12, 13), the Symptom Checklist (SCL-90) (14), and the
Centre for Epidemiologic Studies Depression Scale (CES-D)
(15). It is important to recognize that screening tools are
not diagnostic measures; rather they are helpful indicators
of those who have significant symptoms that might require
further enquiry. It should therefore be noted that throughout
this article when studies have adopted such measures, the
term depression used does not refer to a diagnosed condition, rather high levels of depressive symptoms. Within the
context of renal transplantation, the relative accuracy of
screening and severity measures in relation to a clinical diagnosis of depression requires attention in suitably large studies.
In one of the earliest studies looking at distress in
kidney transplant patients, 46% were found to be distressed
as defined by a General Health Questionnaire-30 score
greater than 5 (16). More recently, Novak et al. (17) reported
a 22% point prevalence of depression (CES-D score Q18)
among 840 kidney transplant patients and Zelle et al. (18)
reported a 31% prevalence using the SCL-90 (925). Use of
the BDI has led to estimates between 13% and 39% (19Y24)
with variability partly being attributable to methodological
differences, such as differences in BDI cutoff scores used.
Few studies have examined the incidence of depression over
time among kidney transplant recipients. An analysis of
Medicare claims in 47,899 kidney recipients revealed a cumulative yearly depression incidence of 5.05%, 7.29%, and
9.1% 3 years posttransplantation (25). Comparing the prevalence of depression symptoms between dialysis and transplant populations has led to mixed findings, which are often
www.transplantjournal.com

Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

717

718

www.transplantjournal.com

Transplantation

hard to interpret because of methodological limits and the

potential for confounding. While it is generally recognized
that transplantation confers a quality-of-life benefit, there is
still significant variation within transplant patients (26, 27).
One of the first studies to compare dialysis and transplant
modalities revealed similar levels of distress (16), while others
suggested that psychiatric morbidity or emotional distress is
lower in transplanted patients (6, 7, 21, 28). For example,
Szeifert et al. (29) found that the prevalence of depression
is lower in transplant patients compared to dialysis patients
(22% vs. 33%, respectively), and in multivariate analysis dialysis modality predicted higher depression scores. In a recent
meta-analysis, Palmer et al. (8) found that the prevalence of
depression, according to self-report or clinician rated tools,
was lower in kidney transplant patients (26.6%, 95% CI,
20.9Y33.1) compared to ESRD patients (39.3%, 95% CI
36.8Y42.0).
Although variation is evident in the literature with
confidence intervals for point prevalence estimates large, it
appears that approximately one in four patients screen positive for depression across the spectrum of advanced kidney
disease, making it one of the more common comorbidities
encountered in renal transplant candidates and recipients.
Nevertheless, it is also clear that studies are needed to establish the trajectory of depression symptoms over time (30),
following up a suitably large sample of patients from dialysis
to transplantation and beyond. This will allow researchers
and clinicians to observe the natural history of symptomatology, identify correlates, and possibly highlight optimal points
for intervention.
Factors Associated With Depression Following
Kidney Transplantation
Multiple studies have examined possible clinical, social,
and psychological factors associated with depression in kidney
transplant patients (Table 1). Demographic correlates of depression include age (25, 31), female gender (17, 25, 32, 33),
race (25), employment status and financial situation (18, 29,
31, 32), education (17, 32), and marital status (17, 29). With
regards to clinical factors, studies have shown a negative association between renal function (estimated glomerular filtration rate, eGFR) and depression in transplant patients (17,
29, 32). Zelle et al. (18) report significantly lower creatinine
clearance and a higher proportion of proteinuria in depressed
transplant patients compared with non-depressed patients.
Lower hemoglobin (18, 32) and serum albumin levels (17, 20)
have also been associated with depression in kidney transplant
patients. Dobbels et al. reported a positive association between

& Volume 97, Number 7, April 15, 2014

Medicare claimYidentified depression and having six HLA

mismatches, rapamycin use, antithymocyte and antilymphocyte globulin for antibody induction therapy, and having diabetic nephropathy as a primary cause of kidney disease (25).
Most of these clinical factors are related to graft function;
therefore, these findings may reflect depression symptoms
resulting from impending graft loss and the associated physical symptoms resulting from low eGFR. However, prospective evaluations are needed to better understand the casual
pathways between depression and clinical factors in kidney
transplant recipients. Others report that higher C-reactive
protein (20), interleukin-6, and longer dialysis vintage (18,
25) are associated with heightened depression symptoms (32),
although again there are conflicting data with respect to these
findings (17, 29). There is little evidence that the duration of
transplant graft survival is associated with depression in kidney recipients (18, 29, 31). More consistent findings suggest an
association between the severity of comorbidity (including
obesity) (17, 25, 29, 32) and heightened depression symptoms
in kidney recipients.
Regarding psychological factors, having a history of
depression predicts concurrent mood following kidney
transplantation (6, 20), which is also the case for hemodialysis patients (34). While psychological predictors of depression have been examined in some detail among dialysis
patients (1, 35) with particular emphasis on patients illness
beliefs (30, 36, 37), fewer data exists in kidney transplant
patients. Poor psychological adjustment and coping are
likely perpetuating contributors. A small study found that
age, general life stress, and transplant-related stress were all
related to levels of adjustment in transplant patients, although interestingly, moderate to high feelings of indebtedness towards to donor was unrelated to adjustment (38).
A strong correlation has been observed between depression
symptoms (BDI) with perceptions of illness and social
support in renal transplant patients, although a small sample size and failure to control for potential confounding
factors are limitations (39). Others have shown that posttransplantation emotional well-being is moderated by the
coping preferences of the patient (40). Specifically, patients
with a more active coping style (i.e., seeking health-related
information) have a reduction in depression symptoms
following transplantation compared to those who have a
low preference for health-related information seeking, who
tend to show increases in depression over time (40). This
work has some relevance regarding extended criteria for
donation because more patients are receiving less than
ideal grafts therefore increasing the potential for clinical

TABLE 1. Summary of common demographic, clinical, and psychosocial correlates of depression in kidney
transplant patients
Demographic
Age (25, 31)
Marital Status (17, 29)
Lower income/employment (18, 29, 31, 32)
Gender (17, 25, 32, 33)
White race (25),
Education (17, 32)

Clinical

Psychological

Renal function (17, 29, 32)

Inflammation (20)
Comorbidity (17, 25, 29, 32)
Serum hemoglobin (18, 32)
Serum albumin (17, 20)

Past history of depression (20)

Perceived stress (82)
Coping style (40)
Illness beliefs (39)
Social support (39)

Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

* 2014 Lippincott Williams & Wilkins

complications and events. Managing the expectations of

such recipients is likely to be an important factor related
to adjustment in the months proceeding transplantation.
Depression Predicts Poor Clinical Outcomes
Not only does depression impact severely on quality of
life in ESRD patients (41), it is associated with poor clinical
outcomes, particularly mortality (42Y45). Among kidney
transplant patients, depression also appears to play an important prognostic role in terms of kidney graft survival and
patient mortality (17, 18, 24, 25, 46). In a large analysis of
US Medicare claims, Dobbels et al. (25) found that depression was associated with a twofold increase in risk of graft
failure, return to dialysis, and death with a functioning graft,
after controlling for several demographic and clinical factors. Novak et al. (17) studied 840 kidney transplant patients
and found that those defined as depressed (based upon a
CES-D score Q18) were at greater risk of death over the study
follow-up compared to non-depressed patients (HR=1.66,
95% CI 1.12Y2.47). Furthermore, baseline depression scores
were also associated with death-censored graft survival
(HR=1.03, 95% CI 1.01Y1.05), albeit failing to utilize
competing risk survival models in their analysis. A recent
study reported that depression, as assessed by the depression subscales of the SCL-90, predicted both all-cause and
cardiovascular diseaseYrelated mortality (18). These findings support the work of others who have also found that
depression predicts survival following heart (47) and liver
transplantation (48), although taken together the evidence
that depression is associated with clinical outcomes in solid
organ transplant recipients is mixed (49).
The association between depression and poor clinical
outcomes in kidney transplant patients might be explained
by several factors, with nonadherence to treatment regimens
a strong explanatory factor. Nonadherence to immunosuppressant medicines is estimated to be approximately 22% to
28%, with around 16% to 36% of failed grafts thought to be
the result of nonadherence behavior (50, 51). Depression has
been found to increase the risk of treatment nonadherence
threefold among patient populations (52). Both retrospective (53) and prospective studies (54, 55) of kidney graft
recipients report an association between nonadherence and
depression [see (56)]. In a recent study of kidney transplant
patients, intentional nonadherence (i.e., choosing not to
take them, or skip/adjusting a dose) to immunosuppressant
medications was associated with depression symptoms (19).
Furthermore, depression in kidney transplant patients is
associated with unhealthy behaviors including lower activity
levels and higher alcohol use, which may in turn impact
upon transplant-related outcomes (18).
Other suggested mechanisms that might explain poor
outcomes in depressed patients include the well-established
association between depression and cardiovascular disease
(CVD) (57, 58) where malnutrition, inflammation, and
immune function are all implicating factors (17, 32, 59Y62).
In dialysis patients, depression has been found to correlate
positively with pro-inflammatory cytokines (60, 62), which
are also an important factor in the pathogenesis of CVD
(63). As described previously, depression symptoms have be
shown to have a small yet significant association with IL-6
among kidney transplant recipients (32). Nevertheless, the

Chilcot et al.

719

apparent relationship between depression and inflammation

is complex and causal assumptions are difficult to infer because pro-inflammatory cytokines can cause symptoms
similar to those observed in depression (64, 65). Taken together, the potential mechanisms linking depression with
transplant-related outcomes are unduly complex, involving
direct and indirect factors, which likely interact to increase
the propensity for a poor outcome.
Interventional Approaches for
Treating Depression
Given that depression is a prevalent and costly comorbidity in kidney transplant patients, efforts to detect
symptoms and intervene with appropriate treatments are
critical. Unfortunately, across the spectrum of advanced
kidney disease, little research has been conducted evaluating
treatments for depression in robust clinical trials. Group
cognitive behavioral therapy has been shown to be effective
at reducing depression symptoms among hemodialysis patients (66). Among renal transplant recipients, 12 weeks of
psychotherapy (individual and group) has been shown to
reduce depression symptoms over 12 months, although it
should be noted that the control arm of this trial had significantly fewer depression symptoms at baseline, and the
analysis failed to adequately consider the interaction between group and time (67). A small study of an intervention
designed to improve quality of life and reduce distress in
ESRD patients awaiting transplantation also demonstrated
benefit to well-being (68), suggesting that targeting symptoms before transplantation might be one effective treatment model. Taken together, there is a need to further
develop specific psychological-based interventions that target maladjustment and distress in renal transplant patients,
which are tested in trials using robust methodologies.
Renal transplant recipients are a heterogeneous population, with a range of baseline renal function, comorbidities, and immunosuppressive regimens, which are factors
that need to be considered when treating depression with
antidepressants. When considering treatment with an antidepressant, similar issues are raised as with treating depression in patients with CKD. The authors found no
published trials of pharmacological treatments for depression purely in the renal graft recipient population. Further,
the evidence for the pharmacological treatment of depression in CKD is very limited, with no robust randomized
controlled trials published. As a result, most guidance imports evidence from the treatment of otherwise healthy individuals (69Y75), which may not be appropriate given the
potential effects of impaired renal function, multiple medications, and comorbidities on existing agents. There is a
clear need for high-quality trials, and the authors await the
first data (76).
There are reasons to be cautious when prescribing an
antidepressant. The most widely used antidepressants, the
selective serotonin reuptake inhibitors (SSRIs), all have an
antiplatelet effect (77, 78). Renal graft recipients already
have a theoretically associated increased risk of gastrointestinal bleeding through use of antiplatelet agents (79, 80) and
immunosuppressants, such as steroids, as well as impaired
platelet function in renal impairment. However, caution
needs to be given to the use of gastroprotective agents if an

Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

720

www.transplantjournal.com

SSRI is to be prescribed because some combinations interact

to produce QTc prolongation. Detailed reviews of the pharmacological treatment options and pharmacokinetic considerations have been reported elsewhere (69Y72, 74, 75, 81).
The authors recommend the careful consideration of
non-pharmacological and pharmacological treatments for
depression to ensure the most appropriate treatment be offered, particularly because untreated depression is a significant risk to well-being and outcome. Given concerns
regarding harm in the form of gastrointestinal bleeding,
the decision to treat depression pharmacologically is one
best made following a discussion between the renal transplant team, specialist psychiatric liaison services, and renal
pharmacists to ensure the safest and most effective agent
is selected.

Transplantation

15.
16.
17.
18.
19.

20.

21.

CONCLUSIONS
Despite advances in renal transplantation, depression
is still a prevalent and problematic comorbidity that remains
mostly overlooked. Depression in this setting predicts poor
outcomes, including inferior graft survival. While the mechanisms underlying this relationship require further empirical
attention, nonadherence is a significant explanatory factor.
Efforts to support the adjustment process are critical and
when mood symptoms require specific attention, psychological therapies show promise but do require further research
into their acceptability and efficacy in this setting. Evidence
regarding pharmacological interventions for clinically diagnosed depression in renal transplant patients also requires
further investigation, specifically the concerns around safety.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Chilcot J, Wellsted D, Farrington K. Depression in end-stage renal

disease: current advances and research. Semin Dial 2010; 23: 74.
Chilcot J, Wellsted D, Da Silva-Gane M, et al. Depression on dialysis.
Nephron Clin Pract 2008; 108: c256.
Cukor D, Peterson RA, Cohen SD, et al. Depression in end-stage renal
disease hemodialysis patients. Nat Clin Pract Nephrol 2006; 2: 678.
Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all
patients on dialysis, patients on dialysis awaiting transplantation, and
recipients of a first cadaveric transplant. N Engl J Med 1999; 341: 1725.
Reimer J, Franke GH, Lutkes P, et al. [Quality of life in patients before
and after kidney transplantation]. Psychother Psychosom Med Psychol
2002; 52: 16.
Sensky T. Psychiatric morbidity in renal transplantation. Psychother
Psychosom 1989; 52: 41.
House A. Psychosocial problems of patients on the renal unit and
their relation to treatment outcome. J Psychosom Res 1987; 31: 441.
Palmer S, Vecchio M, Craig JC, et al. Prevalence of depression in
chronic kidney disease: systematic review and meta-analysis of observational studies. Kidney Int 2013; 84: 179.
Chilcot J, Norton S, Wellsted D, et al. A confirmatory factor analysis of
the Beck Depression Inventory-II in end-stage renal disease patients. J
Psychosom Res 2011; 71: 148.
Afshar M, Rebollo-Mesa I, Murphy E, et al. Symptom burden and
associated factors in renal transplant patients in the U.K. J Pain
Symptom Manage 2012; 44: 229.
Zigmond AS, Snaith RP. The hospital anxiety and depression scale.
Acta Psychiatr Scand 1983; 67: 361.
Beck AT, Steer RA, Brown GK. Beck Depression InventoryV2nd Edition
Manual. San Antonio: The Psychological Corporation; 1996.
Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck
Depression Inventory: twenty-five years of evaluation. Clin Psychol
Rev 1988; 8: 77.
Derogatis LR, Lipman RS, Covi L. SCL-90: an outpatient psychiatric
rating scaleVpreliminary report. Psychopharmacol Bull 1973; 9: 13.

22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.

& Volume 97, Number 7, April 15, 2014

Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977; 1: 385.
Kalman TP, Wilson PG, Kalman CM. Psychiatric morbidity in longterm renal transplant recipients and patients undergoing hemodialysis. A comparative study. JAMA 1983; 250: 55.
Novak M, Molnar MZ, Szeifert L, et al. Depressive symptoms and
mortality in patients after kidney transplantation: a prospective
prevalent cohort study. Psychosom Med 2010; 72: 527.
Zelle DM, Dorland HF, Rosmalen JG, et al. Impact of depression on
long-term outcome after renal transplantation: a prospective cohort
study. Transplantation 2012; 94: 1033.
Griva K, Davenport A, Harrison M, et al. Non-adherence to immunosuppressive medications in kidney transplantation: intent vs. forgetfulness and clinical markers of medication intake. Ann Behav Med
2012; 44: 85.
Spencer BW, Chilcot J, Farrington K. Still sad after successful renal
transplantation: are we failing to recognise depression? An audit of
depression screening in renal graft recipients. Nephron Clin Pract
2011; 117: c106.
Akman B, Ozdemir FN, Sezer S, et al. Depression levels before and
after renal transplantation. Transplant Proc 2004; 36: 111.
Fierz K, Steiger J, Denhaerynck K, et al. Prevalence, severity and
correlates of alcohol use in adult renal transplant recipients. Clin
Transplant 2006; 20: 171.
Moons P, Vanrenterghem Y, Van Hooff JP, et al. Health-related quality
of life and symptom experience in tacrolimus-based regimens after
renal transplantation: a multicentre study. Transpl Int 2003; 16: 653.
Rocha G, Poli de Figueiredo CE, dAvila D, et al. Depressive symptoms
and kidney transplant outcome. Transplant Proc 2001; 33: 3424.
Dobbels F, Skeans MA, Snyder JJ, et al. Depressive disorder in renal
transplantation: an analysis of Medicare claims. Am J Kidney Dis 2008;
51: 819.
Dew MA, Switzer GE, Goycoolea JM, et al. Does transplantation
produce quality of life benefits? A quantitative analysis of the literature. Transplantation 1997; 64: 1261.
Fiebiger W, Mitterbauer C, Oberbauer R. Health-related quality of
life outcomes after kidney transplantation. Health Qual Life Outcomes
2004; 2: 2.
Cameron JI, Whiteside C, Katz J, et al. Differences in quality of life
across renal replacement therapies: a meta-analytic comparison. Am J
Kidney Dis 2000; 35: 629.
Szeifert L, Molnar MZ, Ambrus C, et al. Symptoms of depression in
kidney transplant recipients: a cross-sectional study. Am J Kidney Dis
2010; 55: 132.
Chilcot J, Norton S, Wellsted D, et al. Distinct depression symptom
trajectories over the first year of dialysis: associations with illness
perceptions. Ann Behav Med 2013; 45: 78.
Tsunoda T, Yamashita R, Kojima Y, et al. Risk factors for depression
after kidney transplantation. Transplant Proc 2010; 42: 1679.
Czira ME, Lindner AV, Szeifert L, et al. Association between the
Malnutrition-Inflammation Score and depressive symptoms in kidney
transplanted patients. Gen Hosp Psychiatry 2011; 33: 157.
Gentile S, Beauger D, Speyer E, et al. Factors associated with healthrelated quality of life in renal transplant recipients: results of a national survey in France. Health Qual Life Outcomes 2013; 11: 88.
Cukor D, Coplan J, Brown C, et al. Course of depression and anxiety
diagnosis in patients treated with hemodialysis: a 16-month follow-up.
Clin J Am Soc Nephrol 2008; 3: 1752.
Cukor D, Cohen SD, Peterson RA, et al. Psychosocial aspects of
chronic disease: ESRD as a paradigmatic illness. J Am Soc Nephrol
2007; 18: 3042.
Griva K, Davenport A, Harrison M, et al. An evaluation of illness,
treatment perceptions, and depression in hospital- vs. home-based
dialysis modalities. J Psychosom Res 2010; 69: 363.
Sacks CR, Peterson RA, Kimmel PL. Perception of illness and depression in chronic renal disease. Am J Kidney Dis 1990; 15: 31.
Achille M, Ouellette A, Fournier S, et al. Impact of transplant-related
stressors and feelings of indebtedness on psychosocial adjustment following kidney transplantation. J Clin Psychol Med Settings 2004; 11: 63.
Shah VS, Ananth A, Sohal GK, et al. Quality of life and psychosocial
factors in renal transplant recipients. Transplant Proc 2006; 38: 1283.
Christensen AJ, Ehlers SL, Raichle KA, et al. Predicting change in
depression following renal transplantation: effect of patient coping
preferences. Health Psychol 2000; 19: 348.

Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Chilcot et al.

* 2014 Lippincott Williams & Wilkins

41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.

53.
54.
55.

56.
57.
58.
59.
60.
61.

Valderrabano F, Jofre R, Lopez-Gomez JM. Quality of life in end-stage

renal disease patients. Am J Kidney Dis 2001; 38: 443.
Chilcot J, Davenport A, Wellsted D, et al. An association between depressive symptoms and survival in incident dialysis patients. Nephrol
Dial Transplant 2011; 26: 1628.
Lopes AA, Bragg J, Young E, et al. Depression as a predictor of mortality and hospitalization among hemodialysis patients in the United
States and Europe. Kidney Int 2002; 62: 199.
Kimmel PL, Peterson RA, Weihs KL, et al. Multiple measurements of
depression predict mortality in a longitudinal study of chronic hemodialysis outpatients. Kidney Int 2000; 57: 2093.
Kimmel PL, Weihs K, Peterson RA. Survival in hemodialysis patients:
the role of depression. J Am Soc Nephrol 1993; 4: 12.
Noohi S, Khaghani-Zadeh M, Javadipour M, et al. Anxiety and depression are correlated with higher morbidity after kidney transplantation. Transplant Proc 2007; 39: 1074.
Zipfel S, Schneider A, Wild B, et al. Effect of depressive symptoms on
survival after heart transplantation. Psychosom Med 2002; 64: 740.
Corruble E, Barry C, Varescon I, et al. Depressive symptoms predict
long-term mortality after liver transplantation. J Psychosom Res 2011;
71: 32.
Rosenberger EM, Dew MA, Crone C, et al. Psychiatric disorders as risk
factors for adverse medical outcomes after solid organ transplantation. Curr Opin Organ Transplant 2012; 17: 188.
Butler JA, Roderick P, Mullee M, et al. Frequency and impact of
nonadherence to immunosuppressants after renal transplantation: a
systematic review. Transplantation 2004; 77: 769.
Denhaerynck K, Dobbels F, Cleemput I, et al. Prevalence, consequences, and determinants of nonadherence in adult renal transplant
patients: a literature review. Transpl Int 2005; 18: 1121.
DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for
noncompliance with medical treatment: meta-analysis of the effects of
anxiety and depression on patient adherence. Arch Intern Med 2000;
160: 2101.
Jindal RM, Neff RT, Abbott KC, et al. Association between depression
and nonadherence in recipients of kidney transplants: analysis of the
United States renal data system. Transplant Proc 2009; 41: 3662.
Cukor D, Newville H, Jindal R. Depression and immunosuppressive
medication adherence in kidney transplant patients. Gen Hosp Psychiatry 2008; 30: 386.
Gorevski E, Succop P, Sachdeva J, et al. Is there an association between
immunosuppressant therapy medication adherence and depression,
quality of life, and personality traits in the kidney and liver transplant
population? Patient Prefer Adherence 2013; 7: 301.
Jindal RM, Joseph JT, Morris MC, et al. Noncompliance after kidney
transplantation: a systematic review. Transplant Proc 2003; 35: 2868.
Musselman DL, Evans DL, Nemeroff CB. The relationship of depression to cardiovascular disease: epidemiology, biology, and treatment. Arch Gen Psychiatry 1998; 55: 580.
Glassman A. Depression and cardiovascular disease. Pharmacopsychiatry
2008; 41: 221.
Kalender B, Ozdemir AC, Koroglu G. Association of depression with
markers of nutrition and inflammation in chronic kidney disease and
end-stage renal disease. Nephron Clin Pract 2006; 102: c115.
Wang LJ, Wu MS, Hsu HJ, et al. The relationship between psychological
factors, inflammation, and nutrition in patients with chronic renal
failure undergoing hemodialysis. Int J Psychiatry Med 2012; 44: 105.
Simic Ogrizovic S, Jovanovic D, Dopsaj V, et al. Could depression be
a new branch of MIA syndrome? Clin Nephrol 2009; 71: 164.

62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.

81.

82.

721

Ko GJ, Kim MG, Yu YM, et al. Association between depression symptoms with inflammation and cardiovascular risk factors in patients undergoing peritoneal dialysis. Nephron Clin Pract 2010; 116: c29.
Danesh J, Wheeler JG, Hirschfield GM, et al. C-reactive protein and
other circulating markers of inflammation in the prediction of coronary heart disease. N Engl J Med 2004; 350: 1387.
Dantzer R. Cytokine-induced sickness behaviour: a neuroimmune response to activation of innate immunity. Eur J Pharmacol 2004; 500: 399.
van den Biggelaar AH, Gussekloo J, de Craen AJ, et al. Inflammation
and interleukin-1 signaling network contribute to depressive symptoms but not cognitive decline in old age. Exp Gerontol 2007; 42: 693.
Duarte PS, Miyazaki MC, Blay SL, et al. Cognitive-behavioral group
therapy is an effective treatment for major depression in hemodialysis
patients. Kidney International 2009; 76: 414.
Baines LS, Joseph JT, Jindal RM. Prospective randomized study of
individual and group psychotherapy versus controls in recipients of
renal transplants. Kidney Int 2004; 65: 1937.
Rodrigue JR, Mandelbrot DA, Pavlakis M. A psychological intervention
to improve quality of life and reduce psychological distress in adults
awaiting kidney transplantation. Nephrol Dial Transplant 2011; 26: 709.
Zalai D, Szeifert L, Novak M. Psychological distress and depression in
patients with chronic kidney disease. Semin Dial 2012; 25: 428.
Hedayati SS, Yalamanchili V, Finkelstein FO. A practical approach to
the treatment of depression in patients with chronic kidney disease
and end-stage renal disease. Kidney Int 2012; 81: 247.
Hedayati SS, Finkelstein FO. Epidemiology, diagnosis, and management
of depression in patients with CKD. Am J Kidney Dis 2009; 54: 741.
Cohen SD, Norris L, Acquaviva K, et al. Screening, diagnosis, and
treatment of depression in patients with end-stage renal disease. Clin J
Am Soc Nephrol 2007; 2: 1332.
Rabindranath KS, Butler J, Roderick PJ, et al. Physical methods for
treating depression in dialysis patients. Cochrane Database Syst Reviews 2009.
Wuerth D, Finkelstein SH, Finkelstein FO. The identification and
treatment of depression in patients maintained on dialysis. Semin Dial
2005; 18: 142.
Tossani E, Cassano P, Fava M. Depression and renal disease. Semin
Dial 2005; 18: 73.
Jain N, Trivedi MH, Rush AJ, et al. Rationale and design of the chronic
kidney disease antidepressant sertraline trial (CAST). Contemp Clin
Trials 2013; 34: 136.
Dalton SO, Sorensen HT, Johansen C. SSRIs and upper gastrointestinal bleeding: what is known and how should it influence prescribing? CNS Drugs 2006; 20: 143.
Paton C, Ferrier IN. SSRIs and gastrointestinal bleeding. BMJ 2005;
331: 529.
Gansevoort RT, Correa-Rotter R, Hemmelgarn BR, et al. Chronic
kidney disease and cardiovascular risk: epidemiology, mechanisms,
and prevention. Lancet 2013; 382: 339.
Palmer SC, Di Micco L, Razavian M, et al. Effects of antiplatelet
therapy on mortality and cardiovascular and bleeding outcomes in
persons with chronic kidney disease: a systematic review and metaanalysis. Ann Intern Med 2012; 156: 445.
Nagler EV, Webster AC, Vanholder R, et al. Antidepressants for depression in stage 3-5 chronic kidney disease: a systematic review of pharmacokinetics, efficacy and safety with recommendations by European
Renal Best Practice (ERBP). Nephrol Dial Transplant 2012; 27: 3736.
Achille MA, Ouellette A, Fournier S, et al. Impact of stress, distress and
feelings of indebtedness on adherence to immunosuppressants following kidney transplantation. Clin Transplant 2006; 20: 301.

Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.