0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Contribution |

Association Between Major Depressive Episodes in Patients With Chronic Kidney Disease and Initiation of Dialysis, Hospitalization, or Death FREE

S. Susan Hedayati, MD, MHSc; Abu T. Minhajuddin, PhD; Masoud Afshar, MD; Robert D. Toto, MD; Madhukar H. Trivedi, MD; A. John Rush, MD
[+] Author Affiliations

Author Affiliations: Division of Nephrology, Department of Medicine, VA North Texas Health Care System, Dallas (Dr Hedayati); Division of Biostatistics, Department of Clinical Sciences (Dr Minhajuddin), Division of Nephrology, Department of Medicine (Drs Hedayati, Afshar, and Toto), and Department of Psychiatry (Dr Trivedi), University of Texas Southwestern Medical Center, Dallas; and Division of Clinical Sciences, Duke-NUS, Singapore (Dr Rush).


JAMA. 2010;303(19):1946-1953. doi:10.1001/jama.2010.619.
Text Size: A A A
Published online

Context Patients with chronic kidney disease (CKD) experience increased rates of hospitalization and death. Depressive disorders are associated with morbidity and mortality. Whether depression contributes to poor outcomes in patients with CKD not receiving dialysis is unknown.

Objective To determine whether the presence of a current major depressive episode (MDE) is associated with poorer outcomes in patients with CKD.

Design, Setting, and Patients Prospective cohort study of 267 consecutively recruited outpatients with CKD (stages 2-5 and who were not receiving dialysis) at a VA medical center between May 2005 and November 2006 and followed up for 1 year. An MDE was diagnosed by blinded personnel using the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria.

Main Outcome Measures The primary outcome was event-free survival defined as the composite of death, dialysis initiation, or hospitalization. Secondary outcomes included each of these events assessed separately.

Results Among 267 patients, 56 had a current MDE (21%) and 211 did not (79%). There were 127 composite events, 116 hospitalizations, 38 dialysis initiations, and 18 deaths. Events occurred more often in patients with an MDE compared with those without an MDE (61% vs 44%, respectively, P = .03). Four patients with missing dates of hospitalization were excluded from survival analyses. The mean (SD) time to the composite event was 206.5 (19.8) days (95% CI, 167.7-245.3 days) for those with an MDE compared with 273.3 (8.5) days (95% CI, 256.6-290.0 days) for those without an MDE (P = .003). The adjusted hazard ratio (HR) for the composite event for patients with an MDE was 1.86 (95% CI, 1.23-2.84). An MDE at baseline independently predicted progression to dialysis (HR, 3.51; 95% CI, 1.77-6.97) and hospitalization (HR, 1.90; 95% CI, 1.23-2.95).

Conclusion The presence of an MDE was associated with an increased risk of poor outcomes in CKD patients who were not receiving dialysis, independent of comorbidities and kidney disease severity.

Figures in this Article

Depression is associated with poor cardiovascular outcomes13 and is found to be prevalent in patients with chronic kidney disease (CKD), affecting up to 20% of patients even before initiation of dialysis.4 Approximately 13% of the US adult population has CKD, and it is well recognized as an independent predictor of cardiovascular morbidity and mortality.57 Moreover, those with CKD are more likely to die from cardiovascular disease than to progress to end-stage renal disease (ESRD).8 Patients who survive to progress to ESRD experience a mortality rate of 21% in their first year of dialysis6 compared with 0.5% for the general US population,9 with cardiovascular disease accounting for 50% of all deaths.6 In addition, increased hospitalizations and dialysis care for ESRD patients result in substantial health care costs, such that expenditures consumed $24 billion in 2007, approximately 6% of the entire Medicare budget.6

Previous studies have identified depression as an independent risk factor for hospitalization and death in patients receiving maintenance dialysis.1013 However, studies investigating the clinical outcomes of patients with earlier-stage CKD and depression prior to progression to ESRD and dialysis initiation are lacking. Because processes of care for patients with CKD are predictive of clinical outcomes in those with ESRD, better recognition of disease processes, such as depression, which portend morbidity and mortality, could lead to improved treatment outcomes for such patients.14,15 A cohort of patients with CKD not yet started on maintenance dialysis was prospectively studied to determine whether there was an association between a current major depressive episode (MDE), based on Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria,16 and progression to dialysis, hospitalization, or death during 1 year of follow-up.

Patients were recruited consecutively from the Dallas VA Medical Center between May 2005 and November 2006 (Figure 1). The study was approved by the VA institutional review board. Informed written consent was obtained by study personnel prior to patient enrollment. Inclusion criteria were presence of CKD (stages 2-5), defined as an estimated glomerular filtration rate (GFR) of less than 90 mL/min/1.73 m2 for 3 months, using the 4-variable Modification of Diet in Renal Disease formula.17 Patients with stage 2 CKD (estimated GFR of 60-89 mL/min/1.73 m2) had to have other evidence manifest by either a pathological abnormality of the kidney on biopsy or markers of kidney damage present for at least 3 months.5 Exclusion criteria were initiation of maintenance dialysis or kidney transplantation and no health care power of attorney.

Place holder to copy figure label and caption
Figure 1. Description of Chronic Kidney Disease Cohort
Graphic Jump Location

GFR indicates glomerular filtration rate; MINI, Mini International Neuropsychiatric Interview.

Detailed methods of recruitment were previously published.4 Prior to each clinic visit, the CKD clinic roster was reviewed to identify patients for screening. The VA electronic centralized patient record system was then searched for eligibility criteria. Due to the large numbers of patients with CKD, all eligible patients could not be approached on any 1 clinic day. Therefore, every sixth eligible patient (starting at a random number between 1 and 6 for each specific clinic day) was approached consecutively to minimize selection bias.

All patients underwent a structured interview at enrollment to ascertain the presence of an MDE using the Mini International Neuropsychiatric Interview, a widely used reliable and well-validated interview based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition).18,19 The Mini International Neuropsychiatric Interview, which takes 30 to 45 minutes to complete, was administered by 1 of 2 trained research assistants blinded to patients' medical histories. Those with a current MDE were categorized as depressed, while those without one were deemed not depressed. If a current MDE was diagnosed, both the patient and their primary care provider were informed. The patient also was offered either treatment with a selective serotonin reuptake inhibitor or an increase in dose if he or she was already receiving treatment with an antidepressant medication.

Demographic and baseline clinical data were collected from the centralized patient record system and confirmed with patients at enrollment. Race/ethnicity was recorded based on self-report and then dichotomized as black or nonblack for the Modification of Diet in Renal Disease calculation of estimated GFR. Comorbid medical illness was defined as presence of hypertension, diabetes mellitus, congestive heart failure, coronary artery disease, cerebrovascular disease, peripheral vascular disease, lung disease, liver disease, malignancy other than on skin, and infection with human immunodeficiency virus. Comorbid psychiatric illnesses other than depression ascertained by the Mini International Neuropsychiatric Interview included dysthymia, current or past manic or hypomanic episode, current panic episode, social phobia, obsessive-compulsive disorder, posttraumatic stress disorder, current psychotic disorder, generalized anxiety disorder, and anorexia or bulimia nervosa. Current or past drug or alcohol abuse collected from the centralized patient record system or the patient was coded as drug or alcohol abuse.

Patients were followed up for 1 year from MDE ascertainment. The primary outcome formulated before data collection was event-free survival defined as the composite of death, maintenance dialysis initiation, and first hospitalization. Secondary outcomes were the occurrence of each of these 3 events assessed individually. Event ascertainment was performed on the same patient by 2 adjudicators blinded to baseline MDE status. Data on death, hospitalizations, and initiation of renal replacement therapy (hemodialysis, peritoneal dialysis, or kidney transplantation) were collected at 6 and 12 months and were confirmed with the patient. Events were first determined by searching the VA centralized patient record system. Each patient was then contacted to determine whether any events had occurred outside the VA medical center; these data were collected from the discharge summary obtained from the institution where the event occurred.

Demographic and clinical data were compared between the 2 groups (with an MDE vs without an MDE) using the t test or 1-way analysis of variance for continuous variables and the χ2 or Fisher exact test for categorical variables. The proportion of composite events was compared among groups using the χ2 test. Time to events was estimated using Kaplan-Meier curves and compared among groups using the log-rank statistic. Censorship took place at the first event, last follow-up, or if the patient had no events at 12 months. If event date was missing, the patient was excluded from the analysis for that specific event. Cox proportional hazards models were used to explore the association of an MDE with the primary composite and each of the secondary end points. Assuming an α level of .05 and an event rate between 40% and 50% (as reported by the US Renal Data System for CKD patients6), a sample size of 208 to 260 patients was needed to have 85% power to detect an 80% increase in the hazard of the composite outcome among CKD patients with an MDE compared with those without an MDE.

Independent covariates were entered into multivariable models only if clinically relevant and significantly associated with the outcome measure in univariate analyses; a retention P value of less than .05 was determined a priori. Candidate variables included age, race, employment status, drug or alcohol abuse, number of medical comorbidities (other than diabetes), diabetes mellitus, CKD stage, and serum levels of hemoglobin, albumin, phosphorus, and calcium. Chronic kidney disease stage was replaced by estimated GFR as a measure of kidney disease severity in the models with dialysis as the outcome, given there were not enough events to include the 4 categories of CKD. Complete case analysis was used when data were missing for included covariates. A sensitivity analysis was performed by entering new treatment for an MDE into the multivariable Cox model as an independent variable to investigate whether treatment was associated with a change in the composite outcome. New treatment was defined as the initiation of treatment with an antidepressant medication or increasing the dose of a previously prescribed antidepressant within 3 weeks of an MDE diagnosis. All statistical tests were 2-sided, conducted at the standard significance level of .05, and reported using P values and 95% confidence intervals (CIs). All analyses were performed using SAS Enterprise Guide software versions 3.0 and 9.1.3 (SAS Institute Inc, Cary, North Carolina).

The baseline characteristics of participants and nonparticipants, such as sex, race, CKD stage, presence of diabetes, and prior depression diagnosis were similar. However, mean (SD) age was 64.5 (12.0) years among participants and 68.8 (11.0) years among nonparticipants (P = .001; 95% CI for the difference, −6.9 to −1.8 years). Two patients in this VA cohort were women and more than half of the patients were white. About half of the patients had diabetes and a fourth had a prior depression diagnosis. Among participants, the prevalences were 6.4% for CKD stage 2, 37.8% for stage 3, 41.2% for stage 4, and 14.6% for predialysis stage 5. Nonparticipants had similar prevalences for the CKD stages.

Of 267 participants, 56 had a current MDE (21%; 95% CI, 3% to 31%) and 211 did not (Table 1). The MDE group was younger based on a mean (SD) age of 60.6 (11.9) years compared with the group without an MDE (mean [SD], 65.4 [11.8] years; P = .007; 95% CI for the difference, −8.3 to −1.3 years). There were no significant between-group differences in regard to race, educational level, or marital status. Patients with an MDE, however, were two-thirds less likely to be employed as those without an MDE. The median number of medical comorbidities was 4.0 (interquartile range, 2.0 to 5.0) among those with an MDE and 3.0 (interquartile range, 2.0 to 4.0) among those without an MDE. Diabetes mellitus was significantly more prevalent among those with an MDE (69.6%) compared with those without an MDE (51.9%; P = .02; 95% CI for the difference, 4% to 32%). More patients with an MDE had histories of drug or alcohol abuse and concurrent psychiatric disorders. Sixty-six percent of those with an MDE had prior depression vs 13.6% of those without an MDE (95% CI for the difference, 39% to 66%; P < .001); and 50.0% with an MDE vs 11.9% without an MDE were taking antidepressant medications (95% CI for the difference, 24% to 52%; P < .001). Twenty-three of 56 patients (41%) agreed to have a new antidepressant prescribed or the dose of their current antidepressant increased at the time of MDE diagnosis (defined as new treatment).

Table Graphic Jump LocationTable 1. Baseline Characteristics by Depression Statusa

The only difference between groups for laboratory values was for mean (SD) serum phosphorus level, which was higher in those with an MDE (4.2 [1.1]) compared with those without an MDE (3.9 [1.0]) (P = .04; 95% CI for the difference, 0.02 to 0.63; Table 1). There was not a difference between groups in the proportion of patients by CKD stage.

During the 12-month observation period, 127 patients had at least 1 composite event (death, hospitalization, or maintenance dialysis initiation). More patients with an MDE had at least 1 event (60.7%) compared with those without an MDE (44.1%) (P = .03; 95% CI for the difference, 2%-31%; Table 2). The mean (SD) time to the composite event was 260.2 (8.1) days (95% CI, 259.2-261.2 days) overall, and was shorter for those with an MDE (206.5 [19.8] days; 95% CI, 167.7-245.3 days) compared with those without an MDE (273.3 [8.5] days; 95% CI, 256.6-290.0 days) (log-rank P = .003; Figure 2). Four patients were excluded from the survival analysis because the date for the first event (hospitalization in each of these cases) was missing. Of the 4 patients, 1 had an MDE and 3 did not have an MDE.

Place holder to copy figure label and caption
Figure 2. Survival Curves for Outcome Measures
Graphic Jump Location

The composite event is defined as death, hospitalization, or maintenance dialysis initiation. Four patients with missing dates of hospitalization were excluded from the composite event and hospitalization models. One patient with missing event date was excluded from the dialysis model.

Those with an MDE had a higher risk of death, hospitalization, or maintenance dialysis initiation within 12 months of MDE diagnosis compared with those without an MDE (hazard ratio [HR], 1.82 [95% CI, 1.22-2.71]; Figure 3). Variables associated with the composite event in univariate analyses included younger age, white race, higher CKD stage, medical comorbidity, diabetes mellitus, drug or alcohol abuse, lower serum albumin and hemoglobin levels, and higher serum phosphorus levels (data not shown). After adjusting for these covariates, the adjusted HR for the composite outcome was not diminished and remained significant (1.86 [95% CI, 1.23-2.84]; Figure 3). Inclusion of new treatment for an MDE was not significantly associated with the composite outcome in the adjusted model (HR, 1.05 [95% CI, 0.48-2.30]; P = .90), and it did not significantly change the hazard of an MDE for the composite outcome (adjusted HR, 1.84; 95% CI, 1.14-2.96).

Place holder to copy figure label and caption
Figure 3. Adjusted Risks of Events Associated With Major Depressive Episode
Graphic Jump Location

CI indicates confidence interval; CKD, chronic kidney disease; GFR, glomerular filtration rate.

One hundred sixteen were hospitalized, 38 initiated maintenance dialysis, and 18 died (Table 2). More patients with an MDE compared with those without an MDE were hospitalized (55.4% vs 40.3%, respectively, P = .04; [95% CI for the difference, 0.5% to 29.7%]), but no statistically significant differences in reasons for hospitalization could be observed (Table 2). More patients with an MDE were initiated on maintenance dialysis compared with those without an MDE (26.8% vs 10.9%, respectively, P = .003; [95% CI for the difference, 3.6% to 28.2%]; Table 2). Death occurred in 8.9% of those with an MDE and in 6.2% of those without an MDE, but this difference was not statistically significant (95% CI for the difference, −5.4% to 10.8%) (Table 2).

Patients with CKD and an MDE had almost twice the risk of being hospitalized (HR, 1.85; 95% CI, 1.22-2.81), and 3 times the risk of initiating dialysis within 1 year (HR, 3.12 [95% CI, 1.62-6.01]; Figure 3). After controlling for demographic and clinical variables, the association of having an MDE with both hospitalization (HR, 1.90; 95% CI, 1.23-2.90) and dialysis initiation (HR, 3.51; 95% CI, 1.77-6.97) remained significant (Figure 3). The HR of death for patients with an MDE was 1.53 (95% CI, 0.55-4.30).

The new finding in this prospective study of consecutively enrolled patients with CKD is that the presence of an MDE ascertained by an interview based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition)16 predicts progression to maintenance dialysis, hospitalization, or death within 1 year of depression diagnosis. This is the first report, to our knowledge, of such an association in CKD patients prior to maintenance dialysis initiation. Patients with CKD and an MDE were twice as likely to be admitted to the hospital and more than 3 times as likely to progress to ESRD and maintenance dialysis initiation as patients without an MDE. This increased risk was robust and independent of age, race, and presence of diabetes or other medical comorbidities, and remained significant even after controlling for other markers of disease progression such as CKD stage, serum levels of hemoglobin, albumin, and phosphorus.

Most1013,2027 but not all28,29 of the studies of ESRD patients receiving maintenance dialysis reported an association between depressive symptoms and poor outcomes. Study limitations included small samples, retrospective design, selection bias, lack of control for comorbidity,1113,2029 and depression ascertainment using self-report measures.12,13,20,22,29 Such measures may misclassify loss of energy, sleep disturbance, and poor appetite as symptoms of depression in those with advanced CKD.3032 We previously validated the use of easily administered self-report scales, such as the Beck Depression Inventory and the 16-item Quick Inventory of Depressive Symptomatology Self-Report, in this same cohort of predialysis CKD patients compared with the Mini International Neuropsychiatric Interview for depression screening.33 In the present study, diagnosis of an MDE was ascertained blindly using a psychiatric interview based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition),16 not self-report of depressive symptoms. Finally, we studied CKD patients with earlier stages of disease, prior to ESRD. Twenty-six million individuals in the United States have CKD and millions more are at increased risk,34 whereas about half a million are affected by ESRD.35

A key question is whether depression itself has a direct mechanistic role in the development of morbidity and mortality in CKD or whether depressive symptoms are merely a surrogate marker for comorbidity and cardiovascular disease severity.10 We found that inclusion of comorbidity and other risk factors does not attenuate the association between depression and poor outcomes.

Plausible mechanisms to explain this association include nonadherence to medical advice, such as to diet and fluid intake as observed in hemodialysis patients with increased depressive symptoms.3639 Decreased behavioral adherence is consequently associated with decreased survival.40 A recent large study41 reported increased depressive symptoms in patients being treated for diabetes. In our study, a significantly higher number of patients with an MDE had diabetes compared with those without an MDE. Those with diabetes and depression may develop progressive nephropathy due to nonadherence and are at a higher risk for hospitalization and death due to diabetic complications. Other mechanisms may include poor nutrition, lack of social support, increased inflammation, and compromised immunity.4246 Altered serotonin levels observed in depressed patients with ensuing platelet activation leading to coronary events has also been proposed.47,48 Treatment of depression with a selective serotonin reuptake inhibitor compared with placebo after diagnosis of an acute coronary syndrome was associated with reductions in platelet activation and a trend toward improved cardiovascular outcomes in the Sertraline Antidepressant Heart Attack Randomized Trial.4749

Our study has several limitations. First, patients were primarily male veterans, which may limit generalizability to the US population with CKD. However, studies of ESRD patients that included a large proportion of women have demonstrated a similar relationship between depression and outcomes.10,12,13,50 Second, given that the Modification of Diet in Renal Disease estimating equation for GFR is imprecise above the range in which it was derived,17 it is possible that those with an estimated GFR greater than 60 mL/min/1.73 m2 may have been misclassified as having CKD. To minimize this bias, patients with an estimated GFR of 60 to 89 mL/min/1.73 m2 included in our analysis were required to also have other evidence of kidney disease manifest by either pathological abnormalities on kidney biopsy or other markers of kidney damage present for at least 3 months.5 A third but unavoidable limitation is the exclusion of those who refused participation. In addition, patients with more advanced CKD or other conditions prompting more frequent physician visits would be more likely to be recruited. We tried to minimize these potential biases by approaching patients consecutively for enrollment. Baseline characteristics of participants and nonparticipants were similar except that participants were younger. Because worse outcomes were found in patients with an MDE, who were also younger than patients without an MDE, it is unlikely that the inclusion of older nonparticipants would have biased the results toward the null. Another limitation is that the time-varying covariates were not adjusted for, although, survival models did control for baseline variables. Finally, the statistically significant associations between the presence of an MDE and poor outcomes was primarily due to increased rates of hospitalizations and dialysis initiation, and the event rate may have been too small to detect a significant association between having an MDE and death if one did exist.

In conclusion, the presence of a current MDE was associated with progression to maintenance dialysis, hospitalization, or death in CKD patients, independent of comorbidities and kidney disease severity. The US Agency for Healthcare Research and Quality's US Preventive Services Task Force recommends screening for depression if practices “have systems in place to assure accurate diagnosis, effective treatment, and follow-up.”51 Our findings support the need for randomized controlled trials to investigate the safety and efficacy of antidepressant treatments in this vulnerable population, and to establish whether a positive effect on depression will improve renal outcomes and quality of life.

Corresponding Author: S. Susan Hedayati, MD, MHSc, VA North Texas Health Care System, Nephrology Section, MC 111G1, 4500 S Lancaster Rd, Dallas, TX 75216 (susan.hedayati@utsouthwestern.edu).

Author Contributions: Dr Hedayati had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Hedayati, Toto, Trivedi, Rush.

Acquisition of data: Hedayati, Afshar.

Analysis and interpretation of data: Hedayati, Minhajuddin, Toto, Trivedi, Rush.

Drafting of the manuscript: Hedayati, Afshar.

Critical revision of the manuscript for important intellectual content: Hedayati, Minhajuddin, Toto, Trivedi, Rush.

Statistical analysis: Minhajuddin, Hedayati.

Obtaining funding: Hedayati.

Study supervision: Hedayati, Toto, Trivedi.

Financial Disclosure: Dr Rush reported receiving consulting fees from Advanced Neuromodulation Systems, AstraZeneca, Best Practice Project Management, Bristol-Myers Squibb/Otsuka, Cyberonics, Forest Pharmaceuticals, Gerson Lehrman Group, GlaxoSmithKline, Jazz Pharmaceuticals, Magellan Health Services, Merck & Company, Neuronetics, Novartis Pharmaceuticals, Ono Pharmaceuticals, Organon, Otsuka Pharmaceuticals, Pamlab, Pfizer, Transcept Pharmaceuticals, Urban Institute, and Wyeth Ayerst; speaking fees from Cyberonics Inc, Forest Laboratories, GlaxoSmithKline, and Otsuka; royalties from Guilford Publications and Healthcare Technology Systems; and research support from the National Institute of Mental Health and the Stanley Medical Research Institute. He also reported owning shares of stock in Pfizer.

Funding/Support: This work was supported by grants from the Veterans Integrated Systems Network 17 and the VA North Texas Health Care System Research Corporation, which were used for the design and conduct of the study and collection, management, and analysis of data; and grant P30DK079328 to the University of Texas Southwestern Medical Center O’Brien Kidney Research Core Center (pilot and feasibility awarded to Susan Hedayati, MD), which was used for the analysis and interpretation of data and preparation of the manuscript. This work also was supported by National Institutes of Health grant 2K24DK002818-0 (awarded to Robert Toto, MD), which was used for the preparation and review of the manuscript. Support for Dr Rush was provided by the Rosewood Corporation Chair in Biomedical Science.

Role of the Sponsor: None of the funding agencies had any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or in the preparation, review or approval of the manuscript.

Disclaimer: The views expressed here are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

Previous Presentation: The results of this study were presented in abstract form at the American Society of Nephrology 41st Annual Meeting; November 8, 2008; Philadelphia, Pennsylvania.

Frasure-Smith N, Lespérance F, Talajic M. Depression following myocardial infarction: impact on 6-month survival.  JAMA. 1993;270(15):1819-1825
PubMed   |  Link to Article
Lespérance F, Frasure-Smith N, Talajic M, Bourassa MG. Five-year risk of cardiac mortality in relation to initial severity and one-year changes in depression symptoms after myocardial infarction.  Circulation. 2002;105(9):1049-1053
PubMed   |  Link to Article
Ariyo AA, Haan M, Tangen CM,  et al; Cardiovascular Health Study Collaborative Research Group.  Depressive symptoms and risks of coronary heart disease and mortality in elderly Americans.  Circulation. 2000;102(15):1773-1779
PubMed   |  Link to Article
Hedayati SS, Minhajuddin AT, Toto RD, Morris DW, Rush AJ. Prevalence of major depressive episode in CKD.  Am J Kidney Dis. 2009;54(3):424-432
PubMed   |  Link to Article
National Kidney Foundation.  K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.  Am J Kidney Dis. 2002;39(2):(suppl 1)  S1-S266
PubMed   |  Link to Article
US Renal Data System.  USRDS 2009 Annual Report: Atlas of End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2009
Go AS, Chertow GM, Fan D, McCulloch CE, Hsu C. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.  N Engl J Med. 2004;351(13):1296-1305
PubMed   |  Link to Article
Foley RN, Parfrey PS, Sarnak MJ. Epidemiology of cardiovascular disease in chronic renal disease.  J Am Soc Nephrol. 1998;9(12):(suppl)  S16-S23
PubMed
Heron M, Hoyert DL, Murphy SL, Xu J, Kochanek KD, Tejada-Vera B. Deaths: final data for 2006.  Natl Vital Stat Rep. 2009;57(14):1-134
PubMed
Hedayati SS, Bosworth H, Briley L,  et al.  Death or hospitalization of patients on chronic hemodialysis is associated with a physician-based diagnosis of depression.  Kidney Int. 2008;74(7):930-936
PubMed   |  Link to Article
Hedayati SS, Grambow SC, Szczech LA, Stechuchak KM, Allen AS, Bosworth HB. Physician-diagnosed depression as a correlate of hospitalizations in patients receiving long-term hemodialysis.  Am J Kidney Dis. 2005;46(4):642-649
PubMed   |  Link to Article
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(5):2093-2098
PubMed   |  Link to Article
Lopes AA, Bragg J, Young E,  et al; Dialysis Outcomes and Practice Patterns Study (DOPPS).  Depression as a predictor of mortality and hospitalization among hemodialysis patients in the United States and Europe.  Kidney Int. 2002;62(1):199-207
PubMed   |  Link to Article
Renal Physicians Association.  Appropriate Preparation of the Patient for Renal Replacement Therapy, Clinical Practice Guideline, No. 3. Rockville, MD: Renal Physicians Association; 2002:4-11
Owen WF Jr. Patterns of care for patients with chronic kidney disease in the United States: dying for improvement.  J Am Soc Nephrol. 2003;14(7):(suppl 2)  S76-S80
PubMed   |  Link to Article
American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994
Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D.Modification of Diet in Renal Disease Study Group.  A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation.  Ann Intern Med. 1999;130(6):461-470
PubMed   |  Link to Article
Sheehan DV, Lecrubier Y, Harnett-Sheehan K,  et al.  The validity of the Mini International Neuropsychiatric Interview (MINI) according to the SCID-P and its reliability.  Eur Psychiatry. 1997;12(5):232-241
Link to Article
Sheehan DV, Lecrubier Y, Sheehan KH,  et al.  The Mini International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10 .  J Clin Psychiatry. 1998;59:(suppl 20)  22-33
PubMed
Einwohner R, Bernardini J, Fried L, Piraino B. The effect of depressive symptoms on survival in peritoneal dialysis patients.  Perit Dial Int. 2004;24(3):256-263
PubMed
Zimmermann PR, Camey SA, Mari Jde. A cohort study to assess the impact of depression on patients with kidney disease.  Int J Psychiatry Med. 2006;36(4):457-468
PubMed   |  Link to Article
Troidle L, Watnick S, Wuerth DB, Gorban-Brennan N, Kliger AS, Finkelstein FO. Depression and its association with peritonitis in long-term peritoneal dialysis patients.  Am J Kidney Dis. 2003;42(2):350-354
PubMed   |  Link to Article
Soucie JM, McClellan WM. Early death in dialysis patients: risk factors and impact on incidence and mortality rates.  J Am Soc Nephrol. 1996;7(10):2169-2175
PubMed
Shulman R, Price JDE, Spinelli J. Biopsychosocial aspects of long-term survival on end-stage renal failure therapy.  Psychol Med. 1989;19(4):945-954
PubMed   |  Link to Article
Wai L, Richmond J, Burton H, Lindsay RM. Influence of psychosocial factors on survival of home dialysis patients.  Lancet. 1981;2(8256):1155-1156
PubMed   |  Link to Article
Burton HJ, Kline SA, Lindsay RM, Heidenheim  AP. The relationship of depression to survival in chronic renal failure.  Psychosom Med. 1986;48(3-4):261-269
PubMed
Drayer RA, Piraino B, Reynolds CF III,  et al.  Characteristics of depression in hemodialysis patients: symptoms, quality of life, and mortality risk.  Gen Hosp Psychiatry. 2006;28(4):306-312
PubMed   |  Link to Article
Devins GM, Mann J, Mandin H,  et al.  Psychosocial predictors of survival in end-stage renal disease.  J Nerv Ment Dis. 1990;178(2):127-133
PubMed   |  Link to Article
Christensen AJ, Wiebe JS, Smith TW, Turner CW. Predictors of survival among hemodialysis patients: effects of perceived family support.  Health Psychol. 1994;13(6):521-525
PubMed   |  Link to Article
Hedayati SS, Bosworth HB, Kuchibhatla M, Kimmel PL, Szczech LA. The predictive value of self-report scales compared with physician diagnosis of depression in hemodialysis patients.  Kidney Int. 2006;69(9):1662-1668
PubMed   |  Link to Article
Kimmel PL, Peterson RA. Depression in end-stage renal disease patients treated with hemodialysis: tools, correlates, outcomes, and needs.  Semin Dial. 2005;18(2):91-97
PubMed   |  Link to Article
Hedayati SS, Finkelstein FO. Epidemiology, diagnosis, and management of depression in patients with CKD.  Am J Kidney Dis. 2009;54(4):741-752
PubMed   |  Link to Article
Hedayati SS, Minhajuddin AT, Toto RD, Morris DW, Rush AJ. Validation of depression screening scales in patients with CKD.  Am J Kidney Dis. 2009;54(3):433-439
PubMed   |  Link to Article
National Kidney Foundation.  The facts about chronic kidney disease (CKD). http://www.kidney.org/kidneydisease/ckd/index.cfm. Accessibility verified April 14, 2010
US Renal Data System.  USRDS 2008 Annual Report: Atlas of End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2008
Ziegelstein RC, Fauerbach JA, Stevens SS, Romanelli J, Richter DP, Bush DE. Patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a myocardial infarction.  Arch Intern Med. 2000;160(12):1818-1823
PubMed   |  Link to Article
Everett KD, Brantley PJ, Sletten C, Jones GN, McKnight GT. The relation of stress and depression to interdialytic weight gain in hemodialysis patients.  Behav Med. 1995;21(1):25-30
PubMed   |  Link to Article
Safdar N, Baakza H, Kumar H, Naqvi SA. Non-compliance to diet and fluid restrictions in haemodialysis patients.  J Pak Med Assoc. 1995;45(11):293-295
PubMed
Sensky T, Leger C, Gilmour S. Psychosocial and cognitive factors associated with adherence to dietary and fluid restriction regimens by people on chronic haemodialysis.  Psychother Psychosom. 1996;65(1):36-42
PubMed   |  Link to Article
Kimmel PL, Peterson RA, Weihs KL,  et al.  Psychosocial factors, behavioral compliance and survival in urban hemodialysis patients.  Kidney Int. 1998;54(1):245-254
PubMed   |  Link to Article
Golden SH, Lazo M, Carnethon M,  et al.  Examining a bidirectional association between depressive symptoms and diabetes.  JAMA. 2008;299(23):2751-2759
PubMed   |  Link to Article
Friend R, Hatchett L, Wadhwa NK, Suh H. Serum albumin and depression in end-stage renal disease.  Adv Perit Dial. 1997;13:155-157
PubMed
Koo JR, Yoon JW, Kim SG,  et al.  Association of depression with malnutrition in chronic hemodialysis patients.  Am J Kidney Dis. 2003;41(5):1037-1042
PubMed   |  Link to Article
Bonnet F, Irving K, Terra JL, Nony P, Berthezène F, Moulin P. Anxiety and depression are associated with unhealthy lifestyle in patients at risk of cardiovascular disease.  Atherosclerosis. 2005;178(2):339-344
PubMed   |  Link to Article
Barefoot JC, Burg MM, Carney RM,  et al.  Aspects of social support associated with depression at hospitalization and follow-up assessment among cardiac patients.  J Cardiopulm Rehabil. 2003;23(6):404-412
PubMed   |  Link to Article
Empana JP, Sykes DH, Luc G,  et al.  Contributions of depressive mood and circulating inflammatory markers to coronary heart disease in healthy European men: the Prospective Epidemiological Study of Myocardial Infarction (PRIME).  Circulation. 2005;111(18):2299-2305
PubMed   |  Link to Article
Serebruany VL, Glassman AH, Malinin AI,  et al; Sertraline AntiDepressant Heart Attack Randomized Trial Study Group.  Platelet/endothelial biomarkers in depressed patients treated with the selective serotonin reuptake inhibitor sertraline after acute coronary events: the Sertraline AntiDepressant Heart Attack Randomized Trial (SADHART) Platelet Substudy.  Circulation. 2003;108(8):939-944
PubMed   |  Link to Article
Serebruany VL, Glassman AH, Malinin AI,  et al.  Enhanced platelet/endothelial activation in depressed patients with acute coronary syndromes: evidence from recent clinical trials.  Blood Coagul Fibrinolysis. 2003;14(6):563-567
PubMed   |  Link to Article
Glassman AH, O'Connor CM, Califf RM,  et al; Sertraline Antidepressant Heart Attack Randomized Trial (SADHEART) Group.  Sertraline treatment of major depression in patients with acute MI or unstable angina.  JAMA. 2002;288(6):701-709
PubMed   |  Link to Article
Boulware LE, Liu Y, Fink NE,  et al.  Temporal relation among depression symptoms, cardiovascular disease events, and mortality in end-stage renal disease: contribution of reverse causality.  Clin J Am Soc Nephrol. 2006;1(3):496-504
PubMed   |  Link to Article
Larkin M. Depression screening may be warranted for adults, says US task force.  Lancet. 2002;359(9320):1836
Link to Article

Figures

Place holder to copy figure label and caption
Figure 1. Description of Chronic Kidney Disease Cohort
Graphic Jump Location

GFR indicates glomerular filtration rate; MINI, Mini International Neuropsychiatric Interview.

Place holder to copy figure label and caption
Figure 2. Survival Curves for Outcome Measures
Graphic Jump Location

The composite event is defined as death, hospitalization, or maintenance dialysis initiation. Four patients with missing dates of hospitalization were excluded from the composite event and hospitalization models. One patient with missing event date was excluded from the dialysis model.

Place holder to copy figure label and caption
Figure 3. Adjusted Risks of Events Associated With Major Depressive Episode
Graphic Jump Location

CI indicates confidence interval; CKD, chronic kidney disease; GFR, glomerular filtration rate.

Tables

Table Graphic Jump LocationTable 1. Baseline Characteristics by Depression Statusa

References

Frasure-Smith N, Lespérance F, Talajic M. Depression following myocardial infarction: impact on 6-month survival.  JAMA. 1993;270(15):1819-1825
PubMed   |  Link to Article
Lespérance F, Frasure-Smith N, Talajic M, Bourassa MG. Five-year risk of cardiac mortality in relation to initial severity and one-year changes in depression symptoms after myocardial infarction.  Circulation. 2002;105(9):1049-1053
PubMed   |  Link to Article
Ariyo AA, Haan M, Tangen CM,  et al; Cardiovascular Health Study Collaborative Research Group.  Depressive symptoms and risks of coronary heart disease and mortality in elderly Americans.  Circulation. 2000;102(15):1773-1779
PubMed   |  Link to Article
Hedayati SS, Minhajuddin AT, Toto RD, Morris DW, Rush AJ. Prevalence of major depressive episode in CKD.  Am J Kidney Dis. 2009;54(3):424-432
PubMed   |  Link to Article
National Kidney Foundation.  K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.  Am J Kidney Dis. 2002;39(2):(suppl 1)  S1-S266
PubMed   |  Link to Article
US Renal Data System.  USRDS 2009 Annual Report: Atlas of End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2009
Go AS, Chertow GM, Fan D, McCulloch CE, Hsu C. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.  N Engl J Med. 2004;351(13):1296-1305
PubMed   |  Link to Article
Foley RN, Parfrey PS, Sarnak MJ. Epidemiology of cardiovascular disease in chronic renal disease.  J Am Soc Nephrol. 1998;9(12):(suppl)  S16-S23
PubMed
Heron M, Hoyert DL, Murphy SL, Xu J, Kochanek KD, Tejada-Vera B. Deaths: final data for 2006.  Natl Vital Stat Rep. 2009;57(14):1-134
PubMed
Hedayati SS, Bosworth H, Briley L,  et al.  Death or hospitalization of patients on chronic hemodialysis is associated with a physician-based diagnosis of depression.  Kidney Int. 2008;74(7):930-936
PubMed   |  Link to Article
Hedayati SS, Grambow SC, Szczech LA, Stechuchak KM, Allen AS, Bosworth HB. Physician-diagnosed depression as a correlate of hospitalizations in patients receiving long-term hemodialysis.  Am J Kidney Dis. 2005;46(4):642-649
PubMed   |  Link to Article
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(5):2093-2098
PubMed   |  Link to Article
Lopes AA, Bragg J, Young E,  et al; Dialysis Outcomes and Practice Patterns Study (DOPPS).  Depression as a predictor of mortality and hospitalization among hemodialysis patients in the United States and Europe.  Kidney Int. 2002;62(1):199-207
PubMed   |  Link to Article
Renal Physicians Association.  Appropriate Preparation of the Patient for Renal Replacement Therapy, Clinical Practice Guideline, No. 3. Rockville, MD: Renal Physicians Association; 2002:4-11
Owen WF Jr. Patterns of care for patients with chronic kidney disease in the United States: dying for improvement.  J Am Soc Nephrol. 2003;14(7):(suppl 2)  S76-S80
PubMed   |  Link to Article
American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994
Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D.Modification of Diet in Renal Disease Study Group.  A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation.  Ann Intern Med. 1999;130(6):461-470
PubMed   |  Link to Article
Sheehan DV, Lecrubier Y, Harnett-Sheehan K,  et al.  The validity of the Mini International Neuropsychiatric Interview (MINI) according to the SCID-P and its reliability.  Eur Psychiatry. 1997;12(5):232-241
Link to Article
Sheehan DV, Lecrubier Y, Sheehan KH,  et al.  The Mini International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10 .  J Clin Psychiatry. 1998;59:(suppl 20)  22-33
PubMed
Einwohner R, Bernardini J, Fried L, Piraino B. The effect of depressive symptoms on survival in peritoneal dialysis patients.  Perit Dial Int. 2004;24(3):256-263
PubMed
Zimmermann PR, Camey SA, Mari Jde. A cohort study to assess the impact of depression on patients with kidney disease.  Int J Psychiatry Med. 2006;36(4):457-468
PubMed   |  Link to Article
Troidle L, Watnick S, Wuerth DB, Gorban-Brennan N, Kliger AS, Finkelstein FO. Depression and its association with peritonitis in long-term peritoneal dialysis patients.  Am J Kidney Dis. 2003;42(2):350-354
PubMed   |  Link to Article
Soucie JM, McClellan WM. Early death in dialysis patients: risk factors and impact on incidence and mortality rates.  J Am Soc Nephrol. 1996;7(10):2169-2175
PubMed
Shulman R, Price JDE, Spinelli J. Biopsychosocial aspects of long-term survival on end-stage renal failure therapy.  Psychol Med. 1989;19(4):945-954
PubMed   |  Link to Article
Wai L, Richmond J, Burton H, Lindsay RM. Influence of psychosocial factors on survival of home dialysis patients.  Lancet. 1981;2(8256):1155-1156
PubMed   |  Link to Article
Burton HJ, Kline SA, Lindsay RM, Heidenheim  AP. The relationship of depression to survival in chronic renal failure.  Psychosom Med. 1986;48(3-4):261-269
PubMed
Drayer RA, Piraino B, Reynolds CF III,  et al.  Characteristics of depression in hemodialysis patients: symptoms, quality of life, and mortality risk.  Gen Hosp Psychiatry. 2006;28(4):306-312
PubMed   |  Link to Article
Devins GM, Mann J, Mandin H,  et al.  Psychosocial predictors of survival in end-stage renal disease.  J Nerv Ment Dis. 1990;178(2):127-133
PubMed   |  Link to Article
Christensen AJ, Wiebe JS, Smith TW, Turner CW. Predictors of survival among hemodialysis patients: effects of perceived family support.  Health Psychol. 1994;13(6):521-525
PubMed   |  Link to Article
Hedayati SS, Bosworth HB, Kuchibhatla M, Kimmel PL, Szczech LA. The predictive value of self-report scales compared with physician diagnosis of depression in hemodialysis patients.  Kidney Int. 2006;69(9):1662-1668
PubMed   |  Link to Article
Kimmel PL, Peterson RA. Depression in end-stage renal disease patients treated with hemodialysis: tools, correlates, outcomes, and needs.  Semin Dial. 2005;18(2):91-97
PubMed   |  Link to Article
Hedayati SS, Finkelstein FO. Epidemiology, diagnosis, and management of depression in patients with CKD.  Am J Kidney Dis. 2009;54(4):741-752
PubMed   |  Link to Article
Hedayati SS, Minhajuddin AT, Toto RD, Morris DW, Rush AJ. Validation of depression screening scales in patients with CKD.  Am J Kidney Dis. 2009;54(3):433-439
PubMed   |  Link to Article
National Kidney Foundation.  The facts about chronic kidney disease (CKD). http://www.kidney.org/kidneydisease/ckd/index.cfm. Accessibility verified April 14, 2010
US Renal Data System.  USRDS 2008 Annual Report: Atlas of End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2008
Ziegelstein RC, Fauerbach JA, Stevens SS, Romanelli J, Richter DP, Bush DE. Patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a myocardial infarction.  Arch Intern Med. 2000;160(12):1818-1823
PubMed   |  Link to Article
Everett KD, Brantley PJ, Sletten C, Jones GN, McKnight GT. The relation of stress and depression to interdialytic weight gain in hemodialysis patients.  Behav Med. 1995;21(1):25-30
PubMed   |  Link to Article
Safdar N, Baakza H, Kumar H, Naqvi SA. Non-compliance to diet and fluid restrictions in haemodialysis patients.  J Pak Med Assoc. 1995;45(11):293-295
PubMed
Sensky T, Leger C, Gilmour S. Psychosocial and cognitive factors associated with adherence to dietary and fluid restriction regimens by people on chronic haemodialysis.  Psychother Psychosom. 1996;65(1):36-42
PubMed   |  Link to Article
Kimmel PL, Peterson RA, Weihs KL,  et al.  Psychosocial factors, behavioral compliance and survival in urban hemodialysis patients.  Kidney Int. 1998;54(1):245-254
PubMed   |  Link to Article
Golden SH, Lazo M, Carnethon M,  et al.  Examining a bidirectional association between depressive symptoms and diabetes.  JAMA. 2008;299(23):2751-2759
PubMed   |  Link to Article
Friend R, Hatchett L, Wadhwa NK, Suh H. Serum albumin and depression in end-stage renal disease.  Adv Perit Dial. 1997;13:155-157
PubMed
Koo JR, Yoon JW, Kim SG,  et al.  Association of depression with malnutrition in chronic hemodialysis patients.  Am J Kidney Dis. 2003;41(5):1037-1042
PubMed   |  Link to Article
Bonnet F, Irving K, Terra JL, Nony P, Berthezène F, Moulin P. Anxiety and depression are associated with unhealthy lifestyle in patients at risk of cardiovascular disease.  Atherosclerosis. 2005;178(2):339-344
PubMed   |  Link to Article
Barefoot JC, Burg MM, Carney RM,  et al.  Aspects of social support associated with depression at hospitalization and follow-up assessment among cardiac patients.  J Cardiopulm Rehabil. 2003;23(6):404-412
PubMed   |  Link to Article
Empana JP, Sykes DH, Luc G,  et al.  Contributions of depressive mood and circulating inflammatory markers to coronary heart disease in healthy European men: the Prospective Epidemiological Study of Myocardial Infarction (PRIME).  Circulation. 2005;111(18):2299-2305
PubMed   |  Link to Article
Serebruany VL, Glassman AH, Malinin AI,  et al; Sertraline AntiDepressant Heart Attack Randomized Trial Study Group.  Platelet/endothelial biomarkers in depressed patients treated with the selective serotonin reuptake inhibitor sertraline after acute coronary events: the Sertraline AntiDepressant Heart Attack Randomized Trial (SADHART) Platelet Substudy.  Circulation. 2003;108(8):939-944
PubMed   |  Link to Article
Serebruany VL, Glassman AH, Malinin AI,  et al.  Enhanced platelet/endothelial activation in depressed patients with acute coronary syndromes: evidence from recent clinical trials.  Blood Coagul Fibrinolysis. 2003;14(6):563-567
PubMed   |  Link to Article
Glassman AH, O'Connor CM, Califf RM,  et al; Sertraline Antidepressant Heart Attack Randomized Trial (SADHEART) Group.  Sertraline treatment of major depression in patients with acute MI or unstable angina.  JAMA. 2002;288(6):701-709
PubMed   |  Link to Article
Boulware LE, Liu Y, Fink NE,  et al.  Temporal relation among depression symptoms, cardiovascular disease events, and mortality in end-stage renal disease: contribution of reverse causality.  Clin J Am Soc Nephrol. 2006;1(3):496-504
PubMed   |  Link to Article
Larkin M. Depression screening may be warranted for adults, says US task force.  Lancet. 2002;359(9320):1836
Link to Article

Letters

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 37

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
JAMAevidence.com

Care at the Close of Life EDUCATION GUIDES
Practical Considerations in Dialysis Withdrawal


Hemodialysis