Searches of the 2 indices revealed 152 articles; 145 were excluded based on the title/abstract. One additional article was found using intensive hemodialysis AND depression in PubMed and included in this study; 3 articles published within the last 5 years were excluded because the primary purpose did not include depression. Ultimately, this review included 8 research articles. None of the studies included patients who had wounds.
Prevalence of depression in adults with ESRD and hemodialysis. Recent research about the occurrence of depression in persons on hemodialysis includes the cross-sectional study by Silva Junior et al,7 who investigated the rates of depression among patients (N = 148) who were treated for ESRD using hemodialysis for a mean of 5.3 years in Brazil. Using the Beck Depression Inventory II8 as the diagnostic tool, depression was noted in 68% of patients. Mild (49.5%) and moderate (41.5%) depression were the most common forms; 9% of patients were severely depressed and only 15.5% of these were previously diagnosed. For most, depression commenced after starting maintenance hemodialysis, underscoring the correlation between maintenance hemodialysis and depression. Many (54.5%) patients were treated using antidepressants or benzodiazepines. Antidepressants were effective in reducing depression symptomology in >80%. The authors concluded depression often is missed in this population; routine screening for depression and its treatment in patients receiving chronic dialysis is important.
In their cross-sectional, correlational study, Khalil and Abed9 examined whether perceived social support mediated depressive symptoms/quality of life for Jordanian patients (N = 190) with ESRD. Using the Brief Symptom Inventory Depression Subscale and Quality of Life Index,10 83% of the surveyed patients had depressive symptoms. Depression was significantly associated with decreased quality of life. Depression is a stigma in the Jordanian culture, reflecting the importance of culture when diagnosing depression. The authors noted the importance of using a standardized method for depression screening. All practitioners need to be involved in the diagnosis of depression.
Using a cross-sectional design, Santos et al11 investigated the occurrence of depression, quality of life, and religious coping in 161 Brazilian adults undergoing maintenance hemodialysis. Diagnostic/assessment instruments used included the Center for Epidemiologic Studies Depression Scale,12 Medical Outcomes Study 36-item Short Form Survey,13 and the Religious Coping Questionnaire.14 The prevalence of depression was 27.3%. Seeking religious direction and counsel from God were the spiritual/religious coping methods that were associated with lower depression and higher quality of life. Patients who used negative religious coping, such as blaming God for their illness, were more likely to be depressed. The authors encouraged practitioners to assess their patients’ religious/spiritual beliefs as affecting coping and to provide religious/spiritual resources as needed.
Ng et al15 longitudinally measured how depression and anxiety fluctuated over 12 months for patients (N = 159) with ESRD on hemodialysis in Singapore. Using the Hospital Anxiety and Depression Scale and the Kidney Disease QoL-Short Form16,17 to measure depression and quality of participant’s social interactions, depression was found to be present in >50% of included participants. Depression, whether apparent at baseline or as new onset, remained unchanged throughout the 12-month course of the study. Participants had lower perceptions of social connections; these lower perceptions increased their risk of depression and anxiety.
In their cross-sectional design study, Rajan and Subramanian3 explored activity performance (eg, exercise) and how it is influenced by depression and anxiety in Indian patients (N = 50) with ESRD and hemodialysis. The authors used the Beck Depression Inventory II and Beck Anxiety Inventory scales to measure depression and anxiety.18,19 Performance was measured using the Karnofsky Performance Status Scale, even though this scale is more commonly used with cancer patients.20 The authors reported a strong concordance (.40) between depression and anxiety and their influence on decreased performance status (-.65 and -.64, respectively). Furthermore, the authors suggested physical activity is a viable intervention for improving quality of life for patients with ESRD.
In their retrospective review of ~5 million hospitalized adults with ESRD on hemodialysis from 2005 to 2013, Chan et al2 examined gaps in knowledge surrounding depression in hospitalized ESRD patients in the United States. In the 2-group comparison — one group with and the other without depression — depression was a concurrent diagnosis for 9.3% of individuals across the years 2005–2013 and increased from 5.01% to 11.78%. Depression was most prevalent among younger, Caucasian women who had more concurrent diagnoses verses patients with fewer additional diagnosis. (ie, the more concurrent diagnoses, the higher the prevalence of depression). The cost of care was similar for patients with depression compared to those without, even though their hospital stays were longer. In addition, the authors found a decline in mortality rates associated with depression, possibly because the sicker the patient, the less likely a diagnosis of depression.2
Yoong et al21 pooled data (N = 526) from 2 controlled (1 randomized) studies in Singapore to compare depression and anxiety in patients with ESRD and hemodialysis as well as patients with (59%) and without (31%) diabetes. Depression (49.9%) and anxiety (45.4%) were elevated and did not differ between patients with and without diabetes. Higher depression rates had a stronger relationship to sociocultural variables than to comorbidities. The authors recommended monitoring depression and anxiety in hemodialysis care and to implement appropriate treatment.
In a randomized controlled trial (N = 332) conducted among patients in the US and Canada, Unruh et al22 explored the effects on depression of in-center intensive (short daily and nocturnal) hemodialysis over a 12-month period. Using the Beck Depression Inventory Scale8 and RAND 36-item Health Survey23 to measure depression and physical health, depressive symptoms did not differ between patients having intensive hemodialysis and in-center hemodialysis; however, intensive hemodialysis improved self-reported mental health, energy, and emotional state. Participant attrition due to death and transplant thwarted the ability to investigate the benefits of nocturnal dialysis, although a nonsignificant decrease in depression scores was reported in this group. Even though this study was randomized, disparate sample sizes between the nocturnal group and the short daily or conventional group limited comparing results.
In summary, depression is common in persons receiving hemodialysis for ESRD and ranged from 9.3%2 to 83%.9 The studies reviewed were international (Brazil, Jordan, Singapore, India, and US)2,3,7,9,11,15,21; most had small sample sizes ranging from 50 to 190. Studies often included other variables such as anxiety, comorbidities, hospitalization, quality of life, well-being, physical performance, and religion.2,3,7,9,11,15,21 No study stated if a patient had a wound. If a wound was present, it is not known how it affected depression. Providers in all clinical settings need to be cognizant of depression in persons receiving hemodialysis.
Wounds in ESRD patients receiving dialysis. Individuals with ESRD receiving hemodialysis are at risk for both surgical and chronic wounds. Otte et al24 retrospectively examined the risk of ulcers in persons with ESRD and hemodialysis treatment in the Netherlands. The analysis compared 3 groups: patients with CKD Stage 3 with an estimated glomerular filtration rate (eGFR) between 59 and 30 without dialysis treatment for >3 months (n = 539); patients with CKD Stage 4-5 with an eGFR <30 without dialysis treatment for >3 months (n = 540); and patients receiving peritoneal or hemodialysis treatment (n = 259). The incidence of foot ulceration was 4 times greater in the CDK Stage 4-5 group and 8-fold greater in the dialysis treatment group versus the CDK Stage 3 group. These increases occurred even after controlling for risk factors such as diabetes. These patients had high rates of amputation and mortality,24 data that were supported by other retrospective research.25 The authors concluded that maximum effort is needed in foot care and preventive practices for patients with CDK Stage 4-5 and dialysis.
Orimoto et al25 retrospectively examined the prognosis of Japanese patients (N = 234) who had hemodialysis and a foot ulcer; 84% had diabetes. Surgery included arterial reconstruction (88 limbs) and amputation (119 limbs). Overall, the 5-year limb salvage rate was 53.8%. Risk of death increased with ischemic changes on an electrocardiogram and age on admission. The 5-year survival rate of patients on hemodialysis with foot lesions was 23%, which was worse than lung (29%), stomach (64%), or breast (88%) cancer, to name a few; it was only better than pancreatic cancer (6%). The authors concluded patients with foot lesions receiving hemodialysis have a poor prognosis.
Meloni et al26 retrospectively examined people with diabetes receiving (n = 99) and not receiving (n = 500) hemodialysis in Italy. Dialysis was a negative predictor of healing (dialysis, 30.3% vs not on hemodialysis, 52.6% healed) and positively associated with amputation (14.4% vs 10.8%) and death (21.1% vs 11%). The authors concluded adults on hemodialysis should be considered a special category of patients, such as patients with diabetes, who would need intensive foot care and vascular disease management.
In their prospective, observational design study, Jones et al27 explored the prevalence of risk factors for lower extremity ulcerations in patients (N = 57) receiving hemodialysis and compared these risk factors in patients with (n = 24) and without (n = 33) diabetes in the UK. Risk factors included peripheral neuropathy, peripheral arterial disease, and foot pathology; 2 or more risk factors were found in 28 patients (16 with and 12 patients without diabetes). Only 7 patients (12%) had no risk factors. The initiation of hemodialysis in persons with diabetes was associated with a 3-fold risk of new ulceration in the first year of dialysis treatment. The findings of a descriptive, cross-sectional study by Kaminski et al28 were similar for adults on hemodialysis (N = 450); this sample included persons with diabetes (50.2%,) previous ulceration (21.6%), amputation (10.2%), and current foot ulcers (10%); 50% had neuropathy and/or peripheral arterial disease. Factors associated with ulceration were previous amputation, peripheral arterial disease, and low serum albumin. The authors concluded persons on hemodialysis have a high burden of lower limb complications.
Wound healing also has been found to be negatively affected by ESRD and hemodialysis. In the comparative study of 2 groups (receiving hemodialysis or not) undergoing endovascular therapy for critical limb ischemia conducted by Honda et al29 among 267 adults in Australia, wound healing rates were significantly lower (79.5% vs 92.4%; P <.001) and time to heal (132 days vs 82 days; P = .005) was significantly longer in patients receiving hemodialysis versus those not on the therapy. Wound recurrence (25% vs 10.2%; P = .007) also was more common in persons undergoing hemodialysis. The authors concluded hemodialysis was an independent predictor of wound healing.
The systematic review and meta-analysis of risk factors for foot ulceration and lower extremity amputation in adults with ESRD receiving hemodialysis by Kaminski et al4 found 30 studies and identified the following risk factors: previous foot ulcers, peripheral arterial disease, diabetes, peripheral neuropathy, and coronary artery disease. The authors concluded adults receiving hemodialysis are at higher risk for foot ulceration and amputation. Scholnick30 reviewed the effects of renal disease on wound healing and reported peripheral arterial disease, uremic neuropathy, immunosuppression, dermatologic disorders in renal disease (calciphylaxis), Charcot, and poor self-care negatively affect healing. Maroz and Simman5 also published a review that found risk factors for poor wound healing included diabetes, neuropathy, peripheral arterial disease, chronic venous insufficiency, uremic toxins, and aging.
In summary, hemodialysis appears to be an independent risk factor for ulcer development, poor healing, and amputation even when patients do not have diabetes. Also, adults who have a foot ulcer and are on dialysis have a poor prognosis. Although lower extremity amputations have decreased 51% for patients with ESRD from 2000 to 2014, they still occurred at the rate of 2.66 per 100 person-years in 2014.31 Patients receiving hemodialysis, regardless of the presence of diabetes, need a concerted and focused effort in preventive foot care practices.
Wounds and depression. Adults with ESRD and hemodialysis are at high risk for depression; a wound can add to a person’s depression risk. The integrative review found wounds were not discussed in any of the studies reported. Thus, depression associated with wounds was explored in a general manner across varied wound types. In their systematic review of 23 studies on the impact of chronic venous leg ulcers, Green et al32 reported depression was common. In their secondary data analyses, Edwards et al33 found 2 symptom clusters in patients (N = 318) with chronic venous ulcers2: one noted depression with pain, sleep disturbance, and fatigue. As part of secondary data analyses of outpatients, Bui et al34 examined 561 patients with chronic leg ulcers to identify risk factors associated with infection. Venous ulcers accounted for 388 (74%) of the leg ulcers; depression was 1 of 7 factors independently associated with a leg ulcer infection (odds ratio = 2.78; P <.035).
In their descriptive study, Souza Nogueira et al35 assessed depression in 30 adults with venous ulcers. Depression was identified in 40% of these patients; it was not significantly related to other sociodemographic variables. The authors concluded depression could occur independent of socioeconomic variables for patients with chronic venous ulcers.
In a cross-sectional study, Zhou and Jia36 examined depressive symptoms in patients (N = 222) with either venous or nonvenous leg ulcers. Minimal to severe depressive symptoms were present in 81.5% of patients. A positive depression screen was more common in patients suffering from wounds for >90 days’ duration and who had pain. The authors concluded depressive symptoms were common in patients with wounds and recommended clinicians carefully consider a patient’s mental status when caring for a person with leg ulcers. In their prospective, observational study, Walburn et al37 examined the effects of stress, illness perception, and behavior on venous ulcer healing for 63 adults followed for 24 weeks. Controlling for sociodemographic and clinical variables, a slower change in ulcer area was associated with greater stress, depression, and negative perceptions/beliefs about the ulcer, leading the authors to conclude psychological factors should be examined with wound healing.
Udovichenko et al38 assessed depression in outpatients (N = 285) with diabetic foot ulcers as part of a prevalence study on depression and diabetic foot ulcers. Depression was present in 39% of included patients. Fortunately, adults with depression did not have poorer ulcer treatment results. When Ahmad et al39 examined depression and anxiety among Jordanian adults (N = 260) with diabetic foot ulcers, prevalence of depression and anxiety were found to be 39.6% and 37.7%, respectively. Depression was associated with age <50 years old, female gender, currently smoking, foot ulcer present >7 months, and >3 comorbidities than those without depression. The authors did not examine the effect of depression on wound healing. Both studies highlight the importance of psychosocial factors with wounds.
In summary, a high percentage of persons with wounds are depressed. Unfortunately, literature about depression and wounds and ESRD could not be found. The most common wound types where depression was explored were chronic venous ulcers and diabetic foot ulcers. Depression may be a factor of the duration of the wound as well as the psychosocial implications of having a wound such as shame, embarrassment, and loneliness. Thus, having a wound is another reason to assess for depression in persons with ESRD and hemodialysis.