Mental Health: Global Challenges Journal
https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138
Letter to Editor
Mental health disorders in patients with end-stage
renal failure
Maria Karastathi-Asimakopoulou1, Anna Loudovikou2
1 University of Crete, Faculty of Medicine, Heraklion, Greece
2 Aristotle University of Thessaloniki, School of Philosophy, Thessaloniki, Greece
Address for correspondence:
Maria Karastathi-Asimakopoulou, University of Crete, Faculty of Medicine, Andrea
Kalokairinou 13, Giofyrakia, 71500, Heraklion, Greece, mariakarasta8i@gmail.com
This work is licensed under a Creative Commons Attribution-Non-Commercial 4.0 International
License (CC BY-NC 4.0).
©Copyright: Karastathi-Asimakopoulou, Loudovikou 2022
Publisher: Sciendo (De Gruyter)
DOI: https://doi.org/10.56508/mhgcj.v5i2.146
Submitted for publication: 12
July 2022
Revised: 20 August 2022
Accepted for publication: 28
August 2022
Introduction
Approximately 10-15% of the global population
suffers from chronic kidney disease. Its principal
causes include diabetes mellitus and
hypertension, two highly prevalent non –
communicable diseases affecting billions of
people worldwide. End-stage kidney disease, also
known as kidney failure, is the fifth and final stage
in the progression of chronic kidney disease.
Chronic renal failure is a progressive and
irreversible deterioration of renal function. Patients
with this grade of kidney disease cannot survive
without dialysis or a kidney transplant. The
management of this condition entails regular
hemodialysis sessions, dietary restrictions and
recurrent hospitalizations to treat infections,
electrolyte disorders and other kidney disease –
related complications (Goh et.al., 2018). Patients
with renal failure tend to have limited
independence and functionality. This conundrum
affects their quality of life and has a dire impact on
their mental health (Stavropoulou et.al. 2017)
Mental health is a vital component of individual
health and wellbeing. Its presence or absence
reflects on everything people do, think, or say.
This is particularly important for people with renal
failure, the majority of whom are hospitalized with
a primary or recondary diagnosis of a mental
disorder. More than one fifth of these patients had
two or more psychiatric diagnoses. Patients with
end-stage kidney disease experience a higher
rate of mental illness than the general adult
population. Beyond depression, patients might
experience a myriad of psychological distress
symptoms including anxiety and fear of chronic
kidney disease progression (concerns about
hopelessness, death, and dying) (Goh et.al.,
2018). They also might experience recurrent
psychological and physical trauma during the
Mental Health: Global Challenges Journal
https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138
chronic kidney disease course. The most frequent
mental illness in this population is anxiety
(20.0%), followed by depression (16.8%), stress
reaction/adjustment disorder (2.5%),
somatoform/conversion disorder (0.9%), and
substance abuse disorder (0.6%).Studies have
shown that patients with chronic kidney failure
experience a high level of emotional distress even
in the early stages of disease progression, and in
most of them, they have low feelings of personal
control (Stavropoulou et.al. 2017).
The burden of the disease and its behavioral
implications have always been considered as
principal contributors to psychological distress and
disorders (Stavropoulou et.al. 2017). However,
emerging research shows that a host of
biochemical and immunological mechanisms can
also play an important role in the development
and the progression of mental health conditions
among patients with renal failure. These
mechanisms may mediate the translation of the
social and behavioral burden of the disease in
psychological stress or may contribute
independently to the development of mental
health disorders.
Purpose
This paper provides an overview of biological
mechanisms that may contribute to the
development or the progression of mental health
disorders among patients with end stage kidney
disease.
Methodology
To identify relevant peer-reviewed publications
and gray literature the authors searched PubMed-
Medline and Cochrane Library-Cochrane Central
Register of Controlled Trials (Central) till June 31,
2022.The reference lists of the selected sources
and relevant systematic reviews were also hand -
searched to identify potentially relevant resources.
The search terms: Mentlal health,chronic kidney
disease,renal failure,depression,COVID-19,were
used in combination with Boolean
operators(AND,OR) when appropriate.Studies,
were included if they fulfilled all the following
eligibility criteria: (1) ongoing or published clinical
studies reporting on digital and remote healthcare
applications in the prevention or management of
mental health in endstage chronic failure and (2)
study types: editorials, opinion articles,
perspectives,letters to the editor. No sample size
restriction was applied when screening for eligible
studies.
Results and limitations
For decades it has been known that
immunologic factors have potent influences on
neurotrasmitter metabolism and neuroendocrine
function.A growing number of studies have
investigated the relatioships between cytokines
and depression.Depression is the most common
psychological disorder among patients with end-
stage renal disease (Chen et.al.,2003; Palmer
et.al.,2013). The etiology of dialysis-related
depression is multifactorial and is related to
biological ,psychological ,and social
mechanisms.Some of the biological mechanisms
include increased cytokine levels ,genetic
predisposition ,and neurotrasmitters affected by
uremia.During hemodialysis ,the blood dialyzer
interaction has the potential to activate
mononuclear and denditic cells ,leading to
production of inflammatory cytokines.In particular
,there is evidence that depression is associated
with interleukin (IL-1),(IL-6) (Kamimura et.al.,
2007; Pereira et.al.,1994) tumor necrosis factor
alpha (TNF-a) and C-reactive protein (CRP) (
Hirotsu et.al.,2011). It has been speculated that
proinflammatory cytokines play a role in the
pathogenesis of depression and growing evidence
suggests that the mood disorder is associated
with inflammation (Dantzer et.al., 2004). In several
studies, it was also shown that there is a positive
relation between depression and proinflammatory
cytokines and C-reactive protein (CRP)
(Panagiotakos et.al.,2004), and also the
alterations of cytokines in hemodialysis (HD) may
be related to depression. Furthermore, an
additional study showed that serum
proinflammatory cytokine levels in end-stage renal
disease patients were 10 times higher than in the
normal population (Heimburger et.al., 2000).
However, the repeatability of these results is yet
to be determined, with conflicting evidence being
reported in some occasions. Many factors may
explain these conflicting results, including
variability in age, gender, nationality, and
methodological differences in the measurement of
cytokine concentrations.
Other researches have demonstrated frequent
and close relatioships between serum albumin
levels and depression. Cytokines production,
particulary IL-6, might induce protein catabolism
and lipolysis ,but cytokines have a strong negative
correlation with serum albumin levels
.However,malnutrition ,which is commonly
observed in dialysis patients ,is related to chronic
inflammation .It has also been reported that
malnutrition is associated with emotional
symptoms among hemodialysis
patients.Thus,chronic inflammation and
malnutrition might result in fatique by either
directly activating the central nervous system
throught adrenal axis or by indirectly triggering
multisystem deregylation ( Friedman et.al.,2010).
Mental Health: Global Challenges Journal
https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138
Figure 1 Τhe biochemical and
immunological underpinnings of mental health
disorders in renal failure are summarized
Accordingly, reduced kidney function has been
independently associated with worse
microstructural integrity of brain white matter, as
evaluated by diffusion tensor imaging magnetic
resonance imaging. Also, albuminuria has been
associated with larger white matter volume and
decreased estimated GFR with higher cerebral
blood flow in nondiabetic hypertensive adults.
Although subclinical cerebrovascular damage in
chronic kidney disease can be easily detected by
MRI, this is not performed routinely in clinical
practice. In addition, studies about this issue are
still scarce. It is important to understand the
mechanisms shared by renal impairment and
brain dysfunction in order to minimize the risk for
future neuropsychiatric conditions due to chronic
kidney disease (Sedaghat et.al., 2015; Tamura
et.al., 2016).
During the last two years, the COVID-19
pandemic has affected the lives of all people,
especially people living with kidney disease. New
challenges and fears surrounding the pandemic
can increase the stress and anxiety (Rayan et.al.,
2021). For patients that go to a dialysis center for
treatment, this can increase their stress and
anxiety of being exposed to COVID-19. If they
have a transplant, they may have a weakened
immune system and fear complications of getting
infected with COVID-19.Social distancing may
also increase feelings of loneliness and isolation.
(Romash et.al., 2020; 2022). We don't have to
forget that suicide is the most serious result of
mental illness among the patients,and the
percentage of suicide attemption have increased
dramatically since the beginning of the COVID-19
pandemic (Reger et.al., 2020)..
Conclusions
To conclude, the prevalence of mental
instability and psychiatric disorder among patients
with chronic kidney disease can be as high as
100%, depending on the diagnosis criteria and the
studied population. The prevalence of depression
and the risk of hospitalization due to psychiatric
disturbances are higher in patients with renal
failure, thus the individual health professionals
and national and international health bodies need
to consider new ways to protect these patient from
the psychological sequelae of chronic kidney
disease. Some examples are the provision of
psychological support by experienced mental
healthcare workers (physicians, psychologists,
community nurses, social workers) throughout the
patients’ treatment. Collaboration between
individual healthcare workers and facilities and
scientific and professional societies is needed in
order to integrate mental health support to the
standard of care and bring quality improvement to
relevant practices that have been already
implemented. In the long term, it is worthwhile to
investigate whether elements of the reported
biochemical and immunological evidence can be
used as biomarkers or therapeutic targets. This
can help devise personalized treatment strategies
for mental health conditions developing along the
progression of kidney disease.
Conflict of interest
The authors declare that they have no conflicts
of interest.
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