Psychiatric Illness Tied to Mortality in Patients With ESRD

Nicola M. Parry, DV

August 23, 2019

Psychiatric illnesses are common in children and adults with end-stage renal disease (ESRD) who are receiving dialysis, according to a study published online August 22 in the Clinical Journal of the American Society of Nephrology.

"In all adults, primary and secondary psychiatric diagnoses during hospitalization within 1 year of dialysis initiation were associated with 29% and 11% higher hazards of death, respectively," write Paul Kimmel, MD, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, and colleagues.

Although psychiatric illnesses are considered common among patients with ESRD, their true prevalence remains unknown.

With this in mind, Kimmel and colleagues conducted a study to investigate the burden of hospitalizations with psychiatric diagnoses and how they affect mortality among patients with ESRD who are receiving dialysis.

Using Part A Medicare inpatient claims data, they identified 9196 children (21 years old or younger), 398,418 adults aged 22 to 64 years, and 626,344 elderly adults aged 65 years or older, with ESRD who initiated dialysis between 1996 and 2013.

The researchers found that most patients (72% of elderly adults, 66% of adults, and 64% of children) underwent at least one hospitalization during their first year of treatment for ESRD.

Although only approximately 2% of all adults and 1% of children had been hospitalized with a primary psychiatric diagnosis, these amounted to a large number of patients (9058 elderly adults, 8570 middle-aged adults, and 122 children).

Adults (3%) and children (4%) were most commonly diagnosed with depression/affective disorders, whereas elderly adults (3%) were most commonly diagnosed with organic disorders/dementias (3%).

During the study, 19% of elderly adults, 25% of adults, and 15% of children were also hospitalized with a secondary psychiatric diagnosis.

The researchers also found that the rate of hospitalizations with psychiatric diagnoses increased over the course of the study period, predominantly attributed to secondary diagnoses.

In the adult population, these rates more than doubled from 1996 to 2013, rising from 19% to 40% among adults, and from 17% to 39% among elderly adults.

After adjusting for demographic characteristics, comorbidities, and other confounding variables, the researchers found that hospitalizations of adults with psychiatric diagnoses within 1 year of dialysis initiation were linked to higher mortality than those of adults without psychiatric diagnoses.

The adjusted hazard ratio for all-cause death was 1.29 (1.26 - 1.32) among adults hospitalized with a primary psychiatric diagnosis, and 1.11 (1.10 - 1.12) among those hospitalized with a secondary psychiatric diagnosis.

The authors suggest that this study likely underestimates the true burden of psychiatric illnesses within this patient population.

"[C]linicians who care for hospitalized dialysis patients should be aware of and prepared to manage psychiatric disorders and associated negative outcomes within these populations," Kimmel and colleagues emphasize.

In an accompanying editorial, Michael J. Fischer, MD, MSPH, and James P. Lash, MD, both from the University of Illinois at Chicago, stress that this study highlights that the nephrology community has a significant responsibility to help manage psychiatric illness in these patients.

And while the results demonstrate the growing burden of psychiatric illness in patients with ESRD, the editorialists note that its true prevalence is undoubtedly even higher because this particular study included only inpatient diagnoses.

"To achieve meaningful progress for this high-risk population, it will be necessary to improve the understanding of the causes of psychiatric illness, the engagement of health professionals with psychiatric expertise, and the implementation of effective treatment strategies that are acceptable to patients," Fischer and Lash conclude.

This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases. One author has reported being an editor of a textbook published by Elsevier, Chronic Renal Disease. Another author has reported serving as the Steering Committee Chair for the APOLLO study. The remaining authors and editorialists have reported no relevant financial relationships.

Clin J Am Soc Nephrol. Published online August 22, 2019. Study, Editorial

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