In its advanced stage, chronic kidney disease is characterized by a series of physical symptoms, as well as the need to resort to highly invasive and demanding therapeutic techniques, which cause substantial modifications in the patient's lifestyle. All these conditions contribute significantly to the deterioration of the quality of life of affected patients [2].

Although there is currently no definitive cure, there are therapeutic options to replace renal function, such as hemodialysis (HD), peritoneal dialysis (PD) and kidney transplantation (KT), which can prolong the patient's life [3].

These treatments have different impacts on the quality of life, the general health of the patient and the health system, since they require continuous monitoring, specialized medical resources and long-term follow-ups.

DEPRESSION AS A PREVALENT DISORDER AND ITS CLINICAL RELEVANCE

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [4], a depressive disorder should be diagnosed when a person experiences a depressed mood, loss of interest or pleasure in daily activities for a period of at least two weeks, as well as at least four of the following symptoms:

• Changes in appetite and body weight.
• Changes in sleep patterns with insomnia or hypersomnia.
• Psychomotor agitation or retardation, fatigue.
• Feelings of worthlessness or self-reproach and excessive guilt.
• Decreased concentration.
• Recurrent thoughts of death or suicide.

Depression and anxiety disorders are in the top ten causes of years lived with disability (YLD) globally. In Argentina, disability-adjusted life years (DALYs) due to mental disorders and substance use disorders have increased by 9.7% between 2005 and 2013 [5]. Also, self-harm is the tenth cause of years of life lost (YLL) in Argentina [6]. Numerous studies have shown that depression, anxiety, impaired social support and deterioration in the quality of life have a significant impact on the clinical course and prognosis of the disease subjected to dialysis treatment [2]. Depression is a very common problem, underdiagnosed and poorly treated in patients with CKD who hemodialyzed (HD) can generate adverse effects on the results of said treatment, negatively influencing various somatic and emotional factors of the patient, which are essential for their recovery [7,8].

Although the diagnosis is complex due to the overlap of symptoms with renal pathologies [9], the prevalence in population is estimated to be around 20%, according to the results obtained from psychiatric interviews, while self-reported screening questionnaires suggest a prevalence of approximately 40% [9].

Doctors and nurses in dialysis services also fail to identify symptoms of depression often masked by somatic complaints. The evaluation and diagnosis of depression can be carried out using two types of procedures: Structured clinical interviews and self-reports, although their use in this population presents some complexity since the somatic symptoms of these depressive disorders (fatigue, loss of appetite, difficulty concentrating, problems with sleep or sexual function) can overlap with symptoms associated with renal failure, comorbid pathologies or the treatment itself.

Structured clinical interviews are considered the Gold Standard in the diagnosis of depressive disorders since they take as reference specific diagnostic criteria established by the DSM-5 [4].

COGNITIVE AND AFFECTIVE ASSESSMENT IN PATIENTS WITH KIDNEY DISEASE

In patients with kidney disease, assessment of cognitive and affective aspects associated with depression facilitates the identification of somatic symptoms that could interfere with an accurate and adequate diagnosis.

Among the most used interviews in kidney patients are the Composite International Diagnostic Interview (CIDI), the International Neuropsychiatric Interview (MINI), and the Structured Diagnostic Psychiatric Interview (SCID-5). Self-report instruments are commonly preferred in research and clinical settings for depression screening, because they require less time resources for both the physician and the patient. These include the Beck Depression Inventory in its BDI and BDI-II versions, the Cognitive Depression Index (CDI), the Center for Epidemiologic Studies Depression Scale (CES-D), the Hamilton Depression Rating Scale, the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire-9 (PHQ-9), with the BDI-II standing out as the questionnaire with the greatest support in terms of scientific evidence.

The following table, taken from the article 'Psychosocial aspects of the patient on dialysis', presents the different cut-off points proposed for the diagnosis of depression in patients on dialysis, with the aim of avoiding overdiagnosis and inappropriate use of resources (Table 1).

Although there is currently no consensus on the instrument most suitable established for depression in this population or the cut-off point that should be adopted, these values provide as a guide for clinical evaluation [10].

DEPRESSION, QUALITY OF LIFE AND LACK OF THERAPEUTIC ADHERENCE

Depression in patients on dialysis treatment is closely linked to a significant deterioration in their quality of life, a higher prevalence of cardiovascular diseases and an increase in the mortality rate [9,11].

Lack of therapeutic adherence represents a significant public health problem, with negative consequences that include therapeutic failures, higher hospitalization rates and an increase in health costs. Having detailed information on therapeutic adherence has proven to be more effective for accomplish treatment successfully [12].

THERAPEUTIC APPROACHES IN THE TREATMENT OF DEPRESSION

There are various therapeutic approaches for the treatment of depression in the general population, which depend on the severity of the disorder. The evidence available to date suggests that mild cases of depression do not benefit significantly from psychopharmacological treatments, while cases of moderate to severe depression do show positive responses to this type of approach.

On the other hand, the typicality versus atypicality of the clinical picture also requires a variation in the therapeutic approach. Likewise, the chronicity of the disorder and the response pattern to treatments require additional diagnostic and therapeutic distinctions.

In cases of mild depression, a non-pharmacological approach is recommended, which may include Cognitive-Behavioral Therapy (CBT) and/or a regular physical activity program [13]. Pharmacological treatment is only indicated in cases of moderate to severe depression. There are reports on the use of various antidepressants in patients on dialysis.

In this context, it is convenient for drug selection to use the new classification of antidepressants proposed by Alvano and Zieher in "An updated classification of antidepressants: A proposal to simplify treatment" [14], which facilitates a logical and epistemic analysis of antidepressants, considering both their mechanism of action and their adverse effects (Table 2).

Drugs in Group A IIa1, also known as Selective Serotonin Reuptake Inhibitors (SSRIs), are the most recommended due to their lower adverse effects and higher safety profile compared to other groups of antidepressants.

Within this group, there are reports that stimulate the use of sertraline in doses ranging from 25 mg/day to 100 mg/day, adjusted according to clinical response, symptom remission, and drug tolerance [15].

Treatment with drugs from the Selective Serotonin Reuptake Inhibitors group is better because they cause fewer anticholinergic effects than those in Group A IVc (Tricyclic Antidepressants) and are not associated with cardiac conduction disturbances. In addition, drugs in Group A IVc can be lethal if taken in high doses, which represents an additional risk of suicide.

However, SSRIs in the group present a higher risk of bleeding, as well as hyponatremia associated with the syndrome of inappropriate antidiuretic hormone secretion (SIADH), nausea, vomiting, and sexual dysfunction. This group is metabolized in the liver and has a high affinity for plasma proteins. A decrease in the incidence of intradialytic orthostatic hypotension has also been reported, attributed to its effects on vascular tone [15].

Group A IIb and A IIc drugs, such as venlafaxine and bupropion, should be used with caution, since they are mainly excreted via the kidneys.

In the case of bupropion, its active metabolites are almost eliminated by the kidney, which may predispose to the appearance of epileptic seizures. On the other hand, Group A I monoamine oxidase (MAO) inhibitors have numerous side effects and should be avoided in patients with chronic kidney disease due to their potential to induce hypotension [15].

The treatment phases of depression aim to achieve symptomatic remission during the acute phase within 12 weeks, with an expected response of at least 50% on assessment scales, such as the MADRS or the HAM-D, at the end of the treatment phase after 6 weeks of treatment.

Finally, the recovery and maintenance phase are pursued, with the purpose of preventing relapses, recurrences and recurrences, as exemplified in the graph adapted by Kupfer [16] (Graph 1).

CONCLUSIONS

Cukor [17] and Weisbord et al. (2009) conclude that depression is a key factor that can precipitate a lower adherence to treatment, as well as a decrease in the adoption of self-care behaviors, which ultimately leads to an increase in the intake of health resources. In this context, the identification of effective and viable therapeutic interventions for the management of depression remains a priority in clinical practice.

Although research in patients with renal failure is particularly complex due to their multiple interrelated medical needs and considering the limited number of high-quality studies with sufficient statistical power, the remain need further research in the field of patients undergoing hemodialysis. This line of research is not only essential to more effectively address depressive symptoms in these patients, but also to improve adherence to treatment, which directly impacts on optimizing their quality of life.

ACKNOWLEDGMENT

To Architect Eugenia Peña for her invaluable contribution to the English texts.

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  Table 1
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  Table 2