Annotated Abstracts of Journal Articles
2013, 3rd Quarter


Annotations by Paula Zimbrean, MD
September 2013

  1. Association between depression and death in people with CKD: a meta-analysis of cohort studies
  2. Subclinical cerebral abnormalities in chronic kidney disease
  3. Modifiable factors in access to living-donor kidney transplantation among diverse populations

PUBLICATION #1 — Psychonephrology
Association between depression and death in people with CKD: a meta-analysis of cohort studies
Palmer SC, Vecchio M, Craig JC, et al
Am J Kidney Dis 2013; 62(3):493-505

ANNOTATION (Paula Zimbrean)

The Findings:  Patient with chronic kidney disease (CDK) and depression had a higher risk of death than CDK patients without depression (1.59, CI 1.35-1.87). The increased risk was still present, although reduced, when results were controlled for cardiovascular risk factors.

Relevance: This trial summarizes the information available on the impact of depression upon mortality in CKD. The findings emphasize the importance of screening and treating depression in this population.

Strengths and Weaknesses: This is a meta-analysis of 22 studies including 83,381 subjects looking at the impact of depression upon mortality in patients with CKD. The limitations of the study consist in the variability of the assessments (some self administered instruments measuring depression may cause confounding bias due to the high prevalence of neurovegetative symptoms in this population) and in the lack of appreciation of the impact of antidepressant treatment.


Background: Depression occurs relatively commonly in people with chronic kidney disease (CKD), but it is uncertain whether depression is a risk factor for premature death in this population. Interventions to reduce mortality in CKD consistently have been ineffective and new strategies are needed.

Study Design: Systematic review and meta-analysis of cohort studies.

Setting & Population: Adults with CKD.

Selection Criteria for Studies: Cohort studies identified in Ovid MEDLINE through week 3 December 2012 without language restriction.

Predictor: Depression status as determined by physician diagnosis, clinical coding, or self-reported scales.

Selection Criteria for Studies: All-cause and cardiovascular mortality. Outcomes were summarized as relative risks (RRs) with 95% CIs using random-effects meta-analysis.

Results: 22 studies (83,381 participants) comprising 12,063 cases of depression (mean prevalence, 27.4%; 95% CI, 20.0%-36.3%) with a follow-up of 3 months to 6.5 years were included. Methodological quality generally was good or fair. Depression consistently increased the risk of death from any cause (RR, 1.59; 95% CI, 1.35-1.87), but had less certain effects on cardiovascular mortality (RR, 1.88; 95% CI, 0.84-4.19). Associations for mortality were similar regardless of the diagnostic method used for depression, but were weaker in analyses controlled for preexisting cardiovascular disease (RR, 1.36; 95% CI, 1.23-1.50).

Limitations: Meta-analyses adjusting for antidepressant medication use were not possible, and data for kidney transplant recipients and individuals with earlier stages of CKD not treated with dialysis were limited.

Conclusions: Depression is associated with a substantially increased risk of death in people with CKD. Effective treatment for depression in people with CKD may reduce mortality.

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PUBLICATION #2 — Psychonephrology
Subclinical cerebral abnormalities in chronic kidney disease
Yao H, Takashima Y, Hashimoto M, Uchino A, Yuzuriha T
Contrib Nephrol 2013; 179:24-34

ANNOTATION (Paula Zimbrean)

The Finding:  42.9% of patients with stage 3 CKD have subclinical lacunar infarcts visible on brain MRI.

Relevance: The findings of this study may contribute to further clarification of the underlying mechanism of cognitive impairment frequently seen in patients with CKD.

Strengths and Weaknesses: This is a cohort study of 675 subjects with CKD with a mean age of 69.9 years without a history of dementia. All patients underwent brain magnetic resonance imaging to assess for lacunar infractions, deep white matter lesions and periventricular hyperintensities. The main limitation of this study is the lack of formal cognitive assessment, which limits the clinical interpretations of these findings. In addition, the study group represented a homogenous population (Japanese patients living in a rural area) which may be introducing confounding low prevalence of cardiovascular risk factors.


Background and Purpose: Impaired kidney function or chronic kidney disease (CKD), as measured by estimated glomerular filtration rate (eGFR), is associated with incident stroke risk. However, few studies have examined the relationship between CKD and subclinical cerebral abnormalities.

Methods: We examined 675 elderly subjects (mean age 69.9 years), who were living independently at home without apparent dementia, using magnetic resonance imaging. Serum creatinine values, measured by the enzymatic method, were used for the Japanese equation of eGFR.

Results: Subclinical lacunar infarction, deep white matter lesions, and periventricular hyperintensities were detected in 88 (13.0%), 240 (35.6%) and 158 (23.4%) of the 675 participants, respectively. In the forward stepwise method of logistic analysis, age (OR 2.081/10, 95% CI 1.541-2.810), hypertension (OR 3.656, 95% CI 2.184-6.119), diabetes mellitus (OR 1.961, 95% CI 1.007-3.820), alcohol intake (OR 2.130, 95% CI 1.283-3.535), and eGFR <45 ml/min/1.73 m(2) were significant factors concerning subclinical lacunar infarction. CKD defined as eGFR <60 ml/min/1.73 m(2) was not significantly associated with subclinical lacunar infarction. Decreased eGFR was not a significant factor associated with white matter lesions (WMLs). Age (OR 2.781/10, 95% CI 2.252-3.435), hypertension (OR 1.746, 95% CI 1.231-2.477), diabetes mellitus (OR 1.854, 95% CI 1.070-3.213), but not eGFR were significant factors concerning WMLs.

Conclusions: The present study showed that community-dwelling elderly subjects with late stage 3 CKD were at high risk for prevalent subclinical lacunar infarction. The identification of CKD-specific modifiable risk factors for SBI and WMLs is of increased importance for prevention of subclinical brain ischemic lesions.

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PUBLICATION #3 — Psychonephrology
Modifiable factors in access to living-donor kidney transplantation among diverse populations

Ismail SY, Luchtenburg AE, Kal-V Gestel JA, et al

Transplantation 2013; 96(6):586-90

ANNOTATION (Paula Zimbrean)

The Finding:
Kidney transplant candidates of Western European descent and with good communication patterns were more likely to have a living kidney donor compared with patients of non-Western European descent and poor communication skills. Demographic factors such as age, gender, marital status or education did not differ between the groups of patients with or without a kidney donor.

Relevance: Due to severe organ shortage, any intervention that can increase organ donation can allow patients on the transplant waiting list to receive transplantation. This study investigated modifiable and non-modifiable recipient-related factors which can influence the availability of a living kidney donor.

Strengths and Limitations: The innovation of this study is the fact that it is investigating recipient-related factors that can influence the likelihood of having a living organ donor. Recipients are typically closely followed up in the nephrology clinics where interventions are easier to be implemented than in a potential donor population, which is relatively healthy and less connected with the health care system. The main limitation of the study is that the ethnic/cultural background of Western European vs. non-Western European participants was simplified and did not take into consideration the ethnic/cultural variances within these two broad geographic classifications. All the ethnic/cultural complexities of the decision to pursue living organ donation were unlikely to be included.


Background: We have observed a significant inequality in the number of living-donor kidney transplants (LDKT) performed between patients of non-Western European origin and those of Western European origin. The aim of this study was to investigate modifiable factors that could be used as potential targets for an intervention in an attempt to reduce this inequality.

Methods: A questionnaire on knowledge, risk perception, communication, subjective norm, and willingness to accept LDKT was completed by 160 end-stage renal patients who were referred to the pre-transplantation outpatient clinic (participation rate of 92%). The questionnaire was available in nine languages. Multivariate analyses of variance were conducted to explore differences between patients with and without a living donor.

Results: There were significantly fewer patients of non-Western descent (11 of 82) that brought a living donor to the outpatient clinic than patients of Western descent (38 of 78). After correcting for the unmodifiable sociodemographic factors non-Western descent, low knowledge, little communication about their kidney disease, and low willingness to communicate with individuals from the social network about LDKT were significantly associated with the absence of a living donor.

Conclusions: Knowledge and communication are identified as modifiable factors that are associated with the likelihood of identifying a potential living donor for LDKT. This observation makes knowledge and communication targets for interventions to reduce inequality in access to LDKT.

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