Original Investigation
Pathogenesis and Treatment of Kidney Disease
Association Between Estimated GFR, Health-Related Quality of Life, and Depression Among Older Adults With Diabetes: The Diabetes and Aging Study

https://doi.org/10.1053/j.ajkd.2013.03.039Get rights and content

Background

Although chronic kidney disease (CKD) is a highly prevalent condition among older adults with diabetes, the associations between health-related quality of life (HRQoL) and severity of CKD in this population are not well understood. The objective of this study was to assess HRQoL and depressive symptoms across estimated glomerular filtration rate (eGFR) stages.

Study Design

Cross-sectional.

Setting & Participants

5,805 members of Kaiser Permanente Northern California, 60 years or older with diabetes, from the 2005-2006 Diabetes Study of Northern California (DISTANCE) survey.

Predictor

eGFR categories were defined as ≥90 (referent category), 75-89, 60-74, 45-59, 30-44, or ≤29 mL/min/1.73 m2.

Outcomes

HRQoL was measured using the modified Short Form−8 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. Depressive symptoms were measured using the Patient Health Questionnaire−8.

Results

In unadjusted linear regression analyses, physical (PCS) and mental (MCS) HRQoL scores were significantly lower with worsening eGFR level. However, after adjustment for sociodemographics, diabetes duration, obesity, and cardiovascular comorbid conditions and taking into account interactions with proteinuria, none of the eGFR categories was significantly or substantively associated with PCS or MCS score. In both unadjusted and adjusted analyses, higher risk of depressive symptoms was observed in respondents with eGFR ≤29 mL/min/1.73 m2 (relative risk, 2.02; 95% CI, 1.10-3.71; P < 0.05) compared with the referent group. However, this eGFR-depression relationship was no longer significant after adjusting for hemoglobin level.

Limitations

Participants are part of a single health care delivery system.

Conclusions

Our findings suggest the need for greater attention to and potential interventions for depression in patients with reduced eGFR.

Section snippets

Study Design

In 2005-2006, the DISTANCE survey collected information about demographics, health behaviors, social support, and patient-provider interactions from a race-stratified random sample of members of the diabetes registry of Kaiser Permanente Northern California, an integrated health care delivery system. The diabetes registry consists of all patients within the Kaiser Permanente Northern California health system with diabetes identified from automated databases of pharmacy data, laboratory data,

Patient Characteristics

There were 5,805 respondents 60 years or older who had an identifiable eGFR measurement and who completed the HRQoL questionnaire (Fig 1). The distribution of patients in each eGFR category (all in mL/min/1.73 m2) was as follows: eGFR ≥90 (referent group), 1,222 (21.1%); eGFR of 75-89, 1,513 (26.1%); eGFR of 60-74, 1,602 (27.5%); eGFR of 45-59, 959 (16.5%); eGFR of 30-44, 392 (6.8%); and eGFR ≤29, 117 (2.0%; Table 1). Mean age was 67.2 ± 4.8 (SD) years, with the youngest mean age in respondents

Discussion

This study assessed the relationship between eGFR and HRQoL and depressive symptoms in a population of more than 5,800 community-dwelling insured older adults with diabetes enrolled in Kaiser Permanente Northern California. In this study, we found that after adjustment, there was no substantive relationship between eGFR and physical or mental HRQoL as a whole or separately in those with and without proteinuria. However, we also found that respondents with the lowest eGFRs (eGFR ≤29 mL/min/1.73 m

Acknowledgements

Support: Dr Campbell is supported by a T. Franklin Williams Scholars Award. Funding was provided by Atlantic Philanthropies, Inc; the American Geriatrics Society Foundation for Health in Aging; the John A. Hartford Foundation; and the Association of Specialty Professors. The Diabetes and Aging Study was supported by funding from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK; grants R01DK081796, R01DK080726, and R01DK65664). Investigators also were supported by the

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      Among the 5,555 adults from KNHANES III, patients with eGFRs of 30 to 59 mL/min/1.73 m2, as assessed by the MDRD Study equation, had an almost 1.5-fold higher risk for HRQoL impairment compared with those with eGFRs ≥ 90 mL/min/1.73 m2.9 However, the Heart and Soul Study of 967 outpatients with coronary artery disease did not show a statistically significant difference in risk for HRQoL impairment according to a creatinine clearance cutoff of 60 mL/min after adjusting for sociodemographics and comorbid conditions,11 and a recent study of 5,805 adults 60 years or older with diabetes showed that differences in HRQoL score according to eGFR category were no longer significant after adjusting for all analyzed factors, including cardiovascular disease.12 Thus, overall, results of previous studies in this field have been inconclusive and controversial for the past decade.

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    Originally published online June 7, 2013.

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