Psychiatric aspects related to dialysis and renal transplant

Volume 6 Issue 11 November, 2016

Consultation Liaison Psychiatry Focus: Nephrology

Let me start with an incidence which shook me off from my slumber. I believed that my communication skills and ability to diagnose depression were reasonably good till this incidence. A well-educated middle aged male with diabetes, hypertension and end stage renal disease who was recently initiated on dialysis came to the clinic. He was cheerful to talk and was well aware of the need for regular dialysis for survival. During the session where we were discussing options for his treatment he surprisingly wished to withdraw from dialysis. Withdrawing from dialysis is a major decision. The clinical implication of such a decision was that he would die in one or two weeks. I failed to comprehend what made him take such a decision. He was financial well off and had good family support. His only argument on why he took such a decision was that he did not want to prolong life artificially and he did not have any other responsibilities to fulfill. I asked him if he was depressed which he denied. I then sought help of my psychiatry friends who diagnosed him as having depression. After medications and counseling sessions this particular patient was willing to continue dialysis.

The diagnosis of depression can be confounded by patients who do not realize they are clinically depressed or who deny “being depressed” even when directly asked; this is due in part to the stigma long associated with mental illness. Incidence of psychiatric illness is more common in dialysis patients than what it seems to be. One meta-analysis has estimated that the point prevalence of depression was 37 percent in sharp contrast with general population where point prevalence of major depression was 3 percent.

Depression in dialysis patients is associated with increased morbidity and mortality. The estimated probability of hospitalization was 12 percent greater in patients with depressed affect. Depression in dialysis patients is also associated with a 40 to 50 percent increased risk of all other causes of mortality. Given the large incidence of depression in ESRD patients, huge implications on morbidity and mortality, and difficulty in diagnosis; it is prudent to have periodic screening for depression. Many patients on dialysis do well if individual psychotherapy is administered during the dialysis sessions itself.

The role of psychiatrists in managing issues related to renal transplantation is proving to be vital as both the recipient and donor should go through pre-and post procedure assessments and follow ups. Wherever feasible, a bio-psycho-social approach in the assessment is advisable. At times, the assessing psychiatrist might also need to talk about the patient’s feelings about death and dying and facilitate ventilation regarding the same. Along with assessment, it is also important to ensure that both patients and their families have understood the transplant process fully. The live donors should be informed of the probable risks, benefits and consequences of donation in a complete and understandable fashion.

The post-transplant period is another critical phase wherein apart from medical & surgical team monitoring the progress, psychiatrists need to put in their efforts to evaluate and intervene as necessary. The psychological issues could be related to direct adverse effects of immunosuppressants being used or as indirect distress due to various other physical & cosmetic side effects. The drug interactions between psychiatric medications and immunosuppressants again calls for expert opinion to carefully weigh the potential benefits and risks. Additional psychiatric care is required in cases of graft rejection/failure. Overall a psychiatrist forms an integral part of the multidisciplinary team involved in care of End Stage Renal Disease (ESRD) patients.

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