Song ZY, Li N, Liu HB. Analysis of influencing factors on the nutritional status of non-dialysis elderly patients with chronic kidney disease and depression. World J Psychiatry 2025; 15(5): 102539 [DOI: 10.5498/wjp.v15.i5.102539]
Corresponding Author of This Article
Hong-Bao Liu, PhD, Doctor, Department of Nephrology, Tangdu Hospital, The Fourth Military Medical University (Air Force Medical University), No. 1 Xinsi Road, Baqiao District, Xi’an 710038, Shaanxi Province, China. xjsnlhb@fmmu.edu.cn
Research Domain of This Article
Urology & Nephrology
Article-Type of This Article
Retrospective Cohort Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Zi-Yu Song, Ni Li, Hong-Bao Liu, Department of Nephrology, Tangdu Hospital, The Fourth Military Medical University (Air Force Medical University), Xi’an 710038, Shaanxi Province, China
Author contributions: Song ZY designed the research, wrote the first draft of the manuscript, conducted the analysis, and provided guidance for the research; Song ZY, Li N, and Liu HB contributed to conceiving the research and analyzing the data; All authors reviewed and approved the final manuscript.
Institutional review board statement: This study was approved by the Ethic Committee of Tangdu Hospital, The Fourth Military Medical University (Air Force Medical University) (No. K202404-14).
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
STROBE statement: The authors have read the STROBE Statement—a checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-a checklist of items.
Data sharing statement: No additional data are available.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Hong-Bao Liu, PhD, Doctor, Department of Nephrology, Tangdu Hospital, The Fourth Military Medical University (Air Force Medical University), No. 1 Xinsi Road, Baqiao District, Xi’an 710038, Shaanxi Province, China. xjsnlhb@fmmu.edu.cn
Received: January 10, 2025 Revised: March 7, 2025 Accepted: April 8, 2025 Published online: May 19, 2025 Processing time: 110 Days and 0.9 Hours
Abstract
BACKGROUND
The assessment of nutritional status in non-dialysis elderly patients with chronic kidney disease (CKD) and comorbid depression is clinically important. Determining key determinants of nutritional status in this population significantly improves nutritional management strategies and assists these patients overcome the disease.
AIM
To investigate the factors influencing the nutritional status of non-dialysis elderly patients with CKD and comorbid depression.
METHODS
This study retrospectively collected the clinical data of 182 non-dialysis elderly patients with CKD and comorbid depression admitted at Tangdu Hospital, Air Force Medical University, from January 2022 to June 2023. The participants were categorized based on the presence of malnutrition into the nutritionally normal group (n = 97) and the malnutrition group (n = 85). The clinical data of the two groups were subjected to unifactorial and multifactorial regression to analyze the factors influencing malnutrition among the participants. Data included sex, age, body mass index (BMI), percentage body fat, basal metabolic rate (BMR), blood urea nitrogen (BUN), creatinine (Cr), albumin (Alb), hemoglobin (Hb), pre-albumin (PA), patient-generated subjective global assessment, and Patient Health Questionnaire-9 (PHQ-9) score to identify depressive symptoms. After admitting the patients to the hospital, 5 mL of peripheral serum was withdrawn, the centrifuge was operated at 3500 rpm/minute with a centrifugal radius of 10 cm for 10 minutes, serum was collected, and serum Alb, Hb, PA, BUN, and Cr levels were detected using a fully automatic biochemical analyzer. The results were assessed using Statistical Package for the Social Sciences version 21.0 for conducting technical analyses. Metric data are presented as the mean ± standard error of the mean and replaced using the t-test. Count data are expressed as case counts and percentages and were replaced using the χ2 test. Effective factors were modeled using logistic return modeling.
RESULTS
BMI, BMR, and serum Alb, Hb, PA, and Cr levels were lower in the nutritionally normal group than in the malnutrition group. Furthermore, BUN levels, PHQ-9 scores, and the percentage of anxiety symptoms were greater in the nutritionally normal group than in the normal nutrition group, with statistically significant differences (P < 0.05). Multiple factorial interpretations revealed anxiety and serum Alb, Hb, and PA levels as factors influencing the nutritional status of non-dialysis elderly patients with CKD and depression (P < 0.05).
CONCLUSION
Serum Alb, Hb, PA levels, and anxiety symptoms are all factors influencing malnutrition in non-dialysis elderly patients with CKD and depression; hence, clinical interventions can be targeted to patients with the above characteristics.
Core Tip: Malnutrition is prevalent among non-dialysis elderly patients with chronic kidney disease (CKD) and comorbid depression, which exacerbates disease progression, impairs prognosis, and undermines clinical outcomes. This study enrolled 182 non-dialysis elderly patients with CKD and depression to investigate nutritional status and analyze influencing factors. Results demonstrated that serum albumin (Alb), hemoglobin (Hb), and pre-albumin (PA) levels and anxiety symptoms independently influenced malnutrition risk in this cohort. Specifically, increased serum Alb, Hb, and PA levels were protective factors, whereas the presence of anxiety symptoms was a risk factor. Clinically, regular monitoring of serum Alb, Hb, and PA levels should be prioritized to guide timely nutritional interventions. Moreover, close observation and immediate psychological support should be provided for patients presenting with anxiety symptoms to effectively address their mental health needs.
Citation: Song ZY, Li N, Liu HB. Analysis of influencing factors on the nutritional status of non-dialysis elderly patients with chronic kidney disease and depression. World J Psychiatry 2025; 15(5): 102539
Chronic diseases pose a serious threat to human health globally, and one such disease is chronic kidney disease (CKD)[1]. CKD ranks eleventh in the global mortality rate, with a prevalence of 8%-16%[2,3] and a predilection for older adults. Poorly controlled CKD that progresses to end-stage renal disease inevitably brings a series of complications, such as cardiovascular disorder (CVD), malnutrition, neuropsychiatric disorders, which greatly increases the risk of death, thereby seriously increasing the burden on society[4,5]. Depression, a psychiatric disorder characterized by low mood, lack of pleasure, feelings of worthlessness, and guilt, represents a significant risk factor for disease progression and mortality among elderly patients with CKD[6,7].
Moreover, malnutrition is one of the frequent clinical conditions and an important factor affecting the prognosis of elderly patients with CKD[8]. Patient malnutrition rates during the middle and late stages of CKD remain high, which seriously affects the prognosis and becomes one of the risk factors resulting in further renal dysfunction or even death, whereas malnutrition in patients with CKD is gradually aggravated with the development of the disease and is frequently difficult to be corrected[9-11]. Relevant studies have revealed that timely nutritional intervention therapy effectively delays renal function progression, minimizes patients’ symptom morbidity, increases the long-term life expectancy of patients, etc.[12]. Furthermore, evidence indicates a malnutrition incidence of 29% among non-dialysis patients with uremia[13]. Combining multiple methods for a comprehensive assessment to conduct a more accurate intervention is necessary for assessing the nutritional status of patients with CKD[14,15]. The current application is relatively uniform and includes a comprehensive nutritional status assessment from four major aspects: Dietary intake, anthropometric measurements, laboratory indicators, and nutritional scores[16]. Therefore, nutritional assessment and intervention for elderly patients with CKD is particularly important.
In the present study, we review and investigate the factors affecting the nutritional status of elderly patients with CKD using clinical data of non-dialysis elderly patients with CKD and depression admitted at our institute, to provide a basis for clinical personnel’s nutritional assessment and intervention.
MATERIALS AND METHODS
General data
The analysis included 182 cases of non-dialysis elderly patients with CKD and depression admitted at Tangdu Hospital, Air Force Medical University (Xi’an, Shaanxi, from January 2022 to June 2023. The participants were categorized based on their nutritional status into the nutritional normal (n = 97) and malnutrition groups (n = 85). Among the 67 male and 30 female patients aged 65-80 (mean: 66.67 ± 9.39) years in the nutritional normal group, 42 were complicated with hypertension, 19 with coronary heart disease, 13 with diabetes mellitus, and 17 with a combination of diabetes mellitus and coronary heart disease. Of the 50 male and 35 female patients aged 65-81 (mean: 64.9 ± 12.3) years in the malnutrition group, 38 were complicated with hypertension, 16 with coronary heart disease, 11 with diabetes mellitus, and 13 with a combination of diabetes mellitus and coronary heart disease. The detailed flow chart of this study is shown in Figure 1.
Figure 1 Specific flow chart.
CKD: Chronic kidney disease.
Before enrollment, every case met the CKD eligibility criteria (CKD diagnosis was based on at least one sign of systemic damage): (1) Proteinuria or casturia in blood, urine, or feces; (2) Progressive decline in renal function; and (3) Progressively increased serum creatinine (Cr) levels. All patients underwent renal biopsy and were pathologically diagnosed with chronic renal failure. All patients demonstrated no serious physical or mental illness or severe CVD before admission. During enrollment, all patients underwent blood routine, biochemistry, and liver and kidney function tests outside the hospital.
Inclusion criteria were: (1) Age ≥ 60 years; (2) Confirmed diagnosis of elderly CKD combined with depression; (3) No dialysis treatment; and (4) No other chronic diseases. Exclusion criteria were: (1) A combination of other serious diseases or mental disorders; (2) Cognitive dysfunction which makes communication challenging; and (3) Malnutrition history.
Grouping standards
Nutritional status assessment method: Malnutrition determination criteria[17] involved: (1) Malnutrition: Body mass index (BMI) of < 18.5 kg/m² or ≥ 27 kg/m²; (2) Normal: BMI of ≥ 18.5 kg/m² to < 27 kg/m²; and (3) Overweight/obesity: BMI of ≥ 27 kg/m². Grouping: (1) Normal nutrition group with a BMI ≥ 18.5 kg/m² to < 27 kg/m²; and (2) Malnutrition group with a BMI < 18.5 kg /m² or ≥ 27 kg/m².
Data collection and analysis methods
Venous blood was collected from all patients within 1 day post-admission and a fully automatic biochemical analyzer was used to detect serum albumin (Alb), hemoglobin (Hb), and pre-albumin (PA) levels. The test items included total cholesterol, triglyceride, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, apolipoprotein A1, apolipoprotein B, and other indicators. Concurrently, basic information, such as the patient’s age and gender, was recorded. Furthermore, a general survey was conducted, investigating height, weight, and BMI.
Indicators of observation
Sex, age, BMI, percentage body fat, basal metabolic rate (BMR), dialysis time, blood urea nitrogen (BUN), Cr, Alb, Hb, PA, and anxiety and depression (with/without) were observed in the two groups. After admitting the patients to the hospital, 5 mL of peripheral serum was collected by decenter at 3500 rpm/minute with a centrifugal radius of 10 cm for 10 minutes, and serum Alb, Hb, PA, BUN, and Cr levels were measured using automatic biochemistry analyzer. The aforementioned indicators were included as independent variables, with the presence or absence of malnutrition as the dependent variable. Univariate and multivariate analyses were then conducted to determine factors influencing patients’ nutritional status and to investigate the determinants associated with the occurrence of malnutrition.
The Patient Health Questionnaire-9 (PHQ-9)[18] consists of a scale with nine entries, each entry is divided into four grades according to the degree of depression of the patient, with a score of 0-27 points. Total PHQ-9 scored of 0-4, 5-9, 10-14, and ≥ 15 points indicated no, mild, moderate, and severe depression, respectively.
The patient-generated subjective global assessment (PG-SGA) scores were based on[19], including body mass, eating, reasons affecting eating, body activity ability, overall physical condition, etc. A, B, C, and D scores were obtained, and the sum of the total scores of each item was the total PG-SGA score, with 0-1, 2-3, 4-8, and ≥ 9 points indicating good, dubious-poor, middle-level, and severe nutrition, respectively. The greater the value of its score, the more unsatisfactory the nutritional status of the participants.
Statistical analyses
Statistical Package for the Social Sciences version 22.0 packages were used for statistical data analyses. The measurement data are presented as the mean ± standard deviation, with the t-test adopted for making comparisons, and the count information was presented as the number of cases and percentage, with χ2 testing applied for making comparisons. Furthermore, multifactorial regression was used to analyze the relevant factors affecting the emergence of malnutrition in non-dialysis elderly patients with CKD complicated with depression. P < 0.05 was considered statistically significant.
RESULTS
Nutritional condition and discrimination scores in the two groups
The nutrition status scale and the depression score were 1.63 ± 0.87 and 12.54 ± 2.41 in the normal nutrition group and 6.95 ± 1.31 and 14.35 ± 2.31 in the malnutrition group, respectively. Intergroup comparisons of nutritional status and depression scores were clinically meaningful (P < 0.05; Table 1 and Figure 2).
Figure 2 Comparison of nutritional status and depression scores between the two groups of patients.
PG-SGA: Patient-generated subjective global assessment; PHQ-9: Patient Health Questionnaire-9.
Table 1 Comparison of nutritional status and depression scores between the two groups of patients, mean ± SD.
Group
Number of cases
PG-SGA score
PHQ-9 score
Normal nutrition
97
1.63 ± 0.87
12.54 ± 2.41
Malnutrition
85
6.95 ± 1.31
14.35 ± 2.31
t value
5.954
2.228
P value
0.012
0.041
Comparison of complete clinical data in the two sets of patients
The BMI, BMR, and serum Alb, Hb, PA, and Cr levels were lower and PHQ-9 scores, the percentage of anxiety symptoms, and BUN levels were higher in the malnutrition group than in the normal nutrition group (P < 0.05; Table 2).
Table 2 Comparison of clinical data between the two groups of patients, mean ± SD/n (%).
Category
Malnutrition group (n = 85)
Normal nutrition group (n = 97)
χ2/t
P value
Sex
1.528
0.084
Male
50 (58.82)
67 (69.07)
Female
35 (41.18)
30 (30.92)
Age (years)
64.9 ± 12.3
66.67 ± 9.39
1.098
0.274
BMI (kg/m2)
19.78 ± 2.1
24.32 ± 2.09
12.542
< 0.001
PBF (%)
31.19 ± 13.56
29.1 ± 9.38
1.056
0.093
BMR (%)
1148.73 ± 116.85
1350.47 ± 199.47
8.484
< 0.001
Alb (mg/L)
30.31 ± 5.4
42.11 ± 3.27
14.874
< 0.001
Hb (g/L)
80.81 ± 13.84
112.08 ± 10.27
13.872
< 0.001
PA (mmol/L)
0.25 ± 0.05
0.64 ± 0.19
21.054
< 0.001
BUN (mmol/L)
46.25 ± 8.45
30.21 ± 5.48
13.852
< 0.001
Cr (μmol/L)
801.71 ± 123.87
1151.38 ± 193.06
14.851
< 0.001
PHQ-9 score
14.35 ± 2.31
12.54 ± 2.41
2.228
0.041
Anxiety symptoms
6.541
< 0.001
Have
49 (57.65)
28 (28.87)
None
36 (42.35)
69 (71.13)
Logistic correlation analysis
According to the results of univariate factors that may affect the malnutrition of non-dialysis elderly patients with CRD complicated with hypertension, multifactorial logistic regression analysis was conducted considering the indicator with statutory meaning in the differences between the two groups as the indicator of free variable and the nutritional status as the dependent variable. Table 3 presents the assigned values, and the findings indicated anxiety and serum Alb, Hb, and PA levels as factors affecting the nutritional status of non-dialysis elderly patients with CKD combined with hypertension (P < 0.05; Table 4).
Table 4 Analysis of factors affecting nutritional status in non-dialysis elderly patients with chronic kidney disease and depression.
Influencing factors
β
SE
Wald value
P value
OR value
95% confidence interval of Exp (B)
Lower limit
Upper limit
BMI
0.768
0.485
2.183
0.153
2.046
0.768
6.414
BMR
0.792
0.631
1.685
0.183
2.185
0.695
6.934
Alb
-0.583
0.321
5.108
0.023
0.631
0.308
0.975
Hb
-0.315
0.152
4.521
0.031
0.682
0.419
0.935
PA
-0.582
0.231
7.854
0.003
0.583
0.308
1.052
BUN
0.743
0.416
3.393
0.093
2.152
0.854
3.934
Cr
-0.522
0.483
1.328
0.238
0.284
0.017
1.382
Anxiety symptoms
0.692
0.287
6.748
0.014
1.038
0.843
3.319
DISCUSSION
Depression is a prevalent complication in patients with CKD[20]. Studies have reported that 22.7% of elderly patients with CKD suffer from depressive symptoms[21]. The rates of CVD, anemia, mild cognitive impairment, and malnutrition were significantly higher in elderly patients with CKD with depressive symptoms than in those without depressive symptoms[22]. The clearance ability of the kidney is significantly weakened due to the decline of renal function in elderly patients and low physical fitness. Some elderly patients with CKD may experience malnutrition because the existence of the disease will cause certain obstacles to the body’s nutrient absorption[23]. Concurrently, long-term hemodialysis results in the loss of various nutrients, thereby affecting the protein synthesis in the patient’s body and accelerating protein consumption and decomposition[24]. Therefore, elderly patients with CKD and depression are more likely to suffer from malnutrition. The occurrence of malnutrition in non-dialysis elderly patients with CKD and depression is associated with various factors, including: (1) Diet: Elderly patients with CKD frequently eat little or no food due to loss of appetite, causing insufficient intake and malnutrition; (2) Psychological: Emotions, such as anxiety and depression, arise in elderly individuals due to fear of the treatment process, financial burden, and worry about the effect of the disease on future life. These negative emotions cause loss of appetite and insufficient nutritional intake among patients; and (3) Exercise: Elderly patients with CKD are prone to motor dysfunction, which decreases daily activity ability, thereby reducing dietary intake, causing insufficient nutritional intake[25]. BMI, BMR, and serum Alb, Hb, PA, and Cr levels were lower in the malnutrition group than in the nutritional normal group, whereas PHQ-9 scores, the percentage of anxiety symptoms, and BUN levels were higher, with statistically significant differences (P < 0.05). Multifactorial analysis revealed that anxiety and serum Alb, Hb, and PA levels were all influential factors in the nutritional status of non-dialysis elderly patients with CKD and depression (P < 0.05). Risk factors for malnutrition in non-dialysis elderly CKD patients with depression include symptoms of anxiety. Protective factors include high serum Alb, Hb, and PA levels. Analysis of possible reasons indicated that symptoms of anxiety will cause the body to be in a state of stress, thereby reducing the body’s ability to synthesize protein and affecting its protein and energy intake[26].
Studies have revealed that Alb, Hb, and PA levels are important indicators that reflect the degree of renal function damage, and their reduction is a risk factor for renal function deterioration. The renal function of the elderly decreases, and serum Alb, Hb, and PA levels are relatively low[27]. Studies have demonstrated that abnormal Alb, Hb, and PA levels indicate that the body is in a state of chronic inflammation, thereby decreasing the body’s resistance and adverse reactions such as anemia and infection[28]. Therefore, Alb, Hb, and PA levels can be used as important indicators to represent the nutritional status of patients with CKD. This study conducted blood biochemical tests on non-dialysis elderly patients with CKD who met the inclusion criteria and compared Alb, Hb, and PA levels between the two groups of patients. The results of the study revealed that Alb, Hb, and PA levels in non-dialysis elderly patients with CKD were greater in the nutritionally normal set than in the malnourished set. Maintaining adequate nutrition required by the body, developing a good regular schedule, and engaging in appropriate physical exercise help to increase the speed of toxin removal from the body. Clinically, treatment and intervention personnel must closely observe the mental status and emotional changes of elderly patients. Abnormal findings must be communicated effectively with the patients so that their families can help them improve their treatment compliance and the degree of cooperation increases their appetite[29].
This study reveals that the nutritional status of non-dialysis elderly patients with CKD and depression is generally poor. The patients’ total energy, protein, and fat intake are insufficient, and their muscle tissue content and muscle mass are reduced, which seriously affects their quality of life and survival rate. Therefore, when clinical medical staff conduct nutritional assessment and intervention for elderly non-dialysis patients with CKD and depression, they need to consider the effect of these factors (Alb, Hb, PA, and anxiety symptoms) on the nutritional status of non-dialysis elderly patients with CKD and depression, to formulate corresponding intervention measures to improve the nutritional status of such population. This study has certain limitations that warrant further investigation. The sample size was substantial, but the data were derived from a single-center cohort. Future studies incorporating larger, multi-center populations are warranted to validate and extend these results.
CONCLUSION
Closely monitoring the nutritional status of elderly patients before and after treatment, establishing a reasonable nutrition plan, and promptly replenishing various nutrients required by the body are crucial during the treatment period. Serum Alb, Hb, PA, and other indicators can better reflect the body’s protein reserves and intake. During the treatment process, attention should be paid to monitoring the patient’s nutritional status. Once nutritional problems are discovered, enteral and parenteral nutrition support should be provided promptly. The results of this study provide reliable clinical guidance for nutritional management in non-dialysis elderly patients with CKD and comorbid depression. By identifying key determinants of malnutrition, this research establishes a foundation for targeted preventive strategies and provides robust evidence to inform clinical practices in nutritional management for this vulnerable population.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Psychiatry
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade B, Grade C, Grade C
Novelty: Grade B, Grade C
Creativity or Innovation: Grade B, Grade C
Scientific Significance: Grade B, Grade C
P-Reviewer: Mastrantonio E; Mazza M; Taylor BL S-Editor: Fan M L-Editor: Filipodia P-Editor: Yu HG
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