Depressive disorder in renal transplantation: An analysis of medicare claims

Background: Little is known about depression after kidney transplantation. Study Design: Retrospective observational study. Setting & Participants: US Renal Data System data; first kidney-only recipients who underwent transplantation in 1995 to 2003 with Medicare as primary payer (n = 47,899). Predictor: Demographic and clinical characteristics of recipients (age, sex, race, ethnicity, primary cause of kidney disease, pretransplantation time on dialysis therapy, body mass index, initial immunosuppressive medications, and use of induction antibodies) and donors (age, sex, race, and living or deceased), transplantation year, and number of HLA mismatches. Outcomes & Measurements: Depression incidence identified in Medicare claims and associations with clinical outcomes during the first 3 years posttransplantation. Results: Depression was identified in 3,360 transplant recipients in the 3 years posttransplantation. Cumulative incidences were 5.05%, 7.29%, and 9.10% at 1, 2, and 3 years posttransplantation. In Cox proportional hazards analysis, white race, female sex, diabetes as primary cause of kidney disease, more than 3 years on dialysis therapy before transplantation, marked obesity (body mass index 35 kg/m(2)), rapamycin use, antilymphocyte globulin or antithymocyte globulin for antibody induction therapy, donor age of 65 years or older, more recent transplantation, and presence of 6 HLA mismatches were associated with more depression, as identified in claims. Controlling for other known risk factors, time-dependent Cox proportional hazards analysis showed that depression was associated with increased graft failure (hazard ratio, 2.10; 95% confidence interval, 1.94 to 2.27; P < 0.001), return to dialysis therapy (hazard ratio, 1.97; 95% confidence interval, 1.76 to 2.19; P < 0.001), and death with a functioning graft (hazard ratio, 2.24; 95% confidence interval, 2.00 to 2.50; P < 0.001). Limitations: Depression identified through Medicare claims, limiting case ascertainment; limited number of recipient- or donor-related factors explored for potential associations; and limited depression treatment and pretransplantation depression information. Conclusions: Depression is associated with several identifiable factors and a 2-fold greater risk of graft failure and death with a functioning graft.