Handgrip Strength and Estimated Glomerular Filtration Rate as Screening Tools for Mental Health Assessment in Chronic Kidney Disease Patients Undergoing Hemodialysis

Chronic kidney disease (CKD) is a long-standing, debilitating medical condition characterized by progressive loss of renal function. In its advanced stages, CKD leads to end-stage renal disease (ESRD), necessitating renal replacement therapy in the form of hemodialysis or kidney transplantation. In India, the rising incidence of CKD represents an escalating public health challenge, with an increasingly large patient population dependent on hemodialysis for survival.

 

Despite the substantial physical burden of CKD, psychiatric comorbidity remains critically underestimated. Disturbed mental status — particularly depression and anxiety — profoundly impairs quality of life, reduces adherence to treatment, and contributes to increased morbidity and mortality. The American Psychiatric Association (2020) has highlighted that CKD-related disease burden, poor satisfaction with life, and persistent suicidal ideation are clinically significant phenomena that demand systematic attention.

 

The need for effective, routine screening tools to identify psychiatric vulnerability in this population has never been more urgent. Currently, many nephrology units lack integrated psychiatric assessment protocols, leaving a significant proportion of patients undiagnosed and untreated. Practical physiological parameters — such as handgrip strength (HGS) and estimated glomerular filtration rate (eGFR) — which are already routinely measured in hemodialysis settings, may offer a clinically accessible bridge to psychiatric screening.

 

This study was designed to evaluate the prevalence of depression and anxiety among CKD patients undergoing hemodialysis, and to investigate the utility of eGFR and HGS as correlates of psychiatric morbidity and its severity, with the ultimate goal of establishing a practical, low-cost triage system for psychiatric referral.

 

Aims and Objectives

•             To evaluate the prevalence of depressive and anxiety disorders among patients with CKD undergoing regular hemodialysis.

•             To examine the relationship between mental status (depression and anxiety) and estimated glomerular filtration rate (eGFR).

•             To explore the association between mental status and handgrip strength (HGS) as a surrogate of physical function and muscle strength.

•             To assess the impact of psychiatric comorbidity on satisfaction with life (SWL) in this patient population.

A hospital-based cross-sectional study was conducted at the Department of Physiology, in collaboration with the Departments of Nephrology and Psychiatry, "Tertiary Care Hospital In Odisha", Cuttack, Odisha, India.

 

Study Population

A total of 124 adult CKD patients undergoing regular hemodialysis (minimum duration of three months) were enrolled. Patients were aged between 18 and 60 years. The following exclusion criteria were applied to ensure diagnostic clarity:

•             History of psychiatric illness prior to the diagnosis of CKD.

•             Presence of chronic, serious, or unstable comorbid medical or surgical conditions.

•             Uremic psychosis.

 

Assessment Tools

Estimated GFR (eGFR) was calculated using the Cockcroft-Gault equation, which incorporates serum creatinine, age, weight, and sex to estimate renal function.

 

Handgrip Strength (HGS) was measured using a calibrated hand dynamometer, providing an objective index of peripheral muscle strength and overall physical functional capacity.

 

The Hamilton Depression Rating Scale (HDRS) — a 17-item clinician-administered scale (maximum score: 50) — was used to assess the presence and severity of depressive symptoms. Higher scores indicate greater severity.

 

The Hamilton Anxiety Rating Scale (HARS) — a 14-item scale (maximum score: 56) — was employed to quantify the severity of anxiety symptoms.

 

The Satisfaction with Life Scale (SWLS) — a 5-item self-report instrument (maximum score: 35; clinical cut-off: 20) — was used to assess global life satisfaction. Scores below 12 have been associated with increased risk of suicidal ideation.

Among the 124 CKD patients included in the study, depressive disorder was identified in 82 patients (66%) and anxiety disorder in 76 patients (61%). Both conditions were simultaneously present in 72 patients (58%), indicating a high prevalence of comorbid depression and anxiety in this population (Table 1). These findings are consistent with the literature; a study by Gadia et al. (2020) reported depression in 62% and anxiety in 59% of CKD patients on hemodialysis.

 

Table 1: Prevalence of Depression and Anxiety Among CKD Patients on Hemodialysis

 

Patients with depression or anxiety demonstrated significantly lower mean eGFR values compared to their non-affected counterparts (p = 0.001 for both; Table 2). This strongly suggests that deteriorating renal function is associated with a greater likelihood of psychiatric morbidity. Specifically, the mean eGFR in depressed patients was 9.5 ± 3.0 ml/min/1.73m² compared to 18.6 ± 6.8 ml/min/1.73m² in non-depressed patients. These findings align with Wang et al. (2019), who demonstrated a significant association between impaired kidney function and depression in elderly CKD patients. Severity scores on both HDRS and HARS were negatively correlated with eGFR (r = -0.3 and r = -0.4 respectively), indicating that as kidney function declines, the severity of psychiatric symptoms tends to increase.

 

HGS was significantly reduced in patients with depression (20.5 ± 3.5 kg) compared to those without (30.0 ± 5.6 kg; p = 0.012). Similarly, patients with anxiety showed markedly lower HGS (21.0 ± 4.5 kg) versus those without (32.5 ± 4.0 kg; p = 0.015; Table 3). Severity scores on both HDRS and HARS were negatively correlated with HGS (r = -0.4 and r = -0.3 respectively). These findings support the notion that HGS — a proven marker of muscle strength and physical activity — can serve as a proxy for overall mental health status. Dziubek et al. (2021) similarly found significant associations between depression, anxiety, and reduced physical function in CKD and post-transplant populations.

 

Table 2: Association of Depression and Anxiety with eGFR

 

Table 3: Association of Depression and Anxiety with Handgrip Strength

Mean SWLS scores were significantly lower in patients with depression (14.5 ± 3.0) compared to those without (19.0 ± 2.5; p = 0.013), and in those with anxiety (15.0 ± 2.6) compared to those without (21.7 ± 4.5; p = 0.016; Table 4). These findings underscore the significant negative impact of psychiatric comorbidity on perceived quality of life. Particularly alarming is that depressed and anxious patients had mean SWLS scores well below the cut-off of 20, placing many within the range associated with suicidal ideation (SWLS < 12).

 

Table 4: Depression and Anxiety with Satisfaction with Life (SWLS; Max Score = 35, Cut-off = 20)

 

This study highlights the alarmingly high prevalence of psychiatric morbidity among CKD patients on hemodialysis — with two in three patients meeting criteria for depression and three in five for anxiety. These figures are consistent with existing literature and underscore the urgent need for systematic psychiatric evaluation in nephrology practice.

 

The significant association between low eGFR and psychiatric morbidity is consistent with a growing body of evidence suggesting that uremic toxin accumulation and systemic inflammation — hallmarks of deteriorating renal function — may directly contribute to neuropsychiatric changes. The negative correlation between eGFR and HDRS/HARS scores implies a dose-response relationship: as renal function worsens, psychiatric burden intensifies.

 

HGS, traditionally regarded as a marker of musculoskeletal health and nutritional status, has emerged in this study as a significant correlate of mental health. Physical deconditioning in CKD may perpetuate a vicious cycle: diminished physical activity leads to reduced serotonin and endorphin production, further worsening mood; conversely, depression reduces motivation for physical rehabilitation, resulting in further loss of muscle strength. The negative correlation between HGS and psychiatric severity scores supports this bidirectional relationship.

 

Importantly, both eGFR and HGS are routinely available in hemodialysis settings at virtually no additional cost or procedural burden. Their integration into a structured psychiatric triage protocol represents a pragmatic, implementable solution for identifying high-risk patients without the need for specialized psychiatric resource allocation at the point of initial screening.

 

The reduced satisfaction with life scores in depressed and anxious patients further highlights the pervasive impact of psychiatric comorbidity beyond clinical symptomatology, affecting perceived meaning, purpose, and overall well-being. The association with suicidal ideation risk (SWLS < 12) in a subset of patients underscores the potential life-saving implications of early identification and intervention.

Handgrip strength and estimated glomerular filtration rate are significantly associated with the presence and severity of depression and anxiety in CKD patients undergoing hemodialysis. Both parameters are routinely available and require no additional cost or specialist involvement for measurement, making them ideal first-line screening tools to identify patients warranting formal psychiatric assessment.

 

Clinicians, patients, and caregivers should be sensitized to the high burden of psychiatric comorbidity in CKD. All patients on hemodialysis should have periodic assessment of eGFR and HGS, and those with declining values should be referred for psychiatric evaluation. Appropriate counselling and motivation for physical activity may attenuate the severity of psychiatric symptoms, reduce suicidal ideation, and ultimately improve quality of life in this vulnerable population.