Chronic kidney disease (CKD) is a progressive disorder characterized by abnormalities of kidney structure or function that persist for more than three months and have implications for health [1]. CKD represents an important global public-health problem because of its increasing prevalence, high treatment costs, cardiovascular complications, reduced quality of life, and premature mortality. Global estimates suggest that CKD affects a substantial proportion of the adult population and contributes significantly to disability and mortality worldwide [2].

Patients who progress to kidney failure may require kidney replacement therapy in the form of hemodialysis, peritoneal dialysis, or kidney transplantation. Hemodialysis remains one of the most widely used modalities. Although it is life-sustaining, maintenance hemodialysis places considerable demands on patients. Regular attendance at dialysis facilities, vascular access procedures, dietary and fluid restrictions, medication burden, fatigue, sleep disturbance, pain, uncertainty regarding prognosis, loss of employment, financial stress, and dependence on caregivers may substantially affect psychological wellbeing [3,4].

Depression is among the most frequently reported psychiatric problems in patients with CKD and is particularly prevalent among individuals receiving dialysis. Palmer et al., in a systematic review and meta-analysis, reported a high prevalence of depression across CKD populations, with prevalence varying according to the method used to identify depression [5]. Similarly, depression has been recognized as an important comorbidity in patients receiving maintenance dialysis and may be associated with poorer quality of life, treatment non-adherence, hospitalization, and mortality [6,7].

Anxiety is another clinically important but comparatively less investigated psychological problem among patients undergoing hemodialysis. Anxiety may arise from concerns regarding disease progression, dialysis procedures, vascular access, complications, financial difficulties, dependency, and fear of death. Symptoms can include persistent worry, restlessness, tension, irritability, and sleep disturbances. Anxiety and depression frequently coexist, potentially producing greater impairment than either condition alone [8].

The relationship between psychological morbidity and CKD is multifactorial. Biological factors including inflammation, uraemic toxin accumulation, neuroendocrine abnormalities, anemia, sleep disturbances, and comorbid cardiovascular disease may contribute to depressive and anxiety symptoms. Psychosocial factors such as unemployment, financial burden, poor social support, impaired physical functioning, and loss of independence may further increase vulnerability [4,9].

Despite their potential clinical importance, anxiety and depression frequently remain under-recognized in dialysis settings. Symptoms such as fatigue, sleep disturbance, appetite changes, and reduced energy may be attributed to kidney disease itself, complicating recognition of psychiatric disorders. Screening instruments designed to minimize the influence of physical symptoms can therefore be useful in medically ill populations. The Hospital Anxiety and Depression Scale (HADS) is a brief instrument consisting of separate anxiety and depression subscales and has been extensively used to assess psychological distress in patients with physical illnesses [10].

Understanding the prevalence and determinants of anxiety and depression among hemodialysis patients can assist clinicians in identifying vulnerable individuals and planning integrated psychological care. Therefore, the present study aimed to assess anxiety and depressive symptoms among patients with CKD receiving maintenance hemodialysis and to evaluate their associations with selected sociodemographic and clinical factors.

Aim To determine the prevalence of anxiety and depression among patients with chronic kidney disease undergoing maintenance hemodialysis.

A hospital-based cross-sectional observational study was designed among patients with CKD receiving maintenance hemodialysis. Study Setting The study was conducted in the hemodialysis unit of a tertiary care teaching hospital. Patients receiving scheduled maintenance hemodialysis during the study period were screened for eligibility and recruited consecutively. Study Population Adult patients diagnosed with CKD/kidney failure who had been receiving maintenance hemodialysis were considered for inclusion. Sample Size For the illustrative manuscript, 150 patients were included. For an actual study, sample size should be calculated using the expected prevalence of anxiety or depression among dialysis patients, desired absolute precision, confidence level, and anticipated non-response. Inclusion Criteria 1. Patients aged ≥18 years. 2. Patients diagnosed with CKD receiving maintenance hemodialysis. 3. Patients undergoing hemodialysis for at least three months. 4. Patients clinically stable at the time of assessment. 5. Patients providing written informed consent. Exclusion Criteria 1. Patients who were critically ill or medically unstable. 2. Patients with severe cognitive impairment interfering with assessment. 3. Patients with active psychosis or mania. 4. Patients unable to communicate sufficiently to complete the study questionnaire. 5. Patients declining participation. Data Collection After informed consent, information was collected using a structured case-record form. Sociodemographic variables included age, sex, marital status, educational status, employment, residence, socioeconomic characteristics, and perceived family/social support. Clinical information included duration of CKD, duration of maintenance hemodialysis, dialysis frequency, major comorbidities, hemoglobin level, vascular access type, history of hospitalization, and relevant treatment details. Comorbidities included diabetes mellitus, hypertension, cardiovascular disease, and other documented chronic medical illnesses. Assessment of Anxiety and Depression Anxiety and depressive symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS) developed by Zigmond and Snaith [10]. HADS contains 14 items divided into two seven-item subscales: HADS-Anxiety (HADS-A) and HADS-Depression (HADS-D). Each item is scored from 0 to 3, producing a score between 0 and 21 for each subscale. For descriptive interpretation, scores were categorized as: • 0–7: normal range • 8–10: borderline/possible case • 11–21: probable clinically significant case For the primary prevalence analysis in this study, a score of ≥8 on the respective subscale was considered a positive screen for clinically relevant anxiety or depressive symptoms. HADS was used as a screening instrument rather than as a substitute for a structured psychiatric diagnostic interview. Ethical Considerations Institutional Ethics Committee approval should be obtained before commencement of the actual study. Participation should be voluntary, and written informed consent should be obtained from all participants. Confidentiality of participant information should be maintained. Patients with significant psychological symptoms should be offered appropriate clinical evaluation and referral to Psychiatry/Psychology services. Statistical Analysis Data were entered into a spreadsheet and analyzed using appropriate statistical software. Continuous variables were expressed as mean ± standard deviation or median and interquartile range depending on distribution. Categorical variables were expressed as frequencies and percentages. The prevalence of anxiety and depression was calculated using HADS-A and HADS-D scores ≥8, respectively. Associations between categorical variables were assessed using the chi-square test or Fisher's exact test. Independent predictors were evaluated using multivariable binary logistic regression. Adjusted odds ratios (AORs), 95% confidence intervals (CIs), and p-values were reported. A two-sided p-value <0.05 was considered statistically significant.

A total of 150 patients undergoing maintenance hemodialysis were included. Their mean age was 51.8 ± 12.6 years. Ninety (60.0%) were male and 60 (40.0%) were female. Eighty-two (54.7%) had been undergoing hemodialysis for ≥2 years.

Table 1. Sociodemographic and Clinical Characteristics of Study Participants (n=150)

More than half of the patients had received hemodialysis for at least two years. Approximately 61% were not currently employed, 42% had multiple medical comorbidities, and 26% reported inadequate family/social support.

Table 2. Prevalence and Severity of Anxiety and Depression According to HADS (n=150)

Clinically relevant anxiety symptoms were identified in 38.0% of participants, while 44.0% screened positive for depressive symptoms. Probable clinically significant anxiety (HADS-A ≥11) was present in 17.3%, while probable clinically significant depression (HADS-D ≥11) was found in 20.7%.

Table 3. Coexistence of Anxiety and Depression Among Participants

More than half (56.0%) of the participants screened positive for at least one of the two psychological conditions, and approximately one-quarter (26.0%) had coexisting anxiety and depressive symptoms.

Table 4. Factors Associated with Anxiety Among Hemodialysis Patients

Female sex, dialysis duration ≥2 years, multiple comorbidities, and inadequate social support were significantly associated with anxiety symptoms.

Table 5. Factors Associated with Depression Among Hemodialysis Patients

Depressive symptoms were significantly more common among patients who were unemployed/not working, had been receiving dialysis for ≥2 years, had multiple comorbidities, or reported inadequate social support.

Table 6. Multivariable Logistic Regression of Factors Associated with Anxiety and Depression

After adjustment, female sex, longer dialysis duration, and inadequate social support remained independently associated with anxiety. Unemployment, dialysis duration ≥2 years, and multiple comorbidities remained independently associated with depressive symptoms.

The present illustrative study demonstrates a substantial burden of anxiety and depressive symptoms among patients with CKD undergoing maintenance hemodialysis. Approximately 38% of participants screened positive for clinically relevant anxiety and 44% for depressive symptoms. Furthermore, 26% screened positive for both conditions, emphasizing the considerable overlap between anxiety and depression in this population. Depression is recognized as one of the most common psychiatric problems among patients with CKD. Palmer et al. conducted a systematic review and meta-analysis and demonstrated a substantial prevalence of depression among individuals with CKD, particularly among dialysis patients [5]. Variations in prevalence between studies may result from differences in study populations, cultural and socioeconomic conditions, dialysis characteristics, and methods used to assess depression. The observed prevalence of anxiety is also clinically important. Patients undergoing hemodialysis experience repeated exposure to potentially stressful procedures and uncertainty regarding their future health. Cukor et al. emphasized that anxiety disorders and depressive symptoms are important but frequently under-recognized problems in patients with end-stage kidney disease [8]. The coexistence of anxiety and depression observed in the present study further indicates that assessment of one psychological condition should prompt consideration of the other. Female sex was independently associated with anxiety. Similar sex differences have been observed in psychological disorders in both general and medically ill populations. Biological, social, economic, and caregiving factors may contribute to increased psychological vulnerability among women. Longer duration of dialysis was independently associated with both anxiety and depressive symptoms. Although some patients psychologically adapt to dialysis over time, prolonged treatment may also result in cumulative physical and emotional burden. Repeated hospital visits, restrictions on employment and travel, dependence on dialysis equipment, vascular access complications, and uncertainty regarding transplantation can adversely influence psychological wellbeing [3,4]. Depressive symptoms were significantly associated with unemployment. Hemodialysis schedules and CKD-related functional impairment may interfere with regular employment. Loss of employment can lead to financial difficulties, reduced social participation, loss of occupational identity, and greater dependency on family members, potentially increasing vulnerability to depression. Multiple medical comorbidities were independently associated with depression. Patients with several chronic illnesses are likely to experience greater symptom burden, polypharmacy, functional impairment, healthcare utilization, and uncertainty regarding prognosis. Depression in dialysis patients is clinically important because it has been associated with adverse outcomes, including reduced treatment adherence and increased hospitalization and mortality [6,7]. Social support also appeared important. Patients reporting inadequate family/social support experienced substantially more anxiety and depression in unadjusted analyses, while inadequate support remained independently associated with anxiety after multivariable adjustment. Strong social networks may provide emotional reassurance, practical assistance with treatment, transportation, financial support, and encouragement regarding adherence. Recognition of psychological morbidity in dialysis units can be challenging because symptoms of kidney failure—including fatigue, sleep problems, appetite disturbance, and reduced energy—overlap with manifestations of depression. HADS may be useful in medically ill populations because it focuses comparatively less on somatic symptoms [10]. Nevertheless, screening instruments should not be interpreted as equivalent to formal psychiatric diagnosis. The findings have potential implications for clinical practice. Periodic screening for anxiety and depression could be incorporated into multidisciplinary dialysis care. Patients with positive screening results should undergo further assessment, and appropriate psychological, psychiatric, social, and rehabilitative interventions should be offered. Collaborative care involving nephrologists, psychiatrists, psychologists, dialysis nurses, social workers, and family members may help address both physical and psychological aspects of CKD.

Anxiety and depressive symptoms are common among patients with chronic kidney disease receiving maintenance hemodialysis. In this illustrative study, 38% screened positive for anxiety, 44% for depression, and 26% experienced symptoms of both conditions.

Female sex, longer duration of dialysis and inadequate social support were independently associated with anxiety, while unemployment, longer dialysis duration and multiple comorbidities were independently associated with depression.

These findings support the incorporation of periodic mental-health screening into comprehensive hemodialysis care. Early identification, appropriate psychiatric assessment, psychosocial support, and multidisciplinary intervention may improve psychological wellbeing and potentially enhance treatment adherence and quality of life.