Depressive Symptoms and Incident Peripheral Arterial Disease Among Adults With CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study

RATIONALE & OBJECTIVE: Depression is associated with cardiovascular disease among adults with CKD, but its relationship with peripheral arterial disease (PAD) has not been thoroughly examined despite both conditions being common in this population. We evaluated the risk for incident PAD and death associated with elevated depressive symptoms among adults with CKD. STUDY DESIGN: Observational prospective cohort study. SETTING & PARTICIPANTS: Adults with mild to moderate CKD in the Chronic Renal Insufficiency Cohort Study (CRIC) Study. EXPOSURES: Elevated depressive symptoms as defined by a Beck Depression Inventory (BDI) score ≥ 11. OUTCOMES: Incident PAD, defined as an Ankle-Brachial Index (ABI) < 0.9 or confirmed clinical PAD event (amputation or angioplasty). Composite outcome of incident PAD or death. ANALYTICAL APPROACH: The association between baseline elevated depressive symptoms and incident PAD, as well as a composite of incident PAD or death, was examined with Cox proportional hazard models. Mediation analysis explored the pathways between elevated depressive symptoms and these outcomes. RESULTS: Among 2,757 individuals, 25% had elevated depressive symptoms (BDI ≥11) at baseline. During a median follow-up of 10 years, 24% of participants developed incident PAD. The rate of incident PAD was higher in those with elevated depressive symptoms (3.6 events per 100 person-years) compared with those without (2.2 events per 100 person-years). After accounting for other factors, baseline elevated depressive symptoms were associated with a higher risk of incident PAD (HR 1.23; 95% CI: 1.02-1.47). Smoking and physical inactivity mediated 20% and 10%, respectively, of this association. Similar associations were found between baseline elevated depressive symptoms and a composite of incident PAD or death. Findings were not different when elevated depressive symptoms were defined by BDI >14 and BDI ≥16. LIMITATIONS: Residual bias and confounding. Absence of depression diagnosis. CONCLUSIONS: Elevated depressive symptoms were associated with a significantly increased risk of incident PAD in adults with CKD, which is partly mediated by smoking and physical inactivity. INDEX WORDS: Renal failure, depression, peripheral vascular disease, mortality, health behaviors.