Association between depression and mortality in patients receiving long-term dialysis: a systematic review and meta-analysis.

BACKGROUND: We aimed to systematically review and analyze the association between depression and mortality risk in adults with kidney failure treated by long-term dialysis. STUDY DESIGN: A systematic review and meta-analysis of observational studies. SETTING & POPULATION: Patients receiving long-term dialysis. SELECTION CRITERIA FOR STUDIES: Searching MEDLINE, EMBASE, and PsycINFO, we identified studies examining the relationship between depression, measured as depressive symptoms or clinical diagnosis, and mortality. PREDICTOR: Depression status as determined by physician diagnosis or self-reported scales. OUTCOMES: Pooled adjusted HR and OR of depression for all-cause mortality. RESULTS: 15 of 31 included studies showed a significant association between depression and mortality, including 5 of 6 studies with more than 6,000 participants. A significant link was established between the presence of depressive symptoms and mortality (HR, 1.51; 95% CI, 1.35-1.69; I(2)=40%) based on 12 studies reporting depressive symptoms using depression scales (N=21,055; mean age, 57.6 years). After adjusting for potential publication bias, the presence of depressive symptoms remained a significant predictor of mortality (HR, 1.45; 95% CI, 1.27-1.65). In addition, combining across 6 studies reporting per-unit change in depression score (n=7,857) resulted in a significant effect (HR per unit change in score, 1.04; 95% CI, 1.01-1.06; I(2)=74%). LIMITATIONS: Depression or depressive symptoms were documented only from medical charts or a single self-report assessment. Included studies were heterogeneous because of variations in measurement methods, design, and analysis. CONCLUSIONS: There is considerable between-study heterogeneity in reports of depressive symptoms in dialysis patients, likely caused by high variability in the way depressive symptoms are measured. However, the overall significant independent effect of depressive symptoms on survival of dialysis patients warrants studying the underlying mechanisms of this relationship and the potential benefits of interventions to improve depression on the outcomes.

Gender impact on the correlation between sexuality and marital relation quality in patients with coronary artery disease.

INTRODUCTION: Although the negative impact of coronary artery disease (CAD) on sexual and marital relation of the patients is known, data are lacking regarding possible gender difference. AIM: We designed a study on patients with CAD to investigate sexual relation and marital adjustment and their association with regard to gender differences. MAIN OUTCOME MEASURES: Questionnaires including the Dyadic Adjustment Scale for evaluating the couple's agreement on decisions and appropriate behavior, marital satisfaction, and marital cohesion, and the Relation and Sexuality Scale (RSS) for sexual function, frequency, and fear. METHODS: We surveyed 650 patients with documented CAD without any other major comorbidities. RESULTS: The patients were 464 men (73.1%) and 171 women (26.9%) with CAD. The mean age of the men and the women were 57.1 +/- 11.6 years and 56.3 +/- 9.7 years, respectively. The women had a significantly poorer dyadic adjustment and sexual relation than men, except for sexual fear, which was more prominent in men with CAD and their spouses. The sexual frequency and the total RSS scores correlated with all aspects of the patients' marital relation in both genders. However, only men suffered from a poorer dyadic satisfaction, dyadic consensus, affectional expression, and overall marital adjustment if they were more afraid of sexual relation. In women, but not men, sexual function was significantly associated with their dyadic satisfaction and their overall marital relation. CONCLUSIONS: Poorer sexual relation and marital adjustment was detected in our women with CAD. To manage all the problems of the patients that may impact their cardiac status, we should consider factors such as fear of sexual activity in men sexual dysfunction in women, and their correlation with marital adjustment.

Sexual function and psychological status among males and females with ischemic heart disease.

INTRODUCTION: Patients with coronary artery disease (CAD) may also suffer from mental and sexual problems, and we should consider the mutual influence such conditions have on each other. However, the interrelation between sexual and mental problems in the context of CAD has not been fully investigated, especially when it comes to gender. AIM: Our aim was to evaluate sexuality and psychiatric symptoms among patients with CAD and the relation between them in each gender. METHODS: In this cross-sectional study, 550 (397 men and 153 women) patients with documented CAD were surveyed for anxiety and depression using the hospital anxiety and depression scale (HADS) self-administered questionnaire as well as the relation and sexuality scale (RSS). Three subscores were calculated for sexual function, frequency, and fear, with higher scores indicative of a poorer condition. MAIN OUTCOME MEASURES: The HADS and the RSS. RESULTS: Depressive symptoms and anxiety were more severe among our female subjects than they were among the male ones. In addition, the scores for sexual frequency, sexual function, and the total RSS were significantly higher in women, while men had a significantly higher score for sexual fear. The total RSS score correlated with depressive symptoms in women (r = 0.19, P = 0.03), but not in the male subjects. Considering the subscores, a higher score for sexual frequency correlated with depressive symptoms in both genders; however, being afraid of sexual relation correlated with depressive symptoms only in men with CAD and their spouses (r = 0.18, P = 0.001). CONCLUSION: We found that women with CAD have poorer sexual relation and more severe depressive symptoms than men do. Among men with CAD and their wives, fear of sexual relationship is a more serious problem. Such gender-specific characteristics and their interrelations ought to receive due consideration in the management of CAD.

Patient-perceived barriers to a screening program for depression: a patient opinion survey of hemodialysis patients.

BACKGROUND: Depression is a prevalent, yet underdiagnosed, psychiatric disorder among patients with end-stage renal disease. Active case identification through routine screening is suggested; however, patient-related barriers may reduce the effectiveness of screening for, and treating, depression. This study aimed to explore the perceived barriers that limit patients from participating in screening and treatment programs for depression. METHODS: In a cross-sectional study of chronic maintenance hemodialysis patients, the Perceived Barriers to Psychological Treatment questionnaire, adapted to include screening, was used to measure perceived barriers. The two-item Patient Health Questionnaire was used to identify patients with depressive symptoms. RESULTS: Of 160 participants, 73.1% reported at least one barrier preventing them from participation [95% confidence interval (95% CI) 66.2-80.0%]. Patients with depressive symptoms were more likely to perceive at least one barrier to a screening program for depression compared with those without depressive symptoms (96% versus 68.9%, respectively; odds ratio = 10.8; 95% CI 1.4-82.8; P = 0.005). The association of the barrier scores with depressive symptoms remained significant after adjustment for patient's characteristics. The most common barriers that patients expressed were concerns about the side effects of any antidepressant medications that may be prescribed (40%), concerns about having more medications (32%), feeling that the problem is not severe enough (23%) and perceiving no risk of depression (23%). CONCLUSIONS: Negative perceptions about depression and its treatment among hemodialysis patients constitute an important barrier to identifying this condition and first need to be addressed before implementing a screening program in this population.

Plasmapheresis in the treatment of early acute kidney allograft dysfunction.

OBJECTIVE: To evaluate the efficacy of plasmapheresis (PP) in kidney transplant recipients with acute humoral rejection (AHR). PATIENTS AND METHODS: A retrospective review was conducted of all kidney allograft recipients who had undergone PP rescue therapy for early acute allograft dysfunction diagnosed as AHR at Shaheed Labbafinejad Medical Center from 1995 to 2002. RESULTS: Twelve patients (4 men and 8 women; median age, 32 years; age range, 15-68 years) with AHR were treated with PP. The median time from transplantation to AHR was 6 days (range, 2-7 days). PP was performed in 2 to 11 sessions (median, 8.5 sessions) in the patients studied. Eight patients responded to that treatment, and their creatinine value normalized. Those responders were monitored for a median of 162.5 weeks (range, 69.3-484.7 weeks), and all had a functioning allograft during the follow-up period except for 1 patient in whom the graft failed 154 weeks after transplantation. In the 4 remaining patients (nonresponders), the allograft failed within the first posttransplant month. The median time from the acute serum creatinine elevation to the initiation of PP was 6 days in responders and 18.6 days in nonresponders (P = .37). CONCLUSIONS: We suggest that PP with or without other therapeutic measures may have a role in the salvage of grafts with early acute dysfunction that is resistant to conventional therapy. Our findings indicate that graft survival in patients with AHR who respond to PP can be comparable to that in other kidney recipients.

Survival of Patients on Hemodialysis and Predictors of Mortality: a Single-Centre Analysis of Time-Dependent Factors.

INTRODUCTION: This study aimed to evaluate the outcome and predictors of survival in hemodialysis patients of Hasheminejad Kidney Center where a comprehensive dialysis care program has been placed since 2004. MATERIALS AND METHODS: Data of 560 hemodialysis patients were used to evaluate 9-year survival rates and predictors of mortality. Cox regression models included comorbidities as well as averaged and 6-month-averaged time-dependent values of laboratory findings as independent factors. RESULTS: Survival rates were 91.9%, 66.0%, 46.3%, and 28.5%,  at 1, 3, 5, and 9 years, respectively, in all patients and 90.8%, 61.6%, 42.1%, and 28.0% in 395 incident patients starting hemodialysis after 2004. Adjusted survival models demonstrated age, male sex, diabetes mellitus, cardiovascular disease, and high-risk vascular access as baseline predictors of mortality, as well as averaged low hemoglobin level (hazard ratio [HR], 1.98; 95% confidence interval [CI], 1.36 to 2.90) and a single-pool KT/V < 1.2 (HR, 2.28; 95% CI, 1.60 to 3.26). The averaged high-density lipoprotein cholesterol (HR, 0.67; 95% CI, 0.55 to 0.81) and serum creatinine (HR, 0.71; 95% CI, 0.64 to 0.79) levels demonstrated protective effects. The adjusted time-dependent model further revealed the significant association of hypocalcemia (HR, 1.63; 95% CI, 1.13 to 2.34), hypercalcemia (HR, 1.50; 95% CI, 1.02 to 2.21), and hyperphosphatemia (HR, 1.68; 95% CI, 1.20 to 2.37) with death. CONCLUSIONS: Our patients have relatively comparable survival rates with high-profile dialysis centers. Aiming to better achieve the recommended targets, especially hemoglobin and nutritional and bone metabolism factors, should be considered for optimal dialysis outcomes.

Laparoscopy-assisted autotransplantation in child with renovascular hypertension.

A 7-year-old boy with hypertension secondary to intimal hyperplasia of the left renal artery was normotensive after laparoscopic autotransplantation following failed angioplasty. This appears to be the first such case reported.

Routine use of an abbreviated 4-item scale to assess dependence in essential activities of daily living amongst elderly hemodialysis patients: a validation study.

BACKGROUND: Poor functional status is associated with reduced survival and poor outcomes in older dialysis patients. The Geriatric Nephrology Advisory Group recommends routine evaluation of functional status on all older patients; however, assessments can be time consuming and burdensome to clinical care providers. The objective of this study was to validate an abbreviated 4-item self-report screening tool for use in elderly hemodialysis patients. METHODS: The functional dependence of community-dwelling hemodialysis patients, aged ≥65 years, was measured by trained evaluators. The accuracy of a 4-item self-report activities of daily living (ADL) score was compared against formal evaluation by the Barthel Index and the outcomes using agreement statistics and Cox regression analysis. RESULTS: The cohort included 167 patients with a mean age of 74.8 ± 5.9 years (57 % males). The 4-item scale correctly identified 83 % of the patients dependent in ≥1 ADL. Those incorrectly identified as independent on the abbreviated scale were uniformly unable to climb stairs without assistance. The sensitivity and specificity, and coefficient for agreement between the 4-item scale and the Barthel Index were 83.2, 100 and 0.78 %, respectively. The positive and negative predictive values of the 4-item scale were 100 and 76.9 %, respectively. Using the 4-item scale, the presence of severe disability was predictive of increased mortality (HR 12.5; 95 % CI 2.5-65.0; P = 0.03). CONCLUSIONS: The 4-item scale is a simple, valid screening test for disability which can be used in the elderly population on dialysis as a screening tool. Difficulties with stair climbing may be overlooked using this score.

Predictive factors for prostatic involvement by transitional cell carcinoma of the bladder.

PURPOSE: To evaluate the predictive factors for prostatic involvement according to the bladder transitional cell carcinoma (TCC) characteristics in a prospective study. MATERIALS AND METHODS: Hundred patients with the bladder TCC who had undergone standard radical cystoprostatectomy were enrolled in this study. A number of factors, including vascular and perineural invasion, number of tumors, maximum diameter of the tumor, presence of carcinoma in situ, distance between the tumor and the bladder neck, grade, and local stage of the tumor were recorded, and their relationships with prostatic involvement were studied. In addition, hydronephrosis and age of the patients were included in the analysis. RESULTS: The mean age of the patients was 62.6 ± 10.8 years. Of a total of 100 patients, 21 (75%) were found to have prostatic involvement with TCC. Univariate statistical analysis showed that vascular invasion and the distance between the tumor and the bladder neck were significantly related to the prostatic involvement (P = .001 and P < .001) and tumor stage had relatively low P value (P = .08). In the logistic regression, only the distance between the tumor and the bladder neck was found to be significantly related to the prostatic involvement (P = .004). CONCLUSION: This study demonstrated that distance between the tumor and the bladder neck is a predictive factor for prostatic involvement; hence, prostate-sparing or capsule-sparing cystectomy in patients with tumors in short distances from prostatovesical junction is not rationale and should be avoided.

Penile reconstruction: evaluation of the most accepted techniques.

PURPOSE: Loss of the penis can have a devastating effect on the lives of sufferers with significant psychogenic implications. Penile reconstruction or phallus construction poses a difficult challenge and a demanding problem to the urologists and plastic surgeons. Different techniques have been used for construction of a total penis and reconstruction of severely injured penis. The objective of this review was to determine the efficacy, advantages and disadvantages of the most popular penile reconstruction (PR) and phallus construction techniques. MATERIALS AND METHODS: We searched without language restriction MEDLINE, Pre-MEDLINE EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from January 1960 to January 2009. In addition, we searched the citation lists of relevant articles and book chapters. Studies evaluating the functional and cosmetic results of different techniques of total phallus construction (TPC) and penile reconstruction (PR) were identified. Two authors independently evaluated studies for selection, study quality, and extracted data. The primary outcome was creation of a sensate and cosmetically acceptable phallus. The secondary outcomes were competent neourethra that allows voiding in comfortable position, sexual intercourse, and the rate of complications. RESULTS: One hundred and forty-six studies with a total of 1622 patients were included in this review. CONCLUSION: Data from the available studies are insufficient to recommendany technique for TPC or PR. In the absence of evidence to support any method, the review authors recommend the one-stage TPC or PR. Further studies are warranted, preferably multi-centered studies.

Different doses of oral folic acid for homocysteine-lowering therapy in patients on hemodialysis: a randomized controlled trial.

INTRODUCTION: We compared the effect of higher and lower doses of folic acid compared to our routine daily dose on plasma homocysteine levels, in our hemodialysis patients. MATERIALS AND METHODS: Eighty patients on hemodialysis receiving oral folic acid, 10 mg/d, were randomized to receive folic acid at either doses of 5 mg/d (group 1) or 15 mg/d (group 2) for 2 months. Plasma levels of total homocysteine were measured before and after the study period. RESULTS: Hyperhomocysteinemia was seen in 75 patients (93.8%) before, and in 37 patients of group 1 (92.5%) and 39 of group 2 (97.5%) after the study period. In group 1, a nonsignificant decrease occurred in plasma homocysteine level (29.67 +/- 12.26 micromol/L to 27.78 +/- 9.94 micromol/L, P = .30), while in group 2, there was a significant decrease in homocysteine level (32.40 +/- 9.76 micromol/L to 29.58 +/- 9.62 micromol/L, P = .01). Changes in homocysteine level correlated with its baseline level (r = -0.42, P < .001). In both groups, significant reductions in homocysteine level were seen mostly in those patients with high baseline homocysteines. CONCLUSIONS: Routine folic acid supplementation of 10 mg/d could not normalize plasma homocysteine levels in most of our patients. Increasing folic acid dose made a statistically significant but clinically trivial decrease in homocysteine levels, and could not normalize homocysteine level in most patients. Patients with a higher baseline homocysteine level achieved a greater reduction, which may be explained by primary noncompliance of some patient. Further investigation of folic acid dosage is suggested.

Pre-transplant and post-transplant soluble CD30 for prediction and diagnosis of acute kidney allograft rejection.

BACKGROUND: Serum levels of soluble CD30 (sCD30) have been considered as a predictor of acute kidney allograft rejection. We have evaluated the pre-transplant and post-transplant levels of sCD30 with the aim of determining its value in predicting and diagnosing kidney rejection. METHODS: We measured sCD30 serum levels before kidney transplantation, 5 days post-operatively, and at creatinine elevation episodes. The predictive value of sCD30 for diagnosing acute rejection (AR) within the first 6 post-operative months was assessed in 203 kidney recipients from living donors. RESULTS: Pre-transplant and post-operative levels of serum sCD30 were 58.10 +/- 52.55 and 51.55 +/- 49.65 U/ml, respectively (P = 0.12). Twenty-three patients experienced biopsy-proven acute rejection, and 28 had acute allograft dysfunction due to non-immunologic diseases. The pre-transplant sCD30 level was not different between patients with and without AR. However, post-transplant sCD30 was higher in the AR group. The median serum level of post-transplant sCD30 was 52 U/ml in the AR group and 26.3 U/ml in a control group (P < 0.001). The relative changes of sCD30 on day 5 were higher in patients with AR (P = 0.003). Based on post-transplant sCD30 levels, we were able to differentiate between kidney recipients who experienced an AR within 6 months post-surgery and those without an AR (cutoff value 41 U/ml; sensitivity 70%; specificity 71.7%). The level of sCD30 during periods of elevated serum creatinine was not independently associated with the diagnosis of AR. CONCLUSION: Post-transplant sCD30 levels and their relative changes are higher in patients experiencing AR. We propose further studies on the post-transplant trend of this marker for the prediction of AR.

Burden of chronic kidney disease in Iran: a screening program is of essential need.

INTRODUCTION: The latent nature of chronic kidney disease (CKD) in primary stages precludes early diagnosis. This necessitates plans such as screening, but we should first introduce CKD as a public health problem. This study was designed to define the burden of CKD in Iran. MATERIALS AND METHODS: We calculated disability-adjusted life years (DALYs) according to the World Health Organization's practical guidelines for national burden of disease studies. The sum of years of life lost and years lived with disability were estimated for CKD stages 1 to 4 and end-stage renal disease (ESRD) based on the national registry data and the published reports about CKD in Iran in 2004. RESULTS: Over 700 000 people were estimated to have CKD in Iran in 2004 and 61 000 new cases of CKD were anticipated. The prevalence rate of CKD was estimated to be 1083 and its incidence rate was 173.5 per 100 000 population. Chronic kidney disease was responsible for 1 145 654 DALYs. The highest DALYs for stages 1 to 4 of CKD were due to unknown etiology, diabetes mellitus, and hypertension (382 000 years, 347 400 years, and 311 800 years, respectively). The DALY for ESRD and CKD stages 1 to 4 were 21 490 years and 1 124 164 years, respectively. CONCLUSIONS: The present study provides an estimate of the burden of CKD in Iran. As CKD can be controlled by practical cost-effective plans, we strongly recommend the information given by this study be considered for future action plans.

Genetics of azoospermia: current knowledge, clinical implications, and future directions. Part II: Y chromosome microdeletions.

INTRODUCTION: We reviewed the most recent advances in the genetics of male infertility focusing on Y chromosome microdeletions. MATERIALS AND METHODS: We searched the literature using the PubMed and skimmed articles published from January 1998 to October 2007. The keywords were the Y chromosome, microdeletions, male infertility, and azoospermia factor (AZF). The full texts of the relevant articles and their bibliographic information were reviewed and a total of 78 articles were used. RESULTS: Three regions in the long arm of the Y chromosome, known as AZFa, AZFb, and AZFc, are involved in the most frequent patterns of Y chromosome microdeletions. These regions contain a high density of genes that are thought to be responsible for impaired spermatogenesis. In 2003, the Y chromosome sequence was mapped and microdeletions are now classified according to the palindromic structure of the euchromatin that is composed of a series of repeat units called amplicons. Although it has been shown that the AZFb and AZFc are overlapping regions, the classical AZF regions are still used to describe the deletions in clinical practice. CONCLUSION: Y chromosome microdeletions are the most common genetic cause of male infertility and screening for these microdeletions in azoospermic or severely oligospermic men should be standard. Detection of various subtypes of these deletions has a prognostic value in predicting potential success of testicular sperm retrieval for assisted reproduction. Men with azoospermia and AZFc deletions may have retrievable sperm in their testes. However, they will transmit the deletions to their male offspring by intracytoplasmic sperm injection.

Successful treatment of infective endocarditis in four kidney transplant recipients.

Infective endocarditis (IE) is a serious complication in kidney transplantation, leading to graft loss and a high mortality rate. We report 4 successfully managed cases of IE in kidney transplant recipients. Blood culture revealed Enterococcus in 2 patients, group D Streptococcus in 1, and no bacteria in 1. All of the patients were diagnosed based on at least 2 major Duke criteria for diagnosis of IE. Although a mild increase in the serum creatinine level was observed in 3 out of 4 patients, no graft rejection occurred during the follow-up. Early diagnostic and therapeutic intervention, particularly intensive antibiotic therapy and surgical management can preserve the patient and the kidney allograft. Studies on previous recurrent infections and simultaneous diseases such as cytomegalovirus in these patients are warranted.

Kidney transplantation in children with augmentation cystoplasty.

PURPOSE: Treatment of children with end stage renal disease, especially those with significant bladder dysfunction, is difficult. A high pressure and low capacity bladder is a major risk factor for a transplanted kidney. Cystoplasty can protect the kidney allograft by reducing the intravesical pressure and creating an appropriate capacity. The aim of this study was to evaluate the outcome of kidney transplantation in children with and without prior cystoplasty. MATERIALS AND METHODS: A total of 43 children with bladder dysfunction in urgent need of cystoplasty were enrolled in the study and were compared to a control group with regard to acute and chronic rejection rates, survival of the transplanted kidney, surgical complications and febrile urinary tract infection. RESULTS: The rates of febrile urinary tract infection and chronic rejection were significantly higher in patients with prior cystoplasty (p<0.001 and p=0.004, respectively). Also, graft loss was much more frequent in these patients (34.9% vs 20.9%), although this difference was not statistically significant. In patients with prior cystoplasty graft survival rates were 92%, 73%, 58% and 45% at postoperative years 1, 3, 5 and 7, respectively. In the control group these rates were 94%, 87%, 81% and 75%, respectively (p=0.007). CONCLUSIONS: Based on our findings, the survival rate of the kidney is significantly lower in children with prior cystoplasty, possibly due to the higher prevalence of chronic rejection and febrile urinary tract infection in this group.

Bowel preparation versus no preparation before ileal urinary diversion.

OBJECTIVES: To compare the outcome and complications of urinary diversion using ileum, with and without bowel preparation. Recent studies have questioned the necessity of bowel preparation, especially for urinary diversion when ileum is used. METHODS: In this clinical trial, 30 candidates for urinary diversion underwent a 3-day standard bowel preparation (group 1), and 32 were admitted 24 hours before surgery and received only a soft diet, with no oral intake, 8 hours before surgery (group 2). They were followed up for at least 6 months and were evaluated for outcome and surgical complications. RESULTS: All surgical operations were performed successfully using ileum. Postoperative complications were documented in 2 and 4 patients in groups 1 and 2, respectively (relative risk 0.69, 95% confidence interval 0.37 to 1.31, P = 0.41). Anastomotic leak, enterocutaneous fistula, and wound infection and dehiscence occurred in 1 patient in group 1, leading to reoperation. One case of ileus was also seen in group 1. In group 2, wound infection and dehiscence occurred 2 in patients and ileus in 2 others. CONCLUSIONS: This study failed to demonstrate any advantage of bowel preparation for urinary diversion when we use the ileal segment. Furthermore, a meticulous use of ileum can be done without the need for a colon segment in bladder substitution procedures.

Low-dose doxepin for treatment of pruritus in patients on hemodialysis.

INTRODUCTION: Pruritus is one of the frequent discomforting complications in patients with end-stage renal disease. We prospectively evaluated the effectiveness of doxepin, an H1-receptor antagonist of histamine, in patients with pruritus resistant to conventional treatment. MATERIALS AND METHODS: A randomized controlled trial with a crossover design was performed on 24 patients in whom other etiologic factors of pruritus had been ruled out. They were assigned into 2 groups and received either placebo or oral doxepin, 10 mg, twice a day for 1 week. After a 1-week washout period, the 2 groups were treated conversely. Subjective outcome was determined by asking the patients described their pruritus as completely improved, relatively improved, or remained unchanged/worsened. RESULTS: Complete resolution of pruritus was reported in 14 patients (58.3%) with doxepin and 2 (8.3%) with placebo (P < .001). Relative improvement was observed in 7 (29.2%) and 4 (16.7%), respectively. Overall, the improving effect of doxepin on pruritus was seen in 87.5% of the patients. Twelve patients (50.0%) complained of drowsiness that alleviated in all cases after 2 days in average. One patient refused to continue the treatment due to its sedative effect. CONCLUSIONS: We suggest that doxepin, a tricyclic antidepressant with anti-H1 receptor effect, can help improve pruritus resistant to antihistamines in end-stage renal disease patients who undergo hemodialysis. A low dose of doxepin is safe while effective and its main adverse effect, drowsiness, is temporary and can be easily tolerated by the patients.