Anxiety and depression in relation to resilience and quality of life in patients with kidney calculi

Abstract

BACKGROUND

Anxiety and depression are understudied in kidney calculi despite their inverse correlation with clinical outcomes.

AIM

To investigate the correlation of anxiety and depression with resilience and quality of life (QoL) in patients with kidney calculi, and to identify contributors to these emotional disorders in such patients.

METHODS

This study included 119 patients with kidney calculi who visited the First Affiliated Hospital of Xi’an Jiaotong University from May 2022 to March 2025. Patients’ anxiety [Hamilton Self-Rating Anxiety Scale (HAMA)], depression [Hamilton Self-Rating Depression Scale (HAMD)], resilience [Connor-Davidson Resilience Scale (CD-RISC)], and QoL [General QoL Inventory-74 (GQOLI-74)] were assessed. Spearman correlation coefficients were calculated to analyze the correlations of anxiety and depression with resilience and QoL. Multivariate modeling identified anxiety and depression contributors in patients with kidney calculi.

RESULTS

Anxiety and depressive symptoms affected 49.58% and 64.71% of participants, respectively. Notably lower CD-RISC scores (across tenacity, strength, and optimism dimensions and the global scale) were observed in the anxiety/depression groups vs their corresponding non-anxiety/non-depression groups. The same pattern was observed in GQOLI-74 global and subscale scores. Both HAMA and HAMD correlated inversely with CD-RISC (HAMA: r = -0.194, P = 0.034; HAMD: r = -0.413, P < 0.001) and GQOLI-74 (HAMA: r = -0.394, P < 0.001; HAMD: r = -0.347,P < 0.001). As confirmed by multivariate regression, per capita monthly income [odds ratio (OR) = 0.158, P = 0.002], complications (risk factor, OR = 3.442, P = 0.032), CD-RISC (OR = 0.075, P < 0.001), and GQOLI-74 (OR = 0.081, P < 0.001) each independently affected anxiety risk. Depression-associated independent predictors included income (OR = 0.090, P < 0.001), social support (OR = 0.136, P = 0.003), CD-RISC (OR = 0.060, P < 0.001), and GQOLI-74 (OR = 0.198, P = 0.023).

CONCLUSION

Anxiety and depression exhibited an intimate connection with resilience and QoL in patients with kidney calculi. High income, great resilience, and superior QoL are protective against psychological distress.

Key Words: Kidney calculi; Anxiety; Depression; Resilience; Quality of life; Determinants

Core Tip: This research investigates anxiety and depression in relation to resilience and quality of life (QoL) in patients with kidney calculi, while exploring anxiety and depression contributors. We revealed an inverse connection between anxiety and depression in patients and their resilience and QoL. Low per capita monthly income (≤ 3500 yuan), poor resilience (Connor-Davidson Resilience Scale ≤ 55 points), and inferior life quality (General QoL Inventory-74 ≤ 45 points) increased the risk of developing both anxiety and depression in such patients. Further, complications and insufficient social support increased anxiety and depression risks, respectively.

INTRODUCTION

Kidney calculi, a predominantly seen urinary condition, are the most common type of urolithiasis, characterized by crystalline mass formation in the urinary tract (UT)[1]. Pathologically, the disease involves oxalate-mediated regulation of the Jupiter microtubule-associated homolog 2/phosphoinositide 3-kinase/protein kinase B axis, thereby inducing crystalline cell adhesion and macrophage metabolism that further exacerbates illness progression[2]. Kidney stone occurrence is associated with gender, climate, diet, etc., causing discomfort symptoms, including ureteral obstruction, blood in urine, frequent UT infection, vomiting, or micturition pain. If the condition worsens, it progresses to permanent renal function damage, which will seriously affect the patient’s health and quality of life (QoL)[3,4]. The prevalence rate in the United States has risen from 3.2% (1980) to 10.1% (2016), and it is commonly identified in men than in women[5]. This disease has several treatments, including extracorporeal shock wave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy; thus, patients suffer from a high recurrence risk (5-year relapse rate: 26%-46%), which brings certain challenges to surgical treatment and psychological burdens to patients[6,7]. Previous studies have indicated a further increase in kidney calculi risk in the presence of anxiety or depression[8]. Anxiety elevates the risk of kidney stone by increasing the estimated glomerular filtration rate, and a causal association has been demonstrated between genetically predicted anxiety and heightened kidney calculi development[9]. Further, Wang et al[10] reported causality between the genetic prediction of depression and an increased risk of kidney calculi. Resilience, which is vital for maintaining positive mentality and mental health, is defined as the adaptability of individuals while dealing with events such as stress, adversity, and trauma. High resilience helps cope with stress or negative events, get rid of negative emotions (e.g., anxiety, depression) faster, and improve the QoL[11,12].

At present, studies on anxiety and depression in relation to resilience and QoL in kidney calculi are limited, with insufficient exploration of affecting factors. This study innovatively investigates in this direction to identify the key contributors to anxiety and depression in such patients and help them face the disease itself more actively.

MATERIALS AND METHODS

Case selection

Inclusion criteria: All patients had a kidney calculus diagnosis following the European Urology Association’s guidelines for urolithiasis management[13]. Besides, all eligible participants demonstrated clinical symptoms, including dysuria, urinary frequency, hematuria, or pain. Additional requirements included intact cognitive function, the ability to communicate effectively, and a comprehensive case profile.

Exclusion criteria: Individuals with significant systemic organ dysfunction, severe UT infections, or concurrent malignancies. Further, the study excluded patients with ureteral calculi, other UT disorders, or cognitive/psychiatric impairments. The First Affiliated Hospital of Xi’an Jiaotong University enrolled 119 patients with kidney stones who met the above-specified criteria from May 2022 to March 2025. Figure 1 illustrates the patient selection flowchart.

Figure 1 Flowchart for patient selection.

Data collection and outcome measurement

Anxiety and depression: Patient anxiety and depression were assessed using the Hamilton Self-Rating Anxiety Scale (HAMA); 14 items and Hamilton Self-Rating Depression Scale (HAMD); 24 items[14]. Each HAMA item is scored from 0 (no symptoms) to 4 (extremely severe symptoms), with a total of 56 points that is proportional to anxiety severity [interpreted as normal (< 7), potential anxiety (7-13), clinical anxiety (14-20), moderate anxiety (21-29), and severe anxiety (> 29)]. Each HAMD item scored either 0-4 or 0-2, with a maximal score of 78 that correlates positively with depressive severity [classified as normal (< 8), mild depression (8-19), moderate depression (20-35), and severe depression (> 35)].

Resilience: The Connor-Davidson Resilience Scale (CD-RISC)[15] was administered to assess psychological resilience in patients with postoperative kidney calculi, thereby evaluating tenacity (maximum score: 52), strength (32), and optimism (16). Improved resilience is associated with increased scores.

QoL: The General QoL Inventory-74 (GQOLI-74)[16] was employed to measure patient QoL. The first domain, material life, was scored from 16 to 80, whereas the remaining three domains (physical, social, and psychological function) each ranged from 20 to 100. Scores proportionally increase with QoL improvements.

Statistical analysis

Statistical Package for the Social Sciences version 22.0 was used for statistical analysis. Quantitative data with normal distribution were summarized using descriptive statistics (mean ± SD) and compared using parametric t-tests. Count data were presented as n (%). Interrelationships among anxiety, depression, resilience, and QoL measures were assessed using Spearman’s coefficients, whereas mood disorder determinants in patients with nephrolithiasis were identified by employing multivariate logistic modeling. Statistical significance was set at P values of < 0.05 for all analyses.

RESULTS

Anxiety and depression evaluation in patients with kidney calculi

Study participants demonstrated mean HAMA and HAMD scores of 6.00 (5.00, 9.00) and 10.00 (5.00, 13.00), respectively. Clinically significant symptoms were present in 49.58% (anxiety) and 64.71% (depression) of cases, predominantly at mild severity levels (Table 1).

Table 1 Anxiety and depression prevalence in kidney calculi patients, n (%).

Anxiety/depression	n = 119
HAMA (points), mean ± SD	6.00 (5.00, 9.00)
Normal (< 7)	60 (50.42)
Potential anxiety (7-13)	56 (47.06)
Clinical anxiety (14-20)	3 (2.52)
Moderate anxiety (21-29)	0 (0.00)
Severe anxiety (> 29)	0 (0.00)
Anxiety (≥ 7)	59 (49.58)
HAMD (points), mean ± SD	10.00 (5.00, 13.00)
Normal (< 8)	42 (35.29)
Mild depression (8-19)	69 (57.98)
Moderate depression (20-35)	8 (6.72)
Severe depression (> 35)	0 (0.00)
Depression (≥ 8)	77 (64.71)

HAMA: Hamilton Self-Rating Anxiety Scale; HAMD: Hamilton Self-Rating Depression Scale.

Resilience assessment in patients with nephrolithiasis

We categorized patients based on their HAMA and HAMD scores (as detailed in Table 1) into non-anxiety (n = 60) vs anxiety (n = 59) and non-depression (n = 42) vs depression (n = 77) groups. CD-RISC total and subscale scores, including tenacity, strength, and optimism dimensions, were documented. Data demonstrated markedly reduced tenacity, strength, and optimism scores and decreased total CD-RISC scores in the anxiety group vs the non-anxiety group (P < 0.01). Patients with depression likewise scored lower than those with no depression (P < 0.05; Figure 2).

Figure 2 Resilience evaluation in kidney calculi patients. ^aP < 0.05; ^bP < 0.01 for inter-group comparisons. A: Tenacity scores stratified by anxiety/non-anxiety and depression/non-depression groups; B: Strength scores across anxiety and depression subgroups; C: Comparison of optimism scores between patients with/without anxiety or depression; D: Total resilience (Connor-Davidson Resilience Scale) comparison between anxiety and depression subgroups. CD-RISC: Connor-Davidson Resilience Scale.

QoL outcomes in patients with kidney calculi

The GQOLI-74 questionnaire was used for QoL evaluation. Patients positive with anxiety scored evidently worse than their non-anxious counterparts in material life, physical/social/psychological function, and overall QoL (P < 0.05). Patients with depression likewise scored lower than those with no depression in all domains (P < 0.05; Figure 3).

Figure 3 Quality of life assessment in kidney calculi patients. ^aP < 0.05; ^bP < 0.01 for inter-group comparisons. A: Material life scores across anxiety and depression subgroups; B: Physical function domain comparisons (non-anxiety group vs anxiety group, non-depression group vs depression group); C: Social function score comparisons between patients with/without anxiety or depression; D: Psychological function scores across anxiety and depression subgroups; E: Total General Quality of Life Inventory-74 score comparison (non-anxiety vs anxiety, non-depression vs depression). GQOLI-74: General Quality of Life Inventory-74.

Correlation of anxiety and depression with resilience and QoL

The study assessed the association of anxiety and depression with psychological resilience (CD-RISC) and QoL (GQOLI-74) using Spearman’s correlation coefficients. The results indicated a significant negative correlation between HAMA scores and both CD-RISC (r = -0.194, P = 0.034) and GQOLI-74 (r = -0.394, P < 0.001). Likewise, increased HAMD scores were associated with reduced CD-RISC (r = -0.413, P < 0.001) and GQOLI-74 (r = -0.347, P < 0.001; Table 2).

Table 2 Correlation of anxiety and depression with resilience and quality of life.

Correlation	CD-RISC (points)	GQOLI-74 (points)
HAMA (points)	r = -0.194, P = 0.034	r = -0.394, P < 0.001
HAMD (points)	r = -0.413, P < 0.001	r = -0.347, P < 0.001

HAMA: Hamilton Self-Rating Anxiety Scale; HAMD: Hamilton Self-Rating Depression Scale; CD-RISC: Connor-Davidson Resilience Scale; GQOLI-74: General Quality of Life Inventory-74.

Multivariate analysis of anxiety and depression determinants in patients with kidney calculi

We assigned potential anxiety and depression contributors - including gender, age, educational level, per capita monthly income, comorbidities, social support, CD-RISC, and GQOLI-74 - as independent variables, and assigned the occurrence of anxiety or depression as dependent variables. Subsequently, all the above indicators were incorporated into a multivariate binary logistic regression model for in-depth analysis. Per capita monthly income [odds ratio (OR) = 0.158, P = 0.002], complications (OR = 3.442, P = 0.032), CD-RISC (OR = 0.075, P < 0.001), and GQOLI-74 (OR = 0.081, P < 0.001) independently influenced anxiety. Significant associations were observed with lower income (OR = 0.090, P < 0.001), diminished social support (OR = 0.136, P = 0.003), decreased resilience (CD-RISC; OR = 0.060, P < 0.001), and impaired QoL (GQOLI-74; OR = 0.198, P = 0.023). Tables 3, 4, and 5 present complete results.

Table 3 Variable assignments.

Factor	Variable	Assignment
Sex	X1	Female: 0
		Male: 1
Age (years)	X2	< 60: 0
		≥ 60: 1
Educational level	X3	≥ Senior high school: 0
		< Senior high school: 1
Per capita monthly income	X4	≤ 3500: 0
		> 3500: 1
Complications	X5	No: 0
		Yes: 1
Social support	X6	No: 0
		Yes: 1
CD-RISC	X7	≤ 55: 0
		> 55: 1
GQOLI-74	X8	≤ 45: 0
		> 45: 1
Anxiety	Y1	HAMA < 7: 0
		HAMA ≥ 7: 1
Depression	Y2	HAMD < 8: 0
		HAMD ≥ 8: 1

CD-RISC: Connor-Davidson Resilience Scale; GQOLI-74: General Quality of Life Inventory-74.

Table 4 Multivariate assessment of anxiety determinants in kidney calculi patients.

Variable	B	SE	Wald	P value	Exp (B)	95%CI
Sex	-0.070	0.561	0.016	0.900	0.932	0.310-2.802
Age	0.682	0.545	1.564	0.211	1.977	0.679-5.756
Educational level	-0.570	0.583	0.955	0.328	0.566	0.180-1.774
Per capita monthly income	-1.845	0.600	9.449	0.002	0.158	0.049-0.512
Complications	1.236	0.575	4.624	0.032	3.442	1.116-10.619
Social support	-0.062	0.552	0.013	0.911	0.940	0.319-2.774
CD-RISC	-2.588	0.591	19.158	< 0.001	0.075	0.024-0.239
GQOLI-74	-2.510	0.598	17.636	< 0.001	0.081	0.025-0.262

CI: Confidence interval; CD-RISC: Connor-Davidson Resilience Scale; GQOLI-74: General Quality of Life Inventory-74.

Table 5 Predictors of depression in kidney calculi patients (multivariate regression).

Variable	B	SE	Wald	P value	Exp (B)	95%CI
Sex	-0.870	0.671	1.683	0.194	0.419	0.112-1.560
Age	-0.082	0.662	0.015	0.901	0.921	0.252-3.372
Educational level	-0.119	0.701	0.029	0.866	0.888	0.225-3.511
Per capita monthly income	-2.406	0.671	12.839	< 0.001	0.090	0.024-0.336
Complications	0.143	0.680	0.044	0.834	1.153	0.304-4.374
Social support	-1.992	0.667	8.912	0.003	0.136	0.037-0.504
CD-RISC	-2.820	0.724	15.170	< 0.001	0.060	0.014-0.246
GQOLI-74	-1.618	0.710	5.197	0.023	0.198	0.049-0.797

CI: Confidence interval; CD-RISC: Connor-Davidson Resilience Scale; GQOLI-74: General Quality of Life Inventory-74.

DISCUSSION

Kidney calculi is a prevalent urinary system disorder, referring to the hard crystalline substances formed by the abnormal accumulation of certain components in urine in the kidneys. Additional contributors, such as inadequate hydration, high-salt/high-protein diets, and obesity, exceeds the disease prevalence by 11% among the ≥ 20 age group[17]. Persistence of this condition potentially contributes to fractures, diabetes, chronic kidney disease, cardiovascular disorders, and other systemic complications, thereby exacerbating the patient’s overall health burden[18]. Moreover, anxiety and depression resulting from pain and surgical outcome uncertainty further hinders recovery[19].

First, we identified anxiety in 49.58% and depression in 64.71% of participants, with the severity primarily being mild, aligning with previous literature[8]. Besides, significant CD-RISC and QoL score reductions were reported among patients with anxiety or depression. Patel et al[20] showed that the subjective pain of patients with kidney calculi also greatly affects their QoL, which align with the results of this study. Correlation analysis revealed that higher anxiety or depression in patients with kidney calculi correlated with lower resilience and QoL. Zhang et al[15] demonstrated that anxiety and depression of patients with mild coronavirus disease 2019 have a negative correlation with resilience, wherein resilience protects from anxiety and depression, corroborating our results. Further, Wojujutari et al[21] reported an intermediary role of resilience in association between high blood glucose and depression in patients with diabetes, revealing the potential relationship between resilience and negative emotions, which complements the results of this study.

Multivariate analysis identified higher monthly income per capita (> 3500 yuan), high psychological resilience (CD-RISC > 55 score), and high QoL (GQOLI-74 > 45 score) as protective factors of anxiety in patients with kidney calculi, whereas the existence of complications was considered a risk factor. Higher per capita monthly income (> 3500 yuan), social support, high psychological resilience (CD-RISC > 55 score), and superior QoL (GQOLI-74 > 45 score) were the protective factors of depression in such patients. Li et al[22] revealed complications and family income per capita as indirect and indirect determinants of depression and anxiety in early pregnancies, respectively, which aligns with our findings. Tian and Wang[23] showed that resilience mediates the fear of disease progression and sleep quality in hematological malignancies, which reveals the potential association between resilience and QoL to some extent, thereby supporting the results of this study. Additionally, some studies have indicated that the depression of middle-aged and elderly patients with chronic diseases is related to low economic level, QoL, and social support[24].

This study has some limitations that need to overcome in the future: (1) The participants were recruited from a single center, which may lead to some data collection bias and insufficient sample size for population representation. Therefore, a multi-centered study is required in the future to support these research conclusions; (2) The cross-sectional design failed to capture the causality between anxiety, depression, resilience, and QoL, thereby warranting validation through longitudinal analysis; and (3) This study did not investigate interventions based on the identified determinants of anxiety and depression, nor did it analyze intervention effects. Future work is recommended to address this limitation by assessing intervention feasibility and effectiveness. The improvement from the above perspectives will be analyzed in the future.

CONCLUSION

In summary, anxiety and depression levels in patients with kidney calculi demonstrate an inverse association with resilience and QoL. Independent predictors of anxiety and depression in patients with kidney stones include resilience, QoL, and monthly income per capita. Further, complications and social support independently modulate these psychological states.