Renal services tend to be specialist settings serving patients from a wide geographical area. Some patients in renal services have primary renal diseases such as inherited polycystic kidney disease, others have a multisystem disease. Patients receiving renal replacement therapy often form the bulk of referrals from renal medicine to a liaison psychiatry service. In common with other patients suffering chronic medical conditions, patients with renal disease have to face the loss of their pre-existing health and they may also suffer other losses such as loss of their job, curtailment of leisure activities, relationship breakdown and loss of self-esteem. The multiple losses experienced by patients with end-stage renal disease increase their vulnerability to grief-like adjustment reactions and depression. Thus, as with other medical conditions, diagnosis of depression in patients with renal disease should rely more heavily on the psychological features such as anhedonia, guilt, loss of self-esteem, hopelessness and suicidal ideation.