Objectives: Incidence of depression increases in patients with end-stage kidney disease (ESKD). We evaluated the association between depression and mortality among older patients with ESKD, which has not been studied previously. Methods: This nationwide prospective cohort study included 487 patients with ESKD aged > 65 years, who were categorized into minimal, mild-to-moderate, and severe depression groups based on their Beck Depression Inventory-II (BDI-II) scores.BDI-II scores were separated into three symptom domains: affective, cognitive, and somatic depressive symptoms.The association between the depression groups and survival were analyzed using multivariate Cox proportional hazard regression models.Predisposing factors for high BDI-II scoreswere evaluated using logistic regression analysis. The associations among the three depressive-symptom domains and survival were also analyzed. Results: The severe depression group showed a higher modified Charlson comorbidity index value and lower serum albumin, phosphate, and uric acid levels than the other depression groups. The KaplanMeier curve revealed a significantly lower survival in the severe depression group than in the minimal and mild-to-moderate depression groups (P = 0.011). Multivariate Cox regression analysis confirmed that severe depression was an independent risk factor for mortality in the study cohort [hazard ratio(HR), 1.39; 95% confidence interval (CI), 1.011.91; P = 0.041). BDI-II scores were associated with modified Charlson comorbidity index (P = 0.009) and serum albumin level (P = 0.004) in multivariate linear regression. Among the three depressive symptoms, higher somatic symptom scores were associated with increased mortality (HR, 2.45; 95% CI, 1.254.79; P = 0.009). Conclusions: Among older patients withESKD, severe depressionincreases mortality compared with minimal or mild-to-moderate depression. And patients with concomitant somatic symptoms require careful management of their comorbidities and nutritional status.