Health status and quality of life reported by incident patients after 1 year on haemodialysis or peritoneal dialysis

BACKGROUND

It has been suggested that there are no large differences in the quality of life of incident patients starting on haemodialysis (HD) and peritoneal dialysis (PD), but few studies have addressed this issue.

METHODS

Association of modality with incident patients' health status and quality of life scores was investigated with propensity score (PS) analysis and also with traditional multivariable regression analyses. We compared patient reported health status and quality of life scores after 1 year of therapy in 455 HD and 413 PD patients who participated in a national study, stayed on the same modality and had complete socio-demographic and clinical information needed to create a PS indicating their expected probability of starting on PD.

RESULTS

One year scores on the majority of health status and quality of life measures were not significantly different for HD and PD patients within propensity-matched quintiles. PD patients' scores were higher than HD patients' scores on effects of kidney disease, burden of kidney disease, staff encouragement and satisfaction with care in some quintiles, and traditional regression analyses confirmed that dialysis modality was associated with patients' scores on these variables.

CONCLUSIONS

This study provides support for making the choice of PD more widely available as an option to patients initiating chronic dialysis therapy. Patient lifestyle opportunities associated with use of PD, a home-based and self-care therapy, may also apply to home-based HD or in-centre self-care HD. Patients' expectations regarding treatment and their attitudes toward management of their health may interact with treatment modality to shape patient-reported experience on dialysis; this is an important focus for future studies.

The prevalence of gastrointestinal symptoms in patients with chronic renal failure is increased and associated with impaired psychological general well-being

BACKGROUND

Malnutrition occurs frequently in patients with end-stage renal disease (ESRD). Gastrointestinal (GI) symptoms may lead to reduced food intake, resulting in malnutrition and impaired well-being in these patients. The prevalence of GI symptoms in various chronic renal failure (CRF) groups is unexplored. We assessed the prevalence of GI complaints in patients on either haemodialysis (HD), peritoneal dialysis (PD), or in the pre-dialysis stage. Patients with and without diabetic nephropathy were also compared.

METHODS

A total of 233 patients with CRF (128 HD, 55 PD, and 50 pre-dialytic patients) completed two self-administered questionnaires: the Psychological General Well-Being (PGWB) index and the Gastrointestinal Symptom Rating Scale (GSRS), which measures GI symptoms. The values were compared with reference values obtained from the general population. The association between GI symptoms and serum (s-)albumin was also studied.

RESULTS

The total GSRS score in patients with CRF was significantly higher than the reference values (HD 2.14 (1.97-2.31), PD 2.24 (2.00-2.48), and pre-dialytic patients 2.03 (1.82-2.25) vs controls 1.53 (1.50-1.55; P<0.001). When comparing CRF subgroups there was no overall difference between the groups, but PD patients had more severe reflux and eating dysfunction. In patients with diabetic nephropathy, only eating dysfunction was significantly more common than in the non-diabetic patients. There was a negative correlation between GI symptoms and psychological general well-being in CRF patients (Rho=-0.46, P<0.001) indicating that patients with a high GI symptom profile have impaired psychological general well-being. A negative correlation was found between eating dysfunction and s-albumin (Rho=-0.33, P<0.01).

CONCLUSION

The prevalence of GI symptoms is high in patients with CRF and is associated with impairment in psychological general well-being. Presence of dialysis or not, type of dialysis, and presence or absence of diabetes mellitus seem to have limited impact on GI symptoms.

Assessing depression and anxiety in chronic dialysis patients

One hundred and twenty-eight patients on chronic dialysis were studied by the Zung Self-Rating Depression Scale and Self-Rating Anxiety Scale, the Differential Emotion Scale (DES), the Test of Emotional Styles (TES), and the Social Dysfunction Rating Scale (SDRS). As measured by the Zung scales, approximately half of the sample manifested depression and anxiety symptoms at clinically relevant levels. The data suggested an inverse correlation between depression and anxiety levels and patients' total length of time on dialysis, which may explain some of the variation in depression and anxiety results obtained with different samples. Depression and anxiety scores were correlated with related DES and SDRS factors, but patients' scores on the DES, TES, and SDRS generally indicated positive mood and functioning. Scales containing disease-related somatic items may yield exaggerated depression and anxiety scores for dialysis patients. It may be useful to assess patients' psychological functioning with several different instruments.

Psychological factors affecting end-stage renal disease. A review

This review summarizes recent systematic research literature regarding psychological factors as they affect chronic renal disease. Special attention is devoted to depression, quality of life, noncompliance, outcome studies, withdrawal from dialysis, and directions for future research.

Health-related quality of life in nephrology research and clinical practice

Physical, psychosocial, and lifestyle disturbances, along with physical and emotional symptoms, have been shown to impact the health-related quality of life (HRQOL) of those dependent on renal replacement therapy. The value of HRQOL measurement as a tool to improve clinical care has been recognized by patients, clinical investigators, and health care providers. The potential importance of HRQOL assessment lies in the additional information it provides and the impact it has on the clinical decision-making process between a patient and a physician. There remain a multitude of challenges facing renal providers who wish to incorporate HRQOL measurement to improve patient care. These challenges include the clinician's understanding of the conceptual model of HRQOL, the quality of the scientific process that contributed to the current literature on HRQOL, a willingness of the clinician to incorporate HRQOL information into clinical practice, and the logistic difficulties of collecting and applying HRQOL data in a busy practice setting. Arguably, optimizing HRQOL may be the most substantial impact the health care team will have on the person with kidney failure. In order to implement HRQOL assessment at the point of care, providers may consider using computer adaptive testing and scoring algorithms using item response theory, which will allow adequate reliability for interpretation of change among individuals. Moreover, the effective assessment and interpretation of HRQOL will be aided by continued publication of norms, outcomes of randomized controlled trials, and continued experience of investigators and clinicians.

Assessment of quality of life in a single centre dialysis population using the KDQOL-SF questionnaire

Health-related quality of life (HRQOL) is a valid marker of outcome for chronic dialysis therapy. A wide range of questionnaires are now available which assess different aspects of an individual's health. Appreciation of those factors that contribute to explaining HRQOL items remains poorly defined. The development of disease-specific questionnaires such as KDQOL-SF, should allow for such questions to be better answered. A cross-sectional analysis of our chronic dialysis population was made using the KDQOL-SF questionnaire. By multiple linear regression analysis demographic, clinical and dialysis-related factors were assessed for their contribution to the HRQOL in this population. The HRQOL of these patients was also compared against a general population sample. From a total of 190 chronic dialysis patients, 146 completed the KDQOL-SF questionnaire. The haemodialysis (HD) and peritoneal dialysis (PD) patients were similar with respect to most demographic, clinical and dialysis variables except for haemoglobin and albumin which were significantly (p < 0.05) greater in the peritoneal and haemodialysis populations respectively. Compared to the general population, the HRQOL of dialysis patients was impaired for all SF-36 subscales. Use of the disease-specific components of KDQOL-SF discriminated between dialysis modality for our dialysis population. Multiple linear regression analysis demonstrated that 27.5 to 42.7% of the variance in the SF-36 subscales could be explained. Satisfactory sleep, dialysis related symptoms, effect of kidney disease on lifestyle and burden of kidney disease were found to be the most important determinants of HRQOL for this population.

Acute variation in cognitive function in hemodialysis patients: a cohort study with repeated measures

BACKGROUND

Although cognitive function in hemodialysis patients is believed to be best 24 hours after the dialysis session, the extent of variation during the dialysis cycle is unknown.

STUDY DESIGN

Cohort study with repeated measures.

SETTING & PARTICIPANTS

Hemodialysis centers; patients aged 55 years or older.

PREDICTOR

Time of assessment related to the dialysis session. Time 1 (T1) occurred approximately 1 hour before the dialysis session; T2, 1 hour into the session; T3, 1 hour after; and T4, the next day.

OUTCOMES

Measures of cognitive function using a 45-minute cognitive battery. An average composite score was calculated to measure global cognitive function, equal to the average of subjects' standardized scores on all tests given at each test time. Times were classified as best and worst according to composite scores.

MEASUREMENTS

Testing was conducted on average over 2 dialysis sessions to avoid test fatigue. The cognitive battery included tests of verbal fluency, immediate and delayed verbal and visual memory, and executive function, administered at 4 times.

RESULTS

In the 28 subjects who completed testing at 3 or 4 testing times, mean age was 66.7 +/- 9.5 years and mean dialysis vintage was 44.7 +/- 33.3 months. Using a general linear model for correlated data, the composite score was significantly lower (poorer) during dialysis (T2) than shortly before the session (T1) or on the next day (T4; P < 0.001 for both).

LIMITATIONS

Relatively small sample size, testing delays, results may not be generalizable.

CONCLUSION

Global cognitive function varies significantly during the dialysis cycle, being worst during dialysis and best shortly before the session or on the day after. Clinician visits may be most effective at these times.

Psychosocial adjustment and adherence to dialysis treatment regimes

Sixty children and adolescents in end-stage renal failure who were undergoing either haemodialysis or continuous ambulatory peritoneal dialysis at one of five United Kingdom dialysis centres were assessed on psychosocial adjustment and adherence to their fluid intake, diet and medication regimes. Parental adjustment was also measured and data on sociodemographic and treatment history variables collected. A structured family interview and standardised questionnaire measures of anxiety, depression and behavioural disturbance were used. Multiple measures of treatment adherence were obtained, utilising children's and parents' self-reports, weight gain between dialysis, blood pressure, serum potassium level, blood urea level, dietitians' surveys and consultants' ratings. Correlational analyses showed that low treatment adherence was associated with poor adjustment to diagnosis and dialysis by children and parents (P < 0.01), self-ratings of anxiety and depression in children and parents (P < 0.001), age (adolescents tended to show poorer adherence than younger children, P < 0.001), duration of dialysis (P < 0.05), low family socioeconomic status (P < 0.05) and family structure (P < 0.01). These findings demonstrate the importance of psychosocial care in the treatment of this group of children. Future research should develop and evaluate psychosocial interventions aimed at improving treatment adherence.

Nonadherence With Diet and Fluid Restrictions Among Adults Having Hemodialysis

PURPOSE

To describe the prevalence of nonadherence with the prescribed diet and fluid restrictions among patients receiving hemodialysis.

METHODS

A multicenter cross-sectional design with 916 patients recruited from 18 dialysis centers in Germany and Belgium. The Dialysis Diet and Fluid Nonadherence Questionnaire (DDFQ) was used to measure patients' nonadherence.

FINDINGS

The results showed that many patients had difficulty following diet (81.4%) and fluid (74.6%) restrictions. Younger male patients and smokers were at highest risk for non-adherence. Higher levels of interdialysis weight gain were associated with nonadherence.

CONCLUSIONS

The findings indicate the need to continue to monitor and study hemodialysis patients' adherence behavior longitudinally and to design interventions to enhance adherence.

Health-Related Quality of Life After Kidney Transplantation in Comparison Intermittent Hemodialysis, Peritoneal Dialysis, and Normal Controls

The purpose of this study was to compare the quality of life (QOL) in renal transplantation patients. QOL is one of the important indicators of the effects of medical treatment. In this cross-sectional study, QOL was analyzed in 302 renal transplant recipients compared with 64 hemodialysis (HD) patients, 207 (PD) peritoneal dialysis patients, and 278 normal controls (NC) matched as closely as possible to the grafted patients regarding age, gender, education, and occupation. All groups were asked to estimate their subjective QOL by responding to sociodemographic data, Turkish adapted instruments of the Nottingham Health profile (NHP), and the Short-form 36 (SF-36). Transplant recipients were significantly younger than the HD and PD patients (P < .0001). There was no statistically significant differences between normal controls and transplant patients ages. Among the three renal replacement methods, QOL in transplants was clearly better than that in HD or PD patients (P < .0001). The QOL measured by the NHP and SF-36 scale showed that the normal population was statistically significantly better than the transplant recipients (P < .0001). Transplant renal replacement therapy provides a better QOL compared with other replacement methods.

Depression levels before and after renal transplantation

Depression is a frequent problem among end-stage renal disease patients and is closely associated with their physical well-being. We sought to compare the depression levels and confounding parameters in renal patients. The 88 patients (62 men, 26 women) included: renal transplant recipients (n = 27); renal transplant waiting list patients (n = 30); and chronic allograft rejection patients on dialysis therapy (n = 31). Their mean age was 31.05 +/- 11.78 years. Age, gender, marital status, presence of chronic rejection, duration of functional graft, and hemodialysis were retrieved from patient records. Depression levels were evaluated by the Beck Depression Inventory. The depression stage of the renal transplant recipients was significantly lower than that of hemodialysis patients with chronic allograft rejection (P =.003). The presence of depression was not related to age or gender. Married patients showed a lower percentage of depression (P <.03). There was an inverse correlation between depression and functional graft duration among patients with transplant failure (r = -.370, P =.04). In conclusion, the return to hemodialysis, especially after a short duration of graft function, is associated with depression. The lower depression percentage among married patients may be due to the psychosocial support of the spouses. Therefore, single persons and transplant failure patients who return to dialysis therapy need greater social and psychologic support. Placing greater numbers of patients on transplant waiting lists decreases depression and may provide a higher quality of life with a better outcome during dialysis therapy.

Renal dialysis abatement: lessons from a social study

AIM

This study aimed to examine the reasons why some people chose to abate (i.e., stop or not start) renal dialysis, together with the personal and social impact of this decision on the person concerned, and/or their families.

METHOD

A qualitative design based on the principles of Grounded Theory was employed. Semi-structured interviews were conducted with sixteen patients and/or carers (depending on whether the patient was able to be interviewed) where the issue of dialysis abatement was being considered, or had recently been decided.

RESULTS

Of 52 participants considered for entry into the study 41 were ineligible, with impaired cognition, rapid medical deterioration, and inability to speak sufficient English being the main reasons for exclusion. The desire not to burden others and the personal experience of a deteriorating quality of life were crucial elements in the decision to stop or decline dialysis. The problem of prognostic uncertainty and a sense of abandonment were also prominently expressed.

CONCLUSIONS

From this small Australian sample, it appears that there would be considerable potential benefit from a more proactive and open approach to end-of-life issues, with incorporation of the clinical and health promoting principles of palliative care into renal dialysis practice. The high number of exclusions shows how sick and unstable this population of patients is, but the issue of data gathering from people whose main language is not English requires attention.

Nutritional status affects quality of life in Hemodialysis (HEMO) Study patients at baseline

OBJECTIVE

To evaluate associations between frequently used indicators for assessing nutritional status and health-related quality of life in hemodialysis patients after controlling for demographics, comorbidity, and dialysis dose.

DESIGN

Survey of 1,387 hemodialysis patients enrolled at baseline in the Hemodialysis (HEMO) Study. Nutritional status indicators included dietary energy intake, equilibrated normalized protein catabolic rate (enPCR), serum creatinine (SCr), serum albumin (SAlb), body mass index (BMI), calf circumference, and appetite. Health-related quality of life was measured by the Medical Outcomes Study Short Form-36 (MOS-SF-36) summary measures: the Physical Component Scale (PCS) and Mental Component Scale (MCS).

SETTING

Fifteen clinical sites throughout the United States providing in-center hemodialysis.

RESULTS

The mean PCS score was 36.1 +/- 10 SD, lower than normative data in healthy populations. PCS scores were lower among women, whites, and those with diabetes, severe comorbidities, and poor appetites. Appetite, dietary energy intake, SAlb, and SCr were strongly associated with PCS scores even after controlling for demographics and comorbidity. The sum of the parameter estimates for the effects of nutritional status on PCS was large, 7 points or more depending on the individual's nutritional status indicators. The mean MCS score was 49.7 +/- 10.1 SD, similar to scores in healthy populations, but lower among those with severe comorbidities, poor appetites, advanced age, and more years on dialysis. Appetite, age, and years on dialysis were significantly associated with MCS after controlling for other demographics and comorbidity. Dialysis dose did not significantly alter these relationships.

CONCLUSION

Easy-to-use indicators for assessing nutritional status (appetite, energy intake, SAlb, and SCr) together are strongly associated with health-related quality of life, even after controlling for comorbidities and dose of dialysis in hemodialysis patients, providing an additional reason for maximizing patients' nutritional status and health.

Family support, physical impairment, and adherence in hemodialysis: an investigation of main and buffering effects

Patient noncompliance is a pervasive problem among end-stage renal disease (ESRD) patients. Previous studies have implicated social support as an important correlate of adherence behavior in other chronic illness groups, but little research has examined this relationship in a hemodialysis population. The present study examined the main and interactive effects of social support in the family and illness-related physical impairment with regard to patient compliance in a sample of 78 hemodialysis patients. Results indicated that patients holding perceptions of a more supportive family environment exhibited significantly more favorable adherence to fluid-intake restrictions than did patients reporting less family support. Family support was not associated with adherence to dietary restrictions. The effect of family support on fluid-intake adherence was not moderated by level of physical impairment. This pattern suggests that the influence of support on adherence is more attributable to a main or direct effect, as opposed to a buffering process in the face of increased physical impairment.

Health locus of control and depression in end-stage renal disease

Research on the association between health locus of control and depression in chronic illness has produced contradictory findings, perhaps because of a failure to consider contextual variables. In this study of 96 hemodialysis patients, the belief that one's health is controllable was associated with less depression among Ss who had not previously experienced a failed renal transplant. This belief was associated with greater depression for Ss who had returned to dialysis following an unsuccessful transplant. This interactive effect occurred among severely ill Ss, but health locus of control was unrelated to depression among Ss with less severe disease. This pattern occurred both when control perceptions reflected a belief in the Ss' own or powerful others' (i.e., health care providers) ability to influence health outcomes. Results underscore the adaptive value of congruence between control beliefs and objective circumstances in chronic illness.

Health-related quality of life in endstage renal failure

The objective of this study was to describe the health-related quality of life (HRQOL) of patients on different forms of treatment for endstage renal failure in such a way that the data could be used in a cost-utility analysis of renal failure treatment in Britain. Twenty-four British renal units participated in this study. 997 adult dialysis and transplant patients were randomly selected from these units using the European Dialysis and Transplant (EDTA) Registry Database. The Health Measurement Questionnaire was completed by 705 of the 900 patients who were alive at the time of the survey (response rate of 78%). The HRQOL data were linked with comorbidity data and with clinical data from the EDTA Registry. Compared to the general population, patients with endstage renal failure experienced a lower quality of life. Many factors contributed to this, but uncertainty about the future and lack of energy emerged as key components. Transplant recipients reported better HRQOL than dialysis patients, they reported fewer problems with physical mobility, self-care, social and personal relationships and usual activities. They also experienced significantly less distress, while dialysis patients reported problems with depression, anxiety, pain and uncertainty about the future. These differences remained after controlling for age and comorbidity.

Quality of life in dialysis patients. A spanish multicentre study. Spanish Cooperative Renal Patients Quality of Life Study Group

The aim of this study was to evaluate the quality of life in patients on chronic dialysis and to research the influence of various factors related to treatment and ESRD on quality of life. The cross-sectional study was carried out nationally and 1013 randomly selected stable patients on dialysis were evaluated. The evaluation of quality of life was by the Karnofsky Scale (KS) and the Sickness Impact Profile (SIP). Both questionnaires were self-reported. Co-morbidity was evaluated according to the Friedman Comorbidity Index. Adjusted quality of life scores for case-mix differences of several groups of patients were compared. Twenty-six per cent of the patients showed severe quality of life restriction on the Global Score of SIP (score > or = 20) and 31% on the KS (score < or = 60). The partial categories of the SIP that were more affected were work, recreation and pastimes, home management, and sleep and rest. No significant differences were found relating to dialysis technique, dialysis solution, or dialyser membrane. Greater haemoglobin concentrations were related to better quality of life scores on Physical Dimension and Global Score of SIP. Advanced age and Comorbidity Index were related to worse quality of life scores. We conclude that 25% of the patients showed an important effect of the disease on their quality of life. An increase in haemoglobin was related to better quality of life in dialysis patients. Advanced age and co-morbidity both adversely affected quality of life.

Cognitive and personality factors in the delay of gratification of hemodialysis patients

On the basis of Mischel's (1984) social learning analysis of the process of delay of gratification in children and in line with Bandura's (1977) self-efficacy theory, we developed a model of delay of gratification in adults and tested it on dialysis patients who were continuously required to comply with a stringent regimen of fluid-intake to keep alive. We hypothesized that patients' self-evaluations of their past compliance and their efficacy expectations would be associated with their actual delay behavior. Underlying these process-regulating cognitions would be stable competencies, such as learned resourcefulness (i.e., one's self-control skills). Fifty-three dialysis patients self-evaluated their fluid intake compliance, their efficacy expectations, and their health beliefs. Resourcefulness was assessed by Rosenbaum's Self-Control Schedule. Actual fluid-intake compliance was reliably assessed by the mean body weight increase between dialyses during the 3-month period prior to the study and during two follow-up periods. The results supported the model. On the one hand, self-efficacy expectations were related to persistence with the fluid diet and on the other hand to subjects' self-evaluation of their past adherence behavior as well as to their resourcefulness. Although the path model suggested a causal pattern, the correlational nature of the study precluded any conclusions on cause-effect relationship.

Patient dialysis knowledge is associated with permanent arteriovenous access use in chronic hemodialysis

BACKGROUND AND OBJECTIVES

Patient knowledge about chronic hemodialysis (CHD) is important for effective self-management behaviors, but little is known about its association with vascular access use.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Prospective cohort of adult incident CHD patients from May 2002 until November 2005 and followed for 6 mo after initiation of hemodialysis (HD). Patient knowledge was measured using the Chronic Hemodialysis Knowledge Survey (CHeKS). The primary outcome was dialysis access type at: baseline, 3 mo, and 6 mo after HD initiation. Secondary outcomes included anemia, nutritional, and mineral laboratory measures.

RESULTS

In 490 patients, the median (interquartile range) CHeKS score (0 to 100%) was 65%[52% to 78%]. Lower scores were associated with older age, fewer years of education, and nonwhite race. Patients with CHeKS scores 20 percentage points higher were more likely to use an arteriovenous fistula or graft compared with a catheter at HD initiation and 6 mo after adjustment for age, sex, race, education, and diabetes mellitus. No statistically significant associations were found between knowledge and laboratory outcome measures, except for a moderate association with serum albumin. Potential limitations include residual confounding and an underpowered study to determine associations with some clinical measures.

CONCLUSIONS

Patients with less dialysis knowledge may be less likely to use an arteriovenous access for dialysis at initiation and after starting hemodialysis. Additional studies are needed to explore the impact of patient dialysis knowledge, and its improvement after educational interventions, on vascular access in hemodialysis.

Acupressure and Transcutaneous Electrical Acupoint Stimulation in improving fatigue, sleep quality and depression in hemodialysis patients

The purpose of this study was to test the effectiveness of acupressure and Transcutaneous Electrical Acupoint Stimulation (TEAS) on fatigue, sleep quality and depression in patients who were receiving routine hemodialysis treatment. The study was a randomized controlled trial; qualified patients were randomly assigned to acupressure, TEAS or control groups. Patients in the acupressure and TEAS groups received 15 minutes of treatment 3 times a week for 1 month, whereas patients in the control group only received routine unit care. A total of 106 patients participated in the study. Methods of measurement included the revised Piper Fatigue Scale (PFS), the Pittsburgh Sleep Quality Index and the Beck Depression Inventory. Data were collected at baseline, during the intervention and post-treatment. The results indicated that patients in the acupressure and TEAS groups had significantly lower levels of fatigue, a better sleep quality and less depressed moods compared with patients in the control group based upon the adjusted baseline differences. However, there were no differences between acupressure and TEAS groups in outcome measures. This study provides an alternative method for health care providers in managing dialysis patients with symptoms of fatigue, poor sleep or depression.

Psychological effects of aromatherapy on chronic hemodialysis patients

Effects of aromatherapy (odorless condition, lavender, and hiba oil) on mood and anxiety were investigated in 14 female patients who were being treated with chronic hemodialysis. A control period consisting of natural hospital smells was established before each test session, and then aromatic test conditions were systematically evaluated for odorless conditions as well as aromatic conditions containing lavender and hiba oil aromas. The effects of aromatherapy were measured using the Hamilton rating scale for depression (HAMD) and the Hamilton rating scale for anxiety (HAMA). Hiba oil aroma significantly decreased the mean scores of HAMD and HAMA, and lavender aroma significantly decreased the mean scores of HAMA. The mean scores of HAMD and HAMA in an odorless condition were not significantly different from those of the control conditions. These results indicate that in chronic hemodialysis patients hiba oil is an effective, non-invasive means for the treatment of depression and anxiety, and that lavender alleviates anxiety.

Psychiatric adjustment in children with chronic renal failure

Problems in psychiatric adjustment were found to be more common in children and adolescents with chronic renal failure (22 subjects on hospital haemodialysis and 22 with less severe renal failure) than in healthy matched controls. There was a trend towards more definite and marked psychological difficulties in patients with more severe renal condition. However, the less severely physically ill children tended to have increased difficulties in school adjustment and they reported more feelings of loneliness. The findings have implications on the management of children with chronic renal failure.

Intervention strategies to improve compliance with medical regimens by ambulatory hemodialysis patients

This research examined the relative efficacies of three intervention strategies designed to increase compliance to medical regimens in a group of ambulatory hemodialysis patients. The interventions examined included behavioral contracting (with or without the involvement of a family member or friend) and weekly telephone contacts with patients. Compliance was assessed with regard to following dietary restrictions and limiting fluid intake. Data were collected from 116 patients drawn from two outpatient clinics. Within clinics, patients were randomly assigned either to an intervention program or to a control group. The study employed a pretest-posttest control group design. Patients were interviewed before the intervention programs began (T1), after a 6-week intervention period (T2), and 3 months after completion of the intervention period (T3). Results showed that the interventions achieved substantial reductions in patients' serum potassium levels and in weight gains between dialysis treatments between T1 and T2. In general, however, these program effects tapered off to preintervention levels between T2 and T3. The findings thus indicate a need for long-term intervention programs.

Nonadherence with diet and fluid restrictions and perceived social support in patients receiving hemodialysis

PURPOSE

To describe nonadherence with diet and fluid restrictions and the level of perceived social support in hemodialysis patients.

DESIGN

Descriptive survey. The data were obtained from 160 patients in three hemodialysis centers in Turkey between March 2006 and May 2006. Descriptive statistics, reliability analysis, correlations, and logistic regression analysis were conducted.

METHODS

Data were collected by using a personal data form, the Dialysis Diet and Fluid Nonadherence Questionnaire, and the Multidimensional Scale of Perceived Social Support.

RESULTS

Most patients showed nonadherence with diet and fluid restrictions. Family members were important providers of social support for patients. Significant factors affecting fluid nonadherence included age, marital status, and family and friend support. Marital status and family support were also the main variables affecting diet nonadherence.

CONCLUSIONS

The results of this study showed that nonadherence was more common among younger, married patients, and those with lower levels of perceived social support.

The haemodialysis machine as a lifeline: experiences of suffering from end-stage renal disease

AIM

The aim of this study was to describe patients' experiences of suffering from end-stage renal disease (ESRD).

RATIONALE

The rationale was to investigate how persons find meaning or make sense of their situation and how they experience suffering. The theoretical basis for the study was to view suffering at three levels. The first level was related to sickness and treatment. The second level was related to the care provided and the third level was related to each person's unique life experience and existence.

METHOD

Data were collected by interviews focusing on questions concerning daily life, needs, and expectations for the future. A qualitative interpretative content analysis was used. Fifteen patients between the ages of 50-86 participated in the study.

FINDINGS

Two main themes were identified describing these patients suffering. The first theme, 'the haemodialysis machine as a lifeline' consisted of three subthemes: 'loss of freedom', 'dependence on the caregiver', and 'disrupted marital, family and social life'. The second theme 'alleviation of suffering' consisted of two subthemes: 'gaining a sense of existential optimism' and 'achieving a sense of personal autonomy'.

CONCLUSION

This study indicated that, in the lives of patients on haemodialysis, the main areas of suffering were related to loss of freedom expressed as dependence on the haemodialysis machine as a lifeline and, the caregivers. This time-consuming and tiring dependence affected marital, family and social life. Alleviation of suffering could be achieved by accepting dependence on the haemodialysis machine and maintaining autonomy by being seen as an individual by the caregivers.