Search

Aim: This paper reports a study seeking to describe characteristic attitudes towards their treatment regime among a group living on home dialysis., Background: Although there are many papers about the problem of renal patient compliance and a number describing the experience of living on dialysis, studies have not focused on client attitudes towards their therapy., Methods: The study used an interpretivist methodology. Twenty home dialysis clients from one renal service were interviewed for an hour each in 2004. Texts of the taped interviews were analysed to formulate a number of themes that summarize the client perspective., Results: During the initial period of adjustment to treatment many participants learned their need for treatment by experimenting with the therapeutic prescription. They then used their knowledge of the therapy to alter their treatment regime to maintain their normal lifestyle. Having modified their therapeutic prescription, participants' motivation to continue meeting the continuing demands of the treatment regime was influenced by their individual life situation, including their relationships, work and personal attitudes towards life., Conclusion: Health professionals have interpreted renal client behaviour in relation to their therapy in terms of compliance, because effectiveness of treatment depends on their cooperation. From a client perspective their attitudes are better understood in terms of negotiation. Renal clients do not simply follow professional advice but, through a process of negotiation, seek to integrate therapy into their pattern of regular activities to maintain their normal lifestyle. Renal clients' motivation to meet the ongoing demands of treatment is not related solely to their health status, but is affected by their general life situation., Relevance to Clinical Practice: Understanding client attitudes towards therapy enables nurses to support people living on dialysis better. Through enhancing their relationships with clients, nurses can assume a key role in service to people living with chronic conditions.

Biopsychosocial problems experienced by renal disease patients were studied within a contextual framework the patients themselves defined, the findings being related to sociodemographic and medical data. Participants were 72 predialysis patients and 73 patients being treated by haemodialysis or peritoneal dialysis (106 men and 39 women, aged 18-84 years). Both stress-related global and situational measures of biopsychosocial problems were assessed by questionnaire. Factor analyses revealed five factors--Bodily problems; Work and leisure time; Sleep, cramps and itching complaints; Financial problems; and Dependence-- explaining 71.1 per cent of the total variance. Fatigue loaded both on Bodily problems and Work and leisure time. Sleep disturbances, itching of the skin and muscle cramps were more stressful for the dialysis than the predialysis patients. Also, fatigue, inability to work and limitation on vacation activities appeared more stressful for the dialysis group. The study supports the usefulness of a contextual approach for gaining a better general understanding of renal disease patients' problems.

Personality psychology is increasingly used in various clinical medicine settings to help in decision-making in difficult situations, especially in chronic disease. Patients with chronic renal disease are very dependent on modern medicine, and psychological aspects could help give answers in certain circumstances. Logotherapy and Existence analysis, after Viktor Frankl (Third Viennese School of Psychotherapy), is the theory of the possibilities and conditions for a fulfilled existence and evaluates a different aspect of personality psychology, namely meaning (in life). We used the existence scale questionnaire in this pilot study to investigate the personal abilities self-distancing, self-transcendence, freedom and responsibility in dialysis patients and compared a group of hemodialysis (HD) patients with patients treated with continuous ambulatory peritoneal dialysis (CAPD). We studied a mixed dialysis cohort (24 HD, 24 CAPD) at two Austrian centers (Innsbruck Medical University Hospital and Wilhelminenspital of the City of Vienna). Overall, results for dialysis patients (n = 48) were very close to those reported for healthy persons; however, CAPD patients scored significantly better than HD patients (p = 0.017) on the subscale self-distancing. This significant difference was also seen in the overall scores (p = 0.045). Our results might indicate that contented CAPD patients have personal abilities that predestine them for this type of treatment. The existence scale might help decide between CAPD and HD treatment alternatives.

Background/aims: It is relevant to investigate health-related quality of life (HRQOL) in dialysis and chronic kidney disease (CKD) patients in order to optimise treatment. The aim of this study was to investigate HRQOL in dialysis and CKD patients, to compare results from patients treated with hemodialysis (HD) and peritoneal dialysis (PD) and to investigate the prediction of dialysis quality control parameters (blood hemoglobin, plasma albumin, and Kt/V) and tobacco smoking in disease-specific HRQOL., Methods: Seventy-one HD, 59 PD, and 63 CKD patients participated in the study. Dialysis quality control parameters were measured and the patients completed the questionnaire Kidney Disease Quality Of Life., Results: PD patients rated Dialysis Staff Encouragement and Patient Satisfaction better than HD patients (p< or = 0.05). Dialysis patients scored significant lower than the general population in all generic HRQOL scales (p < or = 0.01), whereas CKD patients scored lower than the general population in 5 of 8 scales (p < or = 0.05). The dialysis quality parameters did not predict dialysis patients' disease specific HRQOL, but tobacco consumption was independently associated with low scores on a number of HRQOL scales., Conclusion: Based on the results, it is suggested to include elements of HRQOL as a supplement to standard quality control parameters. It is also suggested routinely to include information of the beneficial effects of physical activity already in the predialysis program, and to focus on smoking as a very important risk factor., (Copyright 2007 S. Karger AG, Basel.)

When a child has end-stage renal disease and requires dialysis, a heavy personal and financial toll can be extracted from the caregivers and the family. Tsai et al. have demonstrated an adverse effect on the psychosocial and socioeconomic well-being of caregivers of children on chronic peritoneal dialysis. These findings raise other questions and force us to think about support for the caregiver as well as the patient.

The study was designed to explore the psychosocial effects on caretakers of children in Taiwan on chronic peritoneal dialysis (CPD). This is a case-control study, performed with subjects drawn from eight medical centers. The study group consisted of caretakers of 32 children with renal failure being treated with CPD. For comparison, a control group of caretakers of 64 healthy children as well as the regional Taiwanese studies were used. Two instruments were used to explore the presence of probable depression and quality of life (QOL) of the caretakers: the Taiwanese Depression Questionnaire, and the World Health Organization QOL BRIEF-Taiwan Version. In the study group, only 25% of caregivers had full-time jobs, and 66% of families had an annual income of less than US dollar 15,000. Of the 32 families in the study group, 16% had only a single parent. The prevalence of probable depression was significantly more common in the study group compared with control and referent group (28% vs 5% and 9.44%; P = 0.001). QOL scores in four domains were also significantly lower in the study group. In conclusion, even with the advances of peritoneal dialysis techniques, caring for children on CPD in Taiwan has significant adverse psychosocial effects on the primary caregivers. Attention should be paid to the psycho-social status of the caregivers.

Patient education approaches are currently derived from a biomedical 'acute' model characterized by the sequence of health, disease, and recovery resulting from our professional intervention. Unfortunately, this model proves to be totally inadequate when applied to a chronic disease such as kidney failure. Our patients never fully regain their health and may continue to worsen under our care, even after many state-of-the-art treatments. The solution is represented in acquiring a new professional identity, shifting from the 'biomedical' acute model to a 'bio-psycho-social-educational model'. Within this model, a Therapeutic Education approach in predialysis has been proven to provide both short- and long-term positive results for renal patients. There is a tremendous difference between the learning processes in children and adults and two different sciences have already been described. 'Pedagogy' deals with child learning and 'Andragogy' with adult learning. Nevertheless, when the learner is a patient with a chronic disease, we believe that new considerations must be taken into account. We propose to create a novel science and to call it 'Nosogogy', derived from the ancient Greek word (see text), meaning 'disease'. Nosogogy could be defined as the science of teaching adults affected by chronic disease. The new educator is someone deeply involved in renal care who knows and understands the characteristic conflicts and dynamics that arise in the renal patient, and possesses adequate communication skills to deal with him. In our experience, we prefer to have educational sessions run by nephrologists and nurses who have great experience in the field.

The aim of this multicenter, quantitative, observational study was to analyze compliance and re-training needs of patients on peritoneal dialysis (PD) through the assessment of patient knowledge (with a Patient Questionnaire; phase 1) and patient behavior (home visit with a Score Card; phase 2). A total of 353 patients from 11 Italian centers participated in the first phase and 191 patients from nine centers in the second phase. Overall, 66% of questions on the Patient Questionnaire were answered correctly. Correct answers were more frequent in females than males, in patients under 55 years of age, and in those with higher education. The lowest rate of correct answers involved questions related to diet and physical activity (67% and 51%, respectively). Data collected during the home visit showed that 25% of patients were partially compliant with their drug therapy. Twenty-three percent of patients were non-compliant with the exchange protocol procedures, with a significant association between compliance and the incidence of peritonitis, and 11% were non-compliant with the exit-site protocol procedures without a statistically significant correlation to peritonitis. By combining the two evaluations, we found that approximately one-third (29%) of patients needed reinforcement of knowledge and ability to correctly perform PD as related to infection control and 27% for the correct use of drugs. Looking at the combined evaluation of infection control and drug use, results showed that 47% of patients needed re-training. This need for re-training was greater for younger patients (less than 55 years old), patients with lower education degree and patients in the early or late phase of PD therapy (less than 18 months or more than 36 months). Gender and degree of autonomy had no effect on the need for re-training.

This study was undertaken to examine patient satisfaction with peritoneal dialysis (PD) and hemodialysis (HD) therapies, focusing attention on the positive and negative impact of the therapies on patients' lives. Patients were recruited from a free-standing PD unit and two free-standing HD units. A total of 94% (n = 62) of eligible PD and 84% (n = 84) of eligible HD patients participated. HD patients were significantly older and had higher Charlson Comorbidity Index scores than the PD patients, but there were no differences in duration of dialysis treatment, prevalence of diabetes, educational backgrounds, or home situations. Patients were asked to rate their overall satisfaction with and the overall impact of their dialysis therapy on their lives, using a 1 to 10 Likert scale. In addition, patients were asked to rate the impact of their therapy on 15 domains that had been cited previously as being important for patients' quality of life. The mean satisfaction score for PD patients (8.02 +/- 1.41) was higher than for HD patients (7.4 +/- 1.4; P = 0.15). PD patients indicated that there was less impact of the dialysis treatment on their lives globally (7.25 +/- 2.12 versus 6.19 +/- 2.83; P = 0.019). In addition, PD patients noted less impact of the therapy in 14 of the 15 domains examined. With the use of a proportional odds model analysis, the only significant predictor of overall satisfaction and impact of therapy was dialysis modality (P = 0.037 and P = 0.021, respectively). Patients also were asked to comment freely on the positive and negative effects of the dialysis treatments on their lives, and a taxonomy of patient perceptions and concerns was developed. This study suggests that PD patients in general are more satisfied with their overall care and believe that their treatment has less impact on their lives than HD patients.

Objectives: The purpose of the study was to assess the prevalence and extent of missed peritoneal dialysis (PD) exchanges and to identify possible predictors for regimen modification., Design: The study was a cross sectional postal survey of PD patients. Patients were asked to complete a single questionnaire looking at factors that influenced their management of the prescribed regimen., Patients: 551 patients were invited to participate in the study from 17 centres across three European countries; 10 centres from Belgium, 5 from Italy and 2 from the UK. Patients on continuous ambulatory peritoneal dialysis (CAPD), CAPD and Quantum, or automated peritoneal dialysis (APD) for more than three months and at least 18 years old were included in the study. 376 out of 551 questionnaires were completed; a response rate of 68%., Results: 20% (n=67) of those who responded to the questionnaire admitted to modifying their treatment in the previous month. Those who were more likely to modify their treatment were younger, employed, had greater contact with the PD team, were on APD 10 hours or longer and were less satisfied with their APD treatment., Conclusion: Many of the patients self-reported modifying their dialysis regimen and possible predictors were highlighted from this study. By trying to identifying individual patients who do modify treatment healthcare professionals can target information that can support the patient in making safer treatment modification choices.

Nurses are educators. It is the aim of every educator that his or her teaching should translate into learning. Effective teaching is especially of importance in assuring that patients learn to perform their own peritoneal dialysis (PD). In facilitating an environment where learning can occur, making learning fun is the objective. It is with this mandate that PD Trivia was created. PD Trivia is an interactive game created to facilitate and reinforce learning. PD Trivia consists of 100 essential questions to making PD a success at home. Evaluations at the peritoneal dialysis clinic have revealed excellent quantitative and qualitative results of this simple but comprehensive teaching tool for effective learning of PD.

Objective: The percentage of prevalent end-stage renal disease (ESRD) patients maintained on chronic peritoneal dialysis (CPD) therapy in the United States declined from 15% in 1991 to 8.1% in 2002. Previous studies indicate that nephrologists in the United States feel 32.6% of prevalent ESRD patients should be on CPD therapy. The present study was designed to better understand the reasons for the discrepancy in actual versus desired prevalence of CPD utilization., Methods: The medical directors of all dialysis centers in New England were mailed a questionnaire about the nephrologists' opinions concerning the percentage of patients that should be maintained on CPD therapy, reasons that limited patients' selection of CPD as initial therapy, and concerns about the current status of CPD therapy. The nephrologists were also invited to free text any other comments or concerns., Results: A total of 117 questionnaires were sent; 59 (50.4%) were returned. These medical directors cared for a median of 10 (range 1 - 100) patients on CPD therapy, meaning 15% of dialysis patients in New England are maintained on CPD therapy. The medical directors felt that 29% (range 10% - 50%) of prevalent ESRD patients should be maintained on CPD therapy. The most common reasons cited by the nephrologists as barriers to CPD therapy included patient preference (54%), contraindications to performing CPD therapy (32%), poor social support (31%), significant comorbid disease (20%), late referrals and acute hospital starts (19%), problems with education re chronic kidney disease (12%), and problems with the structure and organization of CPD facilities (12%). These same medical directors stated that concerns about technique failure (25%), long-term viability of CPD therapy (25%), and mortality rates of CPD patients (17%) impacted on their use of CPD therapy as renal replacement therapy for patients with ESRD., Conclusion: Nephrologists in New England felt that 29% of prevalent ESRD patients should be maintained on CPD therapy, yet the actual incidence of CPD utilization in New England is 15%. A variety of factors were cited by the nephrologists as important reasons limiting CPD utilization. These nephrologists were also concerned about technique failure and long-term viability of CPD therapy. It is necessary that we look closely at each domain cited by the nephrologists if CPD therapy is to remain a viable option for patients with ESRD in the United States.

Peritoneal dialysis in elderly patients is not widely applied, although data show that PD is often preferred by elderly patients. This paper describes current restrictions to the application of PD in elderly patients and their possible solutions. This includes (contra) indications to PD as well as data on patients' preference, quality of life specific for elderly patients and data on outcome of PD in older patients. The possibility of assisted peritoneal dialysis is offered as a challenge to the dialysis team.

Background: Dialysis and kidney transplantation represent two effective strategies in treating chronic uremia, albeit with different results. Our study compared the psychological aspects of two categories of patients: patients who faced kidney transplantation and have been on dialysis, and noncompliant patients treated with these therapies., Materials and Methods: On 170 patients (120 hemodialysis and 50 peritoneal dialysis) we used a personality analysis (MMPI2) and the COPE, which assessed the ability of patients to cope under certain conditions that can be perceived as stressful or, in any case, unusual. The screening succeeded in 11 cases among the first group and 9 in the second. Three of the 20 patients were considered to be partially noncompliant: 1 on peritoneal and the other 2 on hemodialysis. We also tested a control group of 300 people of different ages, sexes, social and cultural status, dates and kinds of transplantation (cadaveric or living donors). Of the 36 feedbacks received, only 30 were considered valuable., Results: The results of the research showed that patients with less than 2 years of dialysis treatment and patients with more than 2 years survival after transplantation time were inclined to deny their disease and the possible emotions about their clinical status, drawing an inadequate attention to the difficulties. This behavior was clearer among noncompliant patients. Family problems and couple malaise in everyday life can push more and more of these patients to be noncompliant with therapeutic prescriptions, as they do not feel adequate support. The result is an excessive foreboding, poor disposition, and nervousness., Conclusions: Screening of patients' social and psychological status is useful as is psychological intervention for those who miss emotional support from the family. This psychological support is advisable for uremics who have to enter a waiting list and for those who are subject to postoperative treatment in order to promote compliant behavior.

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.

Background/aims: The utilization of peritoneal dialysis decreases with age. A number of concerns have been raised regarding the suitability of peritoneal dialysis for elderly patients. The purpose of this review is to determine whether these concerns are medically valid., Methods: Literature review and synthesis., Results: Most elderly patients possess the manual and cognitive skills necessary to perform peritoneal dialysis. Elderly patients on peritoneal dialysis exhibit excellent compliance with their treatment regimen and display no increase in the rate of infectious complications though they may have a slight increase in hospital days. They easily achieve adequacy targets, experience good technique survival and their nutritional status is at least as good as that of their hemodialysis counterparts. Patient survival varies around the world but is overall comparable to that of age-matched patients on hemodialysis. Quality of life may be somewhat superior to that of older hemodialysis patients., Conclusion: Elderly patients with end-stage renal disease are appropriate candidates for peritoneal dialysis. It is not medically justifiable to exclude them from consideration for this therapeutic modality.

Measurement of patient outcome by mental and social indexes such as quality of life (QOL) in addition to survival is a growing trend. We examined the feasibility of using a single global QOL question in peritoneal dialysis (PD) patients. We also examined the relationship that QOL has with uremic symptoms and depression in these patients. During a clinic visit, each PD patient completed a single-question QOL measure (0-10 scale, 10 being best). Patients' symptoms were assessed using a 10-symptom checklist, with each symptom scored on a Likert scale of 0 (none) to 5 (severe). We evaluated for depression using two questions from the Primary Care Evaluation of Mental Disorders. Serum albumin, hemoglobin, and phosphorus were obtained, but only phosphorus was associated with QOL on univariate analysis (p = 0.05) and therefore included in the multivariate model. Results (checklist score, depression, phosphorus, age, diabetes, and race) were analyzed using a sequential multivariate analysis with QOL as the dependent variable. The study population consisted of 64 PD patients [mean age: 47 +/- 16 years; 25% black; 23% with diabetes; 31% incident (< or =3 months)]. The median score on the single QOL question was 7 (range: 1-10). Patients scored a median of 9 (range: 0-31) out of 50 on the total symptom checklist. Among responding patients, 34% answered yes to at least one depression question. The sequential incremental r2 values associated with a poorer QOL were higher checklist score (r2 = 0.16, p < 0.02), presence of depression (r2 = 0.13, p < 0.00002), younger age (r2 = 0.06, p < 0.03), and presence of diabetes (r2 = 0.04, p < 0.05). In this model, PO4 and race were nonsignificant. Total r2 in the model was 0.48. The single measure of QOL, the checklist score, and the depression screening score were simple and easy to obtain during a routine clinic visit. We conclude that physical symptoms and depression are strongly associated with a simple single measure of QOL. The extent to which symptoms and depression can be improved by clinical intervention, and the subsequent effect on quality of life and survival, should be examined in longitudinal studies.

The initiation of peritoneal dialysis (PD) requires that the nephrologist address certain key issues. These include patient selection for PD, the timing of the placement of the PD catheter, the timing of the initiation of PD, the schedule of PD to be utilized, and the initial regimen of PD to be prescribed. In addressing these issues, the nephrologist needs to consider not only the medical condition of the patient but also the psychosocial status and quality of life concerns of the patient and his/her family. Furthermore, the dialysis treatment regimen needs to be organized to maintain the long term viability of PD therapy.

Background: Clinical outcomes among patients on peritoneal dialysis (PD) might not be linked to medical factors alone. We studied the clinical impact of various social factors among patients on PD., Methods: In a cohort of 102 consecutive patients who started PD in a single centre between 2003 and 2004, we evaluated the effects of social factors on the development of peritonitis and risk of hospitalization after initiation of PD., Results: Of 102 incident PD patients, 35 subjects (34.3%) were referred to nephrologists more than 3 months before dialysis initiation. During 85.7 patient-years of observation (median follow-up, 10.7 months), four subjects died and six underwent kidney transplantation. Patients receiving social security assistance and those younger than 40 years fared worse than others in terms of their risk of peritonitis. Mean peritonitis-free time for subjects who were on social security assistance was 2.7 months, and for those who were not, 16.4 months (P = 0.045). In the Cox proportional hazards analysis, need for social security assistance and illiteracy were the only statistically significant factors associated with the time to a first peritonitis, after adjustment for social characteristics and relevant coexisting medical factors. Dependence on social security assistance prior to PD was associated with a >2-fold increased likelihood of peritonitis, with an adjusted risk ratio of 2.69 (95% confidence interval, 1.10 to 6.54; P = 0.029). The total number of hospitalization days was similar between those who received social security assistance and those who did not: 17.4+/-14.6 days (range, 4-50 days) vs 17.9+/-14.0 days (range, 0-60 days) (P = 0.89)., Conclusions: Our results confirm that socioeconomic status is closely associated with the rate of peritonitis among PD patients. The long-term reliability of these social predictors remains to be validated.

Background: Quality of life and perceived health status (PHS) are important indicators of patient care together with morbidity, mortality and health-care resource utilization. The aim of this study is to explore how various medical conditions might influence perceived health status., Methods: The study sample consisted of 128 kidney transplant recipients. PHS was measured using the self-administered SF-36 questionnaire. Stepwise linear regression analysis of 17 demographic, dialysis-, transplantation- and co-morbidity-related factors was performed in order to explore predictors of worse PHS., Results: Older age, female gender, lower education, increased number of hospitalizations during the dialysis period and diabetes mellitus were identified as significant predictors of worse PHS. Age was the most important predictor of PHS, explaining 23.3% of variance in the SF-36 physical component and 4.4% in the SF-36 mental component. Between age groups, major differences were found in predictors of perceived health status-serum creatinine was the most important for patients younger than 45 years and the number of hospitalizations for patients of 45 years and over., Conclusions: Biological and medical factors are significant predictors of the physical component of PHS, although they can explain only up to one-third of its variance. Other dimensions of PHS are weakly influenced by these medical parameters. It seems important to evaluate perceived health status separately among the age groups because they differ in their predictors.

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.

Background: The distribution of renal replacement therapy (RRT) modalities among patients varies from country to country, and is often influenced by non-medical factors. In our department, patients progressing towards end-stage renal disease (ESRD) go through a structured Pre-Dialysis Education Programme (PDEP). The goals of the programme, based on both individualized information session(s) given by an experienced nurse to the patient and family and the use of in-house audio-visual tapes, are to inform on all modalities of RRT, in order to decrease anxiety and promote self-care RRT modalities., Methods: To evaluate the influence of our PDEP on the choice of RRT modalities, we retrospectively reviewed the modalities chosen by all consecutive patients starting a first RRT in our institution between December 1994 and March 2000., Results: Two hundred and forty-two patients started a first RRT during the study period. Fifty-seven patients, median age 66 (24-80) years, were directed towards in-centre haemodialysis (HD) for medical or psycho-social reasons (seven of whom were not involved in the PDEP); the remaining 185 patients, median age 53 (7-81) years, with no major medical complications, went through our PDEP. Eight of them (4%) received a pre-emptive renal transplantation. The therapeutic options of the other 177 patients were as follows: 75 (40%) patients, median age 65 (20-81) years opted for in-centre HD, while 102 patients opted for a self-care modality; 55 (31%) patients, median age 56 (7-77) years, chose peritoneal dialysis, 30 (16%) patients, median age 49 (21-68) years, chose to perform self-care HD in our satellite unit, and 17 (9%) patients, median age 46 (19-70) years, opted for home HD. Interestingly, in the whole cohort of patients, the cause of ESRD was associated with the RRT modality: the proportion of patients with chronic glomerulonephritis or chronic interstitial nephritis on self-care therapy was significantly higher than that of patients with nephrosclerosis, diabetic nephropathy or unknown cause of ESRD., Conclusion: In our centre offering all treatment RRT modalities, a high percentage of patients exposed to a structured PDEP start with a self-care RRT modality. This leaves in-centre HD for patients needing medical and nursing care, or for patients refusing to participate in their treatment. Additional large studies, preferably with a randomized design, should delineate the cost-benefit of such a PDEP on the final choice of a RRT modality.

Background: Nephrologists report that patients' choice should play an important role in the selection of renal replacement therapy (RRT) for end-stage renal disease (ESRD). In the United States, kidney transplant rates remain low and <10% of patients utilize home dialysis therapies. This study examined the effect of pre-ESRD processes on the selection of RRT among incident ESRD patients., Methods: Using surveys, data were collected for all patients admitted to 229 dialysis units in ESRD Network 18 between April 1, 2002 and May 31, 2002. A total of 1365 patients began chronic dialysis and 1193 facility (87%) and 428 patient (31%) surveys were returned., Results: Substantial proportions of patients were unaware of their kidney disease (36%) or were not seeing a nephrologist (36%) until <4 months before first dialysis. The presentation of treatment options was delayed (48% either after or < 1 month before the first dialysis). The majority of ESRD patients were not presented with chronic peritoneal dialysis, home hemodialysis, or renal transplantation as options (66%, 88%, and 74%, respectively). Using multivariate analyses, variables significantly associated with selection of chronic peritoneal dialysis as dialysis modality were the probability of chronic peritoneal dialysis being presented as a treatment option and the time spent on patient education., Conclusion: An incomplete presentation of treatment options is an important reason for under-utilization of home dialysis therapies and probably delays access to transplantation. Improvements in and reimbursement for pre-ESRD education could provide an equal and timely access for all medically suitable patients to various RRTs.

Both peritoneal dialysis (PD) and hemodialysis (HD) patients have diminished quality of life (QOL) scores compared to healthy patients. QOL tends to decline over time, with the perception of the quality of physical health deteriorating more than mental health. However, many patients continue to feel hopeless, anxious, and worry about finances, loss of sexual function, family burden, and loss of independence. Depression is the most widely acknowledged psychosocial factor seen in patients with chronic kidney disease. Major depression occurs in 25% of patients facing impending dialysis. Once on PD, the proportion with major depression sharply declines to approximately 6%. This may be due to adjustment to dialysis, but may also be because depressive symptoms are associated with an increased risk of death. A low QOL score and depression are associated with higher comorbidity, poorer nutritional status, anemia, lower residual renal function, and increased hospitalization rates. Increased depressive scores are independently predictive of an elevated peritonitis risk, perhaps due to inattentiveness, or alternatively from a decrease in immune defenses. Small molecule clearances appear to have little to do with depressive symptoms. Depression is a significant problem in PD and other dialysis patients. There is an interrelationship between psychosocial factors, perception of illness, and clinical outcome that requires further study. Serial and simple measures of both depression and QOL should be obtained routinely in all PD patients. This permits rapid recognition of problems and may enhance patients' education on the importance of depression. Further research on interventions is urgently needed.

The aim of this investigation was to gain a retrospective impression of the mood of children undergoing peritoneal dialysis and the mood of their families during the course of their children's disease. The study was carried out at the department of pediatric nephrology (Medical University of Vienna) using structured questionnaires. Interestingly, both the families undergoing treatment and families who had completed treatment considered themselves equally, or even more, happy, harmonic and open than families with healthy children. Retrospectively, intimate relationships experienced by the majority of families were exceptionally close and positive. These findings do not support the subjective evaluation of staff and are contrary to the objective measurability of financial and emotional investment, as well as investment of time, by affected families.

Peritoneal dialysis treatment is as efficient as hemodialysis if properly administered; therefore, psychological aspects of peritoneal dialysis must be taken into account if this is to be the best treatment for patients suffering from terminal renal disease. This paper presents these aspects from the view of logotherapy and existential analysis. The description of the change in viewing patients from a medical aspect is followed by an outline of basic logotherapy and existential analysis. The consequences to patients and their current problems are described, together with theoretical basics and practical guidelines for communication with patients.

This exploratory-descriptive study identifies dimensions of self-management demonstrated by patients with end stage renal disease (ESRD) who have been successfully treated with peritoneal dialysis (PD) for more than 4 years (range = 4.1 to 13.1 years, mean = 7.5 years). After IRB review, semi-structured interviews were conducted with 18 individuals, 10 male and 8 female; 11 Caucasian, 6 African-American, and 1 Hispanic. Respondents ranged in age from 33 to 86 years (mean = 54.4 years). Interviews were audio-recorded and verbatim transcriptions were analyzed according to a content analytic procedure, with movement from specific to general. Two broad domains of self-management were identified: autonomy/control in health care and normality in everyday life. Autonomy/control was comprised of three specific dimensions: partnership in care, self-care, and self-care self-efficacy. Normality in everyday life included the dimensions of flexibility/freedom, interpretation of illness severity, and perception of body image. Although the small sample size and methodology limit generalizability, insights into the lived self-management experience on PD were identified. Such insights lay the groundwork for development of interventions to facilitate informed decision-making regarding dialysis modality, to teach tactics for effective self-management on PD, and to help health care professionals to support the self-management efforts of patients on PD.

Background: How dialysis patients feel about their treatment may influence how they respond to information suggesting that survival is better with a higher dose or different treatment modality. We assessed the strength of dialysis patients' preferences for their current treatment modality versus other modalities, how differences in survival between modalities and doses could influence preferences, and whether preferences differ by patient characteristics., Methods: We measured preference values for current health on dialysis therapy and for standardized descriptions of dialysis modalities and doses by using a sample of dialysis patients in Maryland and Massachusetts and a time trade-off technique scaled between 0 (death) and 1 (perfect health)., Results: We interviewed 109 patients on hemodialysis therapy, 57 patients on continuous ambulatory peritoneal dialysis (CAPD), and 22 patients on continuous cycling peritoneal dialysis (CCPD). Hemodialysis, CAPD, and CCPD patients had similar preference values for current health (mean, 0.69, 0.74, and 0.70, respectively; P > 0.1) and lower preference values for alternative modalities (eg, mean of 0.55 assigned to CAPD by hemodialysis patients). More than 75% of patients would choose a high dose over a lower dose of dialysis if it increased length of survival by 20%, but more than 30% would not switch modality, even if it increased survival by 100%. The only characteristic associated with a difference in preference values was depression, with weaker preferences among those with mild to moderate depressive mood., Conclusion: Dialysis patients have strong preferences for their current modality and are more likely to accept a higher dose of dialysis than switch modality to increase survival. Physicians should talk with patients about the modality and dose they prefer because preferences cannot be predicted by patient characteristics.

Interviewing the prospective patient for peritoneal dialysis (PD) is a critical step in the development of a relationship between the patient and the PD nurse. Individualizing information for the patient and significant others promotes confidence in making an informed decision. This article presents a five-step approach for interviewing the potential patient for PD.

Over the past 15 years, the use of specialised medical equipment by patients at home has increased in most industrialised countries. Adopting a conceptual framework that brings together two research perspectives, i.e. the sociology of technology and the sociology of illness, this paper empirically examines why and how patients use health technology at home and in the broader social world. Our study compares and contrasts the use of four interventions: antibiotic intravenous therapy, parenteral nutrition, peritoneal dialysis and oxygen therapy. We conducted interviews with patients (n = 16) and caregivers (n = 6), and made direct observations of home visits by nurses (n = 16). The content and structure of patient manuals distributed by major manufacturers and hospitals were analysed (n = 26). The aim of our study was to determine how technology was supposed to be used versus how it was actually used. This study shows that patients are deeply ambivalent about the benefits and drawbacks of technology, and that these advantages and disadvantages are shaped by the various places in which the technology is used. While technology can be pivotal in making patients autonomous and able to participate in the social world, it also imposes heavy restrictions that are intimately interwoven with the nature of the particular disease and with the patient's personal life trajectory.

Objective: There is little information on the relationship between depressive symptoms and survival in peritoneal dialysis (PD) patients. We examined whether a single measurement of depressive symptoms using a simple self-administered tool predicts survival., Design: Screening test of depressive symptoms as a predictor of outcome., Setting: Three dialysis centers in Southwestern Pennsylvania., Participants: 66 adult PD subjects were screened in 1997-1998 for depression using the Zung scale., Main Outcome Measures: Baseline data collection included assessments of comorbidity, residual renal function, total Kt/V, nPNA, previous renal transplant, and serum albumin. Outcomes were collected prospectively after completion of the depression survey to 12/01. Cox regression analysis of patient survival was performed using all cofactors with p < 0.05 on univariate analysis., Results: One third of patients had depressive symptoms. Compared to nondepressed patients, depressive symptom patients were older (62.5 vs 52.5 years, p = 0.012), had borderline lower serum albumin levels (3.47 vs 3.70 g/dL, p = 0.058), and were more disabled (Karnofsky score 70 vs 90, p< 0.001), but had similar Kt/V, residual renal function, and previous time on PD at the point of the testing. Using multivariate analysis and controlling for comorbidity (using a measurement that includes diabetes mellitus and age) and serum albumin, the survival of patients with depressive symptoms was significantly reduced compared to nondepressed patients., Conclusion: A single measurement of depressive symptoms using a simple self-administered test was an independent predictor of death in a cohort of PD patients, which extends observations in hemodialysis patients. Screening for depressive symptoms should be routine for dialysis patients, and those depressed should have thorough assessment and treatment. Whether treating depression will have an impact on survival is unclear and needs to be studied.

The incidence of psychopathology, particularly depression, is high in dialysed elderly patients whereas their perceived level of health in the mental domain is similar to that of a non-dialysed and, even younger, population. Although the losses associated with advancing years, chronic disease and then entry into dialysis renders the psyche of elderly people frail, they do not strictly add in negative terms: their psychological reserve or resignation helps very elderly people to tolerate dialysis and its constraints. However, maintaining functional autonomy (ability to provide for one's fundamental needs and preserve leisure activities) while remaining independent to take decisions (particularly in controlling ways of receiving assistance) and preserving close relationships emerge as major determinant factors of the quality of life of very elderly dialysed patients. Added to the dependency due to dialysis, losses in these domains very often represent a turning point by changing the patient's identity, predisposing to the development of relationship problems, leading the patient to question his self-esteem or even resulting in psychological dependency, which itself adversely affects the quality of life. These mechanisms of psychopathology may not hide the possibility of an underlying dementia.

It is not uncommon for renal patients to present with psychosocial problems and behavioral problems. This paper briefly discusses some of the psychosocial factors associated with renal disease and peritoneal dialysis, considers the role that those factors play in relation to clinical treatment, and suggests nursing interventions that involve problem-solving with patients and providing support to caregivers. Because nurses are on the front line in encounters with patients, their contribution can facilitate support for the psychosocial situations of their patients through effective communication within a committed multidisciplinary team that share a vision of the significance of psychosocial intervention.

Being dependent on dialysis is a potentially overwhelming experience where life as previously known is permanently altered. A dialysis-dependent individual may reformulate their identify or perceive that they are a remnant of their former self. This paper will explore and expand Morse and Penrod's (1999) model as a useful way to understand how a person might reconstruct their identify. Grounded in a narrative methodology, interviews of those on haemodialysis and peritoneal dialysis were thematically analysed. It was found that dialysis dependency brings an acknowledgment of a lost past, an inescapable present and an unknowable future, filtered through hope and despair. Nurses need to understand the suffering, wrought by such a struggle, to facilitate the positive re-envisioning of those who are dialysis dependent.

Depression has been documented as the most frequently encountered psychological problem in end-stage renal disease (ESRD) patients and has been correlated with both mortality and morbidity in these patients. Previous work by our group has shown that clinical depression is treatable with psychotropic medications in these patients, but that only a limited number of ESRD patients with depression will successfully complete a course of pharmacologic therapy. From July 1997 to October 2002, all chronic peritoneal dialysis (PD) patients in our facility were encouraged to be screened for depression utilizing the self-administered Beck Depression Inventory (BDI) questionnaire. Based on previous work, a score > or =11 on this questionnaire was used to indicate a possible diagnosis of clinical depression; patients with BDI scores > or =11 were encouraged to complete a more formal evaluation for the presence of clinical depression. A total of 320 BDI questionnaires were completed during the study period: 134 patients. (42%) scored > or =11 on the BDI, 69 of the 134 patients (51%) with BDI scores > or =11 agreed to further evaluation. Sixty of these 69 patients (87%) were diagnosed with clinical depression based on scores > or =18 on the Hamilton Depression Scale and standard Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria. Forty-four patients with clinical depression agreed to pharmacologic treatment. However, only 23 of the 44 patients (52%) successfully completed a 12-week course of drug therapy. Two unit social work reviewers systematically reviewed the records of these 21 patients who did not complete therapy and assessed the reasons for their inability to complete treatment. Reasons identified included eight patients who experienced acute medical problems, three who were active substance abusers, and two who reported medication side effects. The remaining eight patients who did not complete the 12 weeks of therapy were examined by applying the axis 1 and axis 2 DSM-IV criteria. Axis 1 is used to diagnose clinical disorders and axis 2 is used to diagnose personality disorders. While all these patients met the DSM-IV axis 1 criteria for clinical depression, eight of these patients met axis 2 criteria for personality disorders; five patients had borderline personality disorders, one had a narcissistic personality disorder, one had a factitious disorder, and one had features of avoidant personality disorder. While some chronic PD patients can be successfully treated for clinical depression with psychotropic medication prescribed by the dialysis medical team, not all patients will agree to be evaluated for clinical depression and accept pharmacologic treatment. Others cannot or will not complete treatment when additional psychiatric disorders exist. These patients may require additional intervention when diagnosed with clinical depression and a personality disorder. Further trials are warranted.

This study examined the impact of different dialysis treatments on the neuropsychological (NP) functioning of 145 end-stage renal disease patients. Hemodialysis (HD) and peritoneal dialysis (PD) patients were administered an NP test battery and measures of mood on 2 consecutive days (pre- and 24 hr postdialysis). Biochemistry was assessed at each session. Results indicated significant improvements in NP functioning (attention, concentration, verbal and visual memory, and psychomotor speed) in HD patients 24 hr postdialysis. No such fluctuations were found in PD patients. Although biochemical changes were found in the HD patients at the same time points, these were not consistently related to the NP changes.

Unlabelled: In this study quality of life adequacy of treatment was assessed in 32 PD patients over 65 years of age and compared with younger patients on PD (age 40 on average). Quality of life was examined with help of QLQ-C30 questionnaire, negative emotions with use of HADS and own Aggression Scale, life satisfaction on the Cantril's Ladder. Total weekly clearances were used for adequacy assessment as well as nutrition parameters and rate of anaemia and EPO use. Frequency of complications was also compared. Elderly patients were starting dialysis with lower GFR, but in the course of observation neither total clearances nor nutrition parameters and degree of anaemia did not differ between the groups. Elderly used EPO significantly less frequently in comparison to the younger patients. Peritonitis rate was similar and exit site infections were less frequent in elderly population. There was no difference between quality of life and level of negative emotions between the groups., In Conclusion: PD appears to be effective and acceptable method of dialysis for the elderly.

Background: Depression is the most common psychological disorder among patients with end-stage renal disease and has been associated with mortality in patients maintained on hemodialysis therapy. Peritonitis is the leading cause of technique failure among long-term peritoneal dialysis (PD) patients. This prospective study is designed to examine the relationship between depression and peritonitis., Methods: All patients on long-term PD therapy in our unit between January 1, 1997, and January 31, 2002, completed a Beck Depression Inventory (BDI) assessment at 6-month intervals. BDI scores were analyzed 2 ways. First, patients were placed into either group I (BDI score < 10) or group II (BDI score > or = 11) and were reclassified based on subsequent scores. Second, multivariable analysis was performed looking at initial BDI score as a risk factor for peritonitis, adjusting for age older than 65 years, diabetes, coronary artery disease, and race., Results: One hundred sixty-two patients were enrolled, and 281 individual BDI assessments were completed. There was a significantly greater incidence of diabetes and coronary artery disease in group II. Rates for overall and gram-positive peritonitis were significantly greater in group II patients compared with group I patients. Using Cox regression, only BDI score of 11 or greater was associated with the development of peritonitis (hazard ratio, 2.7; 95% confidence interval, 1.2 to 6.0)., Conclusion: There is an association between BDI score of 11 or greater and the development of peritonitis. Whether treatment of depression can impact on the rate of peritonitis remains to be examined.

Background: The guidelines from the US National Kidney Foundation Dialysis Outcomes Quality Initiative on peritoneal dialysis (PD) assume equivalence between the peritoneal and the renal solute clearance. The authors examined in a prospective cohort study of incident dialysis patients the relative contribution of residual renal function and peritoneal clearance to patient survival and quality of life (QoL)., Methods: The authors analyzed the longitudinal data on residual renal function, clearance by dialysis, and QoL of those patients who were treated with PD 3 months after the start of dialysis and participated in a prospective multicenter study in the Netherlands (n = 413)., Results: The mean age was 52 years, the mean residual glomerular filtration rate (rGFR) at 3 months was 4.1 mL/min/1.73 m2 (SD: 2.7), and the mean peritoneal creatinine clearance (pCrCl) at 3 months was 4.1 mL/min/1.73 m2 (SD: 1.1). The 2-year survival was 84%. For each mL/min/1.73 m2 increase in rGFR, a 12% reduction in mortality rate was found (relative risk of death [RR] = 0.88, P = 0.039). In contrast, no significant effect of pCrCl on patient survival was established (RR = 0.91, P = 0.47). The differential impact of rGFR and pCrCl was confirmed in an analysis on combined patient and technique survival and in an analysis on a number of generic and disease-specific dimensions of QoL., Conclusion: The beneficial effect of renal clearance and the absence of an effect of peritoneal clearance in the range of values common in current practice on patient outcome indicate that the 2 components of total solute clearance should not be regarded as equivalent. Higher peritoneal clearance targets do not necessarily improve patient outcome.