Young adults' perspectives on living with kidney failure: a systematic review and thematic synthesis of qualitative studies

INTRODUCTION

Young adults fare worse than younger adolescents or older adults on a broad range of health indicators. Those with a chronic illness such as renal failure are a particularly vulnerable group, who experience poor outcomes compared with both children and older adults. Understanding how being in receipt of renal replacement therapy (RRT) affects the lives of young adults might help us to better prepare and support these individuals for and on RRT, and improve outcomes. This study aimed to synthesise research describing young adults' experiences of the psychosocial impact of kidney failure and RRT.

DESIGN

A systematic literature review identified qualitative research reporting the perspectives of people aged 16-30 years receiving RRT on the psychosocial impact of renal failure. Electronic databases (including Medline/EMBASE/PsycINFO/ASSIA) were searched to November 2017 for full-text papers. The transparency of reporting of each study was assessed using the Consolidated Criteria for Reporting Qualitative Health Research (COREQ) framework. Quality was assessed using the Critical Appraisal Skills Programme qualitative checklist. An inductive thematic synthesis was undertaken.

PARTICIPANTS

Seven studies from five different countries were included, comprising 123 young adults receiving RRT.

RESULTS

Comprehensiveness of reporting was variable: studies reported 9-22 of the 32 COREQ-checklist items.Three global themes about the impact of kidney failure on young adults were identified: (1) difference desiring normality, (2) thwarted or moderated dreams and ambitions, and (3) uncertainty and liminality. These reflected five organising themes: (1) physical appearance and body image, (2) activity and participation, (3) educational disruption and underachievement, (4) career ambitions and employment difficulties, and (5) social isolation and intimate relationships.

CONCLUSIONS

Across different countries and different healthcare settings, young adults on RRT experience difference and liminality, even after transplantation. Tailored social and psychological support is required to allow young adults to experience wellness while in receipt of RRT, and not have life on hold.

Smoking Behaviors of Renal Transplant Recipients: An Analysis of 113 Patients

OBJECTIVES

Smoking is the most important remediable risk factor for the progression of renal diseases. Smoking has serious adverse effects, such as cardiovascular disease, kidney function impairment, and cancer in kidney transplant recipients who are already at high risk for these diseases. In this study, our objective was to evaluate descriptive characteristics and smoking status of renal transplant recipients.

MATERIALS AND METHODS

We evaluated 113 patients who underwent renal transplant at Baskent University Hospital between 1990 and 2015. The medical records of all patients were retrospectively reviewed. Patient demographics, cause of renal diseases, mortality status, smoking status, and amount of smoking were recorded.

RESULTS

In our study, 82 patients (72.7%) were male and 31 were female. The mean age was 38.50 ± 12.94 years. Causes of renal failure were as follows: 15.9% from hypertension, 12.4% from diabetes mellitus (all types), 8% from glomerulonephritis, 8% from vesicoureteral reflux, 6.2% from polycystic kidney disease, 17.6% other, and 31.9% unknown. Comorbid systemic disease was found in 57.6% of the patients. Fifty patients (44.2%) were current smokers, and 63 patients (55.8%) were nonsmokers. Mean age of smokers was 44.68 ± 10.60 years, with most being male patients (92.0%). There was a statistically significant difference between smoking status and sex (P < .001). The presence of comorbid diseases was significantly different between smokers and nonsmokers (P = .001). The smoking status of patients with hypertension (28.2%) was significantly different (P = .032) than others.

CONCLUSIONS

Smoking cessation is associated with substantial health benefits for all smokers. For kidney transplant recipients, cigarette smoking has many adverse effects, causing cardiovascular disease and other comorbid diseases. Therefore, every attempt should be made to encourage kidney transplant candidates to stop smoking.

Adherence in paediatric renal failure and dialysis: an ethical analysis of nurses' attitudes and reported practice

Minors have difficulty adhering to the strict management regimen required whilst on renal dialysis for chronic renal failure. This leads to ethical tensions as healthcare professionals (HCPs) and parents try, in the minor's best interests, to ensure s/he adheres. All 11 dialysis nurses working in a large, regional paediatric dialysis unit were interviewed about their perceptions and management of non-adherence and the ethical issues this raised for them. Participants reported negative attitudes to non-adherence alongside sympathy and feelings of frustration. They discussed the competing responsibilities between nurses, parents and minors, and how responsibility ought to be transferred to the minor as s/he matures; the need for minors to take responsibility ahead of transferring to adult services; and, the process of transferring this responsibility. Our discussion concentrates on the ethical issues raised by the participants' reports of how they respond to non-adherence using persuasion and coercion. We consider how understandings of capacity, traditional individual autonomy, and willpower can be used to comprehend the issue of non-adherence. We consider the relational context in which the minor receives, and participates in, healthcare. This exposes the interdependent triad of relationships between HCP, parent and minor and aids understanding of how to provide care in an ethical way. Relational ethics is a useful alternative understanding for professionals reflecting upon how they define their obligations in this context.

The role of the psychiatrist in obtaining informed consent from patients with somatic and mental comorbidity: Report of one case

The nature of mental disorders, the attitudes and prejudices of the social community towards psychiatric patients, the behavior and treatment of mental patients, all bring about numerous dilemmas and prejudices. When a patient is diagnosed with a mental disorder, he may suffer restrictions in the field of general human rights. However, the biggest problems in clinical practice occur in the treatment of patients who, besides their mental disorder also have a somatic disease. We report a 56-years-old female with a severe renal failure who refused to undergo dialysis. Following the patient's refusal to sign an informed consent, a psychiatrist was called in for consultation and diagnosed an acute psychotic reaction. To manage the delusions and acute psychotic reactions, risperidone in the dose of 2 mg was started. After 22 days, the patient still had marked psychotic symptoms. A psychiatrist, a nephrologist and an anesthesiologist, in the presence of the spouse on the grounds of her life-threatening condition, decided to apply the necessary medical procedures even without the patient's consent. A day after the start of dialysis the patient still had delusional ideas, but without the presence of anxiety, and the patient no longer offered resistance to dialysis. Four days after the first dialysis, the patient was calm, had vague memories about the entire previous period, and signed the informed consent concerning her further treatment.

Evaluation of a single-item screening question to detect limited health literacy in peritoneal dialysis patients

Studies have shown that a single-item question might be useful in identifying patients with limited health literacy. However, the utility of the approach has not been studied in patients receiving maintenance peritoneal dialysis (PD). We assessed health literacy in a cohort of 31 PD patients by administering the Rapid Estimate of Adult Literacy in Medicine (REALM) and a single-item health literacy (SHL) screening question "How confident are you filling out medical forms by yourself?" (Extremely, Quite a bit, Somewhat, A little bit, or Not at all). To determine the accuracy of the single-item question for detecting limited health literacy, we performed sensitivity and specificity analyses of the SHL and plotted the area under the receiver operating characteristic (AUROC) curve using the REALM as a reference standard. Using a cut-off of "Somewhat" or less confident, the sensitivity of the SHL for detecting limited health literacy was 80%, and the specificity was 88%. The positive likelihood ratio was 6.9. The SHL had an AUROC of 0.79 (95% confidence interval: 0.52 to 1.00). Our results show that the SHL could be effective in detecting limited health literacy in PD patients.

Bodily changes among people living with physical impairments and chronic illnesses: biographical disruption or normal illness?

This article focuses on individuals who are growing old with chronic illnesses and early onset impairments. Their experience of illness complications, bodily and functional losses is similar to what Bury has referred to as a biographical disruption. However, whereas Bury argues that a chronic illness amounts to a critical situation for the individual, partly due to its unexpected nature, this does not apply to the participants in our two studies. A second difference concerns Bury's implicit suggestion that the disruption is a single event that is characteristic of the early stage of a chronic illness. Repeated disruptions seemed to shape the lives of several of those interviewed. At the same time, this article challenges studies which suggest that the notion of disruption is less relevant to people in later life and to those who have experienced difficult lives, and also questions the argument that continuity rather than change characterises the lives of people who have had chronic conditions since their early years. In its approach, the article responds to Williams' request for studies in the sociology of chronic illness that extend the predominant biographical focus on the middle years of life to both ends of the life course.

Physiologic and psychosocial approaches to global management of the hemodialysis patient in the Southern Alberta Renal Program

As frontline nurses, we know firsthand the many challenges of renal disease faced by our patients and the impact on their lives and their families. How can we help them cope with their illness? How can we improve their quality of life? How can we prevent the complications inherent to the disease? How do we know we are doing a good job? Where do we start? The purpose of this presentation is to showcase the global management of the hemodialysis (HD) patient. It provides a collaborative and systematic approach to assessing, implementing, evaluating and coordinating the physiologic and the psychosocial aspects of their care. It is a model of case management followed by the Southern Alberta Renal Program (SARP) in meeting the many and complex needs of our hemodialysis patients. The quality indicators, to name a few, that relate to the physiologic aspects of their care are dialysis adequacy and fluid removal, improved blood pressure (BP) control, maintenance and improved vascular access function, anemia, bone and mineral disease management, nutritional, and diabetes management. The psychosocial aspects of care encompass goals of care, residential support, transportation, and mobility programs in the community. There may be positive implications resulting from our practice that we believe would be invaluable in terms of improved patient care, increased adherence to therapeutic regimens, improved mortality and morbidity and overall enhanced quality of life. Moreover, better communication would possibly be fostered and wise and prompt use of resources may be a result. To date, we have not done studies to prove or disprove these outcomes.

Experiences of kidney failure: a qualitative meta-synthesis

The purpose of this study was to conduct a qualitative meta-synthesis on the experiences of kidney failure in the nursing literature. Database searches were not limited by date; however, only 13 peer-reviewed articles, theses, and dissertations met inclusion criteria. Meta-synthesis of the texts suggests individuals with kidney failure have experiences of paradoxical nature, including occurrences of restricted freedom that bring about distant connection, dependent autonomy, abnormal normalcy, and uncertain hope. When nurses are attuned to the seemingly contradictory nature of experiences of individuals living with kidney failure, they may be better able to develop strategies that will increase quality of life for these patients.

The challenge of patients' unmet palliative care needs in the final stages of chronic illness

BACKGROUND

There is consensus in the literature that the end of life care for patients with chronic illness is suboptimal, but research on the specific needs of this population is limited.

AIM

This study aimed to use a mixed methodology and case study approach to explore the palliative care needs of patients with a non-cancer diagnosis from the perspectives of the patient, their significant other and the clinical team responsible for their care. Patients (n = 18) had a diagnosis of either end-stage heart failure, renal failure or respiratory disease.

METHODS

The Short Form 36 and Hospital and Anxiety and Depression Questionnaire were completed by all patients. Unstructured interviews were (n = 35) were conducted separately with each patient and then their significant other. These were followed by a focus group discussion (n = 18) with the multiprofessional clinical team. Quantitative data were analysed using simple descriptive statistics and simple descriptive statistics. All qualitative data were taped, transcribed and analysed using Colaizzi's approach to qualitative analysis.

FINDINGS

Deteriorating health status was the central theme derived from this analysis. It led to decreased independence, social isolation and family burden. These problems were mitigated by the limited resources at the individual's disposal and the availability of support from hospital and community services. Generally resources and support were perceived as lacking. All participants in this study expressed concerns regarding the patients' future and some patients described feelings of depression or acceptance of the inevitability of imminent death.

CONCLUSION

Patients dying from chronic illness in this study had many concerns and unmet clinical needs. Care teams were frustrated by the lack of resources available to them and admitted they were ill-equipped to provide for the individual's holistic needs. Some clinicians described difficulty in talking openly with the patient and family regarding the palliative nature of their treatment. An earlier and more effective implementation of the palliative care approach is necessary if the needs of patients in the final stages of chronic illness are to be adequately addressed.

Quality of life in patients with kidney, liver or heart failure during the waiting list period

We analyzed the possible differences in the perception of quality of life among three groups of transplantation candidates (kidney, liver, and heart) to determine relevant factors. The sample included 113 patients (43 liver, 44 kidney, and 26 heart transplant candidates) with an average age of 52 years. The tools used were the "SF-36" and "EuroQol - 5D". The results showed significant differences among the kidney, liver, or heart transplant candidates (P < .001). No significant differences were detected between liver and heart transplant candidates. The patients on the waiting list to receive a kidney transplant had a better perception of quality of life.

Quality of life of patients with chronic renal allograft rejection and anemia

BACKGROUND

The treatment with recombinant human erythropoietin (rHuEPO) of anemia associated with renal insufficiency (RI) improves the health-related quality of life (HRQOL) of those patients. The objective of this study was to evaluate the HRQOL of patients with chronic allograft nephropathy (CAN) and anemia associated to RI, and the effect of rHuEPO treatment on the HRQOL.

METHODS

This prospective study consisted of 17 kidney transplant patients with RI caused by CAN and anemia who received rHuEPO. The hemoglobin (Hb) target was 12 g/dL. Serum Hb, hematocrit (Hct) and creatinine clearance (CrCl) were collected. HRQOL was evaluated with the Kidney Disease Quality of Life Short-Form 36 (SF-36) questionnaire at the start, at the 3rd and 6th month and at the end of the follow-up. SF-36 scores (eight scales, physical component summary (PCS) and mental component summary (MCS) were standardized by age and gender using the Spanish population norms. The "effect size" was also calculated for each score.

RESULTS

Hb and Hct statistically improved from the start to the 3rd month and to the end of the study (p<0.01). Although the CrCl remained stable during most of the follow-up, it worsened (p=0.002) around the 13th month. SF-36 scores at the beginning were worse than that of the general population. Three SF-36 scales statistically improved; role-physical, vitality and mental health. The effect size was moderate for pain (0.41), role-emotional (0.39) and MCS (0.42); and large for role-physical (0.65), vitality (0.81) and mental health (0.74).

CONCLUSIONS

The poor HRQOL of patients with CAN and anemia improves with rHuEPO treatment, the effect size varying from moderate to large.

Patients' experiences of a dialysis diet and their implications for the role of the dietitian

OBJECTIVE

Although developments in medical technology, pharmacology, and nutritional science continue to improve treatment possibilities for patients with renal failure, the level of compliance with medical and dietetic advice remains poor. Previous research on compliance with treatment of chronic illness has led to recommendations for an improved understanding of what is involved in living with chronic illness in order to tailor treatment more appropriately to individual needs. This qualitative study set out to examine, the experiences and difficulties of patients on hemodialysis who follow dietary restrictions, and to ascertain how the dietitian can most effectively support patients in adapting to dietary change.

DESIGN

A semi structured interview format with thematic analysis was chosen.

SETTING

The interviews took place in the patients' homes and lasted between 30 and 60 minutes.

PATIENTS

Participants for the study were approached at Taunton and Yeovil dialysis centres in Somerset, England, and were selected according to the following criteria: (1) all had been on hemodialysis for at least 6 months, (2) all had been advised to follow dietary and/or fluid restrictions at one time, and (3) none had any diagnosed intellectual impairment. Eight subjects were recruited, 4 men and 4 women. The age range was 20 to 68 years.

INTERVENTION

Participants were asked to describe in depth their experiences of renal failure and of a renal diet. They were asked what had helped them cope with the difficulties they had faced and how they saw the role of the dietitian.

OUTCOME MEASUREMENT

The interviews were recorded, transcribed, and coded according to the following categories: (1) Difficulties experienced by participants. (2) What helped them cope with these difficulties. (3) How the dietitian can help support the coping process.

RESULTS

Findings showed a variety of physical, social, and psychological difficulties that can result from the onset of illness, commencement of dialysis, and the imposition of dietary restrictions. A loss of autonomy was an underlying theme. Greater understanding, hope, support from others, individual activity, and personal responsibility on the part of patients helped them to cope more positively with the changes in life.

CONCLUSION

Recommendations from this research include ways by which the dietitian can encourage greater autonomy when advising patients, and how they can give information in a positive, sensitive, and supportive way.

Patients' beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness

The aim of this cross-sectional study was to quantify patients' personal beliefs about the necessity of their prescribed medication and their concerns about taking it and to assess relations between beliefs and reported adherence among 324 patients from four chronic illness groups (asthma, renal, cardiac, and oncology). The findings revealed considerable variation in reported adherence and beliefs about medicines within and between illness groups. Most patients (89%) believed that their prescribed medication was necessary for maintaining health. However, over a third had strong concerns about their medication based on beliefs about the dangers of dependence or long-term effects. Beliefs about medicines were related to reported adherence: higher necessity scores correlated with higher reported adherence (r=0.21, n=324, p<0.01) and higher concerns correlated with lower reported adherence (r=0.33, n=324, p<0.01). For 17% of the total sample, concerns scores exceeded necessity scores and these patients reported significantly lower adherence rates (t=-4.28, p<0.001). Stepwise multiple linear regression analysis showed that higher reported adherence rates were associated with higher necessity-concerns difference scores (beta=0.35, p<0.001), a diagnosis of asthma (beta= -0.31, p<0.001), a diagnosis of heart disease (beta=0.19, p<0.001), and age (beta=0.22, p<0.001). Gender, educational experience, or the number of prescribed medicines did not predict reported adherence. Medication beliefs were more powerful predictors of reported adherence than the clinical and sociodemographic factors, accounting for 19% of the explained variance in adherence. These data were consistent with the hypothesis that many patients engage in an implicit cost-benefit analysis in which beliefs about the necessity of their medication are weighed against concerns about the potential adverse effects of taking it and that these beliefs are related to medication adherence.

The impact of renal replacement therapy on toddler time

The impact of renal replacement therapy on the day-to-day activity of 5 toddlers is presented. For those on hemodialysis, 50% of the waking hours involved activity related to management of the renal failure; the remainder was spent feeding or in normal (play) activity. Peritoneal dialysis demanded only 10% of waking hours for direct renal activity. The data are potentially useful in counseling families when discussing the impact of renal failure and its management on the toddler.

The features of psychological problems and their significance in patients on hemodialysis--with reference to social and somatic factors

AIM

For the purpose of identifying the features of psychological problems and their significance in patients on hemodialysis, we analyzed how psychological problems are affected by social and somatic factors.

SUBJECTS AND METHODS

The subjects all consisted of patients on hemodialysis at the Kidney Center of Fukuoka Red Cross Hospital between December 1994 and December 1996. We used the Cornell medical index health questionnaire on neurosis and the "easily upset or irritated", State-trait anxiety inventory to determine both state and trait anxiety, the Self rating Depression Scale on depression and divided into the patients who demonstrated each psychological problem and those who did not, and then analyzed the psychological problems between the two groups with reference to somatic and social factors which may have led the patients to develop their respective psychological problems.

RESULTS

According to a chi-square analysis, neurosis, clinical trait anxiety and clinical state anxiety were all more closely related to somatic factors than to social factors. In contrast to neurosis and anxiety, more social factors than somatic factors were related with "easily upset or factors were related with" easily upset or irritated". "Easily upset or irritated" was significantly related to living with a spouse or with children. In addition, depression was related to various factors including both somatic and social factors. In a stepwise multiple logistic regression analysis, the presence of restless legs also correlated with all the psychological symptoms investigated in this study. The prevalence of depression was also related to the degree of awareness regarding the cause of renal failure (p < 0.01).

CONCLUSION

Our results thus revealed the features of the psychological problems and their significance in patients on hemodialysis.

Standards for patients with renal failure

A recent report aims to improve the quality of care for adults with serious kidney failure. An expert committee sets out the recommended standards of care for patients who may need dialysis, transplantation or other treatment for renal disease. This report summarises their work.

Pre-dialysis information: how effective is it?

Many individual with decreased renal function are reviewed in pre-dialysis outpatient clinic for a varying length of time. It is in the pre-dialysis stage that the physician informs the individual about their progressive kidney failure and of the eventual need for dialysis. Despite the length of time that the patient has prior to commencing a renal replacement programme the renal team attempt to prepare the patient for their impending treatment by providing adequate information and allowing them to explore their illness and their future. Research has shown that the more knowledge the patients have about their disease and subsequent treatment, the more they are able to participate in their own care and the better they feel, both mentally and physically. All the patients receiving pre-dialysis information in the last 6 months are included, 14 subjects were chosen at random to participate in the study. A standard information-giving service has now been developed within the renal service, based on the needs of the patients using the service.

Care of the older person with kidney failure

Dialysis and renal transplants have become a reality in the XXIst century. Their use in third world countries has profound impacts on social, economic, political and cultural aspects. Extraordinary achievements for the medical world, that is constantly concerned in improving the health levels for the population; but what are the repercussions for the lower income groups? Is the cost/benefit relationship being analysed? Is there ample information available and is it well distributed regarding how to avoid the need for dialysis or a kidney transplant? What recommendations are made to the health care workers? And, what has been revealed to us after reflecting on the philosophical/historical aspects of the human existence? How valuable are Dr. Ivan Illich's observations and what can we expect from health care workers in relation to such significant achievements as we face the XXIst century?

Personalizing choices: patients' experiences with making treatment decisions

Because little is known about the perceptions of patients who make health care decisions under potentially life-threatening conditions, a grounded theory approach was utilized to describe decision making from the patient's perspective. Eighteen respondents, aged 26 to 81, with diagnoses of heart disease, renal failure, or cancer were interviewed shortly after making a decision regarding treatment of their conditions and again about 1 month later. Respondents reported that their decisions to accept treatment were personalized to correspond with their views of themselves within the context of their life stories. Findings provide a basis for development of effective interaction and educational strategies for use with persons with potentially life-threatening conditions.

Psychiatric complications of hemodialysis at a kidney center in Nigeria

The mental state of 20 consecutive hemodialysis patients investigated at a Nigerian renal unit was assessed using the 30-item General Health Questionnaire, Present State Examination, and clinical evaluation using the Diagnostic and Statistical Manual, revised third edition (DSM-III-R). Findings were compared with those of orthopedic patients and apparently healthy controls. A standard interview was used in eliciting sociodemographic data from the subjects. A significantly higher prevalence of psychiatric disorders was identified in hemodialysis patients (55%) than in orthopedic patients (20%) and apparently healthy controls (0%). The psychiatric disorders encountered in this hemodialysis population included major depressive episode (35%) and generalized anxiety disorder (20%). The probable reasons for the higher prevalence of psychiatric morbidity in this hemodialysis population, compared with those in Western societies, are discussed. Psychiatric morbidity was higher in patients with low levels of education, and did not show statistically significant relationship with other sociodemographic variables.

Personality traits and long-term health status. The influence of neuroticism and conscientiousness on renal deterioration in type-1 diabetes

Stringent long-term control of blood glucose concentration in patients with insulin-dependent diabetes mellitus (IDDM) can decrease albuminuria, presumably forestalling development of renal insufficiency. Personality characteristics may influence a diabetic patient's ability and willingness to follow a prescribed regimen to achieve glycemic control. This study investigated the relationship of 2 personality factors to renal deterioration time (from initiation of insulin therapy to renal failure) in 85 patients with IDDM and end-stage renal disease. Persons moderate in the personality trait of neuroticism and high in conscientiousness had renal deterioration times that were 12 years longer than persons with either high or low neuroticism and low conscientiousness, presumably because of better self-care. The implications of this study's findings are discussed.

Family behavior, adaptation, and treatment adherence of pediatric nephrology patients

In this exploratory study we investigated the relationships among family behavior variables (e.g., family expressiveness), adaptive functioning skills, maladaptive behavior, and adherence to treatment in pediatric renal failure patients. The study included 22 pediatric outpatients with renal failure who had not yet received dialysis or transplantation (RF) and their parents, and 12 pediatric outpatients with kidney transplants (TX) and their parents. For the RF patients, significant correlations were found between some of their adaptive functioning skills and measures of their medication adherence, diet adherence, and clinic appointment adherence; however, for the TX patients significant correlations were found only between some of their adaptive functioning skills and measures of their medication adherence. For the RF patients only, some measures of their family behavior were significantly correlated with measures of their medication adherence and diet adherence. Additionally, some measures of the RF patients' family behavior were significantly related to their communication skills, socialization skills, overall adaptive functioning skills, and maladaptive behavior. For the TX patients, only their socialization skill level was significantly correlated with one measure of their family behavior. It is concluded that facilitation of adaptive and physical functioning among renal pediatric patients likely requires multidimensional training and/or counselling interventions with the children and their families, and that some of the content and/or emphasis of this training likely needs to differ for RF patients versus TX patients.

NHP or SIP--a comparative study in renal insufficiency associated anemia

In this study we compared the feasibility, internal structure and psychometric characteristics (internal consistency, test-retest reliability, construct validity) of two widely used generic health status measures, i.e. the Nottingham Health Profile (NHP) and the Sickness Impact Profile (SIP) when employed among a sample of patients on renal dialysis (n = 63). The NHP was found to be more feasible, i.e. shorter and less difficult, than the SIP. The NHP scales showed somewhat higher levels of internal consistency (mean alpha = 0.67, range = 0.39-0.80) than the SIP scales (mean alpha = 0.65, range = 0.14-0.82). Test-retest reliability with a 24-hour interval was acceptable for most NHP scales (not available for the SIP in this study). Intercorrelations between the NHP scales were somewhat weaker than those for the SIP, and the expected patterns of scale intercorrelations were largely confirmed. The overall pattern of correlations between NHP scales and SIP scales was consistent with expectations, although the correlations were generally rather weak. Correlations between NHP scales and SIP scales and instruments measuring mainly physical functioning (ADL, Karnofsky) were largely as expected. Similarly, correlations between NHP scales and SIP scales and instruments measuring mainly psychological functioning [STAI (anxiety), SDS-Zung (depression)] were also as expected, although here the correlations were weaker for the SIP when compared with the NHP. The Index of Well-being exhibited intra-class correlations > 0.3 with one SIP scale and with five out of six NHP scales. Common factor analysis, yielding a two-factor solution with a physical and a mental factor of equal importance, showed the SIP scales to load more on the physical factor, while the NHP scales loaded more on the mental factor. The NHP generally performed better than the SIP in terms of feasibility and internal consistency. Physical functioning is emphasized in the SIP, whereas the emphasis of the NHP lies on mental functioning. The analysis confirmed to some extent the intentions of the constructors of NHP and SIP respectively, i.e. the NHP to be a measure of perceived health and the SIP to be a more functional measure.

Renal replacement therapy in diabetic nephropathy

The case of a patient with diabetes mellitus and renal failure is presented and discussed. This case represents the very successful course of a diabetic patient who received peritoneal dialysis for 14 years. Not all patients with end-stage renal disease (ESRD) from diabetic nephropathy are this fortunate. The success and complications of dialytic modalities are discussed by a nephrologist and nurse dialysis coordinator. Renal transplantation, the preferred treatment for most diabetic ESRD patients, is discussed by a nurse transplant coordinator. Simultaneous pancreas kidney transplantation, with its potential benefits in the future is discussed by an experienced transplant surgeon. In addition, the psychosocial issues of renal failure, dialysis, and transplantation in the diabetic patient are addressed by clinical social workers. Lastly, the very important issue of foot care and treatment, and prevention of vascular-related morbidity is discussed by a practicing podiatrist. With such a multidisciplinary approach, medical and psychosocial outcomes can be optimized for diabetic patients with renal failure.

Racial differences in perceptions concerning hypertension and its consequences

To investigate racial differences in hypertensive patients' understanding of their disorder, we administered a questionnaire to 83 black and 260 white outpatients with the diagnosis of hypertension designated in their medical chart. No racial differences in systolic or diastolic blood pressure, age, or male/female ratio were observed. However, blacks were more likely than whites to identify renal failure as a consequence of hypertension, whereas whites were more likely to identify atherosclerosis. Blacks also were more likely than whites to accept higher diastolic blood pressures as normal (90 to 100 mm Hg versus 80 to 90 mm Hg). There was no correlation between knowledge and blood pressure. Our observations show that both racial groups are well educated about antihypertensive therapy as well as the consequences and complications of hypertension. Comprehensive treatment of hypertension should include educational strategies that are population-specific and that address ways to change disease-relevant behaviors, rather than merely identifying which behaviors to change.