Psychosocial Aspects of Chronic Disease: ESRD as a Paradigmatic Illness : Journal of the American Society of Nephrology

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Psychosocial Aspects of Chronic Disease

ESRD as a Paradigmatic Illness

Cukor, Daniel*; Cohen, Scott D.; Peterson, Rolf A.; Kimmel, Paul L.

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Journal of the American Society of Nephrology 18(12):p 3042-3055, December 2007. | DOI: 10.1681/ASN.2007030345
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Remarkable advances in the understanding and treatment of ESRD have been achieved over the last 20 yr. However, most of the investigations have focused on medical factors, many of which are fixed features. Over recent years, there has been increasing attention given to the individual characteristics of patients with an emphasis placed on understanding the effects the patients' social situation, perceptions and responses to the illness, their physicians and healthcare providers, their spouses and families, and their SES have on outcomes. Although this area of “psychonephrology”1 has been a subject of research for many years, recent work in patients with2,3 and without renal disease412 has advanced our understanding of the interaction of psychological factors with medical outcomes. The notion of “stress” serves to provide a research context for the study of such interactions.

The concept of stress has resisted definition since it was first introduced in the 1930s by Hans Selye,13 but the word has since permeated the popular cultural idiom. Stress may be thought of as a disruption in the physical condition, environment, or psychosocial setting of an organism.14 The concept of stress has been operationalized through the notion of “stress mediators,” typically hormones that affect or are produced by the central nervous system or hypothalamic-pituitary-adrenal (HPA) axis. Stress mediators are thought to potentially have both protective and maladaptive consequences, depending on their peak intensity and the temporal associations of the response. A further refinement of the idea of stress includes the ability to achieve stability through change, or “allostasis”.14,15 The construct of allostasis was first developed in an effort to understand the physiological basis for disparate patterns of morbidity and mortality unexplained by SES, access issues, or lifestyle choices.16 McEwen and Stellar17 proposed the construct of allostatic load to convey the cumulative impact of progressive physiological wear and tear that could predispose biologic organisms to disease. Interestingly, the factors that comprise the Allostatic Index are weighted toward risk factors for cardiovascular disease (such as systolic BP, cortisol and catecholamine excretion, the waist/hip ratio, glycosylated hemoglobin, and the ratio of serum HDL to total serum cholesterol concentration).15 McEwen15,18 suggested several response patterns that are indicative of excessive wear and tear: 1) a response pattern with excessive and repeated insults over time, 2) a pattern where the organism is unable to habituate to stressful stimuli, 3) a pattern that is activated but remains at a heightened level of activation without sufficient recovery to baseline status, and 4) a pattern where the primary mechanisms are inadequate to the challenge, resulting in the activation of compensatory mechanisms. These four response patterns may lead to variable end-organ responses that may characterize patients with chronic illness, and in particular ESRD.

The ability of stress mediators to return to baseline is a particularly salient issue for patients with renal dysfunction. Because peptide and steroid hormones undergo metabolism by the kidney and often circulate at levels higher than in patients without renal disease,1921 the patient with chronic kidney disease (CKD) can be considered to exist in an internal biochemical milieu that is similar to a chronic stress response.

People's variability in their perception of “stress” is critical, because outcomes may be quite variable in patients with similar allostatic loads.15 Therefore, age, gender, presence of comorbid illness, developmental history, and genetic heterogeneity may be associated with different outcomes, but personality, mood, habits and behaviors (such as diet, level of exercise, use of tobacco, alcohol and regulated substances, and spirituality and religious observance) may play roles in modifying disposition of allostatic load as well. In particular, some of the stressors in the life of a dialysis patient may cause modifications to the patients' status in a variety of marital, familial, and occupational and societal contexts (Figure 1). However, to fully appreciate the dynamic nature of these demands one must also understand the patient's perspective on his or her ability to cope with these stressors. The person's personality, psychological functioning, resources, and even cultural beliefs may all affect the perception of the ability to respond successfully to a challenge (Figure 1).

Anderson and Armstead22 advanced the biopsychosocial model first elaborated by Engel23 to encompass many levels that may interact to determine health status. Some of these stratifications include individual demographic data (age, ethnicity, gender), physiological measures (e.g., body mass index, cardiovascular, immunologic and conditioning status), psychological and behavioral parameters (distress, personality factors, health-promoting or -damaging habits), and social or environmental factors (occupational imperatives, level of social support, access to health care, residential characteristics, and SES). Psychological and social parameters (Table 1) might include personality factors, affect, and perceptions of distress, well-being, or illness, whereas social measures include marital satisfaction, satisfaction with health care, compliance with the dialysis regimen, and level, number, and quality of interactions with dialysis personnel and staff. ESRD patients exist in a complex network encompassing, at the minimum, family, physicians, dialysis staff, clinic personnel, hospitals, and dialysis and insurance companies (Figure 2). This paper updates the literature on the mechanisms and impact of these psychosocial influences on HD patients, first outlined in 2001.24


In a review of hospitalization data from US Medicare ESRD patients who were treated with dialysis in 1993, the most common psychiatric disorders in the population were depression and affective disorders (26%), organic brain syndromes and dementia (26%), schizophrenia and other psychoses (22%), and drug and alcohol abuse (15%).25 In our Brooklyn data, 19% of urban HD patients had an active substance abuse diagnosis and 10% had a diagnosis of psychosis.26 In an in-depth analysis of alcohol use in 163 urban HD patients, 27.6% were found to have troublesome use of alcohol.27


The assessment of depression is complicated by the considerable overlap of depressive and uremic symptoms.2,3,28,29 However, the Beck Depression Inventory (BDI),30 a measure of depressive symptomatology, has been shown to be a valid measure of depressive affect in HD populations.3,26,28,3133 A BDI cut-off score of 14 to 16 appears to best approximate a psychiatric diagnosis of major depressive disorder in HD patients.3,26,3133 The prevalence of a current depressive disorder in HD patients is estimated at 20% to 30% if all depressive disorders are included.3

There was no correlation between time since initiation of renal replacement therapy (RRT) and BDI scores in our studies.34,35 We did not detect differences between mean BDI scores in incident and prevalent hemodialysis populations.36 Using US administrative data, we showed that hospitalization for depression in ESRD patients treated with dialysis was a late event, occurring more frequently in patients treated for more than 2 yr rather than an early characteristic of the response to RRT.25 Lopes et al. found a trend toward greater prevalence of depression, measured using subsets of Kidney Disease Quality of Life questions, in patients treated for ESRD for >1 yr.37 In a recent study, Hedayati et al.38 used the Veterans Administration database to identify 1588 male HD patients. The physician-diagnosed rate of depression was 14.7%. Over the course of 2 yr, a diagnosis of depression was associated with more hospitalizations and increased duration of hospitalization but not with overall mortality when variation in demographic and medical factors was controlled.38

Depression possibly affects medical outcomes in ESRD patients through modification of immunologic and stress responses, impact on nutritional status, and/or reduction of compliance with, or access to, prescribed dialysis and medical regimens2,3,28,34 (Figure 3). Recent studies2,3,24,39,40 have described preliminary data regarding these mechanisms in patients with and without renal disease.41,42

Immunologic Response

The “cytokine theory of depression”43 posits that proinflammatory cytokines, acting as neuromodulators, mediate the behavioral and neurochemical features of depression.4449 There are several suggested mechanisms that might underlie this effect.50,51 One suggestion is that cytokine-induced hyperactivity of the HPA axis causes interference in the negative feedback of circulating corticosteroids.52 This dysregulation may also lower the availability of tryptophan by reducing levels of its precursor, 5-hydoxy-tryptamine (5-HT), an essential component of neurocellular function. Additionally, there is evidence that inflammatory biomarkers such as C-reactive protein are dysregulated and predict outcome in general53,54 and in ESRD patients.5559 We55,60 and others5659 showed cytokine levels were elevated in HD patients, and proinflammatory cytokines were associated with mortality. In subanalyses, increased cytokines were associated with increased depressive affect.60 Stenvinkel et al.61 identified specific immunologic factors such as TNF-α and IL-6 that alter the cytokine network in uremia in ESRD patients. The chronic proinflammatory state intrinsic to ESRD is related to the higher than expected rates of cardiovascular disease and other medical causes of increased mortality in this population.55,6265

There is increasing literature to support an association between depression and risk factors for cardiovascular disease in patients without kidney disease.66 Stress levels have modulating influences on the autonomic nervous system, which can lead to coronary vessel vasoconstriction, tachyarrhythmias, and other adverse cardiac events.66 In addition, increased depressive affect has been associated with the production of various inflammatory cytokines including IL-6 and C-reactive protein in some studies.6769 Inflammation is known to play a key role in the generation and progression of atherosclerosis.66,67,70 Depression is also associated with enhanced platelet aggregation via alterations in serotonin and catecholamine pathways.66


Although we were unable to detect an association between depression and markers of malnutrition in a group of 295 primarily black patients,71 other studies have demonstrated such links.72,73 Diversity in the study samples or treatment conditions may explain these disparate findings. In an interesting but methodologically flawed study, Friend et al. showed that depression preceded the decrease in serum albumin concentration in dialysis patients, implying that depression causes malnutrition and not the reverse.74 There has also been increasing evidence for a molecular mechanism for the cachexia that occurs in CKD patients.75,76 Levels of TNF-α, a cytokine associated with cachexia, and cortisol, a stress hormone associated with depression and dysregulated carbohydrate metabolism, as well as other such mediators have also been shown to be elevated in ESRD patients treated with HD.55,77,78

Treatment Compliance

Studies have indicated a relationship between depressive affect and both laboratory and behavioral markers of poor compliance in dialysis patients.79,80 Decreased behavioral compliance with the dialysis prescription correlated with increased depressive affect in prevalent HD patients.24,40,71,72,81 Decreased compliance with HD prescription has also been associated with poor medical outcomes and increased mortality.71,79,80,82,83

Depression and Mortality

Depression has been associated with increased mortality in the general medical population.8488 Gallo et al. performed a randomized controlled trial to study the effect of a depression intervention in twenty general medicine clinics from the Northeastern United States. They found a decrease in 5-yr mortality rates in the group randomized to the depression intervention.89

A connection between depression and mortality in ESRD patients has been difficult to demonstrate. Some studies9093 and our own work94 initially indicated that depression was associated with mortality in this patient population. These studies, however, often compared means between groups of deceased and surviving patients without accounting for fundamental, potentially confounding medical and demographic factors (reviewed by Kimmel2,24). Several more recent studies had been unable to detect associations between depression and mortality in HD patients.2,24,28,71,9597 However, in a large multinational sample, ESRD patients treated with hemodialysis who were classified as depressed and those who reported frequent depressive affect had higher risk of mortality, withdrawal from therapy, and hospitalization.37 The nontraditional assessment of depression used in this study make these results difficult to interpret. Nevertheless, the results seem to indicate a robust relationship between depressive affect and medical sequelae in contemporary HD patients around the world.71 Although we were able to detect associations between perception of increased burden of illness and mortality, and between perception of a high level of perceived social support and improved survival,71 the baseline level of depressive affect proved not to be a risk factor for increased mortality in our population of almost 300 HD patients. More recently, we performed longitudinal assessments of our study population to evaluate BDI scores obtained up to six times (mean 2.9) over a period of 20 mo to 5 yr. The scores were used as time varying covariates in Cox regression models of patient mortality.35 An increased level of depressive affect over time was associated with increased mortality risk, even when analyses controlled for medical parameters.35 We concluded that models incorporating multiple assessments of depression more accurately predict outcome while still accounting for patients' medical and nutritional status. The effect of timing of assessments, baseline conditions, and averaging depressive affect over time could prove critical when outcomes are assessed. Recently, Boulware and colleagues generated similar results when they evaluated baseline and longitudinal data from the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) study, a large cohort of incident patients starting peritoneal dialysis and hemodialysis.98 Boulware et al. determined that levels of depressive affect at the beginning of the study were not associated with increased overall mortality. However, similar to our findings, using several different time-dependent analyses, the investigators demonstrated that persistently higher levels of depressive affect over time were associated with increased risk of death and cardiovascular events in both adjusted and unadjusted analyses. From the currently available evidence, it is not clear whether depression has a direct causal role in poor outcomes associated with ESRD or if depression is merely a marker of increased disease comorbidity and illness severity.

Withdrawal from Dialysis

Estimates indicate that approximately 20% of US dialysis patients voluntarily choose to discontinue ESRD therapy.24,99104 Interestingly, black patients are much less likely to withdraw from care than white patients across all ages.24,100 Age, medical complications, and failure to thrive are commonly associated with the decision to withdraw from ESRD therapy.24,100,101 A recent study found that depression was a predictor of the decision to withdraw from dialysis.105 Despite the high rate of withdrawal from dialysis, the extent to which it should be considered a suicide equivalent is unclear and controversial.24,102,104 It is known that ESRD patients have the potential to commit suicide with relative ease through noncompliance, and, in fact, an early study reported rates of suicide to be 100 to 400 times higher in dialysis patients compared with the general population.106 Another study of predominately white patients from Minnesota found suicide rates of ESRD patients to be 0.2%, approximately 15 times greater than that of the general population.101 However, true suicidal behavior and ideation might be more difficult to differentiate in this population.24,34,103,105 The early findings might have been a result of evaluating white populations at high risk in an era of relatively primitive dialytic delivery techniques. More recent studies show suicide to be less prevalent in contemporary ESRD populations,24,99 although the rate is 84% higher than in the general population.99 Alcohol dependence and hospitalization for substance abuse and mental illness were strongly associated with subsequent suicide in the ESRD population.99 This recent study shows definitively that populations that withdraw from treatment and those that actively commit suicide represent different clinical entities, highlighting that suicide is associated with alcohol and drug dependency and the presence of mental illness.99 The complex relationship between depression, suicide, and withdrawal from treatment needs further clarification.


In comparison to depression, anxiety disorders have received little clinical attention in the ESRD population. Most studies rely exclusively on self-report scales as a broad measure of anxious distress.107109 Some of our unpublished data suggest that there is poor agreement between self-report measures of anxiety and a formal anxiety diagnosis in an urban HD population. Other studies have used structured clinical interviews to provide a formal anxiety disorder diagnosis. One study found a 30% rate of anxiety disorders in HD patients using the Primary Care Evaluation of Mental Disorders (PRIME-MD) as a diagnostic tool.110 By comparison, the same PRIME-MD questionnaire was given to 2316 general medical patients, and a 19% prevalence of anxiety disorders was found.111 Our work in Brooklyn demonstrated a 27% prevalence of anxiety disorders using the Structured Clinical Interview for the DSM-IV (SCID).26 The impact of high levels of anxiety or an anxiety diagnosis on outcomes is also unclear. Anxiety's negative impact on quality of life (QOL) and disability across multiple illnesses has been demonstrated, but its specific effect in ESRD has not been studied.112 One study from Turkey found that depression but not anxiety correlated with interdialytic weight gain.110 Another Turkish study found that teaching progressive muscle relaxation over a 6-wk course reduced both state and trait anxiety and improved QOL.113

Patients with depression and anxiety, or depression and another psychiatric diagnosis, may represent a population at particular risk. Comorbid (so-called “compound”) depression has been associated with more profound physiological abnormalities and treatment resistance.34,114


Few studies have focused on the treatment of depression and anxiety disorders in ESRD patients. Treatment options including psychotherapy, cognitive behavioral therapy, and pharmacologic agents are similar to those used in the general patient population.24,115118 However, treatment of psychological disease in the ESRD population presents unique challenges. Careful consideration of dose adjustments for level of GFR and dialysis schedule must be addressed each time medical therapy is being considered.

The challenges of treating depression in ESRD patients should not serve to limit use of appropriate therapy. Depression may be undertreated in ESRD patients. Watnick et al. reported that just 16% of HD patients with depression were receiving treatment.119 Ameliorating the symptoms of depression is important because it may improve other adverse outcomes associated with ESRD, including poor nutritional status and treatment compliance. This may in turn affect survival.2,3,34,120,121

Pharmacologic options to treat depression include selective serotonin reuptake inhibitors (SSRIs), as well as the newer selective serotonin and norepinephrine reuptake inhibitors.24,34,115,122125 Other agents such as tricyclic antidepressants, monoamine oxidase inhibitors, and St. John's wort should be avoided if possible because of potential exacerbation of common adverse events in dialysis patients, including drug–drug interactions, arrhythmias, and orthostatic hypotension.24,115,122,125 Patients who receive these antidepressant medications should be closely monitored for development of a prolonged corrected QT interval.126,127 If this complication occurs, the antidepressant medication should be discontinued.

There have been limited studies evaluating the efficacy of SSRIs in ESRD patients.128131 SSRIs should be favored over other antidepressant medication options because of their relatively limited side effect profiles, as well as their favorable potential to reduce the symptoms of orthostatic hypotension, a potentially debilitating problem for patients with ESRD treated with hemodialysis.24,115,132 A strategy is to reduce the initial starting dose of SSRIs by one third.115,125,133

An important adverse event associated with SSRIs that should be considered before prescribing these agents is the potential to increase the risk of mania in bipolar disorder patients who are improperly diagnosed with depression.115,134137 Initial administration of SSRIs may also be associated with an increased risk of suicide during the initial period of administration; however, this issue remains controversial.138140 SSRIs may also exacerbate nausea and bleeding, two common uremic symptoms.115,121,141147

There have been no randomized clinical trials assessing the efficacy of psychotherapy for treating depression in this population,120,148 but there is some clinical evidence that these interventions might be effective.149 Optimal treatment of depressive disorders in ESRD patients, therefore, may involve medical treatment, psychotherapy, or their combination.

The treatment options for anxiety disorders are similar. Like antidepressants, adjustment of anxiolytic dose for level of GFR is needed when these agents are prescribed.125 Older treatment options for anxiety were limited to barbiturates and benzodiazepines. However, their unfavorable side effect profiles, particularly in patients with hepatic or renal failure, have led to the use of newer psychotropic agents including buspirone, a partial agonist of cerebral serotonin 5-HT 1A receptors.125,150154 Antidepressant agents may also have a role in therapy for anxiety, including SSRIs such as paroxetine and the newer serotonin and norepinephrine reuptake inhibitor venlafaxine.150154 In clinical practice, anxiety may coexist with depression.26 Additional studies are needed to determine the specific efficacy of these agents for treatment of anxiety in ESRD as well as general medical patients.155 Close consultation with mental health professionals is always advised before the prescription of any psychotropic agents, particularly if ESRD patients display any complicated clinical symptoms suggesting suicidal ideation or mania.115


Social support refers to a social network's provision of psychological and material resources intended to benefit an individual's ability to cope with stress.24,156158 It is often divided into three types: instrumental, informational, and emotional.157 Instrumental support involves the provision of material aid (e.g., financial assistance). Informational support refers to the provision of helpful information (e.g., guidance). Finally, emotional support involves the expression of empathy and provides opportunities for emotional expression. Another relevant concept is social integration, defined as participation in a broad range of social relationships.158 It includes a behavioral component, active engagement in a wide range of social activities or relationships, and a cognitive component, a sense of communality and identification with one's social roles.158

Social support and integration are now acknowledged as important factors in adjustment to chronic and acute illness.24,71,95,156161 For example, one study of social integration in healthy participants demonstrated that the diversity of one's social network protected against developing the common cold after exposure to the virus.159 Social support has been broadly and consistently linked to improved health outcomes in a variety of chronic illnesses in numerous studies independent of geographic settings, SES, and ethnic backgrounds.156 In fact, differences in social support between groups has been suggested to underlie differences in mortality of dialysis patients between units24,162 or among national populations,24 perhaps as a result of differences in compliance.2,28,79 Although the relationships between social support, social integration, and health are robust, the mechanisms underlying the linkages have not been clearly delineated.24,71,156,163 Suggested mediators for improved health resulting from more developed social support and integration include better access to and utilization of health care, better compliance, and better “stress buffering” through improved psychological, neuroendocrine, nutritional, or immunologic functioning.156,161,163,164

Several studies have shown an association between survival and perception of social support in ESRD patients of different ethnic backgrounds.71,95,160,161,165167 McClellan et al. showed, in a prospective study, that a QOL measure, which included social support, predicted survival of HD patients.166 Christensen et al. showed family cohesion, as a social support indicator measured by the Family Environment Scale, predicted survival in HD patients.95 The effects of medical and treatment parameters such as nutritional status, delivery and intensity of dialysis, and patient compliance were not controlled in these studies, however. McClellan and colleagues further showed patients' assessment of level of giving social support predicted improved survival in HD patients.167 The relationship of social support to other medical and psychosocial parameters, and functional status in particular, was not assessed. Most previous studies also did not include longitudinal reappraisals of psychological or compliance parameters. We showed increased perception of social support, measured by the Multidimensional Scale of Perceived Social Support, predicted survival even when variation in age, severity of comorbid illness, level of serum albumin, dialysis membrane type, and study site were controlled.71

High levels of social support have been associated with increased utilization of medical services (reviewed by Kimmel et al.71, Cohen et al.161, and Patel et al.168). Social support may affect compliance of ESRD patients treated with HD,24,71,79,157,161,168 although the findings have been variable, in part dependent on the parameters assessed in different populations. Support from family and caregivers correlated with a composite compliance measure in HD patients in an urban population (reviewed by Kimmel et al.71). Several studies have suggested that perception of social support was associated with increased compliance.71,79,160,161,169 In a study of HD patients in Utah, patients who perceived high family support had lower levels of interdialytic weight gain and better biochemical compliance measures.160 Leggat et al., in a large study performed using data from the United States Renal Data System, found patients living with someone, rather than living alone, were less likely to shorten HD treatments.83 There was, however, no association of household composition with attendance, interdialytic weight gain, or level of serum phosphate. Moreover, other studies either could not establish relationships between measures of social support from family and friends and compliance measures of HD patients, and such studies have also failed to show a correlation between greater perception of social support and compliance.71

Indices of social support correlated with level of depressive symptoms, perception of illness effects, and satisfaction with life in our studies.24,35,36,168171 One recent ESRD study found that optimism was a mediating influence between social support and depression.172 Another recent study173 highlighted the need to account for the role of individual differences in the relationship between support and depression. The investigators found that greater social support among individuals high in the personality trait of “agreeableness” was associated with a decrease in depressive symptoms over time, whereas support had little effect on depression change for individuals low in “agreeableness.” Social support may affect psychological, medical, and biochemical factors in other unknown ways to engender better health outcomes.71,156,168,169


The intimacy of a relationship with a life partner may be intense and complex. Such relationships may have positive aspects, such as associations with greater perceived social support, or negative ones, perhaps associated with hostility. Marital stability, satisfaction, and perceptions of hostility have been associated with differential health outcomes in the general population.60,174178 Unhappily married individuals report poorer health than do happily married or divorced people with similar demographic and health characteristics. Marital quality has predicted length of stay after bypass surgery for women, but not for men.179 Declines in reported marital satisfaction have been associated with subsequent poorer health evaluations. One fascinating study180 found that couples' blister wounds healed more slowly and local cytokine production (IL-6, TNF-α, and IL-1) was lower at wound sites after marital conflicts than after social support interactions. Kiecolt-Glaser and colleagues also found that hostile couples produced relatively larger increases in plasma IL-6 and TNF-α values the morning after a conflict than after a social support interaction compared with couples without conflict.180 Marital conflict may affect perceptions of illness and interfere with the ability of a patient to comply with the complex regimen entailed by RRT.

The development of a chronic illness in a couple may place strain on usual marital roles. Spouses can become caregivers and may experience depression and/or hostility. There also might be changes in the patient's ability to work, forcing a further shift in the individual's roles within the dyad. In addition, the spouse may be the object of the patients' negative emotions. Finally, sexual dysfunction can change the dynamics of the relationship.181,182 Few studies exist on spousal or family relations in ESRD patients, and almost none focus on outcomes.182190 Most studies performed within families of HD patients have assessed comparisons of members of dyads or families on psychosocial tests.

More than half of couples including a patient with ESRD had evidence of marital disruption.182 Chowanec and Binik187 showed dialysis patients and spouses had strong links between psychological distress and perceptions of marital strain. Twenty percent of spouses of dialysis patients had “significant depressive symptoms” in a Canadian study.187 Spouses' level of distress was not correlated with level of patient function or depression. Social support received from the patient and social and financial stressors experienced by the spouse accounted for a large proportion of spouse perceptions. Another study suggested women caregivers of ESRD patients perceived good QOL and no evidence of burden, but these two parameters were correlated.191 Lowry and Atcherson found lower levels of anxiety, depression, and marital problems in a group of carefully screened home dialysis spouse partners in Iowa than others reported,192 although the reasons underlying differences between this study and others are unclear and may relate to selection bias. Berkman, Katz, and Weissman found that, although there was a high prevalence of sexual dysfunction in home dialysis patients, marital and social adjustment scores were comparable to those of the general population.193 Moguilner, Bauman, and De-Nour found a correlation between patient and spouse BDI scores.194 We found that spousal levels of depression correlated with extent of HD patients' depressive affect, and the greater the level of social support the spouse reported, the less strain they identified in the marriage.186

Marital conflict has been associated with endocrinological and immunologic changes in women, but not men, in subjects without renal disease.195 A study of 68 Israeli prevalent HD patients and their spouses revealed high levels of distress compared with normative groups and high correlations between distress scores of spouses.184 Married female patients had less anxiety than married male patients. However, male spouses had higher levels of distress than female spouses. Giving and receipt of social support within a marriage may also change during the ESRD life cycle. In Canadian couples including a patient with ESRD, women patients felt that family support declined after the onset of illness, but no change in perceived support was noted by male ESRD patients.185

We studied the relationships between medical factors, neuro-endocrinological and immunologic factors, and outcome in a subset of 174 male and female HD patients functioning in dyadic relationships.60 Dyadic satisfaction scores were comparable to those of normative populations, although the women had more negative assessments of their marriages than the men. Interestingly, a different pattern of interactions for men and women was noted. For women, higher levels of depressive affect and increased perception of the burden of illness correlated with increased severity of illness, and greater circulating levels of IL-1 and β-endorphin. Marital satisfaction and conflict scores correlated with medical risk factors, psychosocial parameters, and circulating IL-1 and β-endorphin levels, but again, only in the women in the study. Finally, neurologic, immunologic, and marital indices predicted differential survival in the study group, but the dyadic indices were associated with outcome only in the women. It appears that strong negative emotion, such as perception of dyadic conflict, may be a particularly important stressor in women HD patients, activating physiological and neuroendocrinological pathways.

To expand our understanding of familial support beyond the dyad, we surveyed a prevalent population of almost 500 black HD patients. We defined family composition in terms of size and structure, with a simple household defined as one in which the patient lived alone or only with a spouse or partner, and a complex household as being characterized by patients living with various combinations of relatives and nonrelatives, often in multigenerational groups. After an approximately 3-yr observation period, Cox regression analyses revealed only age and household structure emerged as associated with survival. Patients who lived in complex households had significantly increased risk of mortality, but once again the findings were driven solely by the effects in the group of women.196

These data suggest that black women with ESRD treated with HD functioning in complex households or in difficult marital situations may be at particular risk. This risk may relate to their gender roles or expectations regarding family duties in people with limited economic resources and/or diminished social support in such settings.24,168 Because previous studies have suggested stress and inflammatory responses, and depressive symptoms are greater in women than men,195 perhaps these factors mediate outcomes for women more than men with ESRD.


Given the amount of time most HD patients spend at their dialysis site, it is reasonable to speculate that their relationships within the dialysis unit play an important role in determining adjustment and outcomes, but there are few data available on these issues. One study showed that unmeasured dialysis unit characteristics predicted survival better than the characteristics predicted by differences in case-mix.162 We have demonstrated that dialysis unit staff exhibit sustained characteristics over time in spite of the high turnover of individual employees, suggesting that a particular “culture” typifies each dialysis unit.197 To understand the relationship between patients' feelings about the dialysis staff and outcomes, we surveyed HD patients regarding their level of satisfaction with their nurses, technicians, and nephrologists. Patients' increased satisfaction with staff and their perception that staff cared about them correlated with better dietary compliance. Interestingly, patients' increased satisfaction with physicians, but not nursing or technical personnel, correlated with improved attendance and greater total time compliance with the dialysis prescription.198

The impact of social work groups on the unit or organized social activities are unknown and should also be explored further. It is clear that the culture of the dialysis unit and the connectedness the patient feels to the dialysis staff are important factors and may mediate differential outcomes in dialysis programs with similar patient populations. Specifically, the role of dialysis providers, particularly physicians, may impact HD patients' compliance.


SES has been shown to have a significant impact on the incidence and treatment of ESRD.199,200 Norris and Agodoa201 have developed a model highlighting how socioeconomic factors such as low income, poor education, residence in low-income areas, and poor access to health care are strong predictors of the development of ESRD. Not enough study has been given to the notion that differential quality of physician care may characterize programs in different neighborhoods. The relationships between race, SES, and ESRD outcomes are quite complex and may result from their synergistic combination.24,202 Few studies have assessed the relationship between survival and SES in the ESRD population. Dialysis Outcomes and Practice Pattern Study (DOPPS) data have suggested that higher SES was associated with improved survival, regardless of race.203 A startling finding is the differential survival of black patients compared with whites in the United States ESRD program100,199,202 because in almost all cases higher SES is associated with improved survival in chronic illnesses.204 Rodriguez et al. recently found higher mortality rates among white and black dialysis patients living in areas with zip codes that were predominately composed of blacks. They also found lower rates of transplantation in communities that were made up of a majority of blacks.205 In a preliminary investigation,206 we found a paradoxical association in which minority patients living in areas with higher inequality of distribution of income in the United States had poorer outcomes. These findings are tentative and the underlying reasons are unclear, but they may reflect different allocation of resources between groups in the same residential area, differential access to health care and services, discordance between viewpoints of physicians and patients, or the effects of discrimination.207 Another factor to consider is the interplay of the ethnicities of the patient and the physician. There is evidence that there is decreased trust on behalf of patients when they are of a different ethnicity than the physician.208 The influence of residential factors on ESRD patient outcomes requires further study.

According to a 2001 survey, 55% of Hispanic and 45% of black populations were uninsured or received publicly funded health care, compared with 22% of the white population.209 Minority populations in the ESRD program in the United States may be subject to the consequences of inequitable distribution of resources.

Culture may also play an important role in forming attitudes to health care, including how illness is perceived and what form treatment should take.210 For instance, many minority and immigrant populations may have attitudes toward illness and health care that put them in intellectual conflict with the views of their physicians.79,210,211 These attitudes may be based on spiritual and religious beliefs, and there may even be a general skepticism toward Western medicine. Cultural beliefs may also affect lifestyle factors, such as diet, exercise, and body image, contributing to differential rates of obesity, hypertension, and diabetes among racial and ethnic minorities.200,201,212 The relationship between psychosocial functioning, culture, and SES may explain their connection to health outcomes in the ESRD population.212


Patients with ESRD treated with HD deal with the multiple stressors of their illness and attempt to make their way through life in the context of their intimate relationships, families, social networks, treatment programs, and cultures. They must cope with the demands of their occupations, the changes in their life roles, and the challenges and opportunities that life exposes them to while balancing the restrictions that life on HD entails. As opposed to the mostly invariant biological factors, psychosocial factors are a potential target for successful intervention.2,3,24,28,120,149,213,214

Over the past decades, a tremendous amount has been learned about the physiological and psychological reactions of dialysis patients. Despite this growing body of research, there are many essential elements that are still unknown. The impact that mental health treatment has on outcomes is still unclear. Some evidence2,3,28,120,123,124,149 suggests that depression can be successfully treated in ESRD populations, but the potentially greater impact of improved psychological functioning on burden of care, intimate relationships, compliance, QOL, and mortality is largely unexplored. The results of interventions in earlier stages of renal disease are also unknown, as well as the role of interventions in children.2,120 The role that quotidian dialysis might have upon psychosocial variables has also not been studied in a rigorous manner.215

Although this field of research is still in its infancy, the fields of stress medicine and psychoneuroimmunology are beginning to make connections between emotions and their biological mediators. In many ways ESRD is an excellent research paradigm for the study of the intertwined effects of medical and psychosocial factors in chronic disease, as patients are available for assessment on a consistent basis, standard biochemical markers that are related to outcome are easily measurable and obtainable, and the patients are in great need of supportive services. Nephrologists, psychosocial researchers, and ESRD patients can collaboratively contribute to understanding the impact of stress and the body's attempts to regain allostasis by helping make the connections between psychosocial and biological variables.



Figure 1:
Patient characteristics and stressors that may affect perceived stress in HD patients.
Figure 2:
Psychosocial parameters: Spheres of influence.
Figure 3:
Potential mechanism of vicious cycle between depression and ESRD.
Table 1:
Selected psychosocial parameters in chronic disease

Dr. Cohen is supported by a research fellowship from the National Kidney Foundation

Published online ahead of print. Publication date available at


1. Levy NB: Psychonephrology 2: Psychological Problems in Kidney Failure and Their Treatment, New York, Plenum Medical Book Company, 1983
2. Kimmel PL: Depression in patients with chronic renal disease: What we know and what we need to know. Psychosom Res 53 : 951 –956, 2002
3. Cukor D, Peterson RA, Cohen SD, Kimmel PL: Depression in end-stage renal disease hemodialysis patients. Nat Clin Pract Nephrol 2 : 678 –687, 2006
4. Everson-Rose SA, Lewis TT: Psychosocial factors and cardiovascular disease. Annu Rev Public Health 26 : 469 –500, 2005
5. Vig RS, Forsythe P, Vliagoftis H: The role of stress in asthma: Insight from studies on the effect of acute and chronic stressors in models of airway inflammation. Ann N Y Acad Sci 1088 : 65 –77, 2006
    6. Backman CL: Arthritis and pain. Psychosocial aspects in the management of arthritis pain. Arthritis Res Ther 8 : 221 –233, 2006
      7. McElhone K, Abbott J, Teh LS: A review of health related quality of life in systemic lupus erythematosus. Lupus 15 : 633 –643, 2006
        8. Dunn J, Lynch B, Rinaldis M, Pakenham K, McPherson L, Owen N, Leggett B, Newman B, Aitken J: Dimensions of quality of life and psychosocial variables most salient to colorectal cancer patients. Psychooncology 15 : 20 –30, 2006
          9. Rosenberger PH, Jokl P, Ickovics J: Psychosocial factors and surgical outcomes: An evidence-based literature review. J Am Acad Orthop Surg 14 : 397 –405, 2006
            10. Hagler AS, Norman GJ, Zabinski MF, Sallis JF, Calfas KJ, Patrick K: Psychosocial correlates of dietary intake among overweight and obese men. Am J Health Behav 31 : 3 –12, 2007
              11. Yan LL, Liu K, Matthews KA, Daviglus ML, Ferguson TF, Kiefe CI: Psychosocial factors and risk of hypertension: The Coronary Artery Risk Development in Young Adults (CARDIA) study. JAMA 22 : 2138 –2148, 2003
                12. Astin JA, Shapiro SL, Eisenberg DM, Forys KL: Mind-body medicine: state of the science, implications for practice. J Am Board Fam Pract 16 : 131 –147, 2003
                13. Selye H: The stress of life, New York, McGraw-Hill, 1956
                14. McEwen B: Protecting and damaging effects of mediators of stress: Elaborating and testing the concepts of allostasis and allostatic load. Ann N Y Acad Sci 896 : 30 –47, 1999
                15. McEwen B: Protective and damaging effects of stress mediators. N Engl J Med 338 : 171 –179, 1998
                16. Sterling P, Eyer J Allostasis: A new paradigm to explain arousal pathology. In: Handbook of Life Stress, Cognition and Health, 1st Ed., edited by Fisher S, Reason J, London, England, John Wiley, 1988 , pp 629 –649
                17. McEwen BS, Stellar E: Stress and the individual. Mechanisms leading to disease. Arch Int Med 153 : 2093 –2101, 1993
                18. McEwen BS: Sex, stress and the hippocampus: Allostasis, allostatic load and the aging process. Neurobiol Aging 23 : 921 –939, 2002
                19. Rabkin R, Kitaji J: Renal metabolism of peptide hormones. Miner Electrolyte Metab 9 : 212 –226, 1983
                20. Katz AI, Emmanouel DS: Metabolism of polypeptide hormones by the normal kidney and uremia. Nephron 22 : 69 –80, 1978
                  21. Stenvinkel P, Pecoits-Filho R, Lindholm B: Leptin, ghrelin, and proinflammatory cytokines: Compounds with nutritional impact in chronic kidney disease? Adv Ren Replace Ther 10 : 332 –345, 2003
                  22. Anderson NB, Armstead CA: Toward understanding the association of socioeconomic status and health: A new challenge for the biopsychosocial approach. Psychosom Med 57 : 213 –215, 1995
                  23. Engel GL: The need for a new medical model: A challenge for biomedicine. Science 196 : 129 –136, 1977
                  24. Kimmel PL: Psychosocial factors in dialysis patients. Kidney Int 59 : 1599 –1613, 2001
                  25. Kimmel PL, Thamer M, Richard C, Ray NF: Psychiatric illness in patients with end-stage renal disease. Am J Med 105 : 214 –221, 1998
                  26. Cukor D, Coplan J, Brown C, Friedman S, Cromwell-Smith A, Peterson RA, Kimmel PL: Depression and anxiety in urban hemodialysis patients, Clin J Am Soc Nephrol 2 : 484 –490, 2007
                  27. Hegde A, Veis JH, Seidman A, Khan S, Moore J Jr: High prevalence of alcoholism in dialysis patients. Am J Kidney Dis 35 : 1039 –1043, 2000
                  28. Kimmel PL, Peterson RA: Depression in end-stage renal disease patients treated with hemodialysis: Tools, correlates, outcomes, and needs. Sem Dialysis 8 : 91 –97, 2005
                  29. Smith MD, Hong BA, Robson AM: Diagnosis of depression in patients with end-stage renal disease. Comparative analysis. Am J Med 9 : 160 –166, 1985
                  30. Beck A, Steer R: Manual for the Beck Depression Inventory, San Antonio, TX, The Psychological Corporation, 1987
                  31. Craven JL, Rodin GM, Littlefield C: The Beck Depression Inventory as a screening device for major depression in renal dialysis patients. Int J Psych Med 18 : 365 –374, 1988
                  32. Watnick S, Wang PL, Demadura T, Ganzini L: Validation of two depression screening tools in dialysis patients. Am J Kidney Dis 46 : 919 –924, 2005
                    33. Hedayati SS, Bosworth HB, Kuchibhatla M, Kimmel PL, Szczech LA: The predictive value of self-reported questionnaires compared to physician diagnosis of depression in end stage renal disease patients receiving chronic hemodialysis. Kidney Int 69 : 1662 –1668, 2006
                    34. Kimmel PL, Weihs KL, Peterson RA: Survival in hemodialysis patients: The role of depression. J Am Soc Nephrol 4 : 12 –27, 1993
                    35. Kimmel PL, Peterson RA, Weihs KL, Simmens SJ, Alleyne S, Cruz I, Veis JH: Multiple measurements of depression predict mortality in a longitudinal study of chronic hemodialysis patients. Kidney Int 57 : 2093 –2098, 2000
                    36. Kimmel PL, Peterson RA, Weihs KL, Simmens SJ, Boyle DH, Umana WO, Kovac JA, Alleyne S, Cruz I, Veis JH: Psychological functioning, quality of life, and behavioral compliance in patients beginning hemodialysis. J Am Soc Nephrol 7 : 2152 –2159, 1996
                    37. Lopes AA, Bragg J, Young E, Goodkin D, Mapes D: Depression as a predictor of mortality and hospitalization among hemodialysis patients in the United States and Europe. Kidney Int 62 : 199 –207, 2002
                    38. Hedayati SS, Grambow SC, Szczech LA, Stechuchak KM, Allen AS, Bosworth HB: Physician-diagnosed depression as a correlate of hospitalizations in patients receiving long-term hemodialysis. Am J Kidney Dis 46 : 642 –649, 2005
                    39. Unruh ML, Weisbord SD, Kimmel PL: Health-related quality of life in nephrology research and clinical practice. Semin Dialysis 18 : 82 –90, 2005
                    40. Kimmel PL, Patel SS, Peterson RA: Depression in African-American patients with kidney disease. J Natl Med Assoc 94 : 92S –103S, 2002
                    41. Ng TP, Niti M, Tan WC, Cao Z, Ong KC, Eng P: Depressive symptoms and chronic obstructive pulmonary disease: Effect on mortality, hospital readmission, symptom burden, functional status, and quality of life. Arch Intern Med 167 : 60 –67, 2007
                    42. Sacco WP, Yanover T: Diabetes and depression: The role of social support and medical symptoms. J Behav Med 29 : 523 –531, 2006
                    43. Barden N: Implication of the hypothalamic-pituitary-adrenal axis in the physiopathology of depression. J Psychiatry Neurosci 29 : 185 –193, 2004
                    44. Segerstrom SC, Miller GE: Psychological stress and the human immune system: A meta-analytic study of 30 years of inquiry. Psych Bull 130 : 601 –630, 2004
                    45. Dickerson SS, Kemeny ME: Acute stressors and cortisol responses: A theoretical integration and synthesis of laboratory research. Psych Bull 130 : 355 –391, 2004
                      46. Miller GE, Cohen S, Ritchey AK: Chronic psychological stress and the regulation of pro-inflammatory cytokines: A glucocorticoid-resistance model. Health Psychol 21 : 531 –541, 2002
                        47. Kiecolt-Glaser JK, McGuire L, Robles TF, Glaser R: Psychoneuroimmunology: Psychological influences on immune function and health. J Con Clin Psych 70 : 537 –547, 2002
                          48. Strouse TB: The relationship between cytokines and pain/depression: A review and current status. Curr Pain Headache Rep 11 : 98 –103, 2007
                            49. Kuo HK, Yen CJ, Chang CH, Kuo CK, Chen JH, Sorond F: Relation of C-reactive protein to stroke, cognitive disorders, and depression in the general population: systematic review and meta-analysis. Lancet Neurol 4 : 371 –380, 2005
                            50. Miller GE, Freedland KE, Carney RM, Stetler CA, Banks WA: Cynical hostility, depressive symptoms, and the expression of inflammatory risk markers for coronary heart disease. J Behav Med 26 : 501 –515, 2003
                            51. Elenkov IJ, Chrousos GP: Stress hormones, proinflammatory and antiinflammatory cytokines, and autoimmunity. Ann N Y Acad Sc 966 : 290 –303, 2002
                            52. Yirmiya N, Weidenfeld J, Pollak Y, Morag M, Morag A, Avitsur R, Barak O, Reichenberg A, Cohen E, Shavit Y, Ovadia H: Cytokines, depression due to a general medical condition and antidepressant drugs. In: Cytokines, Stress, and Depression, edited by Dantzer R, Wollman EE, Yirmiya R, New York, Kluwer Academic/Plenum Publishers, 1999 , pp 283 –316
                            53. Schiepers O, Wichers M, Maes M: Cytokines and major depression. Prog Neuro-Psychopharmacol Biol Psychiatry 29 : 201 –217, 2005
                            54. Brydon L, Steptoe A: Stress-induced increases in interleukin-6 and fibrinogen predict ambulatory blood pressure at 3-year follow-up. J Hypertens 23 : 1001 –1007, 2005
                            55. Kimmel PL, Phillips TM, Simmens SJ, Peterson RA, Weihs KL, Alleyne S, Cruz I, Yanovski JA, Veis JH: Immunologic function and survival in hemodialysis patients. Kidney Int 54 : 236 –244, 1998
                            56. Owen WF, Lowrie EG: C-reactive protein as an outcome predictor for maintenance hemodialysis patients. Kid Int 54 : 627 –636, 1998
                            57. Zoccali C, Benedetto FA, Mallamaci F: Inflammation is associated with carotid atherosclerosis in dialysis patients. J Hypertension 18 : 1207 –1213, 2000
                              58. Stenvinkel P, Barany P, Heimburger O: Mortality, malnutrition, and atherosclerosis in ESRD: What is the role of interleukin-6? Kidney Int Suppl 80 : 103 –108, 2002
                                59. Stenvinkel P, Lindholm B, Heimburger M: Elevated serum levels of soluble adhesion molecules predict death in pre-dialysis patients: Association with malnutrition, inflammation, and cardiovascular disease. Nephrol Dial Transplant 15 : 1624 –1630, 2000
                                60. Kimmel PL, Peterson RA, Weihs KL, Shidler NR, Simmens SJ, Alleyne S, Cruz I, Yanovski JA, Veis JH, Phillips TM: Marital conflict, gender and survival in urban hemodialysis patients. J Am Soc Nephrol 11 : 1518 –1525, 2000
                                61. Stenvinkel P, Ketteler M, Johnson R, Lindholm B, Pecoits-Filho R, Riella M, Cederholm T, Girndt M: Interleukin-10, IL-6, and TNF-alpha: Central factors in the altered cytokine network of uremia-the good, bad, and the ugly. Kidney Int 67 : 1216 –1233, 2005
                                62. Girndt M, Ulrich C, Kaul H, Sester U, Sester M, Kohler H: Uremia-associated immune defect: The IL-10-CRP axis. Kidney Int 84 : S76 –S79, 2003
                                63. Stenvinkel P, Alvestrand A: Inflammation in end-stage renal disease: Sources, consequences, and therapy. Sem Dialysis 15 : 329 –337, 2002
                                  64. Qureshi AR, Alvestrand A, Divino-Filho JC: Inflammation, malnutrition, and cardiac disease as predictors of mortality in hemodialysis patients. J Am Soc Nephrol 13 : S28 –S36, 2002
                                    65. Stenvinkel P: Inflammatory and atherosclerotic interactions in the depleted uremic patient. Blood Purif 19 : 53 –61, 2001
                                    66. Ross R. Atherosclerosis: An inflammatory disease: N Engl J Med 340 : 115 –126, 1999
                                    67. Ranjit N, Roux-Diez AV, Shea S, Cushman M, Seeman T, Jackson SA, Ni H: Psychosocial factors and inflammation in the Multi-Ethnic Study of Atherosclerosis. Arch Intern Med 167 : 174 –181, 2007
                                    68. Penninx BW, Kritchevsky SB, Yaffe K, Newman AB, Simonsick EM, Rubin S, Ferrucci L, Harris T, Pahor M: Inflammatory markers and depressed mood in older persons: Results from the Health, Aging and Body Composition Study. Biol Psychiatry 54 : 566 –572, 2003
                                      69. Tiemeier H, Hofman A, van Tuijl HR, Kiliaan AJ, Meijer J, Breteler MM: Inflammatory proteins and depression in the elderly. Epidemiology 14 : 103 –107, 2003
                                      70. Musselman DL, Evans DL, Nemeroff CB: The relationship of depression to cardiovascular disease: Epidemiology, biology, and treatment. Arch Gen Psychiatry 55 : 580 –592, 1998
                                      71. Kimmel PL, Peterson RA, Weihs KL, Simmens SJ, Alleyne S, Cruz I, Veis JH: Psychosocial factors, behavioral compliance and survival in urban hemodialysis patients. Kidney Int 54 : 245 –254, 1998
                                      72. Koo JR, Yoon JW, Kim SG, Lee YK, Oh KH, Kim GH, Kim HJ, Chae DW, Noh JW, Lee SK, Son BK: Association of depression with malnutrition in chronic hemodialysis patients. Am J Kidney Dis 41 : 1037 –1042, 2003
                                      73. Vazquez I, Valderrabano F, Jofre R, Fort J, Lopez-Gomez JM, Moreno F, Sanz-Guajardo D; Spanish Cooperative Renal Patients Quality of Life Study Group: Psychosocial factors and quality of life in young hemodialysis patients with low comorbidity. J Nephrol 16 : 886 –894, 2003
                                      74. Friend R, Hatchett L, Wadhwa NK, Suh H: Serum albumin and depression in end-stage renal disease. Adv Peritoneal Dial 13 : 155 –157, 1997
                                      75. Cheung W, Yu PX, Little BM, Cone RD, Marks DL, Mak RH: Role of leptin and melanocortin signaling in uremia-associated cachexia. J Clin Invest 115 : 1659 –1665, 2005
                                      76. Mak RH, Cheung W, Cone RD, Marks DL: Orexigenic and anorexigenic mechanisms in the control of nutrition in chronic kidney disease. Pediatr Nephrol 20 : 427 –431, 2005
                                      77. Mak RH, Cheung W, Cone RD, Marks DL: Leptin and inflammation-associated cachexia in chronic kidney disease. Kidney Int 69 : 794 –797, 2006
                                      78. Himmelfarb J, Holbrook D, McMonagle E, Robinson R, Nye L, Spratt D: Kt/V, nutritional parameters, serum cortisol, and insulin growth factor-1 levels and patient outcome in hemodialysis. Am J Kidney Dis 24 : 473 –479, 1994
                                      79. Kaveh K, Kimmel PL: Compliance in hemodialysis patients: Multidimensional measures in search of a gold standard. Am J Kidney Dis 37 : 244 –266, 2001
                                      80. Leggat JE Jr: Adherence with dialysis: A focus on mortality risk. Semin Dial 18 : 137 –141, 2005
                                      81. DiMatteo MR, Lepper HS, Croghan TW: Depression is a risk factor for noncompliance with medical treatment: Meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 160 : 2101 –2107, 2000
                                      82. Unruh ML, Evans IV, Fink NE, Powe NR, Meyer KB; Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) Study: Skipped treatments, markers of nutritional nonadherence, and survival among incident hemodialysis patients. Am J Kidney Dis 46 : 1107 –1116, 2005
                                      83. Leggat JE Jr, Orzol SM, Hulbert-Shearon TE, Golper TA, Jones CA, Held PJ, Port FK: Noncompliance in hemodialysis: Predictors and survival analysis. Am J Kidney Dis 32 : 139 –145, 1998
                                      84. Schulz R, Drayer RA, Rollman BL: Depression as a risk factor for non-suicide mortality in the elderly. Biol Psychiatry 52 : 205 –225, 2002
                                      85. Gallo JJ, Bogner HR, Morales KH, Post EP, Ten Have T, Bruce ML: Depression, cardiovascular disease, diabetes, and two-year mortality among older, primary-care patients. Am J Geriatr Psychiatry 13 : 748 –755, 2005
                                        86. Bruce ML, Leaf PJ: Psychiatric disorders and 15-month mortality in a community sample of older adults: Am J Public Health 79 : 727 –730, 1989
                                          87. Bruce ML, Leaf PJ, Rozal GP, Florio L, Hoff RA: Psychiatric status and 9-year mortality data in the New Haven Epidemiologic Catchment Area Study. Am J Psychiatry 151 : 716 –721, 1994
                                            88. Penninx BW, Geerlings SW, Deeg DJ, van Eijk JT, van Tilburg W, Beekman AT: Minor and major depression and the risk of death in older persons. Arch Gen Psychiatry 56 : 889 –895, 1999
                                            89. Gallo JJ, Bogner HR, Morales KH, Post EP, Lin JY, Bruce ML: The effect of a primary care practice-based depression intervention on mortality in older adults: A randomized trial. Ann Intern Med 146 : 689 –698, 2007
                                            90. Ziarnik JP, Freeman CW, Sherrard DJ, Calsyn DA: Psychological correlates of survival on renal dialysis. J Nerv Ment Dis 164 : 210 –213, 1977
                                            91. Wai L, Burton H, Richmond J, Lindsay RM: Influence of psychosocial factors on survival of home dialysis patients. Lancet 2 : 1155 –1156, 1981
                                              92. Burton HJ, Kline SA, Lindsay RM, Heidenheim AP: The relationship of depression to survival in chronic renal failure. Psychosom Med 48 : 261 –269, 1986
                                                93. Shulman R, Price JD, Spinelli J: Biopsychosocial aspects of long-term survival on end-stage renal failure therapy. Psychol Med 19 : 945 –954, 1989
                                                94. Peterson RA, Kimmel PL, Sacks CR, Mesquita ML, Simmens SJ, Reiss D: Depression, perception of illness and mortality in patients with end-stage renal disease. Int J Psych Med 21 : 343 –354, 1991
                                                95. Christensen AJ, Wiebe JS, Smith TW, Turner CW: Predictors of survival among hemodialysis patients: Effect of perceived family support. Health Psychol 13 : 521 –525, 1994
                                                96. Devins GM, Mann J, Mandin H, Paul LC, Hons RB, Burgess ED, Taub K, Schorr S, Letourneau PK, Buckle S: Psychosocial predictors of survival in ESRD. J Nerv Ment Dis 178 : 127 –133, 1990
                                                  97. Troidle L, Watnick S, Wuerth DB, Gorban-Brennan N, Kliger AS, Finkelstein FO: Depression and its association with peritonitis in long-term peritoneal dialysis patients. Am J Kidney Dis 42 : 350 –354, 2003
                                                  98. Boulware LE, Liu Y, Fink NE, Coresh J, Ford DE, Klag MJ, Powe NR: The temporal relation between depression symptoms, cardiovascular disease events and mortality in ESRD: Contribution of reverse causality. Clin J Am Soc Nephrol 1 : 496 –504, 2006
                                                  99. Kurella M, Kimmel PL, Young BS, Chertow GM: Suicide in the United States end-stage renal disease program. J Am Soc Nephrol 16 : 774 –781, 2005
                                                  100. US Renal Data System, USRDS 2004 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, Bethesda, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2004
                                                  101. Neu S, Kjellstrand CM: Stopping long-term dialysis: An empirical study of withdrawal of life-supporting treatment. N Engl J Med 314 : 14 –20, 1986
                                                  102. Cohen LM, Germain MJ: The psychiatric landscape of withdrawal. Semin Dialysis 18 : 147 –153, 2005
                                                  103. Cohen LM, Germain MJ, Poppel DM: Practical considerations in dialysis withdrawal: “To have that option is a blessing.” JAMA 289 : 2113 –2119, 2003
                                                  104. Murtagh F, Cohen LM, Germain M: Dialysis discontinuation: Quo vadis? Adv Chron Kidney Dis 14 : 379 –401, 2007
                                                  105. McDade-Montez EA, Christensen AJ, Cvengros JA, Lawton WJ: The role of depression symptoms in dialysis withdrawal. Health Psychol 25 : 198 –204, 2006
                                                  106. Abram HS: Survival by machine: the psychological stress of chronic hemodialysis. Psychiatry Med 1 : 37 –51, 1970
                                                  107. Martin CR, Tweed AE, Metcalfe MS: A psychometric evaluation of the Hospital Anxiety and Depression Scale in patients diagnosed with end-stage renal disease. Br J Clin Psych 43 : 51 –64, 2004
                                                  108. Martin CR, Thompson DR: Utility of the Hospital Anxiety and Depression Scale in patients with end-stage renal disease on continuous ambulatory peritoneal dialysis. Psych Health Med 4 : 369 –376, 1999
                                                    109. Jadoulle V, Hoyois P, Jadoul M: Anxiety and depression in chronic hemodialysis: Some somatopsychic determinants. Clin Nephrol 63 : 113 –118, 2005
                                                    110. Taskapan H, Ates F, Kaya B, Emul M, Kaya M, Taskapan C, Sahin I: Psychiatric disorders and large interdialytic weight gain in patients on chronic haemodialysis. Nephrology 10 : 15 –20, 2005
                                                    111. Ansseau M, Dierick M, Buntinkx F, Cnockaert P, De Smedt J, Van Den Haute M, Vander Mijnsbrugge D: High prevalence of mental disorders in primary care. J Affect Disord 78 : 49 –55, 2004
                                                    112. Sareen J, Jacobi F, Cox BJ, Belik SL, Clara I, Stein MB: Disability and poor quality of life associated with comorbid anxiety disorders and physical conditions. Arch Intern Med 166 : 2109 –2116, 2006
                                                    113. Yildirim YK, Fadiloglu C: The effect of progressive muscle relaxation training on anxiety levels and quality of life in dialysis patients. EDTNA ERCA J 32 : 86 –88, 2006
                                                    114. Pollack MH: Comorbid anxiety and depression. J Clin Psychiatry 8 : 22 –29, 2005
                                                    115. Cohen SD, Norris L, Acquaviva K, Peterson RA, Kimmel PL: Screening, diagnosis, and treatment of depression in patients with end-stage renal disease. Clin J Am Soc Nephrol 2 : 1332 –1342, 2007
                                                    116. Snow V, Lascher S, Mottur-Pilson C: Pharmacologic treatment of acute major depression and dysthymia. American College of Physicians–American Society of Internal Medicine. Ann Intern Med 132 : 738 –742, 2000
                                                      117. Whooley MA, Simon GE: Managing depression in medical outpatients. N Engl J Med 343 : 1942 –1950, 2000
                                                        118. Mann JJ: Drug therapy: The medical management of depression. N Engl J Med 353 : 1819 –1834, 2005
                                                        119. Watnick S, Kirwin P, Mahnensmith R, Concato J: The prevalence and treatment of depression among patients starting dialysis. Am J Kidney Dis 41 : 105 –110, 2003
                                                        120. Kimmel PL, Peterson RA: Depression in patients with end-stage renal disease treated with dialysis: Has the time to treat arrived? Clin J Am Soc Nephrol 1 : 349 –352, 2006
                                                        121. Cohen SD, Kimmel PL: Nutritional status, psychosocial issues, and survival in hemodialysis patients. In: Nutrition and Kidney Disease: A New Era, edited by Suzuki H, Kimmel PL, Basel, Switzerland, Karger, 2007 , pp 1 –17
                                                        122. Cohen LM, Tessier EG, Germain MJ, Levy NB: Update on psychotropic medication use in renal disease. Psychosomatics 45 : 34 –48, 2004
                                                        123. Finkelstein FO, Finkelstein SH: Depression in chronic dialysis patients: Assessment and treatment. Nephrol Dial Transplant 15 : 1911 –1913, 2000
                                                        124. Finkelstein FO, Watnick S, Finkelstein SH, Wuerth D: The treatment of depression in patients maintained on dialysis. J Psychosom Res 53 : 957 –960, 2002
                                                        125. Cohen SD, Perkins V, Kimmel PL: Psychosocial issues in ESRD patients. In: Handbook of Dialysis, 4th Ed., edited by Daugirdas J, Ing T, Boston, Little Brown, 2007 , pp 455 –461
                                                        126. Novotny T, Florianova A, Ceskova E, Weislamplova M, Palensky V, Tomanova J, Sisakova M, Toman O, Spinar J: Monitoring of QT interval in patients treated with psychotropic drugs. Int J Cardiol 117 : 329 –332, 2007
                                                        127. Reilly JG, Ayis SA, Ferrier IN, Jones SJ, Thomas SH: QTc interval abnormalities and psychotropic drug therapy in psychiatric patients. Lancet 355 : 1048 –1052, 2000
                                                        128. Blumenfield M, Levy NB, Spinowitz B, Charytan C, Beasley CM Jr, Dubey AK, Solomon RJ, Todd R, Goodman A, Bergstrom RF: Fluoxetine in depressed patients on dialysis. Int J Psychiatry Med 27 : 71 –80, 1997
                                                        129. Levy NB, Blumenfield M, Beasley CM Jr, Dubey AK, Solomon RJ, Todd R, Goodman A, Bergstrom RR: Fluoxetine in depressed patients with renal failure and in depressed patients with normal renal function. Gen Hosp Psychiatry 18 : 8 –13, 1996
                                                          130. Wuerth D, Finkelstein SH, Kliger AS, Finkelstein FO: Chronic peritoneal dialysis patients diagnosed with clinical depression: Results of pharmacologic therapy. Sem Dialysis 16 : 424 –427, 2003
                                                            131. Wuerth D, Finkelstein SH, Ciarcia J, Peterson R, Kliger AS, Finkelstein FO: Identification and treatment of depression in a cohort of patients maintained on chronic peritoneal dialysis. Am J Kidney Dis 37 : 1011 –1017, 2001
                                                            132. Dheenan S, Venkatesan J, Grubb BP, Henrich WL: Effect of sertraline hydrochloride on dialysis hypotension. Am J Kidney Dis 31 : 624 –630, 1998
                                                            133. Wyszynski A, Wyszynski B: Manual of psychiatric care for the medically ill. Washington, DC, American Psychiatric Press, 2005
                                                            134. Ghaemi SN, Hsu DJ, Soldani F, Goodwin FK: Antidepressants in bipolar disorder: The case for caution. Bipolar Disord 5 : 421 –433, 2003
                                                            135. Goldberg JF, Truman CJ: Antidepressant-induced mania: An overview of current controversies. Bipolar Disord 5 : 407 –420, 2003
                                                              136. Ghaemi SN, Rosenquist KJ, Ko JY, Baldassano CF, Kontos NJ, Baldessarini RJ: Antidepressant treatment in bipolar versus unipolar depression. Am J Psychiatry 161 : 163 –165, 2004
                                                                137. Ghaemi SN, Boiman EE, Goodwin FK: Diagnosing bipolar disorder and the effect of antidepressants: A naturalistic study: J Clin Psychiatry 61 : 804 –808, 2000
                                                                138. Healy D: Lines of evidence on the risks of suicide with selective serotonin reuptake inhibitors. Psychother Psychosom 72 : 71 –79, 2003
                                                                139. Isacsson G, Holmgren P, Ahlner J: Selective serotonin reuptake inhibitor antidepressants and the risk of suicide: A controlled forensic database study of 14,857 suicides. Acta Psychiatr Scand 111 : 286 –290, 2005
                                                                  140. Hall WD: How have the SSRI antidepressants affected suicide risk? Lancet 367 : 1959 –1962, 2006
                                                                  141. Yuan Y, Tsoi K, Hunt RH: Selective serotonin reuptake inhibitors and the risk of upper gastrointestinal bleeding: Confusion or confounding? Am J Med 119 : 719 –727, 2006
                                                                  142. Wessinger S, Kaplan M, Choi L, Williams M, Lau C, Sharp L, Crowell MD, Keshavarzian A, Jones MP: Increased use of selective serotonin reuptake inhibitors in patients admitted with gastrointestinal hemorrhage: a multicenter retrospective analysis. Aliment Pharmacol Ther 23 : 937 –944, 2006
                                                                    143. Dalton SO, Johansen C, Mellemkjaer L: Use of selective serotonin reuptake inhibitors and risk of gastrointestinal bleeding: A population-based cohort study. Arch Intern Med 163 : 59 –64, 2003
                                                                      144. Serebruarny VL: Selective serotonin reuptake inhibitors and increased bleeding risk: Are we missing something? Am J Med 119 : 113 –116, 2006
                                                                        145. Spigset O: Adverse reactions of selective serotonin reuptake inhibitors. Drug Saf 29 : 277 –287, 1999
                                                                          146. Bailey JE, Potokar JP, Coupland NJ, et al.: The 5HT 3 antagonist ondansetron reduces gastrointestinal side effects induced by a specific serotonin reuptake inhibitor in man. J Psychopharmacol 9 : 137 –141, 1995
                                                                            147. Ueda N, Yoshimura R, Shinkai K, Sakata Y, Nakamura J: Higher plasma 5-hydroxyindoloacetic acid levels are associated with SSRI-induced nausea. Neuropsychobiology 48 : 31 –34, 2003
                                                                            148. Rabindranath KS, Daly C, Butler JA, Roderick PJ, Wallace S, Macleod AM: Psychosocial interventions for depression in dialysis patients. Cochrane Database Syst Rev 2005 Jul 20; 3 : CD004542
                                                                            149. Cukor D, Friedman S: Towards the psychosocial treatment of depressed patients on dialysis. Internet J Neph 2 : 2 , 2005
                                                                            150. Rickels K, Moller HJ: Anxiety: New treatment perspectives. J Clin Psychiatry 63 : 2 , 2002
                                                                            151. Rickels K, Rynn M: Pharmacotherapy of generalized anxiety disorder. J Clin Psychiatry 63 : 9 –16, 2002
                                                                              152. Sramek JJ, Zarotsky V, Cutler NR: Generalized anxiety disorder. Drugs 62 : 1635 –1648, 2002
                                                                                153. Gale C, Davidson O: Generalized anxiety disorder. BMJ 334 : 579 –581, 2007
                                                                                  154. Allgulander C, Sheehan DV: Generalized anxiety disorder: Raising the expectations of treatment. Psychopharmacol Bull 36[Suppl 2] : 68 –78, 2002
                                                                                  155. Kroenke K, Spitzer RL, Williams J, Monahan PO, Lowe B: Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med 146 : 317 –325, 2007
                                                                                  156. House JS, Landis KR, Umberson D: Social relationships and health. Science 241 :5 40 –545, 1988
                                                                                  157. House JS. Kahn RL: Measures and concepts of social support. In: Social Support and Health, edited by Cohen S, Syme SL, London, Academic Press, 1985 , pp 83 –108
                                                                                  158. Brissette I, Cohen S, Seeman TE: Measuring social integration and social networks. In: Measuring and Intervening in Social Support, edited by Cohen S, Underwood L, Gottlieb B, New York, Oxford University Press, 2000 , pp 53 –85
                                                                                  159. Cohen S, Doyle WJ, Skoner DP, Rabin BS, Gwaltney JM Jr: Social ties and susceptibility to the common cold. JAMA 277 : 1940 –1944, 1997
                                                                                  160. Christensen AJ, Smith TW, Turner CW, Holman JM Jr, Gregory MC, Rich MA: Family support, physical impairment and adherence in hemodialysis: An investigation of main and buffering effects. J Behavior Med 15 : 313 –325, 1992
                                                                                  161. Cohen SD, Sharma T, Acquaviva K, Peterson RA, Patel SS, Kimmel PL: Social support and chronic kidney disease: An update. Adv Chronic Kidney Dis 14 : 335 –344, 2007
                                                                                  162. McClellan WM, Flanders WD, Gutman RA: Variable mortality rates among dialysis treatment centers. Ann Intern Med 117 : 332 –326, 1992
                                                                                  163. Uchino BN, Caccioppo JT, Kiecolt-Glaser JK: The relationship between social support and physiological processes: A review with emphasis on underlying mechanisms and implications for health. Psychol Bull 191 : 488 –531, 1996
                                                                                  164. Cohen S: Social relationships and health. Am Psychol 59 : 676 –684, 2004
                                                                                  165. Husebye DG, Westlie L, Styrvoky TJ, Kjellstrand CM: Psychological, social and somatic prognostic indicators in old patients undergoing long-term dialysis. Arch Intern Med 147 : 1921 –1924, 1987
                                                                                  166. McClellan WM, Anson C, Birkeli K, Tuttle E: Functional status and quality of life: Predictors of early mortality among patients entering treatment for end stage renal disease. J Clin Epidemiol 44 : 83 –89, 1991
                                                                                  167. McClellan WM, Stanwyck DJ, Anson CA: Social support and subsequent mortality among patients with end-stage renal disease. J Am Soc Nephrol 4 : 1028 –1034, 1993
                                                                                  168. Patel SS, Peterson RA, Kimmel PL: The impact of social support on end-stage renal disease. Semin Dial 18 : 98 –102, 2005
                                                                                  169. Kimmel PL, Patel SS: Quality of life in patients with chronic kidney disease: Focus on end-stage renal disease treated with hemodialysis. Semin Nephrol 26 : 68 –79, 2006
                                                                                  170. Kimmel PL, Emont SL, Newmann JM, Danko H, Moss AH: ESRD patient quality of life: Symptoms, spiritual beliefs, psychosocial factors, and ethnicity. Am J Kidney Dis 42 : 713 –721, 2003
                                                                                    171. Patel SS, Shah VS, Peterson RA, Kimmel PL: Psychosocial variables, quality of life, and religious beliefs in ESRD patients treated with hemodialysis. Am J Kidney Dis 40 : 1013 –1022, 2002
                                                                                    172. Symister P, Friend R: The influence of social support and problematic support on optimism and depression in chronic illness: A prospective study evaluating self-esteem as a mediator. Health Psychol 22 : 123 –129, 2003
                                                                                    173. Hoth KF, Christensen AJ, Ehlers SL, Raichle KA, Lawton WJ: A longitudinal examination of social support, agreeableness and depressive symptoms in chronic kidney disease. J Behav Med 30 : 69 –76, 2007
                                                                                    174. Burman B, Margolin G: Analysis of the association between marital relationships and health problems: An interactional perspective. Psychol Bull 112 : 39 –63, 1992
                                                                                    175. Kiecolt-Glaser JK, Newton TL: Marriage and health: His and hers. Psychol Bull 127 : 472 –503, 2001
                                                                                      176. Bierman A, Fazio EM, Milkie MA: A multifaceted approach to the mental health advantage of the married: Assessing how explanations vary by outcome measure and unmarried group. Family Issues 27 : 554 –582, 2006
                                                                                        177. Robles TF, Kiecolt-Glaser JK: The physiology of marriage: Pathways to health. Physiol Behavior 79 : 409 –416, 2003
                                                                                          178. Johnson NJ, Backlund E, Sorlie PD, Loveless CA: Marital status and mortality: The National Longitudinal Mortality Study. Ann Epidemiol 10 : 224 –238, 2000
                                                                                          179. Kulik JA, Mahler HI: Marital quality predicts hospital stay following coronary artery bypass surgery for women but not men. Soc Sci Med 63 : 2031 –2040, 2006
                                                                                          180. Kiecolt-Glaser JK, Loving TJ, Stowell JR, Malarkey WB, Lemeshow S, Dickinson SL, Glaser R: Hostile marital interactions, proinflammatory cytokine production, and wound healing. Arch Gen Psych 62 : 1377 –1384, 2005
                                                                                          181. Palmer BF: Sexual dysfunction in men and women with chronic kidney disease and end-stage kidney disease. Adv Ren Replace Ther 10 : 48 –60, 2003
                                                                                          182. Steele TE, Wuerth D, Finkelstein S, Juergensen D, Juergensen P, Kliger AS, Finkelstein FO: Sexual experience of the chronic peritoneal dialysis patient. J Am Soc Nephrol 7 : 1165 –1168, 1996
                                                                                          183. Finkelstein FO, Finkelstein SH, Steele TE: Assesssment of marital relationships of hemodialysis patients. Am J Med Sci 271 : 21 –28, 1976
                                                                                            184. Soskolne V, De-Nour AK: Psychosocial adjustment of home hemodialysis, continuous ambulatory peritoneal dialysis and hospital dialysis patients and their spouses. Soc Sci Med 29 : 497 –502, 1989
                                                                                            185. Devins GM, Hunsley J, Mandin H, Taub KJ, Paul LC: The marital context of end-stage renal disease: Illness intrusiveness and perceived changes in the family environment. Ann Behav Med 19 : 325 –332, 1997
                                                                                            186. Daneker B, Kimmel PL, Ranich T, Peterson RA: Depression and marital dissatisfaction in patients with end-stage renal disease and in their spouses. Am J Kidney Dis 38 : 839 –846, 2001
                                                                                            187. Chowanec GD, Binik YM: End-stage renal disease and the marital dyad: An empirical investigation. Soc Sci Med 28 : 971 –983, 1989
                                                                                            188. Steele TE, Finkelstein SH, Finkelstein FO: Marital discord, sexual problems, and depression. J Nerv Ment Dis 162 : 225 –237, 1976
                                                                                              189. Rideout EM, Rodin GM, Littlefield CH: Stress, social support and symptoms of depression in spouses of the medically ill. Int J Psychiatry Med 20 : 37 –48, 1990
                                                                                                190. Boulware LE, Ratner LE, Sosa JA: Determinants of willingness to donate living related and cadaveric organs: Identifying opportunities for intervention. Transplantation 73 : 1683 –1691, 2002
                                                                                                191. Wicks MN, Milstead EJ, Hathaway DK, Cetingok M: Subjective burden and quality of life in family caregivers of patients with end-stage renal disease. ANNA J 24 : 527 –540, 1997
                                                                                                192. Lowry MR, Atcherson E: Spouse-assistants' adjustment to home hemodialysis. J Chron Dis 37 : 293 –300, 1984
                                                                                                193. Berkman AH, Katz LA, Weissman R: Sexuality and the life-style of home dialysis patients. Arch Phys Med Rehabil 63 : 272 –275, 1982
                                                                                                194. Moguilner ME, Bauman A, De-Nour AK: Adjustment of children and parents to chronic hemodialysis. Psychosomatics 29 : 289 –294, 1988
                                                                                                195. Kiecolt-Glaser JK, Newton T, Cacioppo JT, MacCallum RC, Glaser R, Malarkey WB: Marital conflict and endocrine function: Are men really more physiologically affected than women? J Consult Clin Psychol 64 : 324 –332, 1996
                                                                                                196. Turner-Musa J, Leidner D, Simmens S, Reiss D, Kimmel PL, Holder B: Family structure and patient survival in an African-American end-stage renal disease population: A preliminary investigation. Soc Sci Med 48 : 1333 –1340, 1999
                                                                                                197. Alleyne S, Reiss D, Leonard KJ, Turner-Musa J, Wagner B, Simmens S, Holder B, Kimmel PL, Kobrin S, Cruz I: Staff security and work pressure: Contrasting patterns of stability and change across five dialysis units. Soc Sci Med 43 : 525 –535, 1996
                                                                                                198. Kovac JA, Patel SS, Peterson RA, Kimmel PL: Patient satisfaction with care and behavioral compliance in end-stage renal disease patients treated with hemodialysis. Am J Kidney Dis 39 : 1236 –1244, 2002
                                                                                                199. Powe NR: To have and have not: Health and health care disparities in chronic kidney disease. Kidney Int 64 : 763 –772, 2003
                                                                                                200. Agodoa L: Lessons from chronic renal diseases in African Americans: treatment implications. Ethn Dis 13 : S118 –S124, 2003
                                                                                                201. Norris KC, Agodoa LY: Unraveling the racial disparities associated with kidney disease. Kidney Int 68 : 914 –924, 2005
                                                                                                202. Powe NR, Melamed ML: Racial disparities in the optimal delivery of chronic kidney disease care. Med Clin North Am 89 : 475 –488, 2005
                                                                                                203. Robinson BM, Joffe MM, Pisoni RL, Port FK, Feldman HI: Revisiting survival differences by race and ethnicity among hemodialysis patients: The Dialysis Outcomes and Practice Patterns Study. J Am Soc Nephrol 17 : 2910 –2918, 2006
                                                                                                204. Gornick ME, Eggers PW, Reilly TW, Mentnech RM, Fitterman LK, Kucken LE, Vladeck BC: Effects of race and income on mortality and use of services among Medicare beneficiaries N Engl J Med 335 : 791 –799, 1996
                                                                                                205. Rodriguez RA, Sen S, Mehta K, Moody-Ayers S, Bacchetti P, O'Hare AM Geography matters: Relationships among urban residential segregation, dialysis facilities, and patient outcomes. Ann Intern Med 146 : 493 –501, 2007
                                                                                                206. Kadlubek P, Thamer M, Richard C, Kimmel PL: Socioeconomic status and survival in the US ESRD program [Abtract]. J Am Soc Nephrol 10 : 1244A , 1999
                                                                                                207. Williams DR: Race, socioeconomic status and health: The added effects of racism and discrimination. Ann N Y Acad Sci 896 : 173 –188, 1999
                                                                                                208. Cooper-Patrick L, Gallo JJ, Gonzales JJ, Vu HT, Powe NR, Nelson C, Ford DE: Race, gender, and partnership in the patient-physician relationship. JAMA 282 : 583 –589, 1999
                                                                                                209. The Henry J. Kaiser Family Foundation: Key Facts Race, Ethnicity and Medical Care, Washington DC, 2003
                                                                                                210. Sue S, Dhindsa MK: Ethnic and racial health disparities research: Issues and problems. Health Edu Behav 33 : 459 –469, 2006
                                                                                                211. Crawley LM: Racial, cultural, and ethnic factors influencing end-of-life care. J Palliat Med 8 : S58 –S69, 2005
                                                                                                212. Adler NE, Boyce T, Chesney MA, Cohen S, Folkman S, Kahn RL, Syme SL: Socioeconomic status and health: The challenge of the gradient. Am Psychol 49 : 15 –24, 1994
                                                                                                213. Wuerth D, Finkelstein SH, Finkelstein FO: The identification and treatment of depression in patients maintained on dialysis. Semin Dial 18 : 142 –146, 2005
                                                                                                214. Koo JR, Yoon JY, Joo MH, Lee HS, Oh JE, Kim SG, Seo JW, Lee YK, Kim HJ, Noh JW, Lee SK, Son BK: Treatment of depression and effect of antidepression treatment on nutritional status in chronic hemodialysis patients. Am J Med Sci 329 : 1 –5, 2005
                                                                                                215. Kurella M, Suri RS, Chertow GM: Frequent hemodialysis and psychosocial function. Semin Dial 18 : 132 –136, 2005
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