Psychological factors in end-stage renal disease: an emerging context for behavioral medicine research.

End-stage renal disease (ESRD) is a chronic, life-threatening condition afflicting over 300,000 Americans. Patient nonadherence and psychological distress are highly prevalent among ESRD patients, and both have been found to contribute to greater morbidity and earlier mortality in this population. A range of factors have been examined as potential determinants of adherence and adjustment. Evidence suggests that adherence and adjustment are maximized when a patient’s preferred style of coping is consistent with the contextual features or demands of the renal intervention the patient is undergoing. Challenges for future clinical research include refining methodologies for the assessment of depression and adherence, more clearly evaluating the efficacy of psychological interventions, and clarifying the role that depression and social support play in influencing patient mortality. The over 300,000 end-stage renal disease (ESRD) patients in the United States face an incurable, life-threatening, chronic disease. Only four decades ago, an ESRD diagnosis meant near certain death. Upon the cessation of renal function, excess fluid, metabolic toxins, and electrolytes rapidly accumulate in blood and bodily tissues. These substances must be removed by alternative means if the ESRD patient is to survive. For most patients, ESRD is the end result of a progressive deterioration in kidney function over a period of months or years that is secondary to another chronic medical condition (e.g., diabetes or hypertension). Diabetic nephropathy is the most common etiological factor, accounting for over one third of new ESRD cases (U.S. Renal Data System [USRDS], 1999). Currently available treatments for ESRD include renal transplantation and several forms of renal dialysis. In general, the choice of a particular ESRD treatment is substantially influenced by nonmedical factors, including patient and provider preferences and judgments about which modality is likely to be associated with the most favorable patient adherence and quality of life (Christensen & Moran, 1998; Davison, 1996). A successful renal transplant is generally thought to hold certain advantages in terms of patient quality of life (Christensen, Holman, Turner, Smith, & Grant, 1991). However, because of a perennial shortage of donor organs and a significant transplant rejection rate, renal dialysis remains the prescribed treatment for the large majority of patients. There is an important difference in the degree of patient involvement in the delivery of the different forms of dialysis. The center hemodialysis patient is a relatively passive recipient of a treatment that is carried out in a hospital or clinic. The hemodialysis procedure is performed three times a week by nurses or technicians with each session lasting approximately 4 hours. Hemodialysis treatment involves a vascular connection made between the artificial kidney (dialyzer) and the patient, usually through an arteriovenous fistula permanently placed in the patient’s forearm. Nurses or technicians are responsible for directing each step in the initiation, monitoring, and discontinuation of each dialysis session. Little participation is required or allowed of the patient during treatment delivery. For some patients, hemodialysis is carried out at home. Although home and center hemodialysis are largely analogous from a physiological and mechanical standpoint, home patients have the opportunity to be much more actively involved in treatment delivery and direction. Moreover, home dialysis patients have considerably less frequent contact with renal care providers and are able to set and maintain their own dialysis schedules. Peritoneal dialysis treatment typically requires the patient to take an even more active role in treatment delivery. In continuous