patients with end - stage kidney disease ( eskd ) are exposed to multiple physical and psychological stressors as a result of their illness . treatment of eskd in the form of dialysis imposes considerable stress , including potential changes in family relations , social interactions , and occupational demands . impact of eskd has been proposed to account for its poorer quality of life ( qol ) compared to patients with other chronic diseases [ 1 , 2 ] . furthermore , survey data has shown significant correlation between poorer qol and higher morbidity and mortality in eskd . as opposed to the mostly invariant biological risk factors , modifiable psychosocial factors may provide avenues for successful intervention and improved clinical outcomes in this population . the renal social worker is the patients ' advocate , serving as a bridge in communicating individual 's needs to the medical and allied health team . commented that  a multidisciplinary team approach is critical to the overall care and qol of patients with eskd . social workers play a central role in the care of these patients , which may be further enhanced by engaging them in the measurement and monitoring of qol  . there is a paucity of data pertaining to the psychosocial factors affecting patients with eskd in australia . this study seeks to identify these issues using the renal social work database of a tertiary hospital . we identify various reasons for initial referral , subsequent consultations , and interventions performed by the renal social worker over a three - year period . ultimately , the study would further explore the significance of social work involvement in the care of patients with eskd and lead to future improvements in service delivery . we conducted a single centre retrospective audit of the patients with eskd ( chronic kidney disease stage - v ( ckd - v ) ) who were referred to one , full - time renal social worker from january 2012 to december 2014 at royal brisbane & women 's hospital , queensland , australia . referrals for social work input were made either by healthcare staff ( medical and allied health ) or directly by patients and/or family members . the reason for referral varied and many individuals were referred for multiple reasons over the study period . all patients underwent an initial psychosocial assessment by the social worker , typically a 60-minute consultation where issues at index were identified . each issue was analysed separately in the case where an individual patient had many issues identified over the study period . instrumental support included patient advocacy ; assistance with paper work / forms ; referrals to relevant government agencies ( e.g. , department of housing , welfare services ) ; and allied health services ( e.g. , psychologist , dietician , and occupational therapist ) . informational support included provision of helpful resources across various domains ( e.g. , predialysis education , treatment adherence , aged care services , management of finances , and employment prospects ) . emotional support was provided through counselling sessions and organising family meetings ( e.g. , for those with adjustment issues , caregiver stress , and palliative care discussions ) . all clinical reviews , documentation , and data collation were performed by the same social worker over the study period . deidentified data was transposed into a spreadsheet , including patient demographics , social history , eskd management modality , summary of social worker encounters , and the respective interventions carried out . this study only included participants with eskd defined by estimated glomerular filtration rate ( egfr ) < 15  ml / min/1.73  m or those with a functioning renal transplant ( ckd - vt ) . patients were subclassified into predialysis , maintenance haemodialysis ( hd ) , peritoneal dialysis ( pd ) , renal transplant , or palliative . adherence is defined as  the extent to which a patient complies with the prescribed treatment under limited supervision  . limited supervision involves monitoring a patient in the community , for example , review at an outpatient appointment or during outpatient dialysis . adherence also can be defined  as the extent to which a person 's behaviour ( taking medication , following a diet , and/or executing lifestyle changes ) corresponds with agreed recommendations from a healthcare provider  . adjustment is described in relation to how the patient adapts to the multitude of stressors posed by the routine and restrictions of treatment . referrals for treatment nonadherence and adjustment were made at the discretion of the treating team , typically when this had serious consequences on the patient 's health outcome , for example , hospitalisation due to nonadherence or difficulty coping with life changes associated with eskd . domestic assistance is a service aimed at helping people to remain independent in their home , by helping with the essential light house work tasks necessary to maintain hygiene and safety standards in the home . we used cross tabs with chi - square test to assess association of demographic variables with socioeconomic issues that were identified . we used univariate and multivariate logistic regression to determine predictors of adjustment issues and nonadherence . age , gender , country of origin , financial status , employment status , reimbursement plan , referral before or after starting renal replacement therapy ( rrt ) , and marital status of the patients were considered for inclusion in multivariate model . since financial status and employment status were highly correlated , separate multivariate models were constructed for each of them to avoid colinearity . a p value < 0.05 was considered as statistically significant and odds ratios with 95% confidence interval were calculated . the study included 244 patients ( 148 men ) with mean age 62.4 ( 16.9 ) years . the majority ( 61.6% ) of referrals to social worker were made after dialysis commencement or transplantation . need for transportation assistance was most prevalent for those patients on hd ( 46/126 [ 36.5% ] ) , followed by pd ( 15/60 [ 25% ] ) and transplant patients ( 7/32 [ 21.8% ] ) , a significant difference between modality of rrt ( p = 0.015 ) and a more commonly identified issue in patients referred prior to starting rrt ( p = 0.004 ) . child protection was needed significantly more often if the country of birth was other than australia ( 5/92 [ 5.4% ] versus 1/152 [ 0.66% ] ; p = 0.03 ) . patients referred prior to starting rrt were more likely to have adjustment problems than those referred after commencement of rrt ( 72.3% versus 21.3% ; p < 0.001 , univariate analysis ) . in multivariate logistic regression , age , referral prior to commencement of rrt , and financial and employment status independently predicted the odds of having adjustment issues ( tables 3(a ) and 3(b ) ) . separate models were created for financial status and employment status to avoid colinearity since the two were highly correlated . increasing age was associated with a significantly decreased risk of having adjustment issues . compared to aged pension , patients with financial stability ( salary or savings ) were significantly less likely to have adjustment issues . compared to employed patients , unemployed patients were significantly more likely to have adjustment issues ( odds ratio 3.34 , 95% confidence interval 1.229.13 , and p = 0.018 ) . issues related to adherence to treatment were also common and were seen in 21.3% patients . age and financial / employment status were significant independent predictors of nonadherence in multivariate logistic regression model ( tables 4(a ) and 4(b ) ) . increasing age was associated with a significantly lower risk of nonadherence . compared to aged pension , disability pension was associated with a significantly greater risk of nonadherence ( odds ratio 3.11 , 95% confidence interval 1.10 to 8.84 , and p = 0.033 ) . compared to employed patients , unemployed patients were significantly more likely to have treatment nonadherence ( odds ratio 4.19 , 95% confidence interval , 1.46 to 12.01 , and p = 0.008 ) . this study sought to assess the psychosocial challenges faced by patients with eskd in an australian population . among the patients referred to social work , the majority were > 60 years of age , male , born in australia , on hd , unemployed , and reliant on government assistance . the most common social work consults related to patients with difficulties with adjustment , treatment nonadherence , management of finances , and domestic assistance . we found that age , timing of referral ( before versus after starting rrt ) , financial status , and employment status were independent predictors of adjustment issues . age , financial status , and employment status also were independent predictors of treatment nonadherence . as defined by beder , adjustment to dialysis is described in relation to how the patient adapts to the multitude of stressors posed by the routine and restrictions of treatment . social work intervention aims to stabilise the individual with a view towards maintenance of functionality and return to work after initiation of treatment . early intervention , especially in  at - risk  patient groups , has been shown to significantly decrease the degree of psychosocial maladjustment in new - start dialysis patients . our current study suggests that patients dependent on government assistance are most at risk of maladjustment in the australian setting . these patients may therefore also be most likely to benefit from social work intervention . the kha - cari guidelines on ckd management suggest the involvement of the social worker in early stages of ckd . of note the majority ( > 60% ) of patients in this study were referred after commencement of dialysis , whereas a substantial number of patients with adjustment issue were referred prior to rrt . maladjustment has been associated with loss of employment , which is not uncommon among dialysis patients [ 10 , 13 ] . earlier referral to social worker may therefore provide an opportunity to more effectively address adjustment concerns . importantly , earlier referral may see more new - start dialysis patients maintaining or returning to employment . treatment nonadherence in eskd has been widely researched and remains a challenge for the care of these patients globally . studies in dialysis patients have shown the association between decreased adherence and increased rates of depression , hospitalisation , morbidity , and overall mortality [ 1417 ] . rates of nonadherence , risk factors , clinical implications , and appropriate interventions have been variably described in the literature , largely owing to the heterogeneity of trials . we found that younger age , patients on disability pension , and unemployed patients were at a significantly higher independent risk of treatment nonadherence . showed that cognitive behavioural therapy improved depressive symptoms , qol , and treatment compliance in hd patients . a systematic review by chan et al . showed the association between psychosocial variables and qol in dialysis patients concluding that targeted interventions to treat psychosocial factors may improve quality of life , morbidity , and ultimately mortality in this population . firstly the psychosocial factors identified in this population may represent surrogate markers of patient qol ; correlation of the findings with validated qol scores would be of interest . secondly , qol scores may be an appropriate way to assess the outcome of social work interventions over time . limitations of our study were that data were collected retrospectively from a single tertiary centre social work database . the findings may therefore underrepresent the true extent and nature of psychosocial issues faced by eskd patients . also the number of encounters per patient was not tracked over the study 's duration . this could have identified specific risk factors and/or groups that required more intensive social work follow - up . in conclusion , this study observed the demographics of eskd patients referred to social work at a tertiary hospital and found the major issues to be related to adjustment , financial difficulty , and domestic assistance . adjustment issues were common and were more likely to be present in patients with younger age and referred before start of rrt . patients with financial stability were less likely to have adjustment issues compared to patients on aged pension . this highlights the need for further financial assistance / support from government and nongovernment agencies . furthermore , we propose the need for earlier and more comprehensive social work support as patients approach eskd which may lead to improvements in qol , morbidity , and mortality .
aim . this study seeks to review the psychosocial factors affecting patients with end - stage kidney disease ( eskd ) from a tertiary hospital in australia . methods . 
 we audited patients with eskd , referred to social work services from january 2012 to december 2014 . 
 all patients underwent psychosocial assessments by one , full - time renal social worker . 
 patient demographics , cumulative social issues , and subsequent interventions were recorded directly into a database . 
 results . of 
 the 244 patients referred , the majority were > 60 years ( 58.6% ) , male ( 60.7% ) , born in australia ( 62.3% ) , on haemodialysis ( 51.6% ) , and reliant on government financial assistance ( 88% ) . 
 adjustment issues ( 41% ) , financial concerns ( 38.5% ) , domestic assistance ( 35.2% ) , and treatment nonadherence ( 21.3% ) were the predominant reasons for social work consultation . 
 younger age , referral prior to start of dialysis , and unemployment were significant independent predictors of increased risk of adjustment issues ( p = 0.004 , < 0.001 , and = 0.018 , resp . ) . 
 independent risk factors for treatment nonadherence included age and financial and employment status ( p = 0.041 , 0.052 , and 0.008 , resp . ) . 
 conclusion . 
 psychosocial and demographic factors were associated with treatment nonadherence and adjustment difficulties . 
 additional social work support and counselling , in addition to financial assistance from government and nongovernment agencies , may help to improve adjustment to the diagnosis and treatment plans as patients approach eskd .