Sleep and pain management are key components of patient care in ESRD

† The results presented in this paper have not been published previously in whole or part, except in abstract format. The care for patients with end-stage renal disease (ESRD) has focused on easily measurable processes of care outcomes such as Kt/V, hemoglobin and serum phosphorus levels. It has been thought that these metrics reflect the quality of care. Furthermore, improving these measurements would favorably influence the quality of life and survival on dialysis. However, an observational study of over 11 000 hemodialysis patients demonstrated no substantial improvement in health-related quality of life (HRQOL), despite secular changes in Kt/V, hemoglobin and serum phosphorus [1]. In addition, randomized trials testing whether increasing Kt/V or hemoglobin reduces mortality and improves the quality of life had demonstrated no substantial increase in quality or length of life [2–4]. As it turns out, these measures may not be adequate proxies for patient well-being and attention to them may not substantially increase survival. The present study by Kimmel and colleagues [5] is noteworthy because of its examination of potential associations between pain, sleep, quality of life and survival. The work of this group supports the position that patient-reported outcomes may present an important tool to improve the quality of life and the survival duration of patients with ESRD. The report measured self-reported pain and sleep in 128 patients with ESRD in two dialysis units in Washington, DC, between 2001 and 2003 with follow-up of the cohort for survival through 2005. The study population had a mean age of 57, 60% male, 91% African-American and had a mean duration of dialysis of 40 months. There was a high rate of other chronic health conditions since 48% were diabetic, 10% had HIV and the average Karnofsky score was 75. One of the strengths of this investigation is the early use of the McGill Pain questionnaire and the Pittsburgh Sleep Quality Index (PSQI). These now widely used tools provide reliable and valid measures of pain and sleep quality. In order to assess whether pain differs between the time on dialysis and non-dialysis, the investigators modified the McGill Pain questionnaire to examine the nature, location, intensity, duration and frequency of pain on and off dialysis. Dialysis pain intentionally was measured by asking the patient to disregard discomfort associated with the use of vascular access. The investigators found that a substantial proportion of ESRD patients reported pain during offdialysis (44%) time and poor sleep (45% have a PSQI score of >5). The measures of pain and sleep quality were later analyzed in relation to survival. After controlling for age, diabetes, serum albumin and HIV, non-dialysis pain was significantly associated with an increased risk of death. While this report demonstrates a high prevalence of pain and poor sleep in patients with ESRD, there are a number of limitations which should be considered when comparing these findings to other studies. First, this was a small study with limited power to demonstrate clinically meaningful associations with survival. Only 32 deaths were reported during the study and observation periods. This lack of power may explain the non-signifi