Kimmel P L, Peterson R A, Weihs K L, Simmens S J, Alleyne S, Cruz I, Veis J H
Department of Medicine, George Washington University Medical Center, Washington, D.C., USA.
Kidney Int. 1998 Jul;54(1):245-54. doi: 10.1046/j.1523-1755.1998.00989.x.
The medical risk factors associated with increased mortality in hemodialysis (HD) patients are well known, but the psychosocial factors that may affect outcome have not been clearly defined. Psychosocial factors could affect mortality through interaction with parents' nutrition or their compliance with the dialysis prescription. We conducted a prospective, longitudinal, multicenter study of urban HD patients to determine the contribution of compliance and psychosocial factors to patient survival.
Patients were assessed using indices of social support, patient's assessments of their well-being, including illness effects (IEQ), and satisfaction with life (SWLS), the Beck Depression Inventory (BDI), serum albumin concentration, Kt/V and protein catabolic rate (PCR). Behavioral compliance was measured three ways: percent time actually dialyzed per treatment compared to prescribed time (shortening behavior); percent sessions attended (skipping behavior) and total integrated time compliance (% TCOMP). A severity index, previously demonstrated to be a mortality marker, was used to grade medical comorbidity. The typed of dialyzer the patient was treated with was noted. A Cox proportional hazards model, controlling for age, medical comorbidity, albumin concentration and dialyzer type was used to assess relative mortality risk of variations in psychosocial factors and behavioral compliance.
A total of 295 patients (60.8% of those eligible) agreed to participate. The mean ( +/- SD) age of our population was 54.6 +/- 14.1 year, mean PCR was 1.06 +/- 0.27 g/kg/day, and mean Kt/V 1.2 +/- 0.4, suggesting the patients were well nourished and adequately dialyzed. The patients' mean BDI was 11.4 +/- 8.1 (in the range of mild depression). Patients' SWLS was similar to that of a group of patients without chronic illness. After a 26 month mean follow-up period, higher levels of perceived social support, improved perception of the effects of illness and increased behavioral compliance were significantly associated with decreased relative mortality risk (0.8, 0.77, and 0.79, respectively), controlled for variations in patients' age, severity of illness, serum albumin concentration and dialyzer type. Variations in depression and Kt/V were not predictors of mortality during the observation period.
Lower levels of social support, decreased behavioral compliance with the dialysis prescription, and increased negative perception of the effects of illness are independently associated with increased mortality in ESRD patients treated with HD. The effects are of the same order of magnitude as medical risk factors. Such effects may be attributable to a relationship between a patients' perception of social support and effects of illness and behavior, with other factors such as the provision of better medical care in patients with larger social networks. The mechanism underlying the relationship of psychosocial factors and compliance and survival, and the effect of interventions to improve perception of illness, and increase social support and compliance with the dialysis prescription in HD patients should be studied.
血液透析（HD）患者死亡率增加相关的医学风险因素已为人熟知，但可能影响预后的社会心理因素尚未明确界定。社会心理因素可能通过与患者营养状况或透析医嘱依从性的相互作用来影响死亡率。我们对城市HD患者进行了一项前瞻性、纵向、多中心研究，以确定依从性和社会心理因素对患者生存的影响。
使用社会支持指标、患者对自身幸福感的评估（包括疾病影响[IEQ]）、生活满意度（SWLS）、贝克抑郁量表（BDI）、血清白蛋白浓度、Kt/V和蛋白分解代谢率（PCR）对患者进行评估。行为依从性通过三种方式测量：每次治疗实际透析时间占规定时间的百分比（缩短行为）；参加治疗的次数百分比（漏治行为）和总综合时间依从性（%TCOMP）。使用先前证明为死亡率标志物的严重程度指数对合并症进行分级。记录患者使用的透析器类型。采用Cox比例风险模型，控制年龄、合并症、白蛋白浓度和透析器类型，评估社会心理因素和行为依从性变化的相对死亡风险。
共有295名患者（符合条件者的60.8%）同意参与。我们研究人群的平均（±标准差）年龄为54.6±14.1岁，平均PCR为1.06±0.27g/kg/天，平均Kt/V为1.2±0.4，表明患者营养良好且透析充分。患者的平均BDI为11.4±8.1（处于轻度抑郁范围内）。患者的SWLS与一组无慢性病患者相似。经过平均26个月的随访期，在控制患者年龄、疾病严重程度、血清白蛋白浓度和透析器类型变化后，较高水平的感知社会支持、对疾病影响的改善认知以及行为依从性增加与相对死亡风险降低显著相关（分别为0.8、0.77和0.79）。抑郁和Kt/V的变化在观察期内不是死亡率的预测因素。
社会支持水平较低、透析医嘱行为依从性降低以及对疾病影响的负面认知增加与接受HD治疗的终末期肾病（ESRD）患者死亡率增加独立相关。这些影响与医学风险因素的影响程度相同。这种影响可能归因于患者对社会支持的感知与疾病影响及行为之间的关系，以及其他因素，如社交网络较大的患者能获得更好的医疗护理。应研究社会心理因素与依从性及生存之间关系的潜在机制，以及改善疾病认知、增加社会支持和提高HD患者透析医嘱依从性的干预措施的效果。
