**4. Variables associated with quality of life among hemodialysis patients**

### **4.1 Objective measures**

74 Technical Problems in Patients on Hemodialysis

Spiritual Well-Being Questionnaire (SWBQ) and Spiritual Belief Scale have only been used in a few studies with HD patients, but their results have clinical relevance. Spirituality was associated with QOL measures, satisfaction with life and perception of depression (Patel et al., 2002; Finkelstein et al., 2007). The SWBQ contains 20 items, five for each of four domains: personal, communal, environmental, and transcendental spiritual well-being (Gomez & Fisher, 2003). Respondents indicate how they feel in relation to 20 statements (items) over the past six months. All items are rated according to the 5-point Likert scale, ranging from "never" to "always do". The Spiritual Belief Scale was used in the study of Patel and associates (2002). The questionnaire has four items, each scored on a scale of 0 to 10. Two items measure the perceived importance of faith and its helpfulness in coping with ESRD and the other two items involve perception of the importance of attending religious services

The Beck Depression Inventory (BDI) is the standard instrument for screening clinical depression (Craven et al., 1988). The BDI covers 21 categories of symptoms. Each category has four levels of severity of that symptom, scored from 0 (little or no distress) to 3 (severe distress). The final score is the sum of the responses to the 21 symptom-items. The validated cut-off of score range of 14 to 16 corresponds to psychiatric diagnosis of major depressive disorder (Hedayati et al., 2006). As an alternative to the BDI, there is a short form (10 items) of the Epidemiological Studies Depression Screening Index (CES-D). The CES-D is not as widely validated as the Beck Depression Inventory, but has fewer questions, so it can be administered more quickly. It can be helpful as a screening tool of depression (Andresen et al., 1994). Each item of the CES-D is scored from 0 to 3 points and the total score ranges from 0 to 30. The CES-D was used in the DOPPS (score ≥ 10 as an indicator of probable depression) and was validated in comparison to the standard BDI (Lopes et al., 2004;

Erectile dysfunction among men is a well-established complication of dialysis. There are many studies in the literature on this theme. The International Index of Erectile Function (IIEF) is the standard instrument to assess male sexual functioning (Rosen et al., 1997). Most studies apply the six questions covering erectile function, but the instrument also covers orgasmic function (2 questions), sexual desire (2 questions), intercourse satisfaction (3 questions) and overall satisfaction (2 questions). The IIEF gives results according to four categories: no, minimum, moderate and advanced dysfunction. On the other hand, there is much less literature on the sexual aspects of women undergoing HD, although a validated instrument is available, the Female Sexual Function Index (FSFI). It is a 19-item questionnaire covering six domains of sexual function: desire, arousal, lubrification, orgasm, satisfaction and pain. The minimum score is 1.2 and the maximum is 36. A score < 26.55

Coping is defined as the cognitive and behavioral efforts to manage, reduce or tolerate external and internal demands and conflicts among them (Lazarus & Folkman, 1984). In the context of ESRD, external demands are the various stressors associated with dialysis therapy. The coping method works as a modulator of stressors. The way patients cope with stress can determine how they will be affected by the problem. According to the theory of coping, patients' efforts may be to manage or alter the source of stress (problem-oriented coping) or to regulate stressful emotions (emotion-oriented coping) (Lazarus & Folkman, 1984). In other words, problem-oriented coping aims to make direct changes in a stressful situation whereas emotion-oriented coping seeks to ameliorate emotions associated with a problem. The Jalowiec Coping Scale (JCS) was the first version, with 40 items and results

indicates the presence of sexual dysfunction (Wiegel et al., 2005).

and its helpfulness in coping with ESRD.

Hedayati et al., 2006).

Objective measures are those associated with socio-demographic aspects and HD quality-ofcare indicators. Most of socio-demographic variables are not modifiable, but quality of HD treatment can be modulated in practice by setting goals: hemoglobin of 11-12 g/dl, equilibrated Kt/V ≥ 1.2, phosphorus of 3.5-5.5 g/L, and adequate nutrition. This section discusses the frequency and duration of dialysis sessions as objective variables in emerging modalities of short daily or nocturnal dialysis.

Age: Older age does not necessarily mean worse QOL among HD patients. Older patients compensate for physical deterioration by adjusting mental outlook aspects. This conclusion is supported by results showing that the main effects of age are on the physical domain of QOL rather than the mental domains (Deoreo, 1997; Singer et al., 1999; Lamping et al., 2000). Older people (> 65 years) perceive less decline of QOL and more satisfaction with life when compared to younger patients (Rebollo et al., 2001; Kimmel et al., 1995). In large samples from the HEMO Study as well as in small samples from single renal units, older patients on HD have better QOL than do younger patients (Unruh et al., 2008; Abdel-Kader et al., 2009). Maybe the larger gap between expected and actual QOL among younger patients makes the treatment restrictions more disturbing to them.

Gender: Among healthy people in countries like Canada, the United States and England, where the SF-36 has been used to estimate QOL in the general population, it has been found that men have better QOL than women (Ware, 1993; Jenkinson et al., 1999; Hopman et al., 2000). This gender difference is not found among HD patients (Kalantar-Zadeh et al., 2001). It seems that stressors associated with dialysis therapy, which are common to both genders, are powerful enough to overcome the gender aspects determining difference within the general population.

Race: African-American HD patients in the United States reported significantly better psychological well-being than non-African-Americans (Owen et al., 1998; Hicks et al., 2004; Unruh et al., 2004a). In countries like Brazil, with more miscegenation, it is difficult to classify patients according to race, so there are not extant studies of race-based differences.

Socioeconomic status: Brazil is a large country and has great regional socioeconomic disparities as well as local class differences. Most studies of HD samples are from the

Subjective Well-Being Measures of Hemodialysis Patients 77

HD have not shown an influence on QOL. In other studies, dialysis modalities with more frequent and longer dialysis sessions, like nocturnal (5 sessions weekly, 6 to 10 hours/session) or short daily dialysis (6 sessions weekly, 2 to 3.5 hours/session), in comparison with conventional HD, have been shown to have a positive influence on QOL (Lindsay, 2004; Culleton et al., 2007; Van Eps et al., 2010). However, everywhere in the world, but particularly in developing countries, the necessary economic and organizational changes will be the main obstacles to conducting more frequent dialysis on a large scale. This is certainly true in Brazil. First, current reimbursement by the National Health System is limited to thrice-weekly hemodialysis, so increased reimbursement to support more frequent and longer dialysis will be necessary. Second, daily HD will overtax the present capacity of renal units, so resources are needed to set up new and accessible satellite dialysis

Objective measures are traditional and well-managed by clinicians. Nonetheless, QOL among HD patients remains poor. The increasing knowledge of subjective measures can be

Depression: The high prevalence - nearly 30% - and the role of depression in affecting wellbeing among HD patients are well established (Cukor et al., 2006). But there are limited studies focused on treatment of depression in HD patients. Serotonin reuptake inhibitors and psychotherapy can be indicated (Blumenfield et al., 1997; Kimmel & Peterson, 2006). But it is difficult to employ successful routines to treat depression in practice (Wuerth et al., 2003). Among HD patients, depressive feelings are associated with low QOL, and are predictors of both death due to any cause and withdrawal from dialysis (Lopes et al., 2004; Berlim et al., 2006; Drayer et al., 2006). Patients' social support interacts with depression, but once again subjective modulators have a central role. Better social support among individuals high in the personality trait of "agreeableness" was associated with a decrease in depressive symptoms, whereas social support had little effect on depression change for

Sexuality: Sexuality is a complex aspect of human lives because it comprises physiological needs and social demands. Dialysis therapy negatively affects sexual function both among men and women. Several well-known factors are associated with erectile dysfunction among men on HD: gonadal dysfunction; hyperprolactinemia; zinc, iodine and manganese deficiencies; hyperparathyroidism; uremic neuropathy; arteriosclerosis; anemia; and use of antihypertensives (Palmer, 1999). Some studies have found a prevalence of erectile dysfunction as high as 80% (Rosas et al., 2001). In the experience of my team, nearly half of young patients (20 to 50 years old) present erectile dysfunction and have significantly lower mental health assessed by the SF-36 when compared to patients with the same age range without erectile dysfunction. There are few studies on the sexuality of women undergoing HD. But similar to our experience among men, Seethala et al. (2010) found 46% sexual dysfunction among sexually active women on dialysis, assessed by the FSFI. But in contrast to men, sexual dysfunction among women has not been associated with low well-being, assessed by the Illness Effects Questionnaire (Seethala et al., 2010). No doubt, women must be studied more to confirm the differences between them and men concerning sexuality as a

Spirituality: The relationship of spirituality, physical health and well-being is well documented in the literature (Levin & Vanderpool, 1991; Ellison, 1991; Powell et al., 2003).

units.

**4.2 Subjective measures**

measure of well-being and QOL.

the key for more effective interventions to improve QOL.

individuals ranked as low in "agreeableness" (Hoth et al., 2007).

southeast region, which is the country's richest, where many universities are located. I work in northeast Brazil, which is a generally poor region. Last year in a chapter of a Brazilian book, I concluded that QOL level is lower among HD patients from low-income areas (Cruz & Cruz, 2010). A previous Brazilian study showed that QOL scores of highsocioeconomic HD patients tended to increase more over time than did the scores among low- and middle-class patients within a sample of eight dialysis units in the state of São Paulo (Sesso et al., 2003).

Travel time: Depending on the region, renal units can be very far from where patients live. In the north and northeast of Brazil, there are few renal units, and patients have to travel long distances to for dialysis (Ritt et al., 2007). In our renal unit, in the city of Sobral in northeastern Brazil, 80% of the patients undergoing regular HD live outside the city where the renal unit is located, in small towns within a radius of 144 miles. My research team has been unable to detect differences regarding laboratory values, adherence, QOL and depression according to the patient travel time. This may be because patients in our region who live in small rural communities are accustomed to traveling long distances to obtain government services of all types. However, in a large sample, longer travel time is associated to higher mortality and decreased QOL (Moist et al., 2008).

Anemia: With the spreading use of erythropoietin, several studies about the relationships between anemia control and QOL have been performed. The current recommendation is to achieve partial control of anemia (hemoglobin of 11-12 g/dl) due to potentially adverse cardiovascular events at higher hemoglobin levels (Besarab et al., 1998; Singh, 2008; Phrommintikul et al., 2007). Distinct approaches to patients with or without symptomatic cardiac disease concerning target hemoglobin are subject to debate, and the results are contradictory (Canadian Erythropoietin Study Group, 1990; Furuland et al., 2003). There are several studies showing better QOL with higher hemoglobin as well as showing no differences of QOL according to hemoglobin level. In a recent systematic review with metaanalysis, Clement et al. (2009) included only 11 studies from a total of 231 and concluded that hemoglobin levels in excess of 12 g/dl lead to small and not clinically meaningful improvements in QOL. The authors suggested, due to safety concerns, targeting treatment to hemoglobin levels in the range of 9-12 g/dl as opposed to hemoglobin > 12 g/dl.

Kt/V index: The dialysis dose, estimated by the Kt/V index, was a constant variable of interest in the early studies of QOL. The hypothesis was that higher dose would be associated with better QOL. With the exception of studies with small samples (Powers et al., 2000; Manns et al., 2002), no correlation between Kt/V and QOL was found (Kalantar Zadeh et al., 2001; Mittal et al., 2001). The advent of new membranes has rekindled interest in the relationships between high flux membranes and QOL. But once again, this time in a multicenter randomized trial, neither the dose (Kt/V 1.45 vs. 1.05) nor the dialysis membrane (high flux vs. low flux) demonstrated clinically meaningful benefits (Unruh et al., 2004b).

Malnutrition: There are several reports of associations between nutritional status and QOL through nutritional markers: creatinine, albumin, calf circumference and protein/energy intake (Ohri-Vachaspati & Seghal, 1999; Allen et al., 2002; Kalantar-Zadeh et al., 2001; Fujisawa et al., 2000; Raimundo et al., 2006). In our renal unit, we found different patterns of relationships between nutritional status and QOL according to gender: malnutrition and low protein intake correlated with low QOL among women but not among men.

Frequency and duration of dialysis sessions: An important current issue is the potential of more frequent and longer dialysis sessions to improve several clinical outcomes. As stated above, studies of dialysis dose and different membrane types in the context of conventional HD have not shown an influence on QOL. In other studies, dialysis modalities with more frequent and longer dialysis sessions, like nocturnal (5 sessions weekly, 6 to 10 hours/session) or short daily dialysis (6 sessions weekly, 2 to 3.5 hours/session), in comparison with conventional HD, have been shown to have a positive influence on QOL (Lindsay, 2004; Culleton et al., 2007; Van Eps et al., 2010). However, everywhere in the world, but particularly in developing countries, the necessary economic and organizational changes will be the main obstacles to conducting more frequent dialysis on a large scale. This is certainly true in Brazil. First, current reimbursement by the National Health System is limited to thrice-weekly hemodialysis, so increased reimbursement to support more frequent and longer dialysis will be necessary. Second, daily HD will overtax the present capacity of renal units, so resources are needed to set up new and accessible satellite dialysis units.

#### **4.2 Subjective measures**

76 Technical Problems in Patients on Hemodialysis

southeast region, which is the country's richest, where many universities are located. I work in northeast Brazil, which is a generally poor region. Last year in a chapter of a Brazilian book, I concluded that QOL level is lower among HD patients from low-income areas (Cruz & Cruz, 2010). A previous Brazilian study showed that QOL scores of highsocioeconomic HD patients tended to increase more over time than did the scores among low- and middle-class patients within a sample of eight dialysis units in the state of São

Travel time: Depending on the region, renal units can be very far from where patients live. In the north and northeast of Brazil, there are few renal units, and patients have to travel long distances to for dialysis (Ritt et al., 2007). In our renal unit, in the city of Sobral in northeastern Brazil, 80% of the patients undergoing regular HD live outside the city where the renal unit is located, in small towns within a radius of 144 miles. My research team has been unable to detect differences regarding laboratory values, adherence, QOL and depression according to the patient travel time. This may be because patients in our region who live in small rural communities are accustomed to traveling long distances to obtain government services of all types. However, in a large sample, longer travel time is

Anemia: With the spreading use of erythropoietin, several studies about the relationships between anemia control and QOL have been performed. The current recommendation is to achieve partial control of anemia (hemoglobin of 11-12 g/dl) due to potentially adverse cardiovascular events at higher hemoglobin levels (Besarab et al., 1998; Singh, 2008; Phrommintikul et al., 2007). Distinct approaches to patients with or without symptomatic cardiac disease concerning target hemoglobin are subject to debate, and the results are contradictory (Canadian Erythropoietin Study Group, 1990; Furuland et al., 2003). There are several studies showing better QOL with higher hemoglobin as well as showing no differences of QOL according to hemoglobin level. In a recent systematic review with metaanalysis, Clement et al. (2009) included only 11 studies from a total of 231 and concluded that hemoglobin levels in excess of 12 g/dl lead to small and not clinically meaningful improvements in QOL. The authors suggested, due to safety concerns, targeting treatment

to hemoglobin levels in the range of 9-12 g/dl as opposed to hemoglobin > 12 g/dl.

low protein intake correlated with low QOL among women but not among men.

Frequency and duration of dialysis sessions: An important current issue is the potential of more frequent and longer dialysis sessions to improve several clinical outcomes. As stated above, studies of dialysis dose and different membrane types in the context of conventional

Kt/V index: The dialysis dose, estimated by the Kt/V index, was a constant variable of interest in the early studies of QOL. The hypothesis was that higher dose would be associated with better QOL. With the exception of studies with small samples (Powers et al., 2000; Manns et al., 2002), no correlation between Kt/V and QOL was found (Kalantar Zadeh et al., 2001; Mittal et al., 2001). The advent of new membranes has rekindled interest in the relationships between high flux membranes and QOL. But once again, this time in a multicenter randomized trial, neither the dose (Kt/V 1.45 vs. 1.05) nor the dialysis membrane (high flux vs. low flux) demonstrated clinically meaningful benefits (Unruh et al., 2004b). Malnutrition: There are several reports of associations between nutritional status and QOL through nutritional markers: creatinine, albumin, calf circumference and protein/energy intake (Ohri-Vachaspati & Seghal, 1999; Allen et al., 2002; Kalantar-Zadeh et al., 2001; Fujisawa et al., 2000; Raimundo et al., 2006). In our renal unit, we found different patterns of relationships between nutritional status and QOL according to gender: malnutrition and

associated to higher mortality and decreased QOL (Moist et al., 2008).

Paulo (Sesso et al., 2003).

Objective measures are traditional and well-managed by clinicians. Nonetheless, QOL among HD patients remains poor. The increasing knowledge of subjective measures can be the key for more effective interventions to improve QOL.

Depression: The high prevalence - nearly 30% - and the role of depression in affecting wellbeing among HD patients are well established (Cukor et al., 2006). But there are limited studies focused on treatment of depression in HD patients. Serotonin reuptake inhibitors and psychotherapy can be indicated (Blumenfield et al., 1997; Kimmel & Peterson, 2006). But it is difficult to employ successful routines to treat depression in practice (Wuerth et al., 2003). Among HD patients, depressive feelings are associated with low QOL, and are predictors of both death due to any cause and withdrawal from dialysis (Lopes et al., 2004; Berlim et al., 2006; Drayer et al., 2006). Patients' social support interacts with depression, but once again subjective modulators have a central role. Better social support among individuals high in the personality trait of "agreeableness" was associated with a decrease in depressive symptoms, whereas social support had little effect on depression change for individuals ranked as low in "agreeableness" (Hoth et al., 2007).

Sexuality: Sexuality is a complex aspect of human lives because it comprises physiological needs and social demands. Dialysis therapy negatively affects sexual function both among men and women. Several well-known factors are associated with erectile dysfunction among men on HD: gonadal dysfunction; hyperprolactinemia; zinc, iodine and manganese deficiencies; hyperparathyroidism; uremic neuropathy; arteriosclerosis; anemia; and use of antihypertensives (Palmer, 1999). Some studies have found a prevalence of erectile dysfunction as high as 80% (Rosas et al., 2001). In the experience of my team, nearly half of young patients (20 to 50 years old) present erectile dysfunction and have significantly lower mental health assessed by the SF-36 when compared to patients with the same age range without erectile dysfunction. There are few studies on the sexuality of women undergoing HD. But similar to our experience among men, Seethala et al. (2010) found 46% sexual dysfunction among sexually active women on dialysis, assessed by the FSFI. But in contrast to men, sexual dysfunction among women has not been associated with low well-being, assessed by the Illness Effects Questionnaire (Seethala et al., 2010). No doubt, women must be studied more to confirm the differences between them and men concerning sexuality as a measure of well-being and QOL.

Spirituality: The relationship of spirituality, physical health and well-being is well documented in the literature (Levin & Vanderpool, 1991; Ellison, 1991; Powell et al., 2003).

Subjective Well-Being Measures of Hemodialysis Patients 79

resulting from poor physical health. Thus, physical interventions, like physical conditioning programs, occupational activities and physiotherapeutic approaches must be tried on

ESRD requires an individual to make a number of adjustments. To do so, patients need to understand their situation (cognitive effort) and modify their behavior (behavioral effort). The kinds of these efforts determine their coping style. I believe coping style is the principal measure between treatment-related stressors and outcomes. In my view, coping is the best variable for intervention and potentially the most correlated with QOL. I have detected emotion-oriented coping associated with poor QOL. Emotion-oriented coping is associated with passive personality traits, a sense of powerlessness and denial (Gilbar et al., 2005; Klang et al., 1996). Fortunately, coping is a modifiable variable. Patient education in coping skills can be used to change the risk of poor QOL (Tsay et al., 2005). I propose adaptation

Finally, the emerging modalities with more frequent dialysis, like nocturnal or daily dialysis, are promising to enhance QOL. However, the implementation of sufficient renal units to offer this dialysis frequency demands time and resources. Moreover, these modalities may not be acceptable to some patients. It will be even more difficult to offer these modalities on a large scale in underdeveloped countries, where reimbursement of dialysis sessions is very low and there is lack of renal units that even offer conventional HD. Only time will tell whether more frequent dialysis will be standard treatment in the future.

Well-being is a main outcome in treatment of ESRD patients with dialysis. However, scientific evidence is lacking about interventions to improve well-being. The best way of assessing patients' well-being is to estimate the QOL level using validated instruments. Over the last decade neither technical advances nor quality-of-care guidelines have been enough to improve QOL among HD patients. Emerging knowledge about subjective measures associated with QOL can be the key for effective interventions. Clinicians must be familiar with subjective measures and use them in their daily practice to try to improve the well-being of patients undergoing HD. After 50 years of the widespread of dialysis treatment, the improvement of QOL among dialysis patients remains a formidable

Abdel-Kader K, Myaskovsky L, Karpov I, Shah J, Hess R, Dew MA & Unruh M. (2009).

modality. *Clinical Journal of the American Society of Nephrology* 4(4): 711-718 Al-Hilali N, Al-Humoud HM, Ninan VT, Nampoory MRN, Ali JH & Johny KV. (2004).

Allen KL, Miskulin D, Yan G, Dwyer JT, Frydrych A, Leung J, Poole D & the Hemodialysis

Individual quality of life in chronic kidney disease: influence of age and dialysis

(HEMO) Study Group. (2002). Association of nutritional markers with physical and mental health status in prevalent hemodialysis patients from HEMO study. *Journal* 

individuals and also as collective activities in renal units.

training programs aiming to improve patients' coping skills.

*Transplantation Proceedings* 36(6): 1827-1828

*of Renal Nutrition* 12(3): 160-169

**6. Conclusion** 

challenge.

**7. References** 

In the nephrology area, there are reports of better QOL and less depression among dialysis patients with greater perception of spirituality and religiosity (Patel et al., 2002; Finkelstein et al., 2007). People identified as spiritual report better social support (Patel et al., 2002). Cumulative positive effects of social support and spirituality can explain lower mortality and better well-being (Spinale et al., 2008). Nevertheless, more studies on spirituality are necessary among HD patients. But it is promising that spirituality and social support could be targets of intervention. Strategies aiming at engaging patients in discussions about their spiritual concerns together with planning activities to involve patients' social support networks in treatment problems could improve subjective and objective outcomes.

Coping style: Common sense as well as scientific evidence shows that the way people face difficult situations is the main measure of the effects of stress in their lives. This explains why in clinical practice there are patients with many handicaps who still perceive their lives as pleasant, while others with fewer problems do not. This is also the basis of the importance of all subjective measures discussed here. Coping tests are simple and can be used by dialysis stuff without psychologists' help. Moreover, coping style is a modifiable variable, which can be changed by adaptation training programs. My study team found a correlation between emotion-oriented coping and poor QOL regarding the physical (physical functioning and role-physical) and mental (role-emotional and mental health) dimensions of the SF-36, in line with other studies of chronic disease patients, including the ESRD (Bombardier et al., 1990; Wahl et al., 1999; Dunn et al., 1994). In my view, coping is a potent measure and can be a suitable target for interventions to improve QOL. This personal view is addressed in more detail in the next section.

## **5. How to improve well-being among hemodialysis patients**

When thinking about how to improve QOL among HD patients, two facts must be considered. First, despite a great number of studies, there are no recommendations possible based on Level I or II evidence (Madhan, 2010). The reason is that while there are many cross-sectional studies of QOL, there is a lack of interventional and randomized controlled trials. Second, there has been no improvement of QOL among dialysis patients in the past decade (Gabbay et al., 2010). Recent technical advances and treatment guidelines have not been associated with changes in QOL, although a study of a small sample showed it was possible to improve QOL associated with better quality-of-care indicators (Lacson et al., 2009). Thus, targeting the current quality-of-care indicators concerning anemia, nutrition, dialysis dose, phosphorus level and vascular access must be the first step. These indicators are well known by clinicians. But this first step is not enough. Dialysis associated stressors are powerful. So what else can be done? Faced with a lack of adequate evidence, opinion is what determines efforts to improve QOL. As an assistant nephrologist, medical professor and researcher on QOL and correlators, I suggest, based on my study results, that physiotherapeutic approaches along with psychological interventions can minimize the effects of dialysis on patients' well-being.

Dialysis patients have very low physical domains of QOL compared to healthy people. On the other hand, mental aspects are the same or even higher than in the general population (Perneger et al., 2003; Kusek et al., 2002). In my experience, the dimension role-physical (from the SF-36) consistently presents the lowest score among HD patients. Questions which generate role-physical score are related to difficulties in work and other daily activities resulting from poor physical health. Thus, physical interventions, like physical conditioning programs, occupational activities and physiotherapeutic approaches must be tried on individuals and also as collective activities in renal units.

ESRD requires an individual to make a number of adjustments. To do so, patients need to understand their situation (cognitive effort) and modify their behavior (behavioral effort). The kinds of these efforts determine their coping style. I believe coping style is the principal measure between treatment-related stressors and outcomes. In my view, coping is the best variable for intervention and potentially the most correlated with QOL. I have detected emotion-oriented coping associated with poor QOL. Emotion-oriented coping is associated with passive personality traits, a sense of powerlessness and denial (Gilbar et al., 2005; Klang et al., 1996). Fortunately, coping is a modifiable variable. Patient education in coping skills can be used to change the risk of poor QOL (Tsay et al., 2005). I propose adaptation training programs aiming to improve patients' coping skills.

Finally, the emerging modalities with more frequent dialysis, like nocturnal or daily dialysis, are promising to enhance QOL. However, the implementation of sufficient renal units to offer this dialysis frequency demands time and resources. Moreover, these modalities may not be acceptable to some patients. It will be even more difficult to offer these modalities on a large scale in underdeveloped countries, where reimbursement of dialysis sessions is very low and there is lack of renal units that even offer conventional HD. Only time will tell whether more frequent dialysis will be standard treatment in the future.
