Quality-of-Life Issues for End-Stage Renal Disease Patients Roberta G. Simmons, PhD, and Linda Abress • Given the importance of making comparisons regarding quality-of-life issues for end-stage renal disease (ESRD) patients, the research presented here first compares 766 patients who experienced one of the following therapies for at least 1 year: (1) center hemodialysis, (2) continuous ambulatory peritoneal dialysis (CAPO), or (3) successful transplantation (one cohort of patients from the 1970s, a second cohort from 1980 to 1984). Second, since the most recent transplant group was randomized to two alternative immunosuppressive drug regimens, we compared the quality of life of the patients on cyclosporine/prednisone therapy (N = 51) and the patients on a conventional immunosuppressive therapy (antilymphocyte globulin/prednisone/azathioprine; N = 40). Patients had to be age 19 to 56 years and nondiabetic to be included in this research. Data were collected with survey questionnaires containing measures of physical, emotional, and social well-being, vocational rehabilitation, sexual adjustment, and marital and family adjustment. Case mix or background differences were controlled as much as possible using an analysis of covariance (ANCOVA) and comparison of adjusted means. Our results show that the successful transplant patients scored higher than both dialysis groups (P < 0.05 for nine of 11 measures) on almost all variables, demonstrating a higher quality of life. The effect of a failed transplant on quality of life was also examined. In terms of the recent transplant patients, the cyclosporine group scored consistently higher on all physical, emotional, and social well-being measures (excluding males' vocational rehabilitation), although differences are not always significant. An ANCOVA suggests that the lower incidence of infections and rejection among the cyclosporine patients may be responsible for their greater social and psychological well-being. © 1990 by the National Kidney Foundation, Inc. INDEX WORDS: Quality of life; rehabilitation; continuous ambulatory peritoneal dialysis; transplantation; cyclosporine.

M

EDICAL THERAPIES and treatments can no longer be evaluated on the grounds of life extension alone. Physicians, patients, and policy-makers are asking for comparisons of quality of life on alternative therapies. The research reported here compares the quality of life of patients on alternative therapies for end-stage renal disease (ESRD), including kidney transplantation, continuous ambulatory peritoneal dialysis (CAPD), and in-center hemodialysis. Because societal policies and laws influence the distribution of therapies, it is particularly important to consider the comparative quality of life and rehabilitation of the patients, as well as the medical parameters. Two studies are discussed in terms of quality of life of alternative ESRD therapies. The first study compared patients who were experiencing one of three different treatment modalities: (1) center hemodialysis, (2) CAPD, or (3) kidney transplantation. The second study compared a recent group of transplant patients on two alternative immunosuppressive therapies: (1) a conventional regimen, versus (2) a cyclosporine regimen (see Methods). Quality of life in both research studies is conceptualized in multidimensional terms with three main dimensions: physical well-being, emotional wellbeing, and social well-being. 1-s The subdimen-

sions of quality of life include (1) for physical well-being, perceptions of self as healthy or ill, self-ratings of difficulty with daily activities, health satisfaction, and number of nights hospitalized; (2) for emotional well-being, self-esteem, happiness, and life satisfaction; and (3) for social well-being, vocational rehabilitation, sexual adjustment, and marital and family adjustment. Issues of cost of the ESRD program under Medicare are also relevant to the evaluation of life quality.9 The cost of the program by 1989 is projected to reach 3.2 billion.lO Currently affecting cost is the Omnibus Budget Reconciliation Act (Public Law 99-509), passed recently to provide From the Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, PA; and the Department of Sociology, University of Minnesota, Minneapolis, MN. Supported by the National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases Grants No.5 ROI AM28618 and 2 POI AM13083, a grant from the Minnesota Medical Foundation, and a grant from the Health Care Financing Administration l4-C-98642/5-0l (to R.G.S.J. Address reprint requests to Roberta G. Simmons, PhD, Department of Psychiatry, Western Psychiatric Institute and Clinic,3811 O'Hara St, Pittsburgh, PA 15213. © 1990 by the National Kidney Foundation, Inc. 0272-6386/90//503-0003$3.00/0

American Journal of Kidney Diseases, Vol XV, No 3 (March), 1990: pp 201-208

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202

transplant patients eligible for Medicare with I year of immunosuppressive medication. In spite of costs associated with transplantation, center hemodialysis is still a much more expensive therapy on average. While a failed transplant is particularly expensive, the majority of transplants are currently successful: 75 % of patients receiving cadaver kidneys show I-year graft survival; 90% receiving living related donor kidneys show I-year graft survival. The result of this improvement in transplant success is that, on average, kidney transplants are less costly.1O In terms of CAPD versus center dialysis, Medicare pays a flat and equal rate for both. For both, hospitalization remains costly when it occurs, with CAPD patients hospitalized more for peritonitis, and hemodialysis patients hospitalized for other reasons. (The therapies are compared for frequency of hospitalization below.) Given some cost differences, it is important to try to determine whether patients receiving lowercost ESRD therapies such as transplantation, actually do as well as or better than those patients on the more costly center hemodialysis, and to determine how CAPD differs in terms of quality of life. METHODS

Sample The total number of patients studied was 766, all of whom were nondiabetic, between the ages of 19 and 56 years, and on the present therapy for at least 1 year. Therefore, this study concentrated on "ideal patients" rather than high-risk patients. Differences among therapy groups are not due to the concentration of elderly or diabetic patients in one of the therapeutic regimens. As noted, patients experienced either a successful kidney transplant, a year or more of CAPD, or a year or more of in-center dialysis. * The group of recent transplant patients consisted of 91 recipients who were transplanted between 1980 and 1984 at the University of Minnesota. The group was prospectively randomized to either the conventional regimen (antilymphocyte globulin/ prednisone/azathioprine; N = 40), or cyclosporine/prednisone (N = 51). Patients were measured when they reached 1 year posttransplant. The comparison groups included the following: *It should be noted that we did not have a home hemodialysis comparative group. In terms of cost, home hemodialysis is considered to be inexpensive. In fact, we attempted to secure such a group from the same Midwestern centers that provided the in-center hemodialysis patients. However, given the low proportion of US patients on home hemodialysis, II there was not a large enough number of eligible patients (nondiabetic, age 19 to 56 years) on home hemodialysis for 1 year or longer to be studied. See Evans et al 9 for a comparative study that includes home-dialysis patients.

(1) a historical control of 82 patients who were transplanted at the University of Minnesota between 1970 and 1973, who were 5 to 9 years' posttransplant and had a functioning kidney at the time of data collection; (2) 83 in-center hemodialysis patients from eight Midwestern centers; and (3) a sample of 510 CAPD patients from 185 centers located throughout the United States. This large sample was secured with the help of the National CAPD Registry, which lists almost all CAPD patients. Response rates (completed questionnaires) from eligible patients varied from 81 % to 97% among the four groups. Patients whose transplants failed and were currently on CAPD or hemodialysis were also investigated so that the evaluation of transplantation was not based solely on successful cases. The effects of failed therapy have been presented in more detail elsewhere. 7 The method of data collection involved a survey questionnaire containing both well-validated, closed-ended items7.12-18 and unique open-ended items. Also included were measures used by Evans et al 9 and Johnson et al,19 as well as indicators used on large, normal populations. 20 As this comparison was conducted at one point in time, we cannot be absolutely sure that differences between clinical groups are caused by the therapy. As case mix differences may have played a role, we attempted to control for the most important of these differences, while understanding that some other case mix differences may not have been recognized or controlled.

RESULTS

The overall comparisons among the four groups of ESRD regimens in terms of quality of life are presented below. Insofar as there are differences among the therapy groups, we also attempted to determine whether these differences reflected more than initial variations in case mix. Since patients cannot be randomized to ESRD therapies, it is impossible to be absolutely certain that such social-psychological differences do not result from different types of patients selecting or being guided to alternative therapies. However, we have identified background characteristics that differentiate therapy groups and then statistically controlled these characteristics. Not only do we explore the effects of present therapy, but also the consequences of an unsuccessful transplant. In addition, we compare the quality of life of recent transplant patients randomly assigned to either conventional or cyclosporine immunosuppressive therapy. These topics will be discussed in turn. Comparison of Alternative Therapies

Evidence points to a superior quality of life achieved by ESRD patients with a successful transplant than achieved by hemodialysis or CAPD patients. In addition, when only center hemodialysis and CAPD patients are compared,

QUALITY-OF-LiFE ISSUES FOR ESRO PATIENTS

Table 1.

203

Relationship of Therapy to Quality of Life Mean (SO) Center Hemo (N = 83)

CAPO (N = 510)

Current TX (N = 91)

Historical TX (N = 82)

14.64 (4.13) 3 .90 (9 .74) 3.44 (1 .05)

17.55 (3.43) 2.30 (5.40) 4.26 (.92)

16.95 (4.50)

Health satisfaction (range, 1 to 5)

14.04 (3.62) 3.34 (S.S7) 3.24 (1 .04)

Emotional well-being .25, P < 0.001 Self-esteem scaleB:t (range, 0 to 9) B Happiness scale § (range, 0 to 5) b Bradburn happiness item (range, 1 to 3) 8 Campbell's Index of Well-Being (range, 2.1 to 14.7) Index of general affecf (range, 1 to 7) Overall life satisfactionB (range, 1 to 7)

3.46 (2.67) 1.94 (1 .39) 1.96 (.54) 9 .77 (2.53) 4.72 (1 .27) 4.47 (1.4S)

4.37 (2.7S) 2.33 (1 .67) 2.07 (.61) 10.51 (2.S0) 5.00 (1.49) 5.07 (1.45)

5.11 (2.S3) 3 .06 (1.6S) 2.26 (.63) 11.70 (2.69) 5.47 (1 .39) 5 .64 (1 .32)

5.46 (2.40) 3.33 (1.5S)

.40, P < 0.001 .16, P < 0.05 Social well-being summarl (range, 4 to 16)

10.12 (2.66)

10.48 (3.23)

11 .93 (2.S1)

12.S9 (2.60)

.44, P < 0.0001 Satisfaction with therapy Therapy satisfaction summary8 (range, 1 to 5)

3 .59 (1 .10)

4.59 (.SO)

4.S5 (.54)

4.S5 (.45)

MANOVA*

Oimensiont

.34, P < 0 .001 .24, P < 0 .001 Physical well-being summarl (range, -4 to 21) No. of nights hospitalized past 3 moB

Physical well-being

8

2.17 (.65)

Social well-being

Abbreviations: MANOVA, multivariate analysis of variance; Hemo, hemodialysis; CAPO, continuous ambulatory peritoneal dialysis; TX, transplant. 'Relationship of clusters of indicators to therapy expressed in canonical correlation. tOverall analysis of variance F tests of significance: 8p ::5: 0.001; bp ::5: 0.01. :tNine-item self-esteem scale derived from Rosenberg and Simmons 12 is used throughout. §Five-item happiness scale derived from Rosenberg and Simmons 12 is used throughout.

findings suggest that CAPD patients attain a higher quality of life than hemodialysis patients, although less consistently so. Table 1 presents the basic results of these analyses . First, indicators measuring physical, emotional, and social well-being, as well as satisfaction with current therapy have been organized into clusters. Each of the clusters of variables has been related to therapy type with a multivariate analysis of variance (MANOYA), in order to avoid overinterpretation of individual statistically significant findings. MANOYA is designed to simultaneously test differences among groups on multiple dependent variables. Physical, emotional , social well-being and satisfaction with therapy, as clusters, all

relate significantly with therapy type (P < 0.001), and the sizes of the canonical correlations derived from MANOYA are respectable, varying from .25 to .44 for any given cluster. These findings clearly indicate the existence of differences among therapies along all dimensions of quality of life. Next, with a one-way analysis of variance, the effect of therapy type on each specific variable within the clusters was compared. Table I presents the means and SDs. For all 11 variables, differences among the four therapy groups are statistically significant at the .01 level or better (F test). Last, t tests were used to compare pairs of therapy groups where there were clear (P ~ 0.05) or borderline (P ~ 0 . 10) significant differences

204

SIMMONS AND ABRESS Table 2.

Comparison of Pairs of Therapies for Variables That Show Significant or Almost Significant F Tests (P :s; 0.10) Two·Tailed t Tests of:

Dimension '

Center Hemo vCAPD

Physical well-being Physical well-being summaryB No. of nights hospitalized past 3 moB Health satisfaction a

NS NS NS

P:s; .001 NS P:s; .001

P:s; .001 NS P:s; .001

NS

P:s; .01 P:s; .05 P:s; .10

P:s; .05 P:s; .001 P:s; .01

P:s; .001 P:s; .001 P:s; .001

NS NS NS

P:s; .05

P:s; .001

P:s; .001

NS

P:s; .01

P:s; .001

P:s; .001

P:s; .001

P:s; .001

NS

P:s; .001

P:s; .001

P:s; .05

P:s; .001

P:s; .01

P:s; .001

NS

Emotional well-being Self-esteem scale a Happiness scalea Bradburn happiness item b Campbell's Index of a Well-Being Index of general affectb Overall life satisfaction a Social well-being Social well-being summarl Satisfaction with therapy Therapy satisfaction summarl

CAPD v Current TX

Current TX v Center Hemo

Historical TX v Current TX

Abbreviations: NS, not significant. ' Overall analysis of variance F tests of significance: ap :s; 0.001 ; b p :s; 0.01.

among all four groups. The results of the t tests are presented in Table 2. On all variables, both of the transplant cohorts scored significantly more favorably than either the CAPO or the hemodialysis group (P < 0.05 or better). Comparison of the hemodialysis and CAPO group yielded significant differences at the P ~ 0.05 level on five variables, and a difference of borderline significance (P < 0.10) on one other variable (Tables 1 and 2). Emotional well-being and satisfaction with current therapy are most generally affected, with CAPO patients significantly more satisfied on most measures. On no variable does a paired t test show hemodialysis patients scoring significantly better than CAPO patients. Noting hospitalization on Table 1, we find that this is the only variable favoring hemodialysis. As expected, CAPO patients were more likely to be hospitalized because of peritonitis. Paired comparisons of the two transplant groups show only one significant difference, social wellbeing. However, there is no indication that the current transplant group is faring better on quality of life than the historical group. Vocational rehabilitation, which we classify as an aspect of social well-being, is an essential as-

pect of overall rehabilitation. We believe it is important to separate males and females when analyzing and presenting the data, especially since a housewife without work outside the home may be fully rehabilitated according to the norms in our society. Sharp differences in vocational rehabilitation were found when we compared patients on alternative therapies. Within the total subsample of male patients , 75 % in the historical transplant group, 64 % in the current transplant group, 35 % in the CAPO group, but only 19 % in the hemodialysis group work or attend school full-time (P < 0.0001, X2 test) . Within the total sub sample of females, 36 % of the historical transplant patients work or attend school full-time , compared with 31 % of the current transplant patients, 15 % of the CAPO patients, and 11 % of the hemodialysis patients (P < 0.01, X2 test). The differences in vocational rehabilitation, then , are similar for both genders, but more substantial for males. For males the current transplant group has a large advantage vocationally over the two dialysis groups, and the hemodialysis patients are faring least well. Family and sexual adjustment are two more subdimensions of life quality that we

205

QUALITY-OF-LiFE ISSUES FOR ESRD PATIENTS

studied. Patients were asked to what extent their health had disrupted family routine and also to rate their satisfaction with sexual activity. Across therapy types, family disruption was least among transplant patients and greatest among hemodialysis patients (Ftest, P < 0.0001). Similarly, among married males, the transplant patients report highest sexual satisfaction (P < 0.0001), although there were no significant differences among married females when therapy groups were compared. Differences in family and sexual adjustment persist when statistical controls adjusting for case mix factors are instituted (see next section).

specific advantages of CAPD over hemodialysis become evident only as time on therapy lengthens and/or as patients doing less well switch therapies or die. (While we have controlled for the most important case mix characteristics, it is also possible that some personality characteristics [eg, a propensity for or against risk-taking, a differential ability to cope with stressors, a desire for independence versus dependence] could differentiate those who select one treatment over another and also affect quality-of-life responses. Future research should examine the role of such factors.)

Controlling for Background Factors

Baseline Comparisons

To verify that quality of life differences are due to the therapy itself, rather than initial selection differences, we attempted to locate background characteristics that differentiate therapy groups. Of course, it is impossible to control all selection differences without prior randomization, but it is possible to statistically control for those case mix differences known to exist. These characteristics are age, marital status, sex, race, and education, and, in terms of co-morbidity, years sick before treatment. In addition, as noted, the hemodialysis and transplant groups originated from the Midwest, whereas the CAPD patients represent the national population. To control for race and geographic region, a separate analysis was performed on midwestern white patients; there were too few non-white patients to examine separately. An analysis of covariance (ANCOVA) and multiple classification analysis were used to control for age, gender, education, marital status, and length of illness before treatment among these midwestern white patients. (N = 72 center hemodialysis patients, 131 CAPD patients, 85 current transplant patients, and 78 historical transplant patients.) Similar results were found, although the advantage of CAPD over hemodialysis is less pervasive. One other characteristic differentiating the groups was number of years on therapy. When this factor was also controlled, the results show that current transplant patients continue to exhibit a more favorable adjustment than hemodialysis or CAPD patients. However, among patients on therapy for only 1 to 3 years, CAPD patients no longer demonstrate an advantage over the hemodialysis patients. These results may indicate that

Perhaps the ideal way to control for case mix factors and to study issues of causality would involve a longitudinal study in which patients were followed over time, and baseline pretreatment values would be compared with later states of quality of life. In general, this study does not have this longitudinal component and such comparisons will have to await future research. However, the historical transplant group did have such a longitudinal design, including baseline measurement 3.4; 99 % of these transplant patients were on hemodialysis at the time of the baseline measure. Analysis indicated dramatic improvement on most of these and other measures between the pretransplant and posttransplant periods. 3.4 Successful transplant patients showed dramatic and statistically significant improvement between the pretransplant period and 1 year posttransplant, as well as between the pretransplant period and 5 to 9 years posttransplant (eg, for happiness pretransplant v 1 year posttransplant and pretransplant 5 to 9 years posttransplant, P < 0.01; for self-esteem pretransplant v 1 year posttransplant and pretransplant v 5 to 9 years posttransplant, P < 0.01). The Effect of a Failed Transplant

There is disagreement in the literature on the effects of a failed transplant. Evans et al 9 report that a failed transplant does not seem to make any difference in terms of quality oflife. Johnson et aP9 report that a failed transplant is associated with the least-good quality of life of all. For this analysis, we combined CAPD and hemodialysis patients, then distinguished between those who had a transplant failure and those who did not. All the controls for case selection dif-

206

ferences mentioned above are in place. Findings indicate that patients with a successful transplant, both the current and historical groups, experience a superior quality of life when compared with either the dialysis group that had experienced a transplant failure or the group that had not. On all but two variables, findings comparing all four groups are statistically significant (F test, P < 0.05). More to the issue, the dialysis group with the failed transplant scored less favorably than the dialysis group without a failed transplant. However, it should be noted that before the institution of the controls mentioned in the previous section, no clear direction between these two groups was found. The separate examination of midwestern whites and the use of other control variables as covariates showed a consistent pattern of disadvantage for patients with a failed transplant. The subdimensions of sexual and family adjustment were examined to discern the effect a failed transplant may have in each of these areas. We found that among married male dialysis patients (both center hemodialysis and CAPD combined) sexual satisfaction was adversely affected by a failed transplant. In the area of vocational rehabilitation, the results are similarly negative for the effect of a failed transplant on males. Comparing male dialysis patients without a prior transplant with male dialysis patients who have had a prior failed transplant, there is a significant difference in the proportion at full-time work or school (36% v 26%, x 2 test, P < 0.05). Comparison to Normal Controls

Patients who score objectively low on indicators of health may still indicate close to normal scores on subjective quality of life according to the research of both Evans et al 9 and Johnson et al. 19 Our research demonstrates that, in fact, successful transplant patients score slightly higher than national normal controls on the Campbell subjective indices of well-being measures. The same findings are reported in both Johnson's and Evans' studies. Using the Campbell Index of Well-Being, we found that the difference between the current transplant cohort and normal controls is not statistically significant (t test, P > 0.10). It is possible that these high values for transplant patients reflect what Reichsman and Levy21 have termed a "honeymoon effect." That is, the transplant patients are still comparing themselves to the way they felt

SIMMONS AND ABRESS

when they were ill with kidney disease and, at least temporarily, are particularly happy to have been so well rescued. This would be an example of high scores being affected by the point of comparative reference. In any case, while transplant patients score close to normal, both the CAPD and hemodialysis groups score significantly lower than normal on the Index of Well-Being (t test, P < 0.001). CYCLOSPORINE VERSUS CONVENTIONAL THERAPY

Patient and graft survival did not significantly differentiate patients randomized to cyslosporine and patients randomized to conventional immunosuppressive therpay, all of whom were part of the recent transplant cohort. Graft survival for both groups is greater than 80%, and patient survival ranged from 95 % to 98 %. However, the cyclosporine group scored consistently higher on all physical, emotional, and social well-being measures (with the exception of males' vocational rehabilitation); among these ten relevant indicators of quality of life, five were significant at P ~ 0.05. However, in terms of vocational rehabilitation, there is no advantage for male patients randomized to cyclosporine. Yet, female patients on cyclosporine are more likely to be working or in school (43% v 9%; Fisher's exact test, P = 0.056). ANCOVA indicates that the major reason for the greater well-being of cyclosporine patients is due to their lower incidence of infection and rejection. As predicted, there are negative correlations between infection and rejection rate and many of the quality-of-life variables. Therefore, using the number of infections and rejections as covariates in an ANCOVA, we found that all ofthe significant differences between the cyclosporine and conventional groups noted earlier are reduced to a level of nonsignificance. However, the difference in direction remains constant and two differences approach significance (P ~ 0.10). Consequently, infection and rejection appear to be important mediating factors, although they are probably not the only mediating factors in explaining these differences. SUMMARY AND CONCLUSION

The findings presented here for nondiabetic patients age 19 to 56 years, which highlight the higher quality of life after a successful transplant,

207

QUALITY-OF-LiFE ISSUES FOR ESRD PATIENTS

have policy relevance in a variety of ways. It is also noteworthy that our findings replicate those of Evans et al. 9 Evans et al 9 point to the higher objective and subjective quality of life of transplant patients compared with patients undergoing any other form of dialysis. Unlike us, Evans et al also included a home hemodialysis comparison and report that these patients, in contrast to in-center hemodialysis patients or CAPD patients, most resemble transplant patients. While many of these findings also confirm clinical impressions, it is often true that, when measured quantitatively, impressions turn out to be myths. Thus, the fact that these quantifications in many, but not all, cases verify some clinical impressions and replicate some prior research, does not lessen their importance. In terms of policy implications, vocational rehabilitation is a particular area of concern. Although transplant patients are the most likely to be working full-time, it appears that regulations concerning disability payments under the ESRD program operate as disincentives for employment. Fiftyone percent of CAPD patients in our study agreed that some CAPD patients do not work because they are worried they will lose Social Security/disability payments. Clearly not all ESRD patients can be transplanted. On the one hand, there are cadaver organ shortages and positive cross-matches against the pool of donors limiting access to transplantation. On the other hand, there is often a reluctance in some centers to use living related donors, as well as physicians advising patients to undergo one therapeutic regimen versus another for a variety of

reasons. Nevertheless, in this country a great number of patients are being maintained on the more expensive in-center dialysis. It seems to us that more of these patients could be transplanted. Realizing that societal policies and laws do influence the distribution of therapies, we suggest that one factor to be considered should be the comparative quality of life of the patients. There is considerable room for future research in the area of quality oflife. Suggestions for future research have been made throughout this report. While it is clear that different levels of quality of life are experienced on these different therapies, determining the extent to which these differences are caused by the therapies would benefit from additional research. Research that controls for additional variables as well as longitudinal designs would be helpful. In addition to these suggestions, it would be valuable in future research to attempt to predict what types of patients do better on each therapy. Also, analysis of the aspect of the therapy that affects life quality would be valuable-to what extent is the level of independence responsible; to what extent is it the objective degree of energy, or feelings of illness, or differences in the expectations brought to different therapeutic regimens? Where expectations are higher, there is more room for perceived failure on the one hand; on the other hand, there is also a likelihood of a self-fulfulling prophecy in which high expectations lead to higher performances. With more knowledge about the personal characteristics of the patients and the aspects of the therapy responsible for success, changes and recommendations for therapeutic choice could be made with more confidence.

REFERENCES 1. Simmons RG, Kamstra-Hennen L, Thompson CR: Psycho-social adjustment five to nine years posttransplant. Transplant Proc 13:40-43, 1981 2. Simmons RG, Andcerson CR: Related donors and recipients five to nine years posttransplant. Transplant Proc 14:9-12, 1982 3. Simmons RG: Long-term reactions of renal recipients and doinors, in Levy NB (ed): Psychonephrology 2. New York, NY, Plenum, 1983, pp 275-287 4. Simmons RG, Marine SK, Simmons RL: Gift of Life: The Effect of Organ Transplantation on Individual, Family and Societal Dynamics. New Brunswick, NJ, Transaction, 1987 5. Simmons RG, Anderson CR, Kamstra LK: Comparison of quality of life of patients on CAPD, hemodialysis and transplantation. Am J Kidney Dis 4:253-255, 1984 6. Simmons RG, Abress L, Anderson CR: Quality of life after kidney transplantation: A prospective, randomized com-

parison of cyclosporine and conventional immunosuppressive therapy. Transplantation 45:415-421, 1988 7. Simmons RG, Anderson CR, Abress LK: Quality of life and rehabilitation differences among four end-stage renal disease therapy groups. Acta Scand (in press) 8. Simmons RG, Abress L, Anderson CR: Rehabilitation after kidney transplantation, in Cerilli JG (ed): Organ Transplantation and Replacement. Philadelphia, PA, Lippincott, 1988, pp 481-489 9. Evans RW, Manninen DL, Garrison JP Jr, et al: The quality of life of patients with end-stage renal disease. N Engl J Med 312:553-559, 1985 10. Health Care Financing Administration: End-stage renal disease program medical information system, facility survey tables. Department of Health Services, HCFA, January I-December 31, 1984; also personal communication with Dr Paul Eggers, HCFA

208 11. Marine SK, Simmons RG : Policies regarding treatment of end-stage renal disease in the United Kingdom. J Technol Assess Health Care 2:253-274, 1986 12. Rosenberg M, Simmons RG : Black and White Self-Esteem: The Urban School Child . Washington, DC, American Sociological Association , 1972 13 . Rosenberg M: Society and the Adolescent Self-Image. Princeton, NJ , Princeton University, 1965 14. Bradburn NM : The Structure of Psychological Well-Being. Chicago, IL, Aldine, 1969 IS. Veroff J, Kulko RA, Douvan E: Mental Health in America: Patterns of Help-Seeking From 1957 to 1976. New York, NY, Basic Books, 1981 16. Robinson Jp, Shaver PR: Measures of Social Psychological Attitudes. Appendix B to Measures of Political Attitudes .

SIMMONS AND ABRESS Ann Arbor, MI, University of Michigan, Survey Research Center, Institute for Social Research, 1969 17. Wylie RG: The Self-Concept: A Review of Methodological Considerations and Measuring Instruments (vol I) . Lincoln, NE, University of Nebraska, 1974 18. Wells LE, Marwell G: Self-Esteem: Its Conceptualization and Measurement. Beverly Hills, CA, Sage, 1976 19. Johnson Jp, McCauley CR, Copley JB: The quality of life of hemodialysis and transplant patients. Kidney lnt 22:286291, 1982 20. Campbell A, Converse PE, Rodgers WL: The Quality of American Life. New York, NY, Russell Sage, 1976 21 . Reichsman F, Levy NB: Problems in adaptation to maintenance hemodialysis. A four year study of 25 patients, in Levy NB (ed): Living or Dying: Adaptation to Hemodialysis. Springfield, IL, Thomas, 1974, pp 30-49