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Renal failure, dialysis and transplantation

Cambridge Handbook of Psychology, Health and Medicine

The treatment of chronic renal failure

A chronic loss of kidney function may be caused by a number of factors, these commonly
include diabetes, glomerulonephritis, chronic hypertension and familial polycystic renal disease
(see ‘Diabetes mellitus’ and ‘Hypertension’). A decline in renal function causes a gradual
accumulation of the body’s waste products and this is indicated by increasing levels of urea and
creatinine in the blood. The metabolic disturbance accompanying renal failure leads to a
number of physical symptoms, most notably lethargy and drowsiness, nausea and vomiting, as
well as anorexia (see ‘Vomiting and nausea’).
The point at which patients are offered dialysis as a treatment for renal failure can vary
according to the different policies of renal units, but treatment is typically instituted when the
patient’s renal symptoms reach a level that interferes with their ability to carry out their work or
normal daily functions. Earlier treatment is associated with better survival and a preservation of
nutrition. Some patients with a particularly poor medical prognosis, or with other major health
problems that interfere with successful adaptation to a life on dialysis, may be advised against
treatment.
Haemodialysis and continuous ambulatory peritoneal dialysis (CAPD) are the two types of
dialysis treatment used to correct the on-going effects of kidney failure. In haemodialysis, the
patient’s blood is passed through an artificial kidney machine that removes waste products by
passing the blood across a semi-permeable membrane. Most patients on haemodialysis must
dialyse three times a week for between four and six hours. Often this can be done
independently by the patient in their own home or through coming in to a dedicated hospital
haemodialysis unit.
CAPD works according to the same general principle as haemodialysis but the whole process is
conducted inside the body. In CAPD, dialysis fluid is run into the peritoneal cavity via a surgically
implanted catheter. The peritoneum is a large semi-permeable membrane that lines the cavity,
and once the dialysis fluid has been run in, it is left to exchange substances with the patient’s
blood. The fluid is drained after about 4–6 hours and the whole cycle is repeated each day, on
three or four occasions. Improved rates of survival and correction of anaemia, as well as a more
liberal diet, are features of CAPD. The choice between haemodialysis and CAPD is an
important one for patients with each treatment having both advantages and disadvantages that
have to be set against the patient’s social and occupational circumstances.
The transplantation of a kidney from a cadaver or a living relative is the other treatment option
for renal failure patients. The introduction of a new generation of immunosuppressive drugs has
resulted in improved rates of graft function; now, with these drugs, 90% of kidney transplants
from a deceased donor are successful. Transplantation is generally recognized as the best
treatment available for end-stage renal failure. Freed from the drudgery of dialysis and the
symptoms of kidney failure, transplant patients report significantly higher quality of life and have
lower rates of psychological problems (Gudex, 1995) (see ‘Quality of life’). However, there are
some disadvantages to transplantation in terms of the need to take long-term medication and
increased rates of malignancy. The possibility of coping with a failed graft for patients is a
significant psychological blow, and one some patients do not want to risk facing again. A failed
graft is often particularly traumatic when the kidney has been donated by a relative.
Unfortunately, the demand for kidneys is outstripped by their availability, which consigns a
sizeable proportion of patients to long-term dialysis. The impending arrival of successful
xenografts may overcome the current shortage of kidneys but will undoubtedly bring with it
additional psychological adjustment problems.
Psychological problems and quality of life
The difficulties inherent in renal disease are a function of the physiological consequences of
kidney failure, the restrictions imposed by a relentless dialysis regimen and the ongoing
psychological adjustments required by a chronic illness. One of the most disabling effects of
end-stage renal disease (ESRD) is lethargy and tiredness. This interferes not only with daily
work function, but also with family relationships, as the patient often lacks the energy to engage
in previously enjoyed social activities. A reduction in sexual activity is also common in ESRD
(see ‘Sexual dysfunction’). Patients on dialysis also complain of a variety of other physical
symptoms such as itchy skin and sleep problems that interfere with their daily life (see ‘Sleep
disorders’). The recent development of recombinant human erythropoietin that acts to raise the
oxygen-carrying capacity of the blood has had a major impact on treatment of ESRD by
reducing tiredness and other symptoms due to anaemia.
The process of dialysis treatment also creates difficulties that compromise wellbeing. Most
common among these are problems with the fluid and diet restrictions required, the
development of needle stick fears in haemodialysis patients, and trouble with dialysis technique
that can result in periodic infections. Often patients’ frustrations with their condition and ongoing
dialysis show themselves in compliance problems with the treatment, diet and fluid restrictions.
Non-compliance is a major problem in patients on dialysis as the regimen has many of the
characteristics that work to decrease compliance (see ‘Adherence to treatment’). The treatment
is complex, long-lasting and directly impacts on the patient’s lifestyle. Non-compliance can also
lead to conflict between staff and patients. Staff may become aggravated with patients who are
perceived as not doing their share in managing their condition and, conversely, patients can
come to see staff as representing an enforcement rather than a therapeutic role. This can result
in patients feeling unable to bring up their personal difficulties and problems with staff. There is
some evidence that behavioural programmes utilizing self-monitoring and reinforcement can
improve the level of adherence to fluid restrictions among haemodialysis patients (Christensen
et al., 2002) (see ‘Behaviour therapy’).
Given this combination of physiological and psychological problems it is not surprising to find
higher rates of psychiatric problems and impaired wellbeing in dialysis groups when compared
to renal transplant patients and general population groups (Gudex, 1995). Uncertainty about the
future and a lack of energy seem to be important factors in contributing to the differences in
reported quality of life between patients on dialysis and the general population. Compared with
transplant patients, patients on dialysis report a poorer quality of life, more problems with
activities of daily living and significantly more negative emotions such as anxiety and depression
(Cameron et al., 2000; Gudex, 1995; Petrie, 1989). Despite the difficulties in assessing
depression in dialysis patients because of the overlap in somatic symptomotology, high levels of
depression have been consistently found in dialysis patients (Kimmel, 2002; Levenson &
Glocheski, 1991).
Adjustment to treatment
The adjustment to treatment for renal failure shares similar characteristics to other chronic
illnesses. The first part of this process involves coping with a loss of body function and an
awareness of the need for long-term treatment. The next phase is learning the techniques
associated with dialysis and dealing with the restrictions that this routine places on daily life and
relationships. The final phase is an incorporation of the changes in appearance, function and
lifestyle necessary with treatment into a new self-image and identity. The ability of patients to
deal with each of these stages varies quite significantly depending on their own psychological
resources. Difficulties in the early stages can have considerable impact on eventual adjustment
to dialysis. A common emotional reaction is that of denial. This may range from a reluctance to
accept that dialysis is really necessary to a casualness in using proper dialysis technique, or
frequent breaking of dietary and fluid restrictions later in the treatment process (see also
‘Coping with chronic illness’).
A number of psychosocial factors have been shown to be associated with adherence to dialysis
and dietary restrictions. These include lower levels of social support, the patient’s negative
perception of their illness and lower patient satisfaction with the care from their medical
specialist (Kimmel et al., 1998; Kovac et al., 2002) (see ‘Social support and health’, ‘Lay beliefs
about health and illness’ and ‘Patient satisfaction’). Recent work also suggests patients’ own
ideas about the cause of renal failure and the effectiveness of treatment may be promising
areas for future research on adherence to dietary and fluid restrictions (Krespi et al., 2004).
The treatment of renal failure creates considerable difficulties for patients and their families.
They must adapt to the loss of a bodily function and the accompanying energy-sapping
symptoms. Given the demands and restrictions of life on dialysis as well as the psychological
issues of dependency and an uncertain future, the surprising aspect is perhaps not how many
patients become depressed but how resilient the majority are to the demands and restrictions of
renal disease.
REFERENCES
● Cameron, J. I., Whiteside, C., Katz, J. & Devins, G. M. (2000). Differences in quality of life
across renal replacement therapies: a meta-analytic comparison. American Journal of
Kidney Disease, 35, 629-37.
● Christensen, A. J., Moran, P. J., Wiebe, J. S., Ehlers, S. L. & Lawton, W. J. (2002). Effect
of a behavioural self-regulation intervention on patient adherence in hemodialysis. Health
Psychology, 21, 393-7.
● Gudex, C. M. (1995). Health-related quality of life in endstage renal failure. Quality of Life
Research, 4, 359-66.
● Kimmel, P. L., Peterson, R. A., Weihs, K. L. et al. (1998). Psychosocial factors,
behavioural compliance and survival in urban haemodialysis patients. Kidney
International, 54, 245-54.
● Kimmel, P. L. (2002). Depression in patients with chronic renal disease: What we know
and what we need to know. Journal of Psychosomatic Research, 53, 951-6.
● Kovac, J. A., Patel, S. S., Peterson, R. A. & Kimmel, P. L. (2002). Patient satisfaction with
care and behavioural compliance in end-stage renal disease patients treated with
haemodialysis. American Journal of Kidney Diseases, 39, 1236-44.
● Krespi, R., Bone, M., Ahmad, R., Worthington, B. & Salmon, P. (2004). Haemodialysis
patients’ beliefs about renal failure and its treatment. Patient Education and Counseling,
 53, 189-96.
● Levenson, J. L. & Glocheski, S. (1991). Psychological factors affecting end-stage renal
disease: a review. Psychomsomatics, 32, 382-9.
● Petrie, K. J. (1989). Psychological well-being and psychiatric disturbance in dialysis and
renal transplant patients. British Journal of Medical Psychology, 62, 91-6.
Keith J. Petrie
The University of Auckland

© Cambridge University Press 2007

APA citation:
Petrie, K. J. (2007). Renal failure, dialysis and transplantation. In S. Ayers, A. Baum, C.
McManus, & et. al. (Eds.), Cambridge handbook of psychology, health and medicine (2nd ed.).
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