Low Health Literacy Is Associated with Poorer Physical and Mental Health-Related Quality of Life in Dialysed Patients.

Health-related quality of life (HRQoL) is an important health indicator in chronic diseases like kidney diseases. Health literacy (HL) may strongly affect HRQoL, but evidence is scarce. Therefore, we assessed the associations of HL with HRQoL in dialysed patients. We performed a cross-sectional study in 20 dialysis clinics across Slovakia (n = 542 patients, mean age = 63.6 years, males = 60.7%). We assessed the association of categorised HL (low, moderate, high) with the SF36 physical component score (PCS) and mental component score (MCS) using generalised linear models adjusted for age, gender, education, and comorbidity (Charlson Comorbidity Index, CCI). We found significant associations of HL with PCS and MCS in dialysed patients, adjusted for age, gender, education, and CCI. Low-HL patients had a lower PCS (B = -3.27, 95%-confidence interval, CI: -5.76/-0.79) and MCS (B = -6.05, 95%-CI: -8.82/-3.29) than high-HL patients. Moderate-HL patients had a lower MCS (B = -4.26, 95%-CI: -6.83/-1.69) than high-HL patients. HL is associated with physical and mental HRQoL; this indicates that dialysed patients with lower HL deserve specific attention and tailored care to have their HRQoL increased.

Health Literacy and Change in Health-Related Quality of Life in Dialysed Patients.

Health-related quality of life (HRQoL) is likely to deteriorate with the progression of chronic kidney disease (CKD). This change may be worsened by low health literacy (HL). We performed a longitudinal study at over 20 dialysis clinics in Slovakia (n = 413; mean age = 64.8 years; males = 58.4%). We assessed the association of three HL groups with a change in HRQoL over two years using binary logistic regression adjusted for type of vascular access, dialysis effectiveness, comorbidity, age and gender. We found that patients with low HL had poorer HRQoL at baseline in comparison to high-HL patients. We did not find significant associations of lower HL with the deterioration of mental or physical HRQoL after two years. In the adjusted model, patients with lower HL were not more likely to have deteriorated physical (low-HL patients: odds ratio/95% confidence interval: 0.99/0.53-1.84; moderate-HL patients: 0.97/0.55-1.73) or mental HRQoL (low-HL patients: 1.00/0.53-1.87; moderate-HL patients: 0.95/0.53-1.70) in comparison to high-HL patients. The HRQoL of lower-HL patients is worse at baseline but develops similarly to that of high-HL patients during dialysis treatment. Their relative HRQoL, thus, does not worsen further, but it does not improve either. Tailoring care to their needs may help to decrease the burden of low HL in dialysed patients.

Health-Related Quality of Life Profiles in Dialyzed Patients With Varying Health Literacy. A Cross-Sectional Study on Slovak Haemodialyzed Population.

Objectives: Chronic kidney disease (CKD) strongly affects patients' health-related quality of life (HRQoL), mostly in the advanced stages of CKD. Health literacy (HL) may affect this association, in particular for some aspects of HRQoL. The aim of this study is to compare the profiles of HRQoL in dialyzed patients with varying HL. Methods: We obtained data on HL using the Health Literacy Questionnaire (HLQ) and on HRQoL using the Kidney Disease Quality of Life - Short Form (KDQoL-SF 1.3) in a multicentre cross-sectional study in 20 dialysis clinics in Slovakia (n = 542; mean age = 63.6 years; males: 60.7%). We compared HRQoL for three HL groups using ANOVA and the Kruskal-Wallis test. Results: Patients with low HL reported worse HRQoL than patients with moderate and high HL. The greatest differences between HL groups were found in the scales Effect of kidney disease, Cognitive function, Quality of social interaction, Social support, Dialysis staff encouragement, Patient satisfaction, Physical functioning, Pain, Emotional well-being and Social function. p-values in all cases were <0.001. Conclusion: Patients with low HL have a worse HRQoL in several domains than patients with a higher HL. Increasing HL capacities and better supporting patients with low HL should thus be given priority to support their HRQoL and at least maintain its level.

Does Depression and Anxiety Mediate the Relation between Limited Health Literacy and Diet Non-Adherence?

Limited health literacy (HL), depression and anxiety are common in dialyzed patients and affect health outcomes and self-management. We explored whether depression and anxiety mediate the association of HL with diet non-adherence (DN-A) in dialyzed patients. We performed a cross-sectional study in 20 dialysis clinics in Slovakia (n = 452; mean age: 63.6 years; males: 60.7%). Hierarchical cluster analysis was performed to create three HL groups. Logistic regression adjusted for age, gender and education was used to explore whether depression and anxiety mediate the association of HL with DN-A. Patients in the moderate HL group were more likely to be non-adherent to diet (OR (Odds Ratio)/95% CI: 2.19/1.21-3.99) than patients in the high HL group. Patients in the low HL and moderate HL group more likely reported depression or anxiety. Patients reporting depression (OR/95% CI: 1.94/1.26-2.98) or anxiety (OR/95% CI: 1.81/1.22-2.69) were more likely to be non-adherent with diet. Adjustment for depression reduced the association between moderate HL and DN-A by 19.5%. Adjustment for anxiety reduced the association between moderate HL and DN-A by 11.8%. Anxiety and depression partly mediated the association of HL with DN-A. More attention should be paid to treating patients' psychological distress to ensure adequate adherence with recommended diet.

Vascular access as a survival factor for the hemodialysis population: a retrospective study.

BACKGROUND: The creation of vascular access is an essential condition for providing hemodialysis, which remains the only option for most patients suffering from end-stage renal disease. Selection of the type of vascular access affects patients' clinical outcomes, access maintenance frequency, risk of infection and major adverse cardiac events during dialysis. To improve the decision-making process, we performed a retrospective clinical data analysis of dialyzed patients and critically compared the survival rates between two types of vascular access applied during dialysis therapy during a 5 years follow-up period. METHODS: Using nationally representative data from 18 dialysis centers across Slovakia, we explore and compare survival rates of 960 adult patients undergoing hemodialysis using either a central venous catheter (CVC) or an arteriovenous fistula (AVF). Length of dialysis, protein malnutrition and comorbidities were examined as possible covariates that might influence survival rates. RESULTS: Chances of surviving for a one-year period were higher by 52% in AVF patients compared to CVC patients (HR 1.52; 95% CI 1.27-1.83; P<0.001) regardless of age, sex, nutritional status, time spent on dialysis and comorbidities. The presence of cardiac congestion (HR 1.26 [95% CI 1.06-1.50], P<0.01) and malnutrition (protein malnutrition: HR 0.98 [95% CI 0.96-1.00], P<0.05; lean tissue index: HR 0.79 [95% CI 0.67-0.93], P<0.01) decreases chances for survival. CONCLUSIONS: A functional arteriovenous fistula is a significant predictor of survival in the population dependent on hemodialysis, independently of sociodemographic parameters and serious comorbidities. Therefore, if various types of vascular accesses are applicable for the patient, AVF should be prioritized over CVC.

Does Health Literacy of Hemodialyzed Patients Predict the Type of Their Vascular Access? A Cross-Sectional Study on Slovak Hemodialyzed Population.

Effective vascular access (VA) is an essential condition for providing hemodialysis, affecting patients' health outcomes. We aim to explore how health literacy (HL) as a non-clinical factor is associated with the decision-making process regarding VA type selection. Using data from 20 dialysis centers across Slovakia (n = 542, mean age = 63.6, males = 60.7%), the association of HL with type of VA (arteriovenous fistula (AVF) vs. central venous catheter (CVC)) was analyzed using a logistic regression model adjusted for sociodemographic characteristics and comorbidity. Sociodemographic data and data on nine domains of HL were collected by questionnaire. Data on VA and comorbidity were obtained from a medical records. Patients with a greater ability to engage with healthcare providers (odds ratio (OR): 1.34; 95% confidence interval (CI): 1.00-1.78), those with a better ability to navigate the healthcare system (OR: 1.41; 95% CI: 1.08-1.85), those more able to find good health information (OR: 1.52; 95% CI: 1.15-2.03), and those who understand it well enough to know what to do (OR: 1.52; 95% CI: 1.12-2.06) are more likely to have AVF. Patients' HL is associated with the type of VA; therefore, it should be considered in the decision-making process regarding the selection of the type of VA, thereby informing strategies for improving patients' HL and doctor-patient communication.

Is Health Literacy of Dialyzed Patients Related to Their Adherence to Dietary and Fluid Intake Recommendations?

Non-adherence to dietary and fluid intake recommendations (NADFIR) is an important factor for the effective treatment of dialyzed patients and may be hindered by low health literacy (HL). Therefore, we assessed whether low HL of dialyzed patients is associated with their NADFIR. We performed a multicentric cross-sectional study in 20 dialysis clinics in Slovakia (n = 452; response rate: 70.1%; mean age = 63.6 years; males: 60.7%). We assessed the association between nine domains of HL and non-adherence (high serum potassium, high serum phosphate, relative overhydration, and self-reported NADFIR) using general linear models adjusted for age and gender. Moreover, we assessed the moderation by socioeconomic status (SES). We found higher NADFIR among patients with less sufficient information for health management (high serum phosphate level; odds ratio (OR): 0.77; 95% confidence interval (CI): 0.63-0.94), with a lower ability to actively manage their health (self-reported diet non-adherence; OR: 0.74; 95% CI: 0.62-0.89), and those less able to actively engage with healthcare providers (overhydrated; OR: 0.78; 95% CI: 0.65-0.94). Moreover, SES modified this relation. Low HL affects the adherence of dialyzed patients. This shows a need to support patients with low HL and to train healthcare providers to work with these patients, taking into account their SES.

Health Differences between Roma and Non-Roma in the Slovak Dialyzed Population.

BACKGROUND: Roma health has not been studied systematically. Thus far, it has been shown that Roma compared to non-Roma have a significantly higher likelihood of getting end-stage renal disease and that their chances for survival on dialysis are lower. Evidence is lacking regarding morbidity between Roma and non-Roma. The aim was to compare the health status of dialyzed Roma and non-Roma using the Charlson comorbidity index (CCI). All Slovak dialysis centers for adults were asked to fill in a questionaire with demographic and clinical data, including comorbidity. Cross-sectional analysis of 2082 patients with an average age of 63.8 ± 13.8 years was performed. Comorbidity was expressed as the CCI, and ethnic differences were calculated. Linear regression was performed to adjust for differences in gender and age in both ethnic groups. Roma represented 13.0% of the whole dialyzed population (n = 270). Comorbidity expressed as CCI was significantly lower in the Roma population (p < 0.001). After adjusting for gender and age, ethnicity failed to be associated with the CCI in the linear regression analysis (p = 0.965, variance of the model-adjusted R² 38.6%). The health status of dialyzed Slovak Roma does not differ cross-sectionally when adjusted for age and gender from the health status of dialyzed non-Roma.

Posttransplant Anemia as a Prognostic Factor of Mortality in Kidney-Transplant Recipients.

Background. Findings on the association between posttransplant anemia (PTA) and mortality in posttransplant patients are scarce. This study explored whether PTA shortly after kidney transplantation (KT) predicts mortality at up to 10 years' follow-up, stratified for chronic kidney disease (CKD) stages. Methods. PTA was divided into 3 categories according to the hemoglobin (Hb) value: severe (Hb < 10 g/dl), mild (10.0 g/dl ≤ Hb < 11.9 g/dl), or no PTA (Hb ≥ 12 g/dl). CKD stages were estimated using the CKD-EPI formula and divided into 2 groups: CKD1-2 and CKD3-5. Cox regression, stratified according to CKD, was performed to identify whether different categories of PTA predicted mortality in KT recipients. Results. Age, being female, and both mild and severe PTA contributed significantly to the Cox regression model on mortality in CKD1-2. In the Cox regression model for mortality in CKD3-5, age and severe PTA contributed significantly to this model. Conclusion. PTA shortly after KT increased the risk of mortality at up to 10 years' follow-up. Even mild PTA is associated with a 6-fold higher risk of mortality and severe PTA with a 10-fold higher risk of mortality in CKD1-2. Clinical evaluation and treatment of anemia might reduce the higher risk of mortality in patients with PTA in early stages of CKD after KT.

Anemia has a negative impact on self-rated health in kidney transplant recipients with well-functioning grafts: findings from an 8-year follow-up study.

PURPOSE: Anemia is a predictor of mortality and of self-rated health (SRH). However, studies on the relationship between SRH and changes in hemoglobin (Hb) value over time stratified by chronic kidney disease (CKD) stages are lacking. The aim is to explore whether a change in Hb-value over time associates with SRH at up to 8-year follow-up, stratified for CKD stages. METHODS: A prospective study with a baseline measurement between the 3rd and 12th month after KT was performed on 337 consecutive patients. Demographic and clinical data were retrieved from medical records. CKD stages were estimated using the CKD-EPI formula and divided into two groups: CKD1-2 and CKD3-5. Generalized estimating equations (GEE) were performed to identify associations of SRH at follow-up in both CKD groups. RESULTS: Male gender, new-onset diabetes mellitus after KT (NODAT), a decrease in estimated glomerular filtration rate (eGFR) and Hb-value over time contributed significantly to the GEE model on SRH at follow-up in CKD1-2. For SRH at follow-up in CKD3-5, older age, male gender and chronic renal allograft dysfunction (CRAD) contributed significantly to the GEE model. CONCLUSIONS: At up to 8-year follow-up, male gender, NODAT, a decrease in eGFR and Hb-value over time are associated with poorer SRH in CKD1-2. In such patients, we suggest monitoring slight deteriorations in eGFR and Hb-values. In CKD3-5, higher age, male gender and higher presence of CRAD are associated with poorer SRH at up to 8-year follow-up. In these patients, adequate treatment would slow down CRAD progression.

Social participation after kidney transplantation as a predictor of graft loss and mortality over 10 years: a longitudinal study.

BACKGROUND: Social participation is considered to be an objective parameter for evaluating the success of transplantation. This study explores the association between posttransplant factors (kidney function, perceived side effects of immunosuppressive treatment, comorbidity, physical and mental health-related quality of life [HRQoL]) and social participation in patients 3 months to 6 years after kidney transplantation (baseline) and their impact on graft loss and mortality for up to 10 years (follow-up). METHODS: At baseline, 331 patients provided their socioeconomic and medical data (comorbidity, kidney function) and completed the end-stage renal disease symptom checklist (perceived side effects), the Short Form Health Survey-36 and the Participation Scale. At follow-up, information on all-cause graft-loss and mortality was noted. Binary logistical regression exploring the effects of the independent variables on social participation and Cox regression analyses determining whether social participation predicted graft loss and mortality were performed. RESULTS: Restrictions in social participation were associated with living alone, poorer kidney function, lower perceived side effects of corticosteroids, higher perceived cardiac and renal dysfunction, higher perceived posttransplantation distress, lower physical HRQoL, and fewer working hours. Restrictions in social participation increased the risk of all-cause graft loss 2.29-fold and the risk of all-cause mortality 11.94-fold during follow-up. Education, kidney function, and comorbidity also increased the risk for poor patient outcome. CONCLUSION: Kidney function, perceived side effects, comorbidities, and HRQoL affect social participation in patients after kidney transplantation. Additionally, social participation has a positive effect on long-term patient outcomes, decreasing the odds of graft loss and mortality over 10 years.

Higher prevalence of nephropathy in young Roma females compared with non-Roma females.

OBJECTIVES: Ethnic differences in the prevalence of various chronic diseases, including end-stage renal disease, have been previously reported. Surprisingly, data focusing on the lower grade of chronic kidney disease (CKD) are scarce. Thus, the aim of this study was to explore differences in the prevalence of nephropathy between the Roma and non-Roma populations. METHODS: Data from the cross-sectional population based HepaMeta study conducted in Slovakia were used. Nephropathy was defined as: a known history of any kidney disease; or the presence of proteinuria/hematuria; or glomerular filtration rate (GFR) < 60 ml/min. The odds ratio for the prevalence of nephropathy was calculated using binary logistic regression. RESULTS: In an age-adjusted model, Roma females had OR of 1.56 for having nephropathy over non-Roma females (OR 1.56; 95% CI 1.01-2.42; p < 0.05). In addition, Roma females had a significantly lower GFR (mean difference 3.4 ml/min, t = -3.58, p < 0.001); all female patients with proteinuria were Roma. CONCLUSIONS: This cross-sectional study on the young general population found that Roma females have half-higher odds for nephropathy than non-Roma females. Therefore, to prevent risks we should focus on searching for ethnic, social and medical determinants of CKD. Interventions to decrease the incidence of CKD in the target population should also address ethnic inequalities as well as female gender.

Adherence in patients in the first year after kidney transplantation and its impact on graft loss and mortality: a cross-sectional and prospective study.

AIMS: To explore the predictive value of adherence to their immunosuppressive medication in kidney transplant recipients in the first year after kidney transplantation as a determinant of graft loss and mortality up to 12 years (prospective analysis) and its association with sociodemographic and medical factors and social support (cross-sectional analysis). BACKGROUND: Poor adherence to their immunosuppressive medication in kidney transplant recipients remains the leading preventable cause of poor patient outcomes. DESIGN: Prospective and cross-sectional study. METHODS: At baseline, 325 patients 3-12 months posttransplantation were invited to participate. Adherence was assessed using collateral reports - a combination of patients' self-evaluation and an estimate by their nephrologist. The patients provided sociodemographic and medical data and completed the End-Stage Renal Disease Symptom Checklist and Multidimensional scale of perceived social support. At follow-up (average 7·1 years), data on patients and graft survival were obtained. All data were collected from 2002-2013. Multinomial regression analysis and Cox regression were performed. RESULTS: A total of 297 patients (48·1 (12·8) years, 61·6% men) agreed to participate (response rate 91·4%); 67·4% were considered as fully adherent. Poor adherence was associated with higher risk of graft loss and mortality over 12 years. Female sex, higher education, higher perceived side effects of corticosteroids, better perceived cardiac and renal function and higher perceived family social support in the first year posttransplantation were associated with full adherence to immunosuppressive treatment. CONCLUSIONS: Patients with poor adherence to the immunosuppressive medication in the first year after kidney transplantation showed increased likelihood of graft loss and death over 12 years compared with the adherent patients.

Body composition monitor assessing malnutrition in the hemodialysis population independently predicts mortality.

OBJECTIVE: Malnutrition is a known predictor of mortality in the general and hemodialysis populations. However, diagnosing malnutrition in dialysis patients remains problematic. Body composition monitoring (BCM) is currently used mainly for assessing overhydratation in hemodialysis patients, but it also offers the possibility of evaluating nutrition status. This study explored whether malnutrition diagnosed by BCM predicts mortality at up to 54 months follow-up in prevalent hemodialysis patients. DESIGN: This was a retrospective epidemiology cohort study. Dialysis patients with baseline BCM measurement between 2008 and 2013 were enrolled. The observation period was up to 54 months follow-up. SUBJECTS: A total sample consisted of 960 chronic hemodialysis participants. INTERVENTION: All data were retrieved from medical records. Nutrition status was estimated by BCM; malnutrition was diagnosed as lean tissue index less than 10% of the normal value. MAIN OUTCOME MEASURE: Cox regression was performed to identify whether low LTI predicted mortality in hemodialysis patients. RESULTS: BCM-diagnosed malnutrition (hazard ratio [HR] 1.66; 95% confidence interval [CI] 1.1; 2.44), higher age (HR 1.05; 95% CI 1.03; 1.07), longer dialysis vintage (HR 1.00; 95% CI 1.00; 1.00), central venous catheter use (HR 1.96; 95% CI 1.28; 2.99), and low serum albumin (HR 0.91; 95% CI 0.87; 0.95) contributed significantly to the Cox regression model on mortality. CONCLUSION: BCM-diagnosed malnutrition in chronic hemodialysis patients is an independent predictor of mortality at up to 54 months follow-up and is associated with a 1.66-fold higher risk of dying compared with normal nutrition status. Whether intervention (e.g., nutritional supplementation) might improve nutrition and reduce the higher risk of mortality in malnutrition patients on hemodialysis remains a challenge for future research.

Health-related quality of life 3 months after kidney transplantation as a predictor of survival over 10 years: a longitudinal study.

AIM: This study explores the association between kidney function, side effects of immunosuppressive treatment, coping self-efficacy, and physical and mental HRQoL at 3 months (baseline) after kidney transplantation (KT) and their impact on patient and graft survival for up to 10 years (follow-up). METHODS: A group of 151 patients provided at baseline their socioeconomic and medical (CKD-EPI) data and completed the End-Stage Renal Disease Symptom Checklist (perceived side effects), the coping self-efficacy scale, and the SF-36. At follow-up, patients' health status was noted. Univariate GLM exploring the main effects of the independent variables on physical and mental HRQoL was performed; furthermore, Cox regression analyses were performed to determine whether the early posttransplantation factors predicted patient and graft survival. RESULTS: Less severe side effects of immunosuppressive treatment and higher efficacy in stopping unpleasant emotions were associated with both higher physical and mental HRQoL at baseline. Younger age was associated with higher physical HRQoL and older age, and lower efficacy in getting support from family and friend were associated with higher mental HRQoL. Patients reporting higher physical and mental HRQoL at 3 months and with higher age and better kidney function had higher odds of surviving with a functioning graft. CONCLUSION: Older age, higher kidney function, and higher physical and mental HRQoL at baseline significantly improved the odds of graft and patient survival over 10 years. These results show the importance of close monitoring of early posttransplantation HRQoL along with kidney function and reported side effects because of their effect on long-term patient outcomes.

Self-rated health predicts mortality and graft loss after kidney transplantation: a 10-year follow-up study.

BACKGROUND: This study explored whether self-rated health (SRH) shortly after kidney transplantation (KT) predicts mortality and graft loss at up to 10 years' follow-up. METHODS: A total of 276 patients shortly after successful KT were interviewed. SRH was measured using the first item of the SF-36 questionnaire and divided into three tertiles: poor, average and excellent health. Clinical data were retrieved from medical records. Cox regression was used to identify whether different levels of SRH predicted mortality and graft loss in transplant recipients. The observation period was up to 10 years. RESULTS: Poor SRH (HR 11.1, p < 0.001), average SRH (HR 4.21, p < 0.05), estimated glomerular filtration rate (HR 0.26, p < 0.05) and age (HR 1.04, p < 0.05) were significantly associated with mortality. Similarly, poor SRH (HR 6.4, p < 0.001), average SRH (HR 3.6, p < 0.05), new-onset diabetes mellitus after KT (HR 3.3, p < 0.05) and chronic renal allograft dysfunction (HR 3.7, p < 0.00) were significantly associated with graft loss. CONCLUSION: Poor SRH shortly after transplantation indicates an increased risk of mortality and graft loss at up to 10 years' follow-up. SRH could be an inexpensive and reliable indicator for starting diagnostic and/or treatment strategies. The usefulness of SRH compared to other global clinical measures predicting mortality and graft loss should also be studied.

Factors associated with self-rated health after kidney transplantation: a prospective study.

BACKGROUND: This prospective study explores and compares the relationship between patients' self-rated health (SRH) after kidney transplantation (KT) at different follow-up periods and its medical and nonmedical predictors over time. METHODS: Patients (n = 128) who completed a questionnaire (the SRH question of the SF-36 and the End-Stage Renal Disease Symptom Checklist - Transplantation Module) were enrolled. Clinical data were retrieved from medical files. The sample was stratified into early (n = 89) and late (n = 39) cohorts according to time since KT at baseline. Linear regression was used to identify predictors of SRH at follow-up. RESULTS: In both cohorts, a change in glomerular filtration rate (GFR) over time remained a predictor of SRH; in the early cohort, age was an additional predictor; in the late cohort, a change in transplantation-associated psychological distress over time and the number of late acute rejection episodes during the observation period were additional predictors. CONCLUSIONS: Improvement in GFR over time predicted better SRH at each period after KT. Decreased transplantation-associated psychological distress and fewer late acute rejection episodes seemed to predict better SRH at a later follow-up period. Despite these observations, higher SRH was associated with better clinical outcomes.

Differences in perceived health status between kidney transplant recipients and dialyzed patients are based mainly on the selection process.

Kidney transplantation offers longer survival, less morbidity and lower costs than dialysis. It is also believed to improve quality of life. The aim of this study was to compare prospectively the perceived health status (PHS) of dialyzed patients on a waiting list with kidney transplant recipients after transplantation, matched for age, gender and comorbidity. The sample consisted of 93 dialyzed patients on a waiting list for deceased-donor kidney transplantation and 87 incident transplant recipients. A total of 62 dialyzed patients were matched for age, gender and comorbidity with 62 transplant recipients. PHS was measured using the SF-36 questionnaire. Data from baseline and after 12 months were compared between the groups. Patients on dialysis had worse physical (49 +/- 21) and mental (59 +/- 18) PHS than transplant recipients (56 +/- 21 and 64 +/- 18, p < or = 0.05), but when matched pairs were compared, no differences in PHS were found. After 12 months, PHS did not change significantly in either group. The PHS of patients after kidney transplantation is better than that of those on dialysis. However, this fact is significantly influenced by the selection procedure, as only some dialyzed patients are put onto the waiting list while others were actually transplanted. The differences disappear with matching.