An intervention for employment maintenance among blue-collar workers with end-stage renal disease.

An evaluation study was conducted to test the benefit of a predialysis intervention in assisting blue-collar workers with end-stage renal disease (ESRD) to maintain employment. Patients with ESRD were recruited from a large southern California health maintenance organization. In a nonrandomized control trial, employment status among 45 ESRD patients who received a predialysis orientation program followed by in-center dialysis was compared with that of 57 ESRD patients dialyzed at community centers not providing predialysis intervention. Participants had a mean age of 50 years. Sixty-two percent of participants were men and 38% were women. The sample was predominantly Afro-American (35.8%), Hispanic (28.9%), and white (24%). Employment status was assessed prior to dialysis and at least 6 months after beginning maintenance dialysis treatments. The intervention consisted of physician referral to a licensed clinical social worker prior to the initiation of in-center maintenance dialysis treatments, social worker assessment, patient education and counseling, orientation to the dialysis unit, and follow-up care from physicians, licensed clinical social workers, and other team members. A significantly higher proportion of blue-collar workers who received the intervention continued working after beginning dialysis (46.7%) when contrasted with control group blue-collar workers who did not receive the early intervention (23.5%) (chi-squared text = 3.78, P < 0.05). Odds ratio calculations showed that blue-collar workers who received the intervention were 2.8 times more likely to continue working than control group blue-collar workers. The effectiveness of the intervention highlights the importance of early psychosocial intervention in assisting in-center hemodialysis patients in maintaining employment.

Assisted survival, aging, and rehabilitation needs: comparison of older dialysis patients and age-matched peers.

In Western societies a growing number of older persons have their lives extended by medical or surgical intervention. Older persons who suffer kidney failure and are maintained by chronic dialysis therapy are a good example. We compared 349 persons aged 60 years or older, who were on chronic dialysis, with 354 persons similar in age, race, gender, and geographic residence who were not undergoing dialysis. Recent health problems and demographic characteristics were included as control variables in all analyses. Older persons on dialysis reported more functional disability (as measured by ADL-mobility difficulty), less frequent walking for exercise, decreased ability to do the things they would like to do, and lower levels of perceived mastery over their lives. They were also more likely to report a need for health-related aids or services. The residual impairments of disabled elderly persons challenge rehabilitation professionals to address quality of life issues.

Rehabilitation, aging and chronic renal disease.

Restorative management of the disabled elderly requires knowledge about realistic functional expectations, in addition to knowledge about a patient's particular disease. Health outlook, especially sense of control, should also be assessed because rehabilitation depends on the patient's active participation. A comparison of 349 older end-stage renal disease (ESRD) patients on chronic dialysis and 354 similar-age persons selected as a control group showed that significantly compromised physical function and health outlook were reported by the dialysis patients compared with the control group. Increasing exercise capacity and participation in dialysis self-care activity are recommended ways to improve physical functioning and health outlook among ESRD patients. Individuals who cannot perform strenuous activity can improve in level of fitness; improvements in anemia and muscle strength are key variables. Clinical application of therapeutic and rehabilitative strategies to improve physical function and health outlook in the geriatric renal patient is greatly needed.

A disease-specific questionnaire for assessing quality of life in patients on hemodialysis.

A disease-specific questionnaire was developed for patients receiving chronic hemodialysis by interviewing patients to determine which aspects of their quality of life were adversely affected by their disease. The final questionnaire contained 26 questions in five dimensions (physical symptoms, fatigue, depression, relationships with others, frustration). The questionnaire demonstrated construct validity when compared with the Sickness Impact Profile, time trade-off technique and an exercise stress test. It was reproducible in stable, placebo-treated patients (correlation coefficient 0.85-0.98 for the 5 dimensions). It was more responsive than other measures in detecting an improvement with erythropoietin therapy in a randomized, placebo-controlled trial. This questionnaire should be useful for the assessment of the effect of various interventions upon the quality of life of hemodialysis patients.

Rehabilitation of young adults during renal replacement therapy in Europe. 1. The presence of disabilities.

The aim of this study was to analyse rehabilitation during RRT in 617 young adults from different European countries who started dialysis or transplantation before the age of 15 years. The data were derived from the EDTA Registry patient data files and a special questionnaire that was sent to centres reporting to the EDTA Registry. The duration of RRT was more than 10 years in 63% of patients. Fifty-four percent were living with a functioning graft and 46% were on dialysis. The prevalence and severity of motor, hearing, sight, and mental disabilities were analysed retrospectively. They were found to vary according to primary renal disease and method of treatment. One-third of patients had one or more disabilities at the start of RRT. Although disability status had changed in many patients by 31 December 1986, some disability remained in one-third of the patients available for study. Disabilities were recorded as mild in the majority of patients. Both improvement and worsening of motor and mental disability occurred more often than changes of hearing capacity and sight. It is concluded that prevention and treatment of disabilities need special attention in children and young adults on RRT in order to improve rehabilitation.

Rehabilitation of young adults during renal replacement therapy in Europe. 2. Schooling, employment, and social situation.

The educational status, employment rate and social situation were studied in 617 patients between 21 and 35 years of age who started renal replacement therapy (RRT) as children. The data were derived from a special questionnaire concerning disability and rehabilitation sent to dialysis and transplant centres reporting to the EDTA Registry. Fifty-six percent of patients completed secondary school and one in three went on to vocational training. Eleven percent of patients attended university, and 16% were reported to have gone to a special school for the handicapped. Up to one-third of patients who attended different school types failed to complete their education. There were notable geographical differences in schooling and in employment. Fifty-six percent of all patients were employed. Lack of schooling was considered to be a major reason for unemployment. Sixty-one percent of patients with disabilities and 34% without disabilities were receiving invalidity payments. The place of residence of these patients aged 21-35 was usually the parental home. Compared to the general population of similar age, only a few patients were married (13.5% of the total study group) and 8% had children. In summary, the present report shows that the major factors influencing rehabilitation on RRT are the presence of disabilities, the method of treatment, geographical factors, duration of RRT, and the underlying primary renal disease.

Comparison of psychosocial adjustment of male nondiabetic kidney transplant and hospital hemodialysis patients.

Psychosocial adjustment and psychological distress was compared in 31 male nondiabetic successful renal transplant and 31 hospital hemodialysis patients, matched for duration of treatment, age, education, and family status. The only significant difference between the two groups was that the transplant patients were more satisfied with the medical staff. Vocational rehabilitation was similar in both groups. Sexual interrelationships, as reported by the patients, were slightly, but insignificantly, better in the transplanted group. Thus, the psychological adjustment of transplant and hemodialysis patients is similar when demographic differences are accounted for.

Demographics, diabetes type, and degree of rehabilitation in diabetic patients on maintenance hemodialysis in Brooklyn.

A point prevalence study of 232 uremic diabetics undergoing maintenance hemodialysis was conducted at fourteen facilities in Brooklyn, NY, to ascertain extent of rehabilitation, diabetes type, and immediate family history of diabetes according to the diabetes type in the proband. The majority of patients were black (138, 59%) and female (131, 56%). When grouped by diabetes type, insulin-dependent (Type I) diabetics were a small minority (31, 13.4%) of the total study population. With the exception of those with onset of diabetes in childhood, there was no difference between the interval between diagnosis of diabetes and development of renal failure in Type I (15.3 +/- 8.6 years) and the overall group of diabetics (14.9 +/- 9.3 years). A history of diabetes in an immediate family member was found in 114 (49.1%) of the entire group and was approximately the same in Type I (41.9%) and Type II (52.5%) diabetics. Rehabilitation was poor for the group as a whole, with a mean Karnofsky score of 64.9 +/- 14.3, which is a level indicative of the need for assistance in everyday living, and there was an inverse correlation between increasing age and declining Karnofsky score. Factors inhibiting rehabilitation included serious vision loss in 137 (59.1%) subjects, limb amputation, and prior myocardial infarction and stroke. Only 7 of the 153 patients (4.8%) of those younger than age 65 were gainfully employed outside of the home, and only 27% of surveyed patients were able to attend to activities beyond self care. Maintenance hemodialysis, although life extending, does not induce substantive rehabilitation for the uremic diabetic.

[Principles and general practice of goal-oriented planning of training in patients with diabetic nephropathy and in dialysis patients]. / Grundlagen und Praxis einer zielorientierten Trainingsplanung bei Patienten mit diabetischer Nephropathie und bei Dialysepatienten.

Uremic patients on hemodialysis suffer from marked reduction of physical exercise capacity. This reduction cannot solely be explained by the underlying disease and co-existing anemia. We wondered, whether reduced exercise capacity in these patients might be due to lack of physical exercise and whether anaerobic exercise training (AET) would lead to improved work capacity. 8 patients were enrolled in this study. At the beginning and at the end of the training period, which lasted 4 to 6 weeks, a symptom-limited incremental bicycle-spiroergometry was performed. AET led to a significant increase in exercise capacity without any changes in the renal status and hematocrit as well as hemoglobin values. From these data we conclude, that decreased exercise capacity in uremic patients on dialysis is due to inadequate exercise performance of these patients and that AET is able to improve exercise capacity.

Exercise training reduces depression and increases the performance of pleasant activities in hemodialysis patients.

This study compares the effects of a structured exercise training program to the therapeutic benefits of a 'support' group on the depressed mood and reduced performance of pleasant activities by hemodialysis patients. After 6 months of an aerobic exercise training program, the 10 exercisers showed a significant increase in maximal aerobic capacity (VO2max) and a significant decrease in dysphoric mood when compared to 7 patients attending the support group. Support group participants reported a significant decrease in pleasant activities while there was no change in the exercisers. Eighteen months after the exercise training program, the exercisers reported continued low levels of depressed mood, and were performing significantly more pleasant activities than they reported prior to the exercise program. The results of this study suggest an exercise training program may be useful in the psychosocial rehabilitation of some hemodialysis patients.