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.

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

201

SIMMONS AND ABRESS

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

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)
TwoTailed 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
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Eggers, HCFA

208
11. Marine SK, Simmons RG : Policies regarding treatment
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