Spirituality, Social Support, and Survival in Hemodialysis

Patients
Joann Spinale, Scott D. Cohen, Prashant Khetpal, Rolf A. Peterson, Brenna Clougherty,
Christina M. Puchalski, Samir S. Patel, and Paul L. Kimmel
Departments of Medicine and Psychology, George Washington University, Washington, DC

Background and objectives: No studies have evaluated the relationship among spirituality, social support, and survival in
patients with ESRD. This study assessed whether spirituality was an independent predictor of survival in dialysis patients
with ESRD after controlling for age, diabetes, albumin, and social support.
Design, setting, participants, & measurements: A total of 166 patients who had ESRD and were treated with hemodialysis
completed questionnaires on psychosocial variables, quality of life, and religious and spiritual beliefs. The religious variables
were categorized into three scores on a 0 to 20 scale (low to high levels): Spirituality, religious involvement, and religion as
coping. Social support was assessed using the Multidimensional Scale for Perceived Social Support. Analyses were also
performed including and excluding patients with HIV infection. Religious variables were categorized on the basis of means,
medians, and tertiles.
Results: In analyses that used religious variables, only the responses on the spirituality scale split at the mean were
associated with survival. The association of other religious variables with survival did not reach significance. Social support
correlated with spirituality, religion as coping, and religious involvement measures. Only social support and age were
associated with survival when controlling for diabetes, albumin concentration, HIV infection, and spirituality.
Conclusions: These data suggest that the effects of spirituality may be mediated by social support. Larger, multicenter,
prospective studies that use well-validated tools to measure religiosity and spirituality are needed to determine whether there
is an independent association of spirituality variables with survival in patients with ESRD.
Clin J Am Soc Nephrol 3: 1620 –1627, 2008. doi: 10.2215/CJN.01790408

R
elationships between spirituality and mortality have
been investigated in medical populations but remain
controversial (1–13). Variable associations have been
found depending on definitions of spirituality and patient pop-
ulations studied (1–11). Miller and Thoreson (12) explored nine
different hypotheses regarding the relationship among reli-
gious beliefs, spirituality, and mortality. The only hypothesis
that they found to be supported by persuasive evidence stated
that “church/service attendance protects [only] healthy people
against death.” Studies supporting a similar link in patients
with chronic illnesses have also shown mixed results. Koenig et
al. (14) evaluated approximately 4000 elderly patients to deter-
mine whether attendance at religious services during a 6-yr
period was associated with survival. In adjusted analyses, there
was a significantly lower mortality in patients who frequently
attended church services.
Many researchers have suggested a publication bias,
whereby only the studies that indicate a significant relationship
are published (13). Most studies cited the need for more re-
Received April 14, 2008. Accepted July 23, 2008.
Published online ahead of print. Publication date available at www.cjasn.org.
Correspondence: Dr. Paul L. Kimmel, Division of Renal Diseases and Hyperten-
sion, Department of Medicine, George Washington University Medical Center,
2150 Pennsylvania Avenue NW, Washington, DC 20037. Phone: 202-741-2283;
Fax: 202-741-2285; E-mail: pKimmel@mfa.gwu.edu
search on the relationship between spirituality and mortality
before any firm conclusions can be reached. In addition, the
health dimensions of lack of belief have not been well explored.
There also exists considerable debate on how to operational-
ize religiosity and spirituality. Whereas the first term often is
associated with participation in social institutions and adher-
ence to specific beliefs and practices, the latter is a broader term
that typically pertains to life’s vital qualities and an overall
broad belief in the immaterial features of life (12). Spirituality
relates to transcendent values and relationships and the way
people find meaning, purpose, and hope in life and in the midst
of suffering (15). A person may be spiritual and not religiously
observant or observe rituals without a spiritual focus.
Few studies have specifically evaluated the potential associ-
ation between spirituality and survival in patients with ESRD
(16,17). We (18) previously showed that religious and spiritual
beliefs are associated with decreased perception of burden of
illness, decreased depressive affect, increased perception of
social support, and higher satisfaction with life and perception
of quality of life in an urban, predominantly black ESRD pop-
ulation. We also found that a “spiritual beliefs scale” correlated
with several quality-of-life measures in patients with ESRD
(19). Even though many of these psychosocial measures have
been shown to be related to survival independently, no study to
our knowledge has demonstrated a link between spirituality
and survival in this population.

Copyright © 2008 by the American Society of Nephrology ISSN: 1555-9041/306 –1620

Clin J Am Soc Nephrol 3: 1620 –1627, 2008
We determined whether three variables related to spiritual-
ity, religious beliefs, and practices and faith (spirituality, reli-
gious involvement, and religion as a coping measure) were
independently associated with survival in hemodialysis pa-
tients with ESRD. We then assessed the relationship between
social support and survival, regardless of whether the spiritual
variables were included in analyses. We hypothesized that
spiritual variables would be associated with survival in patients
with ESRD.
Materials and Methods
Patient Population and Demographics
Patients were recruited from two dialysis units under the direction of
George Washington University Medical Center full-time faculty neph-
rologists, located in Washington, DC. The population is composed of
primarily black patients and has been described previously (18).
Recruitment
All patients who were enrolled in chronic hemodialysis programs at
the two dialysis units were eligible to participate. The recruitment
period ranged between October 3, 2001, and November 26, 2003. Each
patient was initially approached by a trained research assistant who
explained the study in detail and invited patients to complete a series
of questionnaires regarding psychological status and quality of life.
Questionnaires were administered by research assistants, who recorded
verbal responses. At the time of data collection, patients gave consent to
use the data in mortality analyses. Data collection was approved by the
George Washington University Medical Center Committee on Human
Research. Follow-up for vital status continued through July 2005.
Data Collection
Research assistants tracked the status of all patients by interviews
with doctors and staff at both dialysis units, who verified information
in the facilities’ computer databases. Data obtained was current status
(alive or deceased), date of death, date of transplantation, and last day
of treatment (when no follow-up data were available).
Measures
We used four items to assess spiritual belief, the importance of
attending religious services, and the use of religion in coping with
disease. Each question was scored on a scale from 0 to 10. We defined
the religious variables as previously conceptualized (18). The “spiritu-
ality” score, the perception of the importance of faith and its helpful-
ness in coping with kidney failure, was the combination of questions 4
and 5 (Table 1). “Religious involvement,” or the perception of the
importance of attending religious services and its helpfulness in coping
with kidney failure, was defined as the combination of items 6 and 7. In
addition, questions 5 and 7 were combined to form a “religion as a
coping mechanism” score, a measure of religious feelings as coping
mechanisms for dealing with the burden of kidney disease. Each ques-
tion was scored on a scale from 0 to 10. The highest score attainable was
20 (10 points for each individual item) for each variable.
Social support was assessed using the Multidimensional Scale of
Perceived Social Support (MSP) (20,21). The scale, frequently used for
patients with chronic kidney disease (22–26), includes 12 questions that
measure perceived support from family, friends, and significant others.
Patients’ scores were reported on a seven-point Likert scale with total
scores ranging from 0 to 84, indicating low to high perceived social
support. We (26) previously reported that higher social support scores
Spirituality and Survival in Hemodialysis Patients 1621
Table 1. Questions regarding religious beliefsa
I have felt physically terrible/well.
My life is worthless/worthwhile.
My life is meaningless/meaningful.
For me, faith or spiritual belief is not
important/very important.
For me, in adjusting to my kidney disease,
faith or belief is not helpful/very helpful.
For me, attending religious services is not
worthwhile/very worthwhile.
For me, in adjusting to kidney failure,
attending religious services is not
worthwhile/very worthwhile.
a
Single items were not assessed in this study. Answers
scored on a scale from 0 to 10. Modified from reference (18).
of hemodialysis patients with ESRD were associated with improved
survival.
Statistical Analysis
Statistical analyses were performed using SAS 8.2 (SAS Institute,
Cary, NC). Data from patients who were alive at the end of the study
were censored according to the number of days they survived. Twelve
patients lacked survival time data. Data from 18 patients who were lost
to follow-up were censored at their last day of treatment at their
respective dialysis units. Data from 14 patients who had received
transplants during the study period were censored depending on their
known vital status. Data from transplant patients who were lost to
follow-up were censored at date of transplantation.
Kaplan-Meier curves were constructed on the basis of spiritual pa-
rameters and MSP scores. Religious variables were categorized on the
basis of medians, means, and tertiles. In survival analyses in which
levels of the religious variables were categorized, the results of splits at
the mean are presented.
Spearman correlation analyses were determined on the three spiri-
tual variables and the social support scores. Proportional hazards re-
gression was used to calculate the association of each religious variable
with mortality. Analyses were then performed to assess the relation-
ship of social support to survival with and without the spirituality
variables. Covariates in all analyses included age, diabetes status, se-
rum albumin concentration, presence of HIV infection, and level of
social support in selected analyses. P ⫽ 0.05 was taken as the level of
significance.
Results
Demographics and Patient Population
The sample was composed of 102 (61.4%) men and 64 (38.6%)
women. A total of 89.2% of the study patients were African
American, 7.8% were white, and 3.0% identified themselves as
of other ethnicity. Ninety-five patients were recruited from one
unit and 75 from the other. The study patients’ demographics
are outlined in Table 2. The mean age of the population was
56.2 ⫾ 13.8 yr. A total of 45.2% had diabetes, and 11.5% had
HIV infection. The mean serum albumin concentration was
3.8 ⫾ 0.4 g/dl. Patients’ mean Kt/V was 1.4 ⫾ 0.24. The mean
duration of treatment on dialysis at the time of administration
of the original questionnaire was 41.2 ⫾ 43.5 mo. By the con-
1622 Clinical Journal of the American Society of Nephrology Clin J Am Soc Nephrol 3: 1620 –1627, 2008

Table 2. Patient demographic and clinical patients with diabetes or HIV infection. There were no differ-
characteristicsa ences between the participants with religious involvement
scores above and below the mean level in mean serum albumin
Characteristic Value concentration, vintage, Kt/V, or the proportion of patients with
N 166 HIV infection, but there were differences between the two
Race (%) groups in age and the proportion of patients with diabetes.
black 89.2 Patients with levels above the mean on any of the three spiri-
white 7.8 tuality scores had higher mean levels of perceived social sup-
other 3.0 port.
Male (%) 61.5 The mean MSP score was 69.1 ⫾ 13.2 for the entire sample,
Diabetes (%) 45.2 and the median score was 72. When patients with HIV infection
HIV infection (%) 11.5 were excluded, the mean MSP score was 69.6 ⫾ 13.0, with a
Age (yr; mean ⫾ SD) 56.2 ⫾ 13.8 median of 72. There were no differences between the partici-
HD duration at study initiation 41.2 ⫾ 43.5 pants who were recruited at either unit in mean religion or
(mo; mean ⫾ SD) social support scores.
HD duration at study 68.0 ⫾ 45.7
conclusion (mo; mean ⫾ SD) Correlational Analyses
duration of follow-up (mo; 19.4 ⫾ 11.1 Social support scores correlated with spirituality scores (r ⫽
mean ⫾ SD) 0.33, P ⬍ 0.0001), religion as coping mechanism scores (r ⫽ 0.29,
serum albumin concentration 3.80 ⫾ 0.40 P ⫽ 0.0002), and religious involvement scores (r ⫽ 0.22, P ⫽
(g/dl; mean ⫾ SD) 0.005; Table 4). When patients with HIV infection were ex-
Kt/V (mean ⫾ SD) 1.40 ⫾ 0.24 cluded from analyses, social support correlated with all of the
a
religion variables (data not shown).
HD, hemodialysis.

clusion of the study, mean duration of treatment was 68.0 ⫾
45.7 mo. The mean duration of follow-up for study participants
was 19.4 ⫾ 11.1 mo. There were no differences between the
participants who were recruited at either unit in mean age,
serum albumin concentration, vintage, Kt/V, or the proportion
of patients with diabetes or HIV infection.
The mean spirituality score was 17.5 ⫾ 4.1, mean religious
involvement score was 16.1 ⫾ 6.0, and mean religion as coping
mechanism score was 16.5 ⫾ 4.9 (Table 3). The median spiritu-
ality score was 20, the highest score possible. The median scores
for religious involvement and religion as a coping mechanism
were slightly lower (19 and 18, respectively). For all three
variables, the mode of the sample was 20. When the religious
variables were analyzed excluding patients with HIV infection,
the scores were similar. A total of 119 (67.6%) patients scored
above the mean on the spirituality score. There were no differ-
ences between the participants who were recruited at either
unit in mean spirituality, religious involvement, or religion as a
coping mechanism score. There were no differences between
the participants with spirituality or religion as coping mecha-
nism score above and below the mean level in mean age, serum
albumin concentration, vintage, Kt/V, or the proportion of
Survival
Ninety of 166 patients survived the study and observation
periods. There was no difference in survival between patients
in the study in either unit. When spirituality was divided into
low and high groups on the basis of the mean, patients with
higher spirituality scores had significantly increased survival
(Figure 1). Social support was categorized by the mean. Patients
with higher social support scores had improved survival (Fig-
ure 2). There was no difference between survival of patients
with spirituality scores of 20 and those below the median value
of 20 (data not shown).
In the entire sample, age, hypoalbuminemia, and HIV infec-
tion were also associated with increased risk for mortality
(Table 5). Gender was not associated with survival in any of the
analyses that we performed (data not shown). Because of the
disproportionate number of black study participants, ethnicity
was not used as a covariate. Higher spirituality scores evalu-
ated by mean split in the entire sample were associated with
longer survival (hazard ratio [HR] 0.49; 95% confidence interval
[CI] 0.27 to 0.88; P ⫽ 0.02; Table 5). The relationship between
spirituality and survival approached statistical significance in
the smaller sample when patients with HIV infection were
excluded from the analysis (HR 0.54; 95% CI 0.29 to 1.01; P ⫽

Table 3. Patient spiritual, religious, and social support characteristics

Characteristics Mean Median Mode Range

Spirituality 17.5 ⫾ 4.1 20 20 0 to 20

Religious involvement 16.1 ⫾ 6.0 19 20 0 to 20
Religion as coping 16.5 ⫾ 4.9 18 20 0 to 20
Social support 69.1 ⫾ 13.2 72 84 22 to 84
Clin J Am Soc Nephrol 3: 1620 –1627, 2008 Spirituality and Survival in Hemodialysis Patients 1623

Table 4. Correlation matrix of religious variables and social support (Spearman analyses)a
Parameter IREL CREL SPIR MSP

IREL r ⫽ 1.00 r ⫽ 0.88 r ⫽ 0.67 r ⫽ 0.22

P ⬍ 0.0001 P ⬍ 0.0001 P ⫽ 0.005
CREL r ⫽ 0.88 r ⫽ 1.00 r ⫽ 0.85 r ⫽ 0.29
P ⬍ 0.0001 P ⬍ 0.0001 P ⫽ 0.0002
SPIR r ⫽ 0.67 r ⫽ 0.85 r ⫽ 1.00 r ⫽ 0.33
P ⬍ 0.0001 P ⬍ 0.0001 P ⬍ 0.0001
MSP r ⫽ 0.22 r ⫽ 0.29 r ⫽ 0.33 r ⫽ 1.00
P ⫽ 0.0050 P ⫽ 0.0002 P ⬍ 0.0001
a
CREL, religion as coping mechanism score; IREL, religious involvement score; MSP, Multidimensional Scale of Perceived
Social Support score; SPIR, spirituality score.

Figure 1. Kaplan-Meier analysis of patients with ESRD and with Figure 2. Kaplan-Meier analysis of patients with ESRD and with
high versus low spirituality. Gray line represents high spiritu- high versus low social support. Gray line represents high social
ality (above the mean), and black line represents low spiri- support, and black line represents low (below the mean) social
tuality. support.

0.052; data not shown). Higher religious involvement and reli-
gion as coping mechanism scores were not associated with
survival, regardless of whether patients with HIV infection
were included in analyses (data not shown). There was no
significant association of spirituality scores and survival when
evaluated by median split.
Higher social support scores were also associated with longer
survival in the entire sample (HR 0.48; 95% CI 0.27 to 0.84; P ⫽
0.01; Table 5). This relationship persisted regardless of whether
patients with HIV infection were included in analyses. MSP
scores also predicted survival when analyses with religious
involvement and religion as coping mechanism variables were
entered as covariates in place of the spirituality measure (data
not shown).
When spirituality and MSP scores were included in the anal-
yses together with age, albumin, diabetes, and HIV status as
covariates, social support was still associated with increased
survival (HR 0.53; 95% CI 0.30 to 0.95; P ⫽ 0.03; Table 6). This
relationship persisted regardless of whether patients with HIV
infection were included in analyses (data not shown). MSP
scores also predicted survival when analyses with religious
involvement and religion as coping mechanism scores were
entered as covariates in the place of spirituality (data not
shown). The relationship between spirituality and survival ap-
proached statistical significance in this analysis (HR 0.57; 95%
CI 0.31 to 1.04; P ⫽ 0.066; Table 6). There was no statistically
significant interaction between the spirituality and social sup-
port variables in the Cox analyses outlined in Table 6 in the
entire sample (data not shown).
Discussion
This study showed that increased spirituality, defined as
importance of faith, as measured by a particular tool, was
associated with improved survival in a hemodialysis popula-
tion with ESRD at a single medical center. All three religion and
spirituality measure scores in this study suggested ceiling ef-
fects, with most participants endorsing the maximum score.
The associations between the spirituality variable and survival,
however, were found even though the spirituality measures
displayed ceiling effects. This relationship was previously
shown in general medical populations (1–12). Religious expe-
rience was separated in this study into three variables to deter-
mine how each was associated with survival. Whereas in-
creased “spirituality” was associated with survival, “religion as
1624 Clinical Journal of the American Society of Nephrology Clin J Am Soc Nephrol 3: 1620 –1627, 2008

Table 5. Relationship of spirituality and social support to survival in patients with ESRD: Individual analyses of
role of spirituality and social supporta
Parameter HR 95% CI P

Analysis 1
albumin 0.31 0.13 to 0.75 0.001
HIV infection 3.53 1.32 to 9.48 0.010
spirituality 0.49 0.27 to 0.88 0.020
Analysis 2
albumin 0.32 0.13 to 0.79 0.010
HIV infection 2.71 1.02 to 7.23 ⬍0.050
social support 0.48 0.27 to 0.84 0.010
a
All analyses controlled for age and diabetes. CI, confidence interval; HR, hazard ratio

Table 6. Relationship of social support and spirituality to survival in patients with ESRD: Combined analyses of
role of spirituality and social supporta
Parameter HR 95% CI P

Albumin 0.30 0.12 to 0.73 0.008

HIV infection 3.03 1.12 to 8.19 0.030
Spirituality 0.57 0.31 to 1.04 0.066
Social support 0.53 0.30 to 0.95 0.030
a
All analyses controlled for age and diabetes.

a coping mechanism” and “religious involvement” were not
associated with decreased mortality in this relatively small
study, suggesting that the instruments used may have been
able to discriminate between an overall sense of “spirituality”
and other factors that are associated with religious experience.
We also found that increased perception of social support
was associated with survival. This relationship was shown in
previous studies of patients with a variety of chronic medical
illnesses (25–31); however, there has been limited information
regarding the relationship between social support and survival
in patients with ESRD (26,31–34). In adjusted analyses, we
found that dialysis patients with higher MSP scores survived
longer than those with lower perceived social support levels.
Previously, we showed that a 1-SD increase in perceived social
support among hemodialysis patients was associated with a
20% decrease in mortality (26,31,35).
Social support may improve patient outcomes through at
least five mechanisms in patients with chronic disease, includ-
ing increased access to health care, increased compliance with
physician prescriptions, improvements in nutritional status and
overall sense of quality of life, modulation of the immune
system, and a decrease in depressive affect (26,31). The corre-
lation coefficient between the religious variables and the social
support scores was associated with statistical significance but
indicates a modest relationship among these variables. This
may be the result of a true weak relationship among these
factors, suggesting an independent association of the two fac-
tors with survival, or, alternatively, may be related to the
specific tools that we used. Such issues need to be addressed in
well-designed follow-up studies, with validated measures.
There is also a relationship between religion and increased
perception of social support (36). People who identify them-
selves as spiritual or religious are often involved in religious
communities and typically report higher social support scores
compared with individuals who are not identified as religious.
In a multicenter study that included this patient population,
we previously showed that quality-of-life assessments but not
demographic or medical characteristics correlated with a spir-
itual beliefs scale (19). In a previous report on the baseline
characteristics of this study population, we showed that all
three spiritual scales correlated with increased perception of
satisfaction with life and decreased indices of depressive affect
and assessments of illness burden (18). Both depression and
perception of illness burden have been associated with in-
creased mortality in patients with ESRD in our studies (26,37),
as well as others (38 – 40). Koenig (41) recently delineated the
salient interconnections between spiritual values and coping,
associated with lower levels of depression. These findings sug-
gest that spiritual beliefs are indeed associated with psychoso-
cial factors, which have been linked to enhanced survival in
several different chronic illnesses (42).
Although spiritual factors may have an independent associ-
ation with survival in the chronically ill and in patients with
ESRD, the mechanisms underlying any such links remain un-
clear. Recently, we summarized studies that linked psychoso-
cial factors to stressors (31,42), which may activate immune and
inflammatory responses that are associated with enhancing the
susceptibility to infection or the development of atherosclerosis
(42,43). Unfortunately, we do not have information regarding
Clin J Am Soc Nephrol 3: 1620 –1627, 2008
these mediators or the causes of death in the patients in this
relatively small pilot study.
In analyses in which spirituality and social support were
assessed simultaneously, the link between spirituality and sur-
vival in this population was attenuated. This suggests that
higher social support may mediate the effect of increased spir-
ituality on survival. One reason that spirituality might not have
significantly predicted survival above and beyond social sup-
port, in addition to the limited sample size, is that the ceiling
effects on the spirituality measure may have limited the ability
to detect effects of spirituality. With a modal score of 20 and a
mean score of 17.5, it seems that the scores fell in a fairly
restricted range in this relatively religious population. With a
more sensitive measure allowing a much wider range of scores
in the high spirituality category, it is possible that we might
have been able to detect significant variance above and beyond
that contributed by social support. Such considerations may
have determined the lack of significance in our analyses of
spirituality using median splits. A median split in this case
reflects a comparison between the extremely spiritually ori-
ented and those who scored just slightly lower, perhaps dimin-
ishing the ability to demonstrate differences; however, it is also
possible that other, unaccounted variables contribute to the
relationship of spirituality with survival and between religious
variables and social support. In addition, it would be desirable
to study a population with more diverse spiritual and religious
characteristics, including atheists and nonobservant partici-
pants, including a wide range of denominational affiliations.
This study has several limitations. The spirituality scales that
we used, devised in collaboration with the Robert Wood John-
son Foundation Promoting Excellence in End-of-Life Care End-
Stage Renal Disease Work Group (44), have not been fully
validated or subjected to test–retest reliability determinations;
therefore, confirmatory studies stemming from our exploratory
findings will need to be performed using these measures after
validation or other validated parameters. In addition, because
the determination of “spirituality” and “religiosity” in clinical
studies has not been uniform or endorsed by consensus, it
should be noted that the measures used in this study cannot
reliably distinguish between these characteristics. The skewed
responses to the questionnaires suggest that broader popula-
tions will have to be studied and/or that the measures may
need to be rescaled. The questionnaires were administered by
research assistants. As noted previously, this presents an issue
of potential experimental demand (18), but such data collection
methods are necessary in populations that have high levels of
illiteracy and have the advantage of maintaining uniform ad-
ministration. As outlined previously, surveys that sample a
dialysis unit population over a period of time do not take into
account stage of the life cycle of the patient with ESRD (42,45),
which may contribute to the heterogeneity of findings. Further
studies should be performed in defined populations, such as
incident patients, or using longitudinal follow-up to address
this limitation. The relatively small sample size of this study
and the number of events preclude the use of a large number of
standard covariates in Cox regression analyses (46). We do not
Spirituality and Survival in Hemodialysis Patients 1625
have data on hospitalizations, cause of death, or religious de-
nomination in this pilot study, which limits the conclusions that
can be drawn from our findings. The patient population was
primarily composed of urban black patients with ESRD, which
may further limit study generalizability. Tanyi et al. (17) spe-
cifically showed that black individuals have high spirituality
scores, at baseline, compared with a white cohort. In addition,
our sample was composed primarily of prevalent patients,
raising the possibility of survival bias.
Interactions between patients’ underlying medical illness and
their environment influence psychological adjustment and play
a unique role in the pathogenesis and progression of disease.
This complexity makes it difficult to establish causality in a
cohort study. Another inherent limitation of an observational
study is the potential for recall and selection biases. The more
compliant and “healthier” patients may have been more likely
to participate in surveys. It is also possible that experimental
demand (18) and social desirability may have influenced the
patients’ answers to interviewers’ questions with respect to
quality of life and spirituality.
Conclusions
An association between spirituality and survival may be
partially explained by increased perception of social support in
hemodialysis patients who participate in religious activities.
Larger, multicenter, prospective cohort studies, including lon-
gitudinal observations and assessments of cardiovascular risk
factors and inflammatory mediators, as well as broader consid-
eration of other psychosocial factors such as socioeconomic
factors and perception of discrimination (42) are needed for
further evaluation of any fine-grained relationships between
spirituality and survival in patients with ESRD, with broader
participation of different ethnic groups from different parts of
the country and the world.
Acknowledgments
S.D.C. was supported by a research fellowship award from the
National Kidney Foundation. J.S. and B.C. were supported by Gill
Fellowships at the George Washington University School of Medicine.
Disclosures
None.
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