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1 Originl Pper Nephron 1999;83:31 39 Accepted: My 4, 1999 Qulity of Life in End-Stge Renl Disese Ptients fter Successful Kidney Trnsplnttion: Development of the ESRD Symptom Checklist Trnsplnttion Module Gbriele Helg Frnke Jens Reimer b Mthis Kohnle b Peter Luetkes b Nicole Mehner Uwe Heemnn b Institute for Medicl Psychology nd b Deprtment of Nephrology, Center for Internl Medicine, University Clinics, University of Essen, Germny Key Words Renl trnsplnttion W Chronic renl filure W Qulity of life W Disese-specific questionnire Abstrct The End-Stge Renl Disese Symptom Checklist Trnsplnttion Module (ESRD-SCL ) ws developed to ssess the specific physicl nd psychologicl qulity of life of renl trnsplnt recipients, with specil focus on side effects of immune system suppression therpy. A list of potentilly relevnt items ws dministered to 458 trnsplnt recipients. The symptoms present in 120% of ptients were chosen, nd fctor nlysis ws used to crete the finl questionnire which consists of 43 items in six dimensions: (1) limited physicl cpcity (10 items; internl consistency: Cronbch s = 0.85); (2) limited cognitive cpcity (8 items, = 0.82); (3) crdic nd renl dysfunction (7 items, = 0.76); (4) side effects of corticosteroids (5 items, = 0.77); (5) incresed growth of gum nd hir (5 items, = 0.78), nd (6) trnsplnttionssocited psychologicl distress (8 items, = 0.80). All questions re scored on five-point Likert scle. Vlidity This work ws supported by Fujisw Inc. ws demonstrted in correltion with corresponding SF- 36 scles nd in stepwise hierrchicl regression model predicting the subscles of the ESRD-SCL by sociodemogrphic nd medicl dt. The ESRD-SCL ws found to hve dequte relibility, test-retest correltions in subsmple of 88 stble ptients fter 1 yer, nd construct vlidity. Introduction Since the 1980s, the qulity of life (QOL) [1] in ptients with end-stge renl disese (ESRD) hs received incresing interest [2]. ESRD ptients on renl replcement therpy (RT) live with vrying degrees of physicl nd psychologicl symptoms, especilly side effects of immune system suppression therpy, stress, nd the fer of rejection [2]. Using tool minly developed for helthy people [3, 4] would not be pproprite for investigting the QOL in these ptients. Mesures of the specific symptomtic severity of ESRD ptients fter RT re required s experimentl, control, nd outcome vribles in studies on the QOL of these ptients. Until tody, number of questionnires which mesure the disese-specific QOL in ESRD ptients hve ABC Fx E-Mil krger@krger.ch S. Krger AG, Bsel /99/ $17.50/0 Accessible online t: Dr. Gbriele Helg Frnke Institute for Medicl Psychology, University Clinics Hufelndstrsse 55, D Essen (Germny) Tel , Fx E-Mil gbriele.frnke@uni-essen.de

2 been developed. The questionnire of Prfrey et l. [5] is useful in compring vrious renl replcement therpies (including RT), but it fils to mesure side effects of immunosuppression therpy. Others [6] hve developed specific mesure becuse of culturl resons. Some other disese-specific questionnires re only suitble to dilysis ptients [7 10]. The kidney trnsplnt questionnire of Lupcis et l. [11] mesures only ptient-specific somtic symptoms; therefore, comprison of different ptients is methodologiclly unsound. The current investigtion ws undertken to crete QOL questionnire specific for ESRD ptients fter RT which is brief, esy to dminister, relible, vlid, nd incorportes RT-specific somtic symptoms, side effects of immunosuppression therpy, nd symptoms of trnsplnttion-relted psychologicl distress. Thus, we describe the development of the End-Stge Renl Disese Symptom Checklist Trnsplnttion Module (ESRD- SCL ), its finl content, nd psychometric properties. Methods The study ws conducted t the Deprtment of Nephrology, Center for Internl Medicine, University Clinics, University of Essen, Germny, in 1997 during regulr outptient visits. Informed consent ws obtined from ech study prticipnt. No criterion of therpeutic regimen or durtion of ESRD ws used in the ptient selection process. We excluded ptients with grft loss nd ptients not hving commnd of the Germn lnguge. Frequencies of nonresponders were round 10%, resons for nonresponding were lck of time nd in few cses suspiciousness of psychologicl investigtion. Nonprticiption ws ccepted s the ptient s legl right. Questionnire A list of 79 items tht could potentilly influence the QOL of ESRD ptients fter RT ws collected by (1) identifying items from existing QOL mesures tht might be relevnt to the ptients; (2) discussing the problem with physicins nd nurses of the nephrologicl deprtment, nd (3) by interviewing trnsplnt recipients. The 79 items were dministered to 458 trnsplnt recipients in All questions were scored on 5-point Likert scle (from 0 = not t ll to 4 = extremely ). An exmple question is: How much re you presently distressed by poor physicl cpcity? Instructions nd scoring were similr to the Symptom Checklist SCL-90-R of Derogtis [12, 13], mesuring psychologicl distress. In ddition to the ESRD-SCL, the SF-36 helth survey [14, 15] ws used to evlute the globl QOL. Sociodemogrphic dt on gender, ge, mritl sttus, nd employment were collected. Medicl dt were collected from the clinicl records. Sttistics Items present in 1 20% of the ptients were chosen, nd fctor nlysis (Vrimx rottion) ws used to crete the finl questionnire. To determine the relibility of the ESRD-SCL, Cronbch s ws clculted s mesure of internl consistency for ech of the Tble 1. Clinicl chrcteristics of the 458 ESRD ptients fter successful kidney trnsplnttion Originl disese Glomerulonephritis 191 (41.7%) Pyelonephritis 81 (17.7%) Polycystic kidney 33 (7.2%) Dibetic nephropthy 19 (4.1%) Shrinking kidney 15 (3.3%) Interstitil nephritis 13 (2.8%) Reflux 10 (2.2%) Nephrosclerosis 10 (2.2%) Alport syndrome 7 (1.5%) Abuse of nlgesics 6 (1.3%) Others 73 (15.9%) Trnsplnttion-ssocited dt Men B SD durtion of life with trnsplnted kidney, months (rnge) 77.6B51.6 (1 291) Number of trnsplnttions (88.4%) (11.6%) Weight gin 83 (18.1%) Blood chemistry (men B SD) Cretinine mg/dl (rnge) 1.8B1.1 ( ) Ìmol/l (rnge) 157.5B96.3 ( ) Hemoglobin g/dl (rnge) 13.2B1.9 ( ) mmol/l (rnge) 8.2B1.2 ( ) Cholesterol mg/dl (rnge) 228.8B49.4 (81 429) mmol/l (rnge) 5.9B1.3 ( ) Triglyceride mg/dl (rnge) 185.8B102.0 (36 883) mmol/l (rnge) 2.1B1.2 ( ) Mediction (men B SD) Ciclosporin (n = 300), mg (rnge) 205.5B67.7 (75 575) Prednisolone (n = 432), mg (rnge) 7.2B6.7 (1 125) Comorbidity Dibetes 53 (11.6%) (type I: 12, type II: 41) High blood pressure 361 (78.8%) Myocrdil infrction 13 (2.8%) multi-item subscles. The construct vlidity of the ESRD-SCL ws evluted by clculting the correltion coefficient between the dimensions of the questionnire nd the SF-36 (proven construct vlidity, if the correltions between the dimensions of the ESRD-SCL nd the SF-36 re in the direction nd mgnitude expected). In study of this size, even wek correltions ttin sttisticl significnce, so the p vlue does not constitute useful mesure of the importnce of reltionship. Correltions were clssified into rnges of importnce: not sttisticlly significnt; significnt, but wek ArA! 0.32 (r 2! 10%, p! 0.05); modest Ar A from 0.32 to Nephron 1999;83:31 39 Frnke/Reimer/Kohnle/Luetkes/Mehner/ Heemnn

3 (r 2 from 10 to 30%), nd moderte Ar A (r %). The reproducibility ws ssessed by determining the intrclss correltion coefficient when the questionnire ws dministered to stble trnsplnt recipients ssessed 12 months fter the first investigtion. Multiple regression nlysis ws used to exmine the independent ssocitions between the ESRD-SCL subscles nd sociodemogrphic nd clinicl dt. Results Ptient Popultion The 458 ptients hd men ge of 48 B (SD) 13 (rnge 18 74) yers; 55% were mles. Two thirds of the smple (64.2%) were mrried, 4.6% divorced, 6.3% widowed, nd 24.9% were single. One third of the smple (32.6%) were employed, 15.7% were housewives, 5.9% were unemployed, nd every 2nd ptient (45.9%) ws retired. Tble 1 presents the clinicl chrcteristics of the smple. The mjority suffered from glomerulonephritis. The smple ws evluted on verge 77.6 B 51.6 (rnge 1 291) months fter trnsplnttion (totl cdveric kidney trnsplnttion); the men cretinine concentrtion ws 1.8 B 0.05 (rnge ) mg/dl. Item Identifiction Tble 2 presents the response frequency of the 79 items. Fifty-eight of the initil 79 items demonstrted over 20% prevlence. Limited physicl cpcity, the uncertinty of how long the trnsplnt will function, nd the feeling of exercising too little were the three items with the highest prevlence. Description of the ESRD-SCL Fctor nlysis ws used, regrding the 58 items with the highest response frequency, to produce the ESRD- SCL. Tble 3 presents the results of the fctor nlysis fter Vrimx rottion. The initil sttistics found 16 fctors with n eigenvlue 11 (eigenvlues 13.4, 2.9, 2.3, 2.1, 1.9, 1.7, 1.6, 1.5, 1.4, 1.4, 1.3, 1.3, 1.2, 1.1, 1.1, 1.0). Regrding the Scree test, we decided to define six fctors (explntion of vrince: 22.6, 4.8, 3.9, 3.5, 3.2, nd 2.9%) which contined 43 items; 15 items demonstrted low lodings (! 0.40) nd were rejected in defining the scles. The ESRD-SCL questionnire contins the following six dimensions: (1) limited physicl cpcity (10 items, internl consistency: Cronbch s = 0.85); (2) limited cognitive cpcity (8 items, = 0.82); (3) crdic nd renl dysfunction (7 items, = 0.76); (4) side effects of corticosteroids (5 items, = 0.77); (5) incresed growth of gum nd hir (5 items, = 0.78), nd (6) trnsplnttionssocited psychologicl distress (8 items, = 0.80; tble 3). Construct Vlidity of ESRD-SCL The correltions between the ESRD-SCL nd the SF- 36, the correltions mong the dimensions of the ESRD- SCL, nd the correltions between the dimensions of the Tble 2. Response frequency percentge of the 79 items investigted No. Item Answer ctegories b Limited physicl cpcity Uncertinty of how long the trnsplnt will function Feeling of exercising too little Feeling of being exhusted Incresed blood pressure Decresed visul cuity Proneness to hemtoms Forgetfulness Joint pin Poor generl helth Nervousness Trouble concentrting Hirsutism Moodiness Limited sexul cpcity Bone pin Thoughts bout trnsplnttion Much stronger ppetite thn before Ill feeling Muscle pin Qulity of Life in End-Stge Renl Disese Nephron 1999;83:

4 Tble 2 (continued) No. Item Answer ctegories b Appernce Puffy fce Dry mouth Colds or influenz Sleeplessness Hedches Limited cognitive cpcity Stronger growth of hir Altertions of the skin Swollen feet Swollen legs Gingivl hyperplsi Bleeding of the gingiv Decresed hering cpcity Feeling of not being ble to trvel often Disorders in the hert rhythm Altertions of the gingiv Hertburn Stronger thirst Memory disturbnce Hir loss Presthesi in the legs Brooding bout kidney donor Difficulties in brething Uncontrollble trembling Chest pin Buzzing in ers Proneness to infections Puffy fce in the morning Strong dizziness Stomch pin Anxiety Prolonged wound heling Crmps Urinry trct infections Proneness to sunburn Altertions of the fce Nightmres Problems in ctivities of dily life (shower, dressing) Dirrhe Prolonged bleeding of wounds Confusion Nuse Acne Constiption Allergies Speech disorders Difficulties in brething without physicl exercise Loss of ppetite Lck of smell or tste Migrine Shivering fits Purging Stomch ulcer Jundice Cncer Fever Asthm Gllbldder colics b Position of the item in the originl version of the checklist. 0 = Not t ll; 1 = little bit; 2 = modertely; 3 = quite bit; 4 = extremely. 34 Nephron 1999;83:31 39 Frnke/Reimer/Kohnle/Luetkes/Mehner/ Heemnn

5 Tble 3. Results of fctor nlysis (Vrimx rottion of the 58 items with the highest response frequency) Numerls in itlics indicte items with lodings x0.40; only these items define the finl dimension. h 2 = Communlity; F1 F6 = lodings of the items on the six dimensions of the ESRD-SCL. No. Dimensions nd items h 2 F1 F2 F3 F4 F5 F6 Limited physicl cpcity 44 Joint pin Bone pin Feeling of being exhusted Muscle pin Poor generl helth Limited physicl cpcity Stomch pin Strong dizziness Hedches Colds or influenz Urinry trct infections Hertburn Feeling of not being ble to trvel often Uncontrollble trembling Limited cognitive cpcity 23 Forgetfulness Trouble concentrting Limited cognitive cpcity Memory disturbnce Decresed hering cpcity Nervousness Decresed visul cuity Buzzing in ers Chest pin Limited sexul cpcity Prolonged wound heling Difficulties in brething Crmps Crdic nd renl dysfunctions 73 Swollen legs Swollen feet Incresed blood pressure Stronger thirst Presthesi in the legs Proneness to hemtoms Disorders in hert rhythm Dry mouth Proneness to sunburn Side effects of corticosteroids 55 Puffy fce Altertions of the fce Puffy fce in the morning Appernce Proneness to infections Altertions of the skin Hir loss Much stronger ppetite thn before Feeling of exercising too little Incresed growth of gum nd hir 52 Gingivl hyperplsi Altertions of the gingiv Bleeding of the gingiv Stronger growth of hir Hirsutism Trnsplnttion-ssocited psychologicl distress 08 Thoughts bout trnsplnttion Brooding bout kidney donor Nightmres Uncertinty of how long the trnsplnt will function Ill feeling Sleeplessness Moodiness Anxiety Qulity of Life in End-Stge Renl Disese Nephron 1999;83:

6 Tble 4. Correltions between the ESRD-SCL nd the SF-36, correltions between the dimensions of the ESRD-SCL, nd correltions between the dimensions of the ESRD-SCL nd the sme dimensions, mesured 12 months fter the first investigtion in 88 stble ESRD ptients fter RT Psychologicl dt ESRD-SCL scle SF-36 b PFI 0.62** 0.40* 0.49* * Rolph 0.53* 0.36* 0.35* Pin 0.70** 0.45* 0.42* * GHP 0.55** 0.39* 0.39* * Vitl 0.59** 0.46* 0.35* * Socil 0.54* 0.43* 0.36* * Rolem 0.45* 0.33* * MHI 0.48* 0.48* * ** ESRD-SCL utocorreltion ** 0.59** 0.42* ** * 0.39* ** * 0.36* 0.43* * 0.40* ESRD-SCL repeted mesurement (n = 88) ** 0.53* 0.54* * ** 0.43* 0.34* 0.37* 0.43* ** 0.36* * ** * ** 1 = Limited physicl cpcity; 2 = limited cognitive cpcity; 3 = crdic nd renl dysfunction; 4 = side effects of corticosteroids; 5 = incresed growth of gum nd hir; 6 = trnsplnttion-ssocited psychologicl distress. b PFI = Physicl functioning; Rolph = role, physicl; Pin = bodily pin; GHP = generl helth; Vitl = vitlity; Socil = socil functioning; Rolem = role, emotionl; MHI = mentl helth. + Wek correltion (sttisticlly significnt, r! 0.32); * modest correltion (r x 0.32 nd r! 0.55); ** moderte correltion (r x 0.55). ESRD-SCL nd the sme dimensions mesured 12 months fter the first investigtion in 88 stble ESRD ptients fter RT were similr to those expected (tble 4). The scle limited physicl cpcity of the ESRD-SCL correlted most closely with the scle bodily pin of the SF- 36. The scles limited cognitive cpcity nd trnsplnttion-ssocited psychologicl distress of the ESRD-SCL correlted strongest with the mentl helth scle of the SF-36. The ESRD-SCL scle crdic nd renl dysfunction correlted most closely with the physicl function scle of the SF-36. In summry, the two scles of the ESRD-SCL mesuring side effects of mediction correlted wekly with the SF-36. The wek to moderte utocorreltions were of the expected dimension. Reproducibility The correltion coefficients between the first nd the second mesurement for 88 stble ptients fter 12 months were moderte in five nd modest in one of the six scles. Associtions between the ESRD-SCL Subscles nd Sociodemogrphic nd Clinicl Dt Correltions between the ESRD-SCL nd sociodemogrphic nd medicl dt re given in tble 5, demonstrting tht single ESRD-SCL scores re wekly ssocited with some sociodemogrphic nd medicl dt. Stepwise hierrchicl regression models were used (tble 6) to determine the predictive vlue of the ESRD-SCL subscles 36 Nephron 1999;83:31 39 Frnke/Reimer/Kohnle/Luetkes/Mehner/ Heemnn

7 Tble 5. Correltions between ESRD-SCL nd sociodemogrphic nd medicl dt ESRD-SCL scle Sociodemogrphic dt Gender Age Mritl sttus Employment Trnsplnttion-ssocited dt Men durtion of disese Number of trnsplnttions Men weight gin Blood chemistry Cretinine Hemoglobin Cholesterol Triglyceride Mediction Ciclosporin Prednisolone Comorbidity Dibetes High blood pressure Myocrdil infrction = Limited physicl cpcity; 2 = limited cognitive cpcity; 3 = crdic nd renl dysfunction; 4 = side effects of corticosteroids; 5 = incresed growth of gum nd hir; 6 = trnsplnttion-ssocited psychologicl distress. + Wek correltion (sttisticlly significnt, r! 0.32). with sociodemogrphic dt (gender, ge, mritl sttus, employment) nd medicl dt (trnsplnttion-ssocited dt: durtion of disese, number of trnsplnttions, weight gin; blood chemistry: cretinine, hemoglobin, cholesterol, nd triglyceride levels; mediction: ciclosporin nd prednisolone doses; comorbidity: dibetes, high blood pressure, myocrdil infrction; see tble 1). Globl results indicted tht ll six subscles were predictive by sociodemogrphic nd medicl dt (4 17% explntion of vrince). Employment ws the strongest indictor of high QOL in the scles concerning limited physicl nd cognitive cpcities s well s in the scle mesuring trnsplnttion-ssocited psychologicl distress (bet weight 0.26, 0.13, nd 0.15, respectively). Age predicted crdic nd renl dysfunction (bet weight 0.21) nd three other scles t step three of the stepwise regression nlyses. It is importnt to note tht older ptients suffered more from limited cognitive cpcity nd less from side effects of corticosteroids nd incresed growth of gum nd hir. Gender predicted distress in five of six scles; the mritl sttus hd low predictive vlue. Regrding the medicl dt, hemoglobin ws n importnt predictor for disese-specific QOL in limited physicl cpcity, crdic nd renl dysfunction, nd side effects of corticosteroids ( higher level of hemoglobin indicted higher QOL). A high level of cholesterol (bet weight 0.10) predicted only limited physicl cpcity, but high level of triglyceride predicted low QOL in three of six scles (bet weight ). Ciclosporin predicted incresed gum nd hir growth (bet weight 0.32) nd limited physicl cpcity (bet weight 0.09). As the third predictor, prednisolone ws ssocited with crdic nd renl dysfunction (bet weight 0.13) nd trnsplnttionssocited psychologicl distress (bet weight 0.10). Qulity of Life in End-Stge Renl Disese Nephron 1999;83:

8 Tble 6. Hierrchicl multiple regression nlysis of the predictive vlue of the subscles of the ESRD-SCL ESRD-SCL subscles Step Vrible Multiple entered b r d.f. r 2 chnge F (p! ) ß r (SD) employment , (SD) gender , (BC) triglyceride , (ME) ciclosporin , (BC) hemoglobin , (CO) dibetes , (SD) employment , (TA) weight gin , (SD) ge , (TA) number of trnsplnttions , (BC) cholesterol , (SD) ge , (BC) hemoglobin , (ME) prednisolone , (SD) gender , (SD) employment , (BC) triglyceride , (TA) durtion of life , (TA) weight gin , (BC) hemoglobin , (SD) ge , (BC) triglyceride , (SD) gender , (CO) dibetes , (ME) ciclosporin , (TA) weight gin , (SD) ge , (SD) gender , (SD) employment , (SD) gender , (ME) prednisolone , = Limited physicl cpcity; 2 = limited cognitive cpcity; 3 = crdic nd renl dysfunction; 4 = side effects of corticosteroids; 5 = incresed growth of gum nd hir; 6 = trnsplnttion-ssocited psychologicl distress. b SD = Sociodemogrphic dt: gender, men ge, employment; ME = mediction: ciclosporin, prednisolone; BC = blood chemistry: hemoglobin, cholesterol, triglyceride; CO = comorbidity: dibetes; TA = trnsplnttion-ssocited dt: men durtion of life with the trnsplnt, number of trnsplnttions, weight gin. Discussion The purpose of this study ws to develop disesespecific QOL instrument, mesuring psychologicl nd physicl distress with specil focus on side effects of immune system suppression therpy in ESRD ptients fter RT. Fctor nlysis of the potentilly relevnt symptoms with response frequency 120% in 458 ESRD ptients fter RT produced six relible [14] scles (Cronbch s ). The contents of ech scle were s follows: (1) limited physicl cpcity scle, including questions bout pin, exhustion, nd dizziness; (2) limited cognitive cpcity scle, including questions bout forgetfulness, trouble concentrting, nd decresing hering nd visul cpcities; (3) crdic nd renl dysfunction, contining items concerning edem in the lower extremities, incresed blood pressure, etc.; (4) side effects of corticosteroids, including questions bout ltertions 38 Nephron 1999;83:31 39 Frnke/Reimer/Kohnle/Luetkes/Mehner/ Heemnn

9 of the fce, decresed stisfction with ppernce, nd proneness to infections; (5) incresed growth of gum nd hir, contining items concerning gingivl hyperplsi nd incresing growth of body hir, nd (6) trnsplnttion-ssocited psychologicl distress, including items deling with the uncertinty of how long the trnsplnt will function, nxiety, nd sleeplessness. Construct vlidity ws demonstrted by correltions expected in direction nd mgnitude, with corresponding scles of the SF-36 helth survey [12, 13] s globl mesure of QOL. Another pproch to investigte construct vlidity is to exmine the independent ssocition between the ESRD-SCL subscles nd sociodemogrphic nd clinicl dt in multiple regression nlysis. In summry, the sociodemogrphic vribles (gender, ge, nd employment) nd the clinicl vribles (trnsplnttionssocited dt: durtion of life fter trnsplnttion, number of trnsplnttions, weight gin; blood chemistry: hemoglobin, cholesterol, nd triglyceride levels; mediction: ciclosporin nd prednisolone levels; dibetes s n spect of comorbidity) were predictive for the single scles of the questionnire (explntion of vrince 4 17%). Limittions of the study re bsed on the restriction to successfully trnsplnted ptients only. Dt limittion is due to the dt-collecting process in university hospitl. Future studies should evlute ptients fter grft loss s well s ptients before nd fter kidney trnsplnttion. The development of the ESRD-SCL is work in progress until tody, requiring severl future studies in lrge smples to verify its usefulness in the clinicl prctice [2]. In this study, the ESRD-SCL ws found to hve dequte relibility, test-retest correltions in subsmple of 88 stble ptients fter 1 yer, nd construct vlidity. It is esy to dminister nd suitble s sensitive indictor of the specific QOL in renl trnsplnt recipients. References 1 Aronson NK: Assessing the qulity of life of ptients in cncer clinicl trils: Common problems nd common sense solutions. Eur J Cncer 1992;28: Kpln De-Nour A, Brickmn AL: Determining qulity of life in the renl replcement therpies; in Spilker B (ed): Qulity of Life nd Phrmcoeconomics in Clinicl Trils. Phildelphi, Lippincott-Rven, 1996, pp Bremer BA: Absence of control over helth nd the psychologicl djustment to end-stge renl disese. Anl Behv Med 1995;17: Evns RW, Mnninen DL, Grrison LP, Hrt LG, Blgg CR, Gutmn RA, Hull AR, Lowrie EG: The qulity of life of ptients with endstge renl disese. N Engl J Med 1985;312: Prfrey PS, Vvsour H, Bullock M, Henry S, Hrnett J, Gult MH: Development of helth questionnire specific for end-stge renl disese. Nephron 1989;52: Prk H, Bng WR, Kim SJ, Kim ST, Lee JS, Kim S, Hn JS: Qulity of life of ESRD ptients: Development of tool nd comprison between trnsplnt nd dilysis ptients. Trnsplnt Proc 1992;24: Brrett BJ, Vvsour HM, Mjor A, Prfrey PS: Clinicl nd psychologicl correltes of somtic symptoms in ptients on dilysis. Nephron 1990;55: Crven J, Littlefield C, Rodin G, Murry M: The end-stge renl disese severity index (ESRD-SI). Psychol Med 1991;21: Lupcis A, Wong C, Churchill D, The Cndin Erythropoietin Study Group: The use of generic nd specific qulity-of-life mesures in hemodilysis ptients treted with erythropoietin. Control Clin Trils 1991;12: Hys RD, Kllich JD, Mpes DL, Coons SJ, Ctrer WB: Development of the Kidney Disese Qulity of Life (KDQOL TM ) Instrument. Qul Life Res 1994;3: Lupcis A, Pus N, Mirhed N, Wong C, Ferguson B, Keown P: Disese-specific questionnire for ptients with renl trnsplnt. Nephron 1993;64: Derogtis LR: SCL-90-R, Administrtion, Scoring & Procedures Mnul-II for the R(evised) Version nd Other Instruments of the Psychopthology Rting Scle Series. Townson, Clinicl Psychometric Reserch, Inc., Frnke GH: Die Symptom-Checkliste von Derogtis deutsche Version (The Symptom- Checklist of Derogtis Mnul of the Germn version). Göttingen, Beltz, Wre JE, Sherbourne CD: The MOS 36-item short form helth survey (SF-36). Med Cre 1992;30: Bullinger M: Germn trnsltion nd psychometric testing of the SF-36 Helth Survey: Preliminry results from the IQOLA Project. Soc Sci Med 1995;41: Qulity of Life in End-Stge Renl Disese Nephron 1999;83:

Assessment of Depression in Multiple Sclerosis. Validity of Including Somatic Items on the Beck Depression Inventory II

Assessment of Depression in Multiple Sclerosis Vlidity of Including Somtic Items on the Beck Depression Inventory II Peggy Crwford, PhD; Noh J. Webster, MA Signs nd symptoms of multiple sclerosis (MS)