A Study on the Coping Strategies in Patients with Chronic Kidney Disease Undergoing Dialysis

Dear Editor,

Patients with kidney disease face psychological stress, which affects their quality of life and survival. This leads to emotional distress and cognitive disturbances.^1,2 The cognitive and behavioral efforts by an individual to handle internal and external stressors are called coping strategies. These strategies can be broadly classified as problem-focused, emotion-focused, and avoidant coping.³ The problem-focused approach resolves the underlying issue by finding solutions. The emotion-focused strategy involves managing one’s own emotional response to the stressful situation. Avoidance coping is based on denial, self-blame, and disengagement from the real problem. The problem-focused and emotion-focused approaches are adaptive methods, while avoidance strategies are maladaptive. Maladaptive strategies lead to distress, depression, and substance abuse.⁴

We conducted a cross-sectional quantitative study in 137 patients with ESKD who have been undergoing hemodialysis for ≥3 months, using the Carver Brief COPE Assessment questionnaire.⁵ This consists of 28 questions assessing 14 coping components (two questions for each component). Each question is answered on a Likert scale from 1 to 4. These 14 components are sub-grouped into the above-mentioned three coping strategies.

Of the 137 patients, 103 (75.2%) were males and 34 (24.8%) were females. Most patients (81.7%) received dialysis thrice a week. Classification based on the Charlson comorbidity index shows that the majority had a score ≥5, which corresponds to an estimated 10-year survival of only 21%.

The mean score of coping strategies of our patients was highest for emotion-focused (28.12), followed by problem-focused (18.52), and lowest was avoidance (10.39). This suggests that our patients rely mainly on emotional regulation strategies like seeking support, venting, religious practices, and humor to adapt to the psychological stress of the disease and maintenance dialysis.

When analyzing age-wise coping strategies, the problem-focused strategy yielded the highest mean score (23.5 ± 6.0) among younger participants (≤40 years) [Supplementary table 1, 2]. The score progressively decreased with advancing age, reaching its lowest value among those aged ≥71 years (16.0 ± 5.3). This suggests that younger individuals are more inclined to adopt active coping strategies aimed at problem-solving, while older individuals tend to use such strategies less frequently. In multiple linear regression analysis [Supplementary table 3], for each year increase in age, the problem-focused coping score decreases by 0.12 points, after controlling for the co-morbidity index. The standardized coefficient (β = –0.254) indicates that age has a moderate, significant negative effect. Adjusted R¹ = 0.117, adjusted for the number of predictors and sample size, shows that 11.7% of the variance of problem-focused is explained by age and co-morbidity index.

Females reported higher emotion-focused coping scores than males (29.41 ± 3.783 vs. 27.70 ± 3.398; p = 0.014). In a multiple regression analysis, females (coded as lower) scored about 2.07 points lower than males on emotion-focused coping, controlling for dialysis duration and comorbidities, suggesting a greater reliance on emotion-focused coping among them [Supplementary table 3, 4].

For each additional year on dialysis, the emotion-focused coping score increased by 0.217 points. This is a significant positive predictor, suggesting that longer treatment durations are linked with greater reliance on emotion-based coping strategies. Adjusted R² = 0.078; when corrected for the number of predictors and sample size, the model explains approximately 7.8% of the variance [Table 1].

For each additional year on dialysis, the avoidant coping score increased by approximately 0.11 points, and the predictor is statistically significant (p = 0.016). Adjusted R² = 0.035, adjusted for the number of predictors and sample size, indicated that 3.5% of the variance in Avoidant Coping is explained by the duration since first dialysis [Table 1].

We acknowledge the low R² values in our study. Although the model explained a relatively small proportion of variance, this is consistent with previous psychological research, which shows that coping and behavioral outcomes are influenced by multiple interacting factors. The significant predictors identified still provide meaningful insights into the role of specific coping strategies.

Coping strategies vary by age, sex, and dialysis duration. Assessing coping strategies helps identify patients at risk of poor adjustment, allowing for tailored psychological support. As the duration of illness and dialysis increases, patients become progressively disengaged, highlighting the need for early psychological intervention programs. Counselling for maladaptive avoidance coping focuses on increasing emotional awareness and developing active problem-solving skills through cognitive-behavioral, mindfulness, and motivational approaches. This support may improve their emotional and physical health outcomes, which needs to be proven by further intervention-based studies.