Letter to the Editor 333 Iranian Journal of Kidney Diseases | Volume 7 | Number 4 | July 2013 6. Tavafi M. Inhibition of gentamicin – induced renal tubular cell necrosis. J Nephropathol. 2012;1:83-6. 7. Nemati E, Abbaszadeh S. Re: effect of erythropoietin on kidney allograft survival: early use after transplantation. Iran J Kidney Dis. 2012;6:227. 8. Gobe GC, Morais C, Vesey DA, Johnson DW. Use of high- dose erythropoietin for repair after injury: A comparison of outcomes in heart and kidney. J Nephropathol. 2013;2:154-65. 9. Alhamad T, Blandon J, Meza AT, Bilbao JE, Hernandez GT. Acute kidney injury with oxalate deposition in a patient with a high anion gap metabolic acidosis and a normal osmolal gap. J Nephropathol. 2013;2:139-43. 10. Gheissari A, Hemmatzadeh S, Merrikhi A, Fadaei Tehrani S, Madihi Y. Chronic Kidney Disease in Children: A report from a tertiary care center over 11 years. J Nephropathol. 2012;1:177-82. 11. Fliser D, Bahlmann FH, Haller H. EPO: renoprotection beyond anemia correction. Pediatr Nephrol. 2006;21:1785-9. 12. Gheissari A, Mehrasa P, Merrikhi A, Madihi Y. Acute kidney injury: A pediatric experience over 10 years at a tertiary care center. J Nephropathol. 2012;1:101-8. 13. Kari J. Epidemiology of chronic kidney disease in children. J Nephropathol. 2012;1:162-3. 14. Solati M, Mahboobi HR. Paraoxonase enzyme activity and dyslipidemia in chronic kidney disease patients. J Nephropathol. 2012;1:123-5. 15. Kam-Tao Li PK, Burdmann EA, Mehta RL. Acute kidney injury: global health alert. J Nephropathol. 2013;2:90-7. Re: Self-esteem in Greek Dialysis Patients: the Contribution of Health Locus of Control Dear Editor, We read the article “Self-esteem in Greek Dialysis Patients: the Contribution of Health Locus of Control” written by Theofilou, 1 with great enthusiasm. She investigated the relationship between health locus of control (LOC) and self- esteem among 144 Greek patients undergoing renal replacement therapy (84 on hemodialysis and the other 60 on continuous ambulatory peritoneal dialysis). She found that there was a positive significant correlation between self-esteem and internal LOC. We appreciated the interest that is given in the healthcare process to psychological aspects, which are too often underestimated by physicians. Recently, we carried out a review about the spirituality and religiosity of patients suffering from chronic kidney diseases, 2 and we stressed the importance of a holistic nursing in the framework of the new model of P6 medicine we introduced. 3,4 The 6 “P”s stand for personalized, 5 predictive, preventive, psychological, participatory, and public. 4,6 Patient’s beliefs, self-concepts, models, and representations of the disease are of crucial and fundamental interest for clinicians, who can help patients to better cope with the pathologies, and to be more adherent and compliant to the treatment. The LOC plays indeed a key role, being a method that patients use in order to attribute the cause of their own disease. 7,8 An individual who thinks that he/she can determine events by their own actions is said to have an internal LOC, while the contrary tendency is referred as externality of LOC. Internal LOC in fact correlates with an idea of a controllable disease, while external LOC reflects the patient’s impression of an incurable illness and a denial of its symptoms, which often results in refusing care and rehabilitation, which are vital in chronic diseases. From the literature, evidence has been collected that LOC can be used as a predictor of the effectiveness of clinical outcomes in patients undergoing dialysis and psychological interventions can be designed ad hoc. 9 Few studies have instead explored the relationship between LOC and patient’s self-confidence, 10 and we believe that the findings should be replicated and confirmed as well as the underpinning of related predictors should be validated in large prospective studies. Nicola Luigi Bragazzi, 1 * Giovanni Del Puente 2 1 School of Public Health, Department of Health Sciences, University of Genoa, Genoa, Italy 2 DINOGMI, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy *E-mail: robertobragazzi@gmail.com