Health-related Quality Of Life Of Dialysis Patients Research Articles

#2225 Educational level and gender are associated with emotional well-being in a cohort of Dutch dialysis patients

Abstract Background and Aims Patients undergoing dialysis have an impaired health-related quality of life (HRQOL). There are conflicting data from small series whether patient-related factors such as educational level have an impact on experienced HRQOL. The aim of this study was to investigate the association between educational level and HRQOL in dialysis patients. Method In a single-center retrospective cross-sectional study HRQOL was measured using the Kidney Disease Quality of Life Short Form-36 (KDQOL-SF36) in prevalent chronic dialysis patients. Educational level was categorized into low, intermediate and high subgroups. Univariate and multivariate regression analyses were performed to assess the effects of age, gender, ethnicity, and dialysis vintage on the association between HRQOL and educational level. Results 129 chronic dialysis patients were included. The median age of the patients was 65.0 years and 58% of the patients were male. The median age did not differ between men and women (67.0 vs. 63.0 years, p = 0.673). Median dialysis vintage was 15.0 months. Patients with an intermediate educational level (OR: 4.37 [1.89-10.13]) and a high educational level (OR 4.13 [1.04-16.42]) had significantly higher odds of higher emotional well-being than patients with a low educational level. The odds for women compared to men were 2.83 [1.32-6.06] for better general health and 2.59 [1.15-5.84] for emotional well-being. There was no interaction between gender and educational level for both subdomains. Each year of increasing age was associated with decreased physical functioning (OR 0.94 [0.91–0.97]). Conclusion Low educational level and male sex were associated with worse emotional well-being compared to intermediate and high educational level and female sex in dialysis patients. Physical functioning decreased with increasing age.

Association Between Exercise Self-Efficacy and Health-Related Quality of Life Among Dialysis Patients: A Cross-Sectional Study.

BackgroundExercise self-efficacy is a vital determinant of an individual’s active participation in regular exercise, and exercise is a critical component of improving health-related quality of life (HRQOL) in dialysis patients. This study aimed to describe the relationship between exercise self-efficacy and HRQOL in dialysis patients.Materials and MethodsA cross-sectional study was conducted in Shanghai, China. Structured questionnaires distributed to the patients collected socio-demographic and disease-related information. Physical activity was assessed by a self-administered questionnaire, and the exercise self-efficacy scale (ESES) was used to measure exercise self-efficacy. HRQOL was evaluated by the kidney disease quality of life instrument-short form version 1.3 (KDQOL-SF™ v1.3). Data were analyzed using a univariate generalized linear model, Spearman correlation, and hierarchical multiple regression.ResultsA positive association was observed between exercise self-efficacy and HRQOL (r = 0.310, p < 0.001). Physical activity as a predictor variable explained 9.8% of the variance in overall HRQOL (p < 0.001). Exercise self-efficacy explained an additional 7.1% of the HRQOL variance. In total, 24.6% of the variation in the HRQOL was explained by the socio-demographic variables, disease-related factors, physical activity, and exercise self-efficacy.ConclusionOverall, only 16.9% of the change in HRQOL was explained by physical activity and exercise self-efficacy. Future research is still needed to further explore the factors influencing the HRQOL in dialysis patients. However, this finding suggests the need to consider the importance of HRQOL and physical activity as well as exercise self-efficacy when developing intervention programs.

Impact of Polypharmacy on Health-Related Quality of Life in Dialysis Patients

Introduction: Dialysis patients are often prescribed a large number of medications to improve metabolic control and manage coexisting comorbidities. However, some studies suggest that a large number of medications could also detrimentally affect patients’ health-related quality of life (HRQoL). Therefore, this study aims to provide insight in the association between the number of types of medications and HRQoL in dialysis patients. Methods: A multicentre cohort study was conducted among dialysis patients from Dutch dialysis centres 3 months after initiation of dialysis as part of the ongoing prospective DOMESTICO study. The number of types of medications, defined as the number of concomitantly prescribed types of drugs, was obtained from electronic patient records. Primary outcome was HRQoL measured with the Physical Component Summary (PCS) score and Mental Component Summary (MCS) score (range 0–100) of the Short Form 12. Secondary outcomes were number of symptoms (range 0–30) measured with the Dialysis Symptoms Index and self-rated health (range 0–100) measured with the EuroQol-5D-5L. Data were analysed using linear regression and adjusted for possible confounders, including comorbidity. Analyses for MCS and number of symptoms were performed after categorizing patients in tertiles according to their number of medications because assumptions of linearity were violated for these outcomes. Results: A total of 162 patients were included. Mean age of patients was 58 ± 17 years, 35% were female, and 80% underwent haemodialysis. The mean number of medications was 12.2 ± 4.5. Mean PCS and MCS were 36.6 ± 10.2 and 46.8 ± 10.0, respectively. The mean number of symptoms was 12.3 ± 6.9 and the mean self-rated health 60.1 ± 20.6. In adjusted analyses, PCS was 0.6 point lower for each additional medication (95% confidence interval [95% CI]: −0.9 to –0.2; p = 0.002). MCS was 4.9 point lower (95% CI: −8.8 to –1.0; p = 0.01) and 1.0 point lower (95% CI: −5.1–3.1; p = 0.63) for the highest and middle tertiles of medications, respectively, than for the lowest tertile. Patients in the highest tertile of medications reported 4.1 more symptoms than in the lowest tertile (95% CI: 1.5–6.6; p = 0.002), but no significant difference in the number of symptoms was observed between the middle and lowest tertiles. Self-rated health was 1.5 point lower for each medication (95% CI: −2.2 to –0.7; p < 0.001). Discussion/Conclusion: After adjustment for comorbidity and other confounders, a higher number of medications were associated with a lower PCS, MCS, and self-rated health in dialysis patients and with more symptoms.

MO822POLYPHARMACY NEGATIVELY AFFECTS HEALTH-RELATED QUALITY OF LIFE IN DIALYSIS PATIENTS

Abstract Background and Aims Dialysis patients are often prescribed a large number of medications to improve metabolic control and manage co-existing comorbidities. However, several studies suggest that a large number of medications can also detrimentally affect their health-related quality of life (HRQoL). Therefore, this study aims to provide insight in the association between the number of medications and various aspects of HRQoL in dialysis patients. Method A multicentre study was conducted among dialysis patients from Dutch dialysis centres three months after initiation of dialysis as part of the ongoing prospective DOMESTICO study. The number of medications, defined as the number of concomitantly prescribed types of drugs, was obtained from electronic patient records. Primary outcome was HRQoL measured with the Physical Component Summary (PCS) score and Mental Component Summary (MCS) score (range 0-100) of the Short Form 12. Secondary outcomes were number of symptoms (range 0-30) measured with the Dialysis Symptoms Index and self-rated health (range 0-100) measured with the visual analogue scale of the EuroQol-5D-5L. Data were analysed using linear regression and adjusted for possible confounders, including age, sex, dialysis modality, and comorbidity. Analyses for MCS and number of symptoms were performed after categorising patients in tertiles according to their number of medications because assumptions of linearity were violated for these outcomes. Results A total of 162 patients were included. Mean age of patients was 58 ± 17 years, 35% were female, and 80% underwent haemodialysis. The mean number of medications was 12.2 ± 4.5. Mean PCS and MCS were 36.6 ± 10.2 and 46.8 ± 10.0, respectively. The mean number of symptoms was 12.3 ± 6.9 and mean self-rated health 60.1 ± 20.6. In adjusted analyses, PCS was 0.6 point lower for each additional medication (95%CI -0.9 – -0.2; p=0.002). MCS was 4.9 point lower (95%CI -8.8 – -1.0; p=0.01) and 1.0 point lower (95%CI -5.1 – 3.1; p=0.63) for the highest and middle tertiles of medications, respectively, compared to the lowest tertile. Patients in the highest tertile of medications reported 4.1 more symptoms compared to the lowest tertile (95%CI 1.5 – 6.6; p=0.002) but no significant difference in the number of symptoms was observed between the middle and lowest tertile. Self-rated health was 1.5 point lower for each medication (95%CI -2.2 – -0.7; p&amp;lt;0.001). Conclusion After adjustment for comorbidity and other confounders, a higher number of medications was associated with a lower PCS, MCS, and self-rated health in dialysis patients and with more symptoms. This suggests that it may be relevant to weigh expected therapeutic benefits of medication against their possible harmful effects on HRQoL. An unfavourable balance between expected benefits and impact on HRQoL might be ground to deviate from clinical guidelines, especially for patients with a limited life-expectancy and for whom a kidney transplant is unattainable.

Intensive Hemodialysis and Health-Related Quality of Life

Diminished health-related quality of life (HRQoL) is common in dialysis patients and associated with increased risks for morbidity and mortality. Patients may present limitations in both physical and mental HRQoL. Poor physical HRQoL may be defined by limited physical function, role limitations due to physical health, dissatisfaction with physical ability, and impaired mobility. Sleep disorders such as obstructive sleep apnea, restless legs, and fatigue are typical manifestations of poor physical HRQoL in dialysis patients. Poor mental HRQoL may be defined by depressive thinking, lack of positive affect, anxiety, and feelings of social isolation. The prevalence of depression is high in dialysis patients. Intensive hemodialysis (HD) can positively address HRQoL. In 3 randomized clinical trials, relative to conventional HD, intensive HD increased physical and mental component summary scores from the 36-Item Short-Form Health Survey (SF-36), although individual treatment effects of daily nocturnal HD were not statistically significant. In another large prospective study, initiation of short daily HD therapy was followed after 12 months by improvements in all SF-36 domains, sleep quality, and restless legs symptoms. In a small study of nocturnal HD, apnea and hypopnea episodes per hour decreased by almost 70% after conversion from conventional HD. Intensive HD is also associated with a large reduction in postdialysis recovery time. In contrast, 2 randomized clinical trials failed to demonstrate statistically significant effects of intensive HD on the Beck Depression Inventory score despite a significant decrease in Beck Depression Inventory score in the prospective study of short daily HD. Furthermore, intensive HD may not improve objective physical performance and can increase burden on caregivers in the home setting. In conclusion, intensive HD potentially can address both physical and mental aspects of poor HRQoL relative to conventional HD. However, more studies are needed to understand the effects of intensive HD, including specific schedules, on HRQoL.

Health related quality of life in patients in dialysis after renal graft loss and effect of gender

BackgroundAn increasing number of dialysis patients have returned to dialysis after renal graft loss, and the transition in disease state could likely be associated with reduced health related quality of life (HRQOL). Furthermore, gender differences in HRQOL have been observed in dialysis and kidney transplanted patients, but whether transition in disease state affects HRQOL differently in respect to gender is not known. The aims of this study were to compare HRQOL in dialysis patients with graft loss to transplant naïve dialysis patients, and to explore possible gender differences.MethodsIn a cross-sectional study, HRQOL was measured in 301 prevalent dialysis patients using the Kidney Disease and Quality of Life Short Form version 1.3. Adjusted comparisons were made between dialysis patients with previous graft loss and the transplant naïve patients. Multiple linear regression analyses were performed with HRQOL as outcome variables. Interaction analyses using product terms were performed between gender and graft loss. HRQOL was analysed separately in both genders.ResultsPatients with renal graft loss (n = 50) did not experience lower HRQOL than transplant naïve patients after multiple adjustments. Among patients with graft loss, women (n = 23) reported lower HRQOL than men (n = 27) in the items physical function (40 vs. 80, p = 0.006), and effect of kidney disease (49 vs. 67, p = 0.017). Women with graft loss reported impaired kidney-specific HRQOL compared to transplant naïve women (n = 79) in the items effect of kidney disease (50 vs. 72, p = 0.002) and cognitive function (80 vs. 93, p = 0.006), and this observation persisted after multiple adjustments. Such differences were not apparent in the male counterparts.ConclusionsPatients who resumed dialysis after renal graft loss did not have lower HRQOL than dialysis patients not previously transplanted. However, losing graft function was associated with reduced HRQOL in females, and important interactions were identified between graft loss and gender. This needs to be further explored in prospective studies.

The role of depression, anxiety, stress and adherence to treatment in dialysis patients’ health-related quality of life: a systematic review of the literature.

Health-related quality of life (HRQOL) has been widely studied in the field of dialysis patients. However, there are few studies that include relationships of psychosocial variables and adherence to treatment with HRQOL. The aim of this review is to systematically synthesise available information on the role that psychological variables (depression, anxiety and stress) and adherence to treatment have on HRQOL of dialysis patients through a systematic narrative review. We selected studies that included and related, in their results psychological variables (at least one of the following: depression, anxiety or perceived stress), adherence to treatment and HRQOL in adults on dialysis due to advanced chronic kidney disease (ACKD). The studies included had to incorporate standardised instruments into their assessment protocol. We searched the MEDLINE and PsycINFO databases from January 2002 to August 2012. Thirty-eight studies were included in this review and we assessed their methodological quality. The review revealed that 100% of the studies identified a negative association between indicators of anxiety, depression and stress and HRQL, indicating that these variables are risk factors for quality of life. Adherence to treatment was associated with psychological factors and HRQOL in 8% (N=3) of the studies included and has been demonstrated to be a protective factor for quality of life in 66% of studies (2 of 3) that included this variable. Considering the effect of these variables on HRQOL, it is important to screen for early indicators of anxiety, stress and depression or difficulties in complying with treatment in the ACKD population on dialysis. This will allow preventive interventions to be carried out before HRQOL deteriorates.

Adherence to treatment, emotional state and quality of life in patients with end-stage renal disease undergoing dialysis.

A low rate of adherence to treatment is a widespread problem of great clinical relevance among dialysis patients. The objective of the present study is to determine the relationship between adherence, emotional state (depression, anxiety, and perceived stress), and health-related quality of life (HRQOL) in renal patients undergoing dialysis. Two patient groups (30 in hemodialysis and 31 in peritoneal dialysis) participated in this study. We evaluated aspects of adherence, depression, anxiety, perceived stress, and HRQOL with self-report and standardized instruments. Peritoneal dialysis patients reported significantly higher levels of adherence to treatment and better HRQOL in Physical Function and Bodily Pain domains. Depression level is associated with HRQOL indicators. We did not find any differences regarding specific adherence to antihypertensive and phosphate binder drugs or in psychological variables depending on the modality of dialysis. Patients with adherence to antihypertensive drugs show better physical HRQOL. The predictors of HRQOL in dialysis patients were: work, gender and depression. Our results suggest that the modality of dialysis does not differentially affect the emotional state or specific adherence to drugs, but it is nevertheless related to their overall adherence to treatment and to their HRQOL.

Gender effect on quality of life in hemodialysis patients

We read with interest the article by Peng et al. [1] entitled ‘‘Women on hemodialysis have lower self-reported healthrelated quality of life scores but better survival than men’’ published in your esteemed journal. In this study, females had poor self-reported health-related quality of life (HRQoL), but better survival than men [1]. We have also found a lower quality of life (QoL) score in women among 6,930 HD patients [2]. Peng et al. [1] mentioned that the higher prevalence and severity of psychological disorders in females cause poorer HRQoL in women than in men. On the other hand, women are more capable than men in providing and getting emotional support. Fife et al. [3] have also shown that women benefit more from family support, but men get more support provided by health care professionals. It is fact that health care professionals are not as eagerly available as family members to provide the patient’s needs. It is important to note that Peng et al. [1] did not look at some confounding factors that can influence HRQoL such as patient’s education, work status, sex function, marital state and etc. We showed a correlation between educational level and work status with QoL [2]. Although Peng et al. [1] revealed that men had better HRQoL, women had significantly lower mortality than men. However, HRQoL score may be applied to forecast the risk of important outcomes such as death and previous studies have indicated that lower HRQoL in dialysis patients had strong relationship with higher mortality [4]. It may be due to some other factors which are more prevalent in men and were not detected in the current study [1] such as cigarette smoking, hypertension, viral hepatitis [5] and other chronic illnesses that cause a higher mortality rate in men.

Health-related quality of life in patients on hemodialysis and peritoneal dialysis

Chronic kidney disease (CKD) is a worldwide public health problem, and its treatment imposes a considerable burden on patients and their families. Limitations in everyday activity may worsen the situation and affect the health-related quality of life (HRQOL) of patients with CKD. There are no studies on the HRQOL of dialysis patients in South Africa. We assessed the HRQOL of patients undergoing hemodialysis (HD) and continuous ambulatory peritoneal dialysis (PD) attending the Groote Schuur Hospital renal unit by using the Kidney Disease Quality of Life-Short Form version 1.3 questionnaire. Baseline demographic and clinical details of the participants were recorded. Analysis was performed (unpaired t test and univariate analysis) to compare the HRQOL between HD and PD patients and to identify factors influencing HRQOL. The HRQOL was low but not significantly different between HD and PD patients. In PD patients, the use of erythropoiesis-stimulating agents (ESA) significantly contributed to the emotional well-being (r 2 = 0.267; P = 0.01) and alleviation of pain (r 2 = 0.073; P = 0.049); in HD patients also, ESA use was associated with emotional well-being (r 2 = 0.258; P <0.0001) as well as improvement in energy/fatigue (r 2 = 0.390; P <0.0001). Systolic and diastolic blood pressures significantly influenced cognitive function in PD patients (P <0.05). Parathyroid hormone level significantly influenced the physical functioning and energy/fatigue domains in HD patients (P <0.0001). Serum ferritin (r 2 = 0.441; P = 0.002) and level of hemoglobin concentration (r 2 = 0.180; P = 0.006) were significantly associated with the domain role emotional in PD and HD patients, respectively. Although HRQOL is low in dialysis patients in Cape Town, the factors that have been identified to be associated with these scores (such as anemia and hyperparathyroidism) if aggressively managed and corrected may assist in improving patients' HRQOL.

Cross-sectional validity of a modified Edmonton symptom assessment system in dialysis patients: A simple assessment of symptom burden

Subjective symptom assessment should be a fundamental component of health-related quality of life (HRQL) assessment in end-stage renal disease (ESRD). Unfortunately, no symptom checklist has established reliability or validity in ESRD. We report the validation of a modified Edmonton Symptom Assessment System (ESAS) in 507 dialysis patients who concurrently completed the Kidney Dialysis Quality of Life-Short Form (KDQOL-SF) questionnaire. The ESAS demonstrated a mean of 7.5+/-2.5 symptoms. The symptoms reported as most severe were tiredness, well-being, appetite, and pain. The overall symptom distress score was strongly correlated with the KDQOL-SF subscales symptom/problem list (r=-0.69, P<0.01), effects of kidney disease (r=-0.52, P<0.01), and burden of kidney disease (r=-0.50, P<0.01), as well as lower RAND-12 physical health composite (PHC) (r=-0.54, P<0.01) and lower RAND-12 mental health composite (MHC) (r=-0.62, P<0.001). In the multivariate regression analysis, after controlling for potential confounding variables including comorbidity using the modified Charlson Comorbidity Index, the ESAS symptom distress score remained strongly associated with the MHC (slope=-0.82+/-0.07, P<0.01) and PHC (slope=-0.48+/-0.07, P<0.01). The ESAS symptom distress score accounted for 29% of the impairment in PHC and 39% of the impairment in MHC. The intraclass correlation coefficient for the total symptom distress score in a 1-week test-retest was 0.70, P<0.01. Symptom burden is high and adversely affects HRQL in dialysis patients. The modified ESAS is a reliable, valid, simple, and useful method for regular symptom assessment in this patient population.

Health profiles and health preferences of dialysis patients.

Health-related quality of life (HRQOL) of haemodialysis (HD) and peritoneal dialysis (PD) patients has been assessed with health profiles and health preferences methods. Few studies have used both types of HRQOL instruments. The main objective of this study was to assess the relationship between information from the two types of HRQOL instruments in dialysis patients. We interviewed 135 patients, using two health profiles (Short Form 36 and EuroQol/EQ-5D) and two health preferences methods (Standard Gamble and Time Trade Off). Socio-demographic, clinical, and treatment-related background data were collected from patient charts and during the interview. Relationships between the outcome measures were assessed with Pearson correlation coefficients. Multiple regression models were used to study the relationship of HRQOL outcomes to background variables. The HRQOL of dialysis patients as measured with health profiles was severely impaired. The health preferences scores were higher (0.82-0.89) than scores previously reported in the literature. Correlations between health profiles and health preferences were poor to modest. HRQOL outcomes were poorly explained by background characteristics. Differences between HD and PD groups could not be demonstrated. Health profiles and health preferences represent different aspects of HRQOL. An impaired health status may not be reflected in the preference scores. Coping strategies and other attitudes towards health may affect the preference scores more than they influence health profile outcomes. The added value of health preferences methods in clinical research is limited.

Assessment of quality of life in a single centre dialysis population using the KDQOL-SF questionnaire.

Health-related quality of life (HRQOL) is a valid marker of outcome for chronic dialysis therapy. A wide range of questionnaires are now available which assess different aspects of an individual's health. Appreciation of those factors that contribute to explaining HRQOL items remains poorly defined. The development of disease-specific questionnaires such as KDQOL-SF, should allow for such questions to be better answered. A cross-sectional analysis of our chronic dialysis population was made using the KDQOL-SF questionnaire. By multiple linear regression analysis demographic, clinical and dialysis-related factors were assessed for their contribution to the HRQOL in this population. The HRQOL of these patients was also compared against a general population sample. From a total of 190 chronic dialysis patients, 146 completed the KDQOL-SF questionnaire. The haemodialysis (HD) and peritoneal dialysis (PD) patients were similar with respect to most demographic, clinical and dialysis variables except for haemoglobin and albumin which were significantly (p < 0.05) greater in the peritoneal and haemodialysis populations respectively. Compared to the general population, the HRQOL of dialysis patients was impaired for all SF-36 subscales. Use of the disease-specific components of KDQOL-SF discriminated between dialysis modality for our dialysis population. Multiple linear regression analysis demonstrated that 27.5 to 42.7% of the variance in the SF-36 subscales could be explained. Satisfactory sleep, dialysis related symptoms, effect of kidney disease on lifestyle and burden of kidney disease were found to be the most important determinants of HRQOL for this population.