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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 1999  |  Volume : 10  |  Issue : 4  |  Page : 481-486
Functional Status of Patients on Maintenance Hemodialysis

King Hussein Medical Center, Amman, Jordan

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Factors associated with physical well being were examined in adults with end-stage renal disease (ESRD) in two large hemodialysis units of the Royal Medical Services in Jordan. Utilizing the Karnofski scale we measured the functional status of 200 Patients who had been on maintenance hemodialysis for at least 12 months. A Marnofski scale of less than 70 incidents frank disability (Inability to perform routine living activities without assistance), in addition current vocational status was assessed as well as any existing comorbid conditions. The mean age of the study group was 45.2 years (range 16 to 70) and included 108 (54%) males and 92 (46%) females, there were 39 (19.5%) diabetic patients and 27 (13.5%) patients were receiving erythropoietin (EPO). The mean hematocrit of the entire group was 27.8%. As measured by Karnofski scale, 64 (32%) of the patients were unable to perform routine living activity without assistance; dependence on wheelchair was reported by 9 (4.5%) patients. The mean comorbidity index of patients who scored less than 70 on the Karnofski scale was 1.5 compared to 0.7 for those who scored at least 70 on the same scale (p<0.001). Analysis of factors showed that age and diabetes mellitus affected functional status. Of the laboratory variables measured, only serum albumin concentration correlated significant with Karnofski scale. Fourteen (21.8%) of the patients who scored below 70, had serum albumin concentration above 40g/L compared to 66 (48.5%) of the patients who scored at least 70 on the Karnofski scale (p<0.001). We conclude that a significant proportion of patients on maintenance hemodialysis is functionally disabled. The elderly, diabetics, patients with high co-morbidity index and those with low serum albumin are most likely to have poor functional status.

Keywords: Hemodialysis, Functional, Rehabilitation, Albumin, Comorbidity.

How to cite this article:
Akash N, Ghnaimat M, Haddad A, El-Lozi M. Functional Status of Patients on Maintenance Hemodialysis. Saudi J Kidney Dis Transpl 1999;10:481-6

How to cite this URL:
Akash N, Ghnaimat M, Haddad A, El-Lozi M. Functional Status of Patients on Maintenance Hemodialysis. Saudi J Kidney Dis Transpl [serial online] 1999 [cited 2020 Jun 2];10:481-6. Available from: http://www.sjkdt.org/text.asp?1999/10/4/481/37205

   Introduction Top

Interest in quality of life as a pertinent issue for health care, had been addressed by several investigators [1],[2] and the concept has many definitions. In the Michigan end-stage renal disease (ESRD) study, quality of life was defined as having three major components: psychological, social and physical well bring. [3] Important aspect of physical well being is functional independence, particularly in daily activities. Constraints on normal activities of daily living can reduce the enjoyment of close friendships, contentment with family performance and satisfaction with work and with life in general.

In spite of potential to correct anemia with erythropoietin (EPO) and the introduction of improved and sophisticated dialysis technology, [4],[5],[6] and better management of several aspects of the uremic syndrome, the physical activity of maintenance hemo­dialysis patients remains sub-optimal [5],[7]

Previous studies investigating quality of life for ESRD patients have concentrated on single modality of care [8],[9] and many of those have not included the functional status of ESRD patients.[10],[11] However, others have include measures of physical activity when assessing quality of life in ESRD patients.[12],[13],[14]

In this study we analyze the functional and vocational rehabilitation of patients on maintenance hemodialysis therapy and we examine the demographic and clinical variables that correlate with their functional status.

   Subjects and Methods Top

Data Sources

Data were collected from 200 patients on maintenance hemodialysis in two large hemodialysis centers (one in Amman the capital and one in Irbid north of Jordan). We interviewed patients who had been on maintenance hamodialysis for at least 12 months and who were between the age of 18 and 70 years.

Three physicians and two nurses conducted the survey. To minimize investigator variability all five surveyors were carefully briefed before proceeding in ensure consistent phrasing of questions and all interviews were made on site within the various dialysis units.

The questions included, age, sex, history of diabetes mellitus, duration of hemodialysis, educational level, employment status, present physical activity or performance according to the semiquantitative scale of Karnofski, and prior transplantation.

The most recent predialysis blood chemistry tests including serum creatinine, serum albumin and hematocrit were reviewed and recorded.

Functional Status

The interviewers rated each patient functional level utilizing the Karnofski scale of physical performance, [13] which produced scores ranging from 0 to 100 [Table - 1], with higher scores indicating greater independence in performing daily activities.

The Karnofski scale has been frequently used in medical research related to ESRD, employment status, quality of life and rehabilitation.

A score of less than 70 indicated that the subject was unable to perform routine living activities without assistance, which is a marker of disability.

Comorbidity Index

The presence or absence of each of the following medical conditions in the study group was identified; malignancy, congestive heart failure, use of waling aid, amputation, blindness, angina, obstructive airway disease, wheelchair use, stroke, arthritis, bone disease, endocrine disease, bowel disease, neuropsychiatric disease, and blood disease excluding anemia of renal failure.

Each of these conditions was assigned one scoring degree and a numerial co-morbidity index was calculated for patients. [5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] for instance diabetic patients with heart disease, arthritis and blindness would score 3 while a patient with stroke would score 1.

Statistical Analysis

Statistical analysis was performed using Microsoft Excel version seven computer program. To calculate the mean of the values as well as the comparison between different variables tested. The non-paired Student's "t" test was used for comparison of groups, and Chi-squared When needed. Significance was set at P<0.05.

   Results Top

[Table - 2] summarizes selected demographic and other charactertics of the survey population. There were 108 (54%) males and 92 (46%) females. Original renal diseases in the study subjects were as follows: glomerulonephritis in 57 patients (28.5%), diabetes mellitus in 39 (19.5%), hypertension in 34 (17%), obstructive uropathy in 17 (8.5%), chronic pyelonephritis in 16 (8%), polycystic kidney disease in 9 (4.5%), miscellaneous in 17 (8.5%) and unknown in 11 (5.5%) patients.

The mean duration of maintenance hemodialysis was 50 months (range 12 to 276 months). The level of education in the study group was as follows: 147 (73.5%) patients were below high school, 34 917%) had high school and 19 (9.5%) had college education.

As determind on the day of survey, predialysis laboratory results showed the following: mean serum albumin; 37g/l and mean hematocrit of 28.6%.

Functional Status

A large proportion of the study group was disabled. There were 64 (32%) patients who scored less than 70 on Karnofski scale signifying that they were unable to perform routine living activities without assistance. Dependence on wheelchair was reported in 9 (4.5%) patients of the study population.

Of those who scored below 70, there were 24 (37.5%) patients with diabetes mellitus compared to only 15 (11%) diabetic patients in the group who had a Karnofski scale of at least 70 (p<0.001).

The mean age of patients who scored less than 70 on the Karnofski scale was 49.7 years compared to a mean age of 42.8 years for those who scored above 70 (<002).

Of the measured laboratory variables, only serum albumin concentration correlated significantly with the functional status. Fourteen (21.8%) patients of those who scored less than 70 on the Karnofski scale, had serum albumin above 40g/L, whereas 66 (48.5%) of patients with Karnofski scale above 70 had serum albumin levels above 40g/L (p<0.001).

Twenty-three (35.9%) of patients who scored below 70 had serum creatinine above 1100 µmol/L (p=0.1)

The mean comorbidity index for patients who scored less than 70 on the Karnofski scale was 1.5 compared to 0.7 in patients who scored above 70 (p<001). Comorbid conditions were more prevalent in diabetic patients who had a mean comorbidity index of 2.9 compared to 1.7 in the non-diabetics (p<0.001).

There were 19 (13.5%) Patients treated with EPO subcutaneously on a twice­weekly basis; 12 (18.7%) patients belonged to those who scored below 70. The mean hematocrit was 29.8% in those who were on EPO and scored below 70 on the Karnofski scale compared to a mean hematocrit of 32.2% in the group who scored above 70 (not statistically significant).

   Discussion Top

The analysis presented here illustrates the association between a number of factors and current functional limitations for a sample of ESRD patients on hemodialysis.

In this analysis the factors examined in the sample patients include age, gender, duration of hemodialysis, primary cause of ESRD, the presence of comorbid conditions and some laboratory variables.

The results of these tests showed that sex, duration of hemodialysis, level of serum creatinine and hematocrit do not make statistically significant contribution to the explanation of functional impairment on Karnofski scale. However, age, original renal disease, comorbidity index and serum albumin did prove to be statistically significant indicator of functional impairment.

The main finding in this study is that poor rehabilitation is prevalent in maintenance hemodialysis patients, based on the Karnofski scale; 32% of our patients were disabled (required assistance with routine daily activities).

Diabetic patients and the elderly had inferior rehabilitation compared to non-diabetic and younger patients. However, diabetics and elderly patients on hemodialysis usually have a worse outcome than their respective counterparts in most studies of functional rehabilitation [11],[16],[17] and this could reflect the increased prevalence of comorbid conditions in both groups. [3],[18]

Our results show that only 21% of ambulatory hemodialysis patients were employed outside home and 15 (9.5%) were full-time housemakers.

Serum albumin concentration correlated significantly with functional status, while serum creatinine did not. Interestingly, both indices have been shown to be predictive of early death in hemodialysis patients when their levels were low. [19]

However, we have noticed an overall mean serum albumin concentration of 37.1 g/L that is less that the desired level of at least 40 g/L in well-dialyzed patients.[19]

Failed rehabilitation in our group can be attributed among other reasons to the fact that newly admitted patients for maintenance hemodialysis have been progressively older each year and are sicker. Additionally of great concern is the possible effect of economically forced shortened dialysis prescriptions on patients morbidity and mortality.[19]

We conclude that a significant proportion of patients on maintenance hemodialysis is functionally disabled. The elderly, diabetics and patients with increased prevalence of comorbid conditions and low serum albumin are at high risk for development of poor functional status.

   References Top

1.Edlund M, Tancredi LR. Quality of life: an ideological critique. Perspect Biol Med 1985;28:591-607.  Back to cited text no. 1  [PUBMED]  
2.Chubon RA. Quality of life and persons with end stage renal disease. Dial Transpl 1986;15:450-2.  Back to cited text no. 2    
3.Julius M, Howthrne VM, Carpentier Alting P, et al. Independence in activities of daily living for end-stage renal disease patients: biomedical and demographic correlates. Am J Kidney Dis 1989;13:61-9.  Back to cited text no. 3    
4.Eschbach JW, Egrie JC, downing MR, et al. Correction of the anemia of end stage renal disease with recombinant human erythropoietin. Results of a combined phase I and II clinical trial. N Engl J Med 1987;316:73-8.  Back to cited text no. 4    
5.Ifudu O, Paul H, Mayers JD, et al. Pervasive Failed rehabilitation in center­based maintenance hemodialysis patients. Am J Kidney Dis 1994;23(3):394-400.  Back to cited text no. 5    
6.US Renal Data System. YSRDS 1990 annual Report. Bethesds. MD, National Institute of Health, National Institute of Diabetes and Digestive and Kidney disease 1990.  Back to cited text no. 6    
7.Gutman RA, Stead WW, Robinson RR. Physical activity an employment status of patients on maintenance dialysis. N Engl J Med 1981;304:309-13.  Back to cited text no. 7  [PUBMED]  
8.Levy NB, Wynbrandt GD. The quality of life on maintenance hemodialysis. Lancet 1975;1:1328-30.  Back to cited text no. 8  [PUBMED]  
9.Richmond JM, Lindsay RM, burton HJ, Conley J, Wai L. Psychological and physiological factors prediciting the outcome on home hemodialysis. Cin Nephrol 1982;17:109-13.  Back to cited text no. 9    
10.Kunter NG, Gardenas DD. Rehabilitation status of chronic renal disease patients undergoing dialysis: variationsby age category Arch Phys Med Rehabil 1981;62:626-30.  Back to cited text no. 10    
11.Gutman RA, Stead WW, Robinson RR. Physical activity an employment status of patients on maintenance dialysis. N Engl J Med 1981;304:309-13.  Back to cited text no. 11  [PUBMED]  
12.Rozenbaum EA, Pliskin JS, Barnoon S, Chaimovitz C. Comparative study of costs and quality of life of chronic ambulatory peritoneal dialysis and hemodialysis patients in Israel. Isr J Med Sci 1985;21:335-9.  Back to cited text no. 12  [PUBMED]  
13.Karnfski DA, Burchenal DH. The clinical evaluation of chemotherapeutic agents in cancer, in McCleod CM (ed): Evaluation of Chemotherpeutic Agents Symposium held at New York Academy of Medicine. New York. 1948, New York, Colombia 1949;191-205.  Back to cited text no. 13    
14.Evans RW, Manninen DL, Garrison LP Jr, et al. The quality of life of patients with end stage renal disease. N Engl J Med 1985;2:553-9.  Back to cited text no. 14    
15.Sehgal AR, Grey SF, De Oreo PB, Whitehouse PJ. Prevalene, recognition and implications of mental impairment among hemodialysis patients. Am J Kidney Dis 1997;304)1):41-9.  Back to cited text no. 15    
16.Ifudi O, Mayers J, Mathews J, et al. Rehabilitation of elderly patients on hemodialysis, in nephrology and urology in the aged patient. Dordeeht, the Netherlands, Kluwer Academic 1993;277-91.  Back to cited text no. 16    
17.Bonney S, Finkelstein FO, Lytton B, Schiff M, Steele TE. Treatment of end stage renal failure in a defined geographic area. Arch Intern Med 1978;138:1510-3.  Back to cited text no. 17  [PUBMED]  
18.Shapiro FL, Umen AJ. Risk factor in hemodialysis patient survival. Am Assoc Artif Intern Organs J 1984;6:176-84.  Back to cited text no. 18    
19.Lowrie EG, Lew NL. Death risk in hemodialysis paients: The variables and an evaluation of death rate difference between facilities. Am J Kidney Dis 1990;15:458-82.  Back to cited text no. 19  [PUBMED]  

Correspondence Address:
Nabil Akash
King Hussein Medical Center, P.O. Box 1362, Amman 11953
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PMID: 18212453

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