|Year : 2016 | Volume
| Issue : 2 | Page : 270-280
|A comparison of the quality of life of the patients undergoing hemodialysis versus peritoneal dialysis and its correlation to the quality of dialysis
Abdolamir Atapour1, Salar Nasr2, Amir Momeni Boroujeni2, Diana Taheri3, Shahaboddin Dolatkhah2
1 Department of Nephrology, Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Faculty of Medicine, Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Pathology, Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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|Date of Web Publication||11-Mar-2016|
| Abstract|| |
Over the years, there has been a steady increase in the number of patients requiring dialysis. However, no consensus exists between choosing either hemodialysis (HD) or peritoneal dialysis (PD) as the preferred method of dialysis for patients. In this study, we have compared the quality of life of the patients undergoing either HD or PD. This cross-sectional study was performed in the dialysis center of the Noor and Saint Ali Asghar University Hospital in Isfahan, Iran in 2012. Forty-six patients who underwent PD (28 males and 18 females) and 46 similar patients undergoing HD (26 males and 20 females) were compared. A standardized Persian version of the short form-36 (SF-36) tool was used to assess the quality of life and to assess the quality of dialysis weekly Kt/V in patients undergoing PD and single random Kt/V sampling in HD patients were assessed. Patients undergoing PD reported higher scores in physical functioning. The lowest scores in both groups were reported in mental health section. In physical functioning section, physical role functioning section and overall score of the SF-36 tool, PD patients reported significantly higher scores compared to the HD patients (P <0.05). There was no significant difference between the qualities of the dialysis in the two patient groups. Aspects of quality of life such as physical functioning, physical role functioning, bodily pain, general health perceptions, and overall score were significantly different between the two groups. If these results are substantiated by subsequent longitudinal studies, then the choice of dialysis could be better guided in patients by the quality of life issues.
|How to cite this article:|
Atapour A, Nasr S, Boroujeni AM, Taheri D, Dolatkhah S. A comparison of the quality of life of the patients undergoing hemodialysis versus peritoneal dialysis and its correlation to the quality of dialysis. Saudi J Kidney Dis Transpl 2016;27:270-80
|How to cite this URL:|
Atapour A, Nasr S, Boroujeni AM, Taheri D, Dolatkhah S. A comparison of the quality of life of the patients undergoing hemodialysis versus peritoneal dialysis and its correlation to the quality of dialysis. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2020 Aug 9];27:270-80. Available from: http://www.sjkdt.org/text.asp?2016/27/2/270/178259
| Introduction|| |
In the recent decades, there has been a steady shift from acute illnesses toward chronic and debilitating illnesses in the general population and subsequently the life expectancy as a measure of health has given way to more comprehensive measures such as quality of life. , In accordance with the same trend, clinical measures and objectives in patients with end stage renal disease (ESRD) have moved from survival and biochemical indices toward the quality of life measures. , Although no consensus exists between experts in defining the quality of life, there is a general agreement that it is a multidimensional concept consisting of tangible and intangible elements. Most commonly, it is considered to include aspects such as life satisfaction, physical health, social health, hopefulness, and behavioral and mental health. , Several factors affect the physical well-being of a person. These include the effects of the disease as well as the effects of therapeutic modalities used to treat that disease.  As the quality of life can be adversely affected by the disease states and therapeutic modalities, a better understanding of such correlations can help us to address these adverse effects in the vulnerable individuals. 
Patients with ESRD eventually develop a need for dialysis for their survival; this is an added burden for them who already faced a multitude of stressful physical, mental and social problems, and feel a general anxiety and uncertainty toward their future. As a result, careful study of their quality of life is very important. The quality of life measures should be used in order to assess the success of different therapeutic approaches and these evaluations can be used to guide the clinical decision making process for managing such patients. ,,,,,,
Most survival studies performed in patients on hemodialysis (HD) and peritoneal dialysis (PD) thus far have failed to illicit a clear survival benefit for either of these modalities. ,,,, The effects of confounding factors such as age, gender, and the underlying etiology on the survival of ESRD patients also make the choice of optimal treatment difficult. ,,,, These have caused a refocus of dialysis goals on the quality of life of the patients, their physical functioning, and mental health. As a result, a growing body of evidence has been produced in the past several years highlighting the correlation of the treatment modality and the quality of life of the patients; these studies, however, have been far from conclusive with some showing an advantage either for HD or PD or no difference at all.  While PD is less limiting and a higher incidence of depression and anxiety has been reported in HD patients, most studies have found the effects of both modalities on the quality of life similar. ,,,,
Taking the above facts into consideration as well as the fact that a local comparative study had not been performed in Iran, a decision was made for a limited comparative study in order to identify the difference, if any, between the two modalities in Iranian patients and perhaps set a precedence for a possible guideline in choosing treatment options for Iranian patients. As a result, this study was designed and conducted.
| Materials and Methods|| |
In this descriptive cross-sectional study conducted in 2012, 46 HD patients and 46 comparable and similar PD patients treated in the dialysis center of the Noor and Saint Ali Asghar University Hospital in Isfahan, Iran were studied. The HD patients underwent regular three times a week dialysis and PD patients all had a regular and standardized regimen. This cross-sectional study was approved in the Isfahan University of Medical Sciences by the Research Number of 290208.
After informed consent was obtained, clinical information regarding the patients was gathered using medical records and focused questionnaires. Variables such as age, gender, marital status, occupation, education, base etiology for ESRD, and length of dialysis were documented. If there was a history of hospitalization, the reason and length of stay was also documented and the length and number of hospitalization episodes were recorded as person/year.
Inclusion criteria consisted of adults of consenting age (over 18-year-old) who had undergone at least three months of dialysis and had not changed their treatment modality over the past three months and gave consent to be a part of the study. Exclusion criteria consisted of history of psychosis or cognitive dysfunction, peritonitis in the PD patients in the past three months, history of hospitalization in the past two months, or history of kidney transplantation.
For evaluation of quality of life, a standardized Persian version of the short form-36 (SF-36) questionnaire was used. This questionnaire has 36 questions, 35 of which are classified in eight categories. These include: physical functioning (10 questions), physical role functioning (four questions), bodily pain (two questions), general health perception (five questions), vitality (four questions), social functioning (two questions), mental health (five questions), and emotional role functioning (three questions).
These eight sections are categorized in two overall components: mental and physical, of which physical component includes: physical functioning, physical role functioning, vitality, bodily pain, and general health perception. While the mental component consists of general health perception, vitality, social functioning, mental health and emotional role functioning with general health perception, and vitality being the common sections. 
Consequently, each of the physical and mental categories has five sections each. Each section is assigned a score based on a Likert scale with higher scores showing a higher and better quality of life. ,,,,,
In order to assess the quality of dialysis, the Kt/V of the HD patients was determined using the Daugirdas formula. Based on the 2005 National Kidney Foundation/Disease Outcome Quality Initiative criteria target Kt/V is set at 1/4 and Kt/V >1/2 is considered acceptable. In order to assess the quality of dialysis in PD patients, weekly Kt/V is used. According to 2006 Kidney Disease Outcome Quality Initiative Guideline the minimum acceptable Kt/V urea in patients undergoing continuous ambulatory peritoneal dialysis should 1.7 units which in patients with no residual kidney function can be attained using PD alone and in patients with residual kidney function (urine volume >100 mm in 24 h) the Kt/V is calculated by summing up the PD and residual kidney function. It must be mentioned that acceptable weekly Kt/V in PD (1.7 units) is less than the acceptable amount in HD (1/2 units times 3). ,,
Due to the fact that the acceptable levels for quality of dialysis in the two methods are different and because five years survival rate and general health in the two methods is comparable,  thus in order to compare the means (taking into consideration the comparable minimum standards for dialysis in the two methods) the results were homogenized and analysis was performed using the software program Statistical Package for the Social Sciences (SPSS) version 16.0 (SPSS Inc., Chicago IL, USA).
| Results|| |
In the PD group, 60.9% of the subjects were male and 39.1% were females. In the HD group, 56.5% of the subjects were males while the remaining 43.5% were females. Chi-squared test showed no meaningful difference between the two groups (P >0.05). The age range in the PD group was 25-78 years with a mean age of 51.02 years and the age range for HD patients was 25-68 years with a mean age of 47.78 years. Independent t-test showed no significant difference between the two groups (P >0.05).
In PD group, the etiology of kidney failure was diabetes in 69.6% of the cases, hypertension in 26.1% of the patients, other causes accounted for 2.2%, and in 2.2% the etiology remained unknown. In the other group, diabetes, hypertension, other diseases, and unknown etiologies were the causal underlying condition in 54.3%, 39.1%, 4.3%, and 2.2% of the cases, respectively. Chi-squared test failed to show any significant difference between the two groups in regards to the causal condition for their kidney failure (P >0.05). The minimum dialysis time in the PD group was three months and in the HD group was four months while the maximum dialysis time for PD patients was 72 months and for HD patients it was 56 months with a mean of 18.83 months in the PD group and 24.41 months in the HD group. Independent t-test again failed to show a significant difference between the two groups in this regard (P >0.05) [Table 1].
|Table 1: Descriptive statistics of studied factors in the two types of dialysis.|
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The homogenized quality of dialysis in the PD group was 6.5 and in the HD group it was 6 with the minimum acceptable quality of dialysis in the PD group being 2.7 and 3.11 in the HD group and the highest quality of dialysis attained in the PD group was 12.17 while in the HD group it was 9.44. Independent t-test showed that there is no meaningful difference between the qualities of dialysis of the two groups P >0.05). Furthermore, the mean quality of life score for PD patients was 86.36 (range: 74-101) and for HD patients it was 83.21 (range: 68-97). Independent t -test showed that quality of life is significantly higher in the PD group compared to the HD group (P <0.05) [Table 1]. Kalmegorov-Smirnov test showed that quality of life and quality of dialysis variables have normal distribution.
The comparison of the different sections of the quality of life between the two groups showed that in physical functioning, physical role functioning, general health perception, vitality, social role functioning, and mental health, PD patients fared better (i.e., they score higher in the Likert scale) than the HD patients. The HD patients, however, reported higher scores for bodily pain and emotional role functioning. This difference is meaningful (P <0.05) for physical functioning, physical role functioning, general health perception, and vitality. In other words, there is a significant difference between the two groups when it comes to physical category of quality of life but in emotional aspects there is no significant difference between the two groups [Table 2] and [Figure 1].
In the PD group, the male patients reported a mean quality of life score of 85.32 ± 5.54 while female patients reported higher quality of life scores (88 ± 8.80). In the HD group, however, male patients reported better scores compared with the females (83.76 ± 6.5 vs. 82.55 ± 7.89). The F-test showed that gender has a significant effect on the quality of life in both groups (P <0.05). In regards with quality of dialysis while in both groups women had higher qualities of dialysis, this effect was shown to be not statistically significant (P >0.05) [Table 3].
|Table 3: The role of gender in quality of life and dialysis of the patients.|
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Pearson correlation analysis was used in order to evaluate the relationship between quality of life and its categories as well as the quality of dialysis with baseline variables such as age or duration of dialysis. The analysis showed that in PD group there is a meaningful correlation between age and all aspects of quality of life with the exception of mental health (P <0.05). The correlation coefficient was negative, which means that age had a generally negative effect on the quality of life of the PD patients. In the HD group, age had a negative correlation with all aspects of quality of life with the exception of bodily pain and quality of life in general (P <0.05). In the PD group, duration of dialysis had an adverse effect on the quality of life and aspects such as mental health, physical health, and vitality (P <0.05). In HD patients, however, the duration of dialysis had no significant correlation with quality of life or quality of dialysis (P >0.05).
The evaluation of possible correlation between quality of dialysis and quality of life revealed no significant effect in either group (P >0.05) but in the two groups combined there is a positive and meaningful correlation between quality of dialysis and quality of life (correlation coefficient: 0.27, P <0.05) [Figure 2].
| Discussion|| |
Our results showed that aspect of quality of life including physical functioning, physical role functioning, bodily pain, vitality, general health perception, physical category of the quality of life, and quality of life in general are significantly different in the two treatment groups. While the PD patients fare better in aspects such as physical functioning, physical role functioning, general health perception, physical category, and quality of life in general, the SF-36 tool showed that HD patients report better scores in categories such as bodily pain and vitality. The other aspects of quality of life were not significantly different in the two groups.
In the study by Merkus et al, it was shown that PD patients have a higher quality of life in aspects such as physical functioning, bodily pain, and emotional role functioning and mental health. Multivariable analysis, however, showed that dialysis modality only affects the mental health aspect of quality of life.  CHOICE study, which was one of the most prominent studies on quality of life in dialysis patients, showed that PD patients report better scores in aspects such as bodily pain, physical functioning, and emotional role functioning while HD patients only reported a better outcome in vitality aspect of quality of life. 
In the study by Mau et al on 244 dialysis patients, aspects of quality of life such as vitality, bodily pain, physical functioning, physical role functioning, emotional role functioning, and mental health were better in PD patients although only bodily pain and emotional role functioning were significantly different in between the two groups.  A meta-analysis of 52 articles published on quality of life in dialysis patients, transplant patients, and normal population has shown that dialysis patients report lower quality of life compared to the transplant patients but there was no overall significant difference between the quality of life reported by PD and HD patients. 
The lower general health perception scores reported by patients in our HD group can be justified by their admittance in the dialysis ward and witnessing possible adverse outcomes of other patients during their stay at the ward. The stressful process of HD, problems with access to health care, lack of transportation, and time spent at the dialysis ward are the main contributors to lower quality of life in HD patients. ,,,,,,
Several studies have shown that quality of dialysis has a positive effect on the life expectancy of dialysis patients and their quality of life. While our study showed that in neither of our groups there was no meaningful correlation between quality of dialysis and quality of life but overall analysis showed that there is a meaningful and positive correlation between quality of dialysis and quality of life. These findings are in line with findings from similar studies. ,,
In our study, there was a significant correlation between physical functioning, physical role functioning, mental health, emotional role functioning, and quality of dialysis. In our study, the overall quality of life score reported by PD patients was higher than the HD patients, but the quality of dialysis was not significantly different between the two groups. Our study has shown that the better quality of life reported by PD patients compared to HD patients is not due to differences in quality of dialysis. Manns et al have reported a similar finding in their study. 
In this study and in our PD patients, age had a deteriorating effect on all aspects of quality of life with the exception of mental health and quality of life in general. In HD patients, age again had a detrimental effect on physical functioning, physical role functioning, vitality, social role functioning, mental health, and emotional role functioning. The adverse effect of aging on quality of life of the dialysis patients has been reported in similar studies as well. ,,,,,,,,, There are, however, other studies which report no significant relation between age and quality of life in dialysis patients. 
Duration of dialysis in PD patients had an adverse effect on mental health, physical functioning, vitality, and quality of life. Bakewell et al also reported a decline in quality of life of PD patients as the duration of dialysis increased.  In the HD group, there was no relation between duration of dialysis and quality of life, which is in line with the findings of the study by Esmaieli et al  but in contrast to the study by Anees et al. 
In other studies on comparison of quality of life between PD and HD patients, in contrast to our study, it was shown that the average quality of life score in the aspect of bodily pain was lower in PD patients compared to the HD patients, this issue can be related to possible peritonitis or rheumatologic side effects such as osteoarthritis in PD patients. 
In our study, no meaningful correlation was found between either age or duration and dialysis and quality of dialysis. In a study by Termorshuizen et al, it was shown that quality of dialysis declines over time which is in contrast to our findings.  Studies have shown that the exchange efficacy of peritoneum declines in PD patients over time.  Other studies have shown that this decline happens even in the absence of peritonitis.  Another factor which is effective in the chronological decline of quality of dialysis is the reduction in the residual renal function in dialysis patients, this decline, however, is slower in PD patients. ,,
In our study, while in some aspects of quality of life, men reported higher scores but women in general had a higher quality of life, while in other studies, especially those conducted in North America and Europe women generally have lower quality of life. ,,, In our study, women who underwent PD had a higher quality of life compared to HD patients.
Quality of dialysis had no relation with the gender of the patients, but in other studies women have higher qualities of HD compared to men, which has been justified by better administration of HD (similar filters are used for both men and women, while women generally have smaller body masses). ,
Factors such as age, mental/psychological state of patients, adaptability, cultural and religious beliefs, and character can affect a patient's perception of his/her disease. Patients who have facilitating factors such as social and familial support can adapt to their condition faster and consequently the disease will have a less pronounced effect on their lives. 
As a consequence, one of the reasons for the better reported quality of life among PD patients may stem from familial support. Patients who opt for PD usually have a better social support system. In general, ESRD can lead to high dependence and loneliness and those with better social support systems cope better with their condition. We believe that quality of life should be evaluated at different stages after start of dialysis in order to better reflect the actual consequence of treatment modality on the lives of the patients.
The findings of this study showed that quality of life in aspects such as physical functioning, physical role functioning, general health perception, physical category, and quality of life in general are significantly higher in the PD patients while HD patients generally report higher scores when it comes to bodily pain and vitality. Quality of dialysis was comparable in both groups despite the higher quality of life reported by PD patients. This shows that while few patients opt for PD, health professional may encourage ESRD patients to choose PD as it allows them to have a higher quality of life.
| Acknowledgments|| |
In the end, we want to acknowledge the contributions of all the staff of the Isfahan's Noor and Saint Ali Asghar Hospital's dialysis ward and thank them for tireless efforts.
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Al-Arabi S. Social Support, Coping Methods and Quality of Life in Hemodialysis Patients. Ph.D Dissertation, Galveston, University of Texas; 2003.
Department of Nephrology, Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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