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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 2  |  Page : 212-218
Psychosocial issues and quality of life in patients on renal replacement therapy

1 Department of Internal Medicine-Nephrology, University of Patras, Patras, Greece
2 Department of Psychiatry, University of Patras, Patras, Greece

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The aim of the present study was to investigate psychosocial variables related to objective and subjective indicators of quality of life in a single center cohort study of patients undergoing in-center hemodialysis (HD), Continuous Ambulatory Peritoneal Dialysis (CAPD) and renal transplant recipients (RTx). We studied 40 HD patients, 36 CAPD, and 48 RTx patients by a special questionnaire examining demographics, functional status, employment status, and impact of therapy on psychosocial issues such as anxiety and depression. The RTx patients disclosed a better functional and employment status than the CAPD and the HD patients. They were also more compliant and satisfied with their therapy and their relationship with the medical and nursing personnel. The CAPD patients were also more satisfied, more compliant, better motivated, and less anxious and depressed compared with the HD patients who scored low in every aspect studied. Successful renal transplantation is a superior modality of therapy than HD or CAPD regarding psychosocial and quality of life issues. However these results can partially be explained by some selection bias, as RTx patients are usually younger and CAPD patients are selected for this modality after examining functional and social status.

Keywords: Hemodialysis, Peritoneal dialysis, Renal transplantation, Quality life, Psychological

How to cite this article:
Panagopoulou A, Hardalias A, Berati S, Fourtounas C. Psychosocial issues and quality of life in patients on renal replacement therapy. Saudi J Kidney Dis Transpl 2009;20:212-8

How to cite this URL:
Panagopoulou A, Hardalias A, Berati S, Fourtounas C. Psychosocial issues and quality of life in patients on renal replacement therapy. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2023 Feb 4];20:212-8. Available from: https://www.sjkdt.org/text.asp?2009/20/2/212/45524

   Introduction Top

Physicians and policy-makers are increasingly concerned with the management of chronic diseases in which cure is not feasible, and death is an eventuality. If the goal of medical care is to improve patients' quality of life, it should also be measured as an outcome in research. In fact we have been rather slow and sometimes reluctant to quantify this subjective, personal and human characteristic. [1]

End-stage renal disease (ESRD), despite renal replacement therapy, introduces significant psychosocial stressors and adaptive demands. Patients should contend with a number of cha­llenges such as constant threat of death, re­duced physical strength and stamina, depen­dency on medical machinery and personnel, complex pharmacological regimes, and diet limitations. [2]

The term quality of life refers to the physical, psychological, and social domains of health seen as distinct areas that are influenced by pa­tients' experiences, beliefs, expectations, and perceptions. Calman [3] defined quality of life as the extent to which our hopes and ambitions are matched with experience and suggested that the key aim of medical care should be to narrow the gap between patients' hopes and what actually happens. Each domain of quality of life can be measured in two dimensions: ob­jective assessment of function and subjective perceptions of health. [4] Although objective di­mensions are superior in defining degree of health, the subjective perceptions and expecta­tions of patients translate the objective assess­ment into an actually experienced quality of life.

Perhaps, the greatest barrier to the use of quality of life measurements is the perception that these measures are "soft" and inferior to "hard" measures obtained by laboratories. How­ever, symptom status and functional ability are more salient to patients and communities. Moreover, physicians sometimes may not be unaware of important changes of their pa­tients' physical and emotional changes.

There are many studies in the literature, espe­cially during the last two decades, concerning quality of life in ESRD patients, but without doubt there is a need for the development of risk stratification based upon patients' case­mix in order to draw practical solutions. [5]

We studied several psychosocial variables related to objective and subjective indicators of quality of life in patients undergoing in­center hemodialysis (HD), Continuous Ambu­latory Peritoneal Dialysis (CAPD) and patients who have undergone renal transplantation.

   Materials and Methods Top

The study population consisted of 124 pa­tients. Forty (32%) patients were undergoing chronic maintenance HD for four hours three times per week in the hemodialysis unit of our hospital for more than 6 months (6-120 months). All patients were receiving an adequate HD dose (single-pool Kt/V urea > 1.2), and their hemoglobin levels were higher than 11 g/dL with or without erythropoietin. Thirty-six (29%) patients were undergoing CAPD with 4 daily exchanges (2 L each) for more than 6 months (6-60 months). They were adequately dialyzed (weekly Kt/V urea > 1.8) and reached the same hemoglobin levels as the HD patients. Finally, 48 (39%) patients had undergone renal trans­plantation at least 6 months prior to study (6­240 months) and had good renal allograft func­tion (serum creatinine < 2 mg/dL). Only 13 (10%) diabetic patients were equally allocated into the three study groups.

All the patients signed informed consents to participate in the present study. A special ques­tionnaire was distributed to all the patients. HD patients were asked to complete it just before a mid-week HD session. For the CAPD and renal transplant recipients, the questionnaire was given at the time of the patients' monthly ap­pointments and was completed during the pa­tients' visits. One investigator (AP) was avai­lable to provide explanations and to assist pa­tients who were not able to read and write.

The questionnaire included 4 major sections. The first section asked the patients about basic demographic information such as sex, age, marital status, education, residence, and dura­tion of renal replacement therapy. The second section asked patients about their employment status and there was an extra question to the transplant group regarding their status prior and after renal transplantation. The third section inquired about the impact of therapy on spe­cific aspects of patients' lives such as familial, social, sexual, and recreational activities as well as social and family support, compliance to medical advices, and relationship with the medical personnel. The fourth section inquired about patients' psychological status by the HAD scale regarding two domains: anxiety and dep­ression. [6] Especially for the transplant group there was a fifth section that asked them to score their quality of life and health status before and after renal transplantation, com­pared with previous dialysis therapy with a scale from 0 (very bad) to 10 (excellent).

We also used the 100-point functional status developed by Karnofsky [7] as an indicator of functional impairment. Numerical scores cor­respond to behavioral descriptions ranging from 0 that indicates death of the patient to 100 that indicates normal patient who has no complaints or evidence of disease. Patients are described as "rehabilited or caring for them­selves" when their Karnofsky scores are bet­ween 70 and 100. Although it was developed for the use among cancer patients, it was found to be simple, comprehensive, quantitative, valid, and reproducible in patients with ESRD. [8],[9]

Statistical analysis

All numerical values are expressed as mean ± standard deviation (SD) and range. Student's "t" test for unpaired data and chi-square test were used as appropriate in order to compare data between HD, CAPD, and renal transplant patients.

   Results Top

A total of 124 patients (73M/51F) were studied. Each patients' age and gender are shown in [Table 1]. Renal transplant recipients were younger than HD or CAPD patients (p< 0.05) as younger patients are offered renal trans­plantation more often than the elderly.

[Table 2] shows the functional and social data of the study patients. There were more singles in the transplant group as there were more young patients in this group. The proportion of divorce/separated was rather low and most patients lived with their wives and children or parents and siblings (unmarried). There were more patients with no education or primary school in the HD group and more patients with higher education in the transplant group. More transplant recipients were working part or full­time, or were students, whereas more HD or CAPD patients were retired. Unemployment rates were rather low for each group (HD 12%, CAPD 8%, Renal Tx 8%).

We studied the alterations of employment status prior and after starting dialysis or post Tx.

The HD group disclosed an increase of un­employment (from 5% to 12%) and retirement (from 17% to 45%), however, there was no difference in the full time working patients among this group. In the CAPD group, unem­ployment increased from 0% to 8% and retire­ment from 25% to 47%. Full-time workers declined from 25% to 13%. In the Tx group, unemployment was slightly reduced (from 12% to 8%), whereas retirement increased from 2% to 19%. However, in the patients aged between 21 and 60 years, the unemployment rate in­creased to 29% for the HD group, 20% for the CAPD group and was unchanged for the trans­plant group.

[Table 3] shows the Karnofsky scores for the study groups. The HD patients were less func­tional than the CAPD and the transplant reci­pients, but this phenomenon might be related to a selection bias, as more motivated patients were offered PD and renal transplantation. In addition functional status is related to age and all patients who scored less were elderly.

[Table 4] shows the sexual life in the study pa­tients. The Tx patients were more satisfied than the HD or the CAPD. There were no differences between the HD and the CAPD patients. The Tx recipients demonstrated signi­ficantly higher social life and recreation/hobbies score than the HD and the CAPD patients, whereas there were no differences regarding family support and friendships.

The relationship of the patients with the medical and the nursing personnel was more satisfactory for the transplant and CAPD patients (100% and 94% respectively) than the HD patients (80%).

There was a 92% of the transplant recipients satisfied post-Tx, 78% of the CAPD patients, but only 43% in the HD patients.

The Tx patients reported complete and almost complete compliance with medical advices in 88% and 12%, respectively, while the CAPD patients reported 72% and 20%, respectively. In the HD group only 42% of the patients re­ported complete compliance.

The HD patients reported more anxiety (23%) than the CAPD (5%) or the transplant patients (10%). Furthermore, the HD patients reported more depression (33%) than the CAPD (0%) and renal transplantation (2%) patients, p< 0.05. The female patients were more depressed (77%) than the males (33%), and anxiety and depression were both more common in the unemployed males, whereas depression was more common in the retired males and house­wives.

Finally, when the Tx recipients were asked to evaluate their functioning status and overall health before and after renal transplantation there was a significant improvement post-Tx, [Figure 1].

   Discussion Top

Wilson and Cleary [10] have proposed a new model for different measures of health out­come, dividing it in five levels: biological and physiological factors, symptoms, functioning, general health perception and overall quality of life. They have proposed specific causal relationships between them, linking traditional clinical variables to measures of quality of life. Moving from left to the right of the model, one moves from the cell to the individual, to the interaction of the individual as a member of the society. The authors recognize that the concepts at each level are increasingly integ­rated and difficult to define and measure and that there are many inputs that cannot be controlled by physicians or the health system. Unruh et al have suggested that care providers should consider using computer adaptive tes­ting and scoring algorithms using item res­ponse theory for prospective study of quality of life in ESRD patients. [11]

In the present study we examined several psychosocial issues related with functional sta­tus and quality of life in patients undergoing HD, CAPD and renal transplant recipients. Re­nal transplant recipients were younger than HD or CAPD patients, as there will always be a universal bias of age regarding cadaveric renal transplantation and a rational for living­related transplantation for the younger ages. This difference of age might explain some of the difference in the marital status and em­ployment of the studied population.

In our study, the percentage of divorces was rather low and the young unmarried patients lived with their parents and the elderly with their siblings or offsprings. In Greece, there are still strong family bonds that might explain that the majority of our patients with ESRD did not live alone.

In our population, there were a significant number of patients who did not receive any education and this might be explained by the HD and CAPD patients' age and the case-mix of the study that included mainly patients living in South-East Greece, a rather poor re­gion mainly focusing on agriculture based eco­nomy. Although the total unemployment rate seems to be low, when we considered only patients from 21 to 59 years old it increased to almost 15%, which is higher than the average unemployment rate for Greece. Kaitelidou et al have also reported in a cohort of Greek HD patients, that almost 60% were not able to keep their original work and 36% had to retire prematurely. [12]

Functional status measured with the Karnofsky score was higher in the transplant recipients, followed by the CAPD patients and lower in the HD. This phenomenon might be related to a selection bias, as more motivated patients are offered PD and younger patients with less comorbidity are referred for renal transplan­tation.

In addition, The Tx recipients reported better sexual, social, and recreational activities than HD or PD patients. This might be due to the superiority of renal transplantation as a moda­lity over HD or CAPD to restore the uremic milieu since both HD and CAPD are consi­dered "half-way technologies". The HD patients were less satisfied than the CAPD patients with the nursing and medical personnel. This might be due not only to selection bias but also to the nature of each modality. CAPD is a self­therapy and this increases patients' self­esteem, and CAPD patients receive more trai­ning and education about their disease and have better relationships with the nursing staff. Furthermore, CAPD is a home therapy, where the patient is not obliged to spend a lot of time in the dialysis unit and transportation or reco­very after a complicated HD session. All these issues might also explain the finding of better compliance of PD patients than HD patients and are similar to those of Juergensen et al in a recent US study. [13] The Tx recipients were the most compliant in our study. This might be explained by the higher education of this group of patients and the low number of renal transplants in Greece that makes Tx patients realize that a second transplant might not be feasible in the future.

In our study, the Tx recipients reported higher satisfaction with this kind of therapy than dialysis. Although functional status is superior after a successful renal transplantation, it should also be mentioned that in our study, we selected to examine only patients with good or excellent graft function. Perhaps the results would be worse, if we included patients with chronic allograft rejection or severe complica­tions after transplantation such as post-trans­plant diabetes mellitus or malignancies.

Anxiety and depression in our study were more prevalent in the HD patients and signi­ficantly linked with social issues such as un­employment and retirement. Mollaoglu [14] has reported in a study from Turkey that depre­ssion is very common in HD patients (more than 60%) and is strongly related to un­employment.

Finally, we should be aware that this is a co­hort study. The studied population was biased against HD, as we used to offer PD to patients with higher education, stronger family support, and less comorbidity. We have also already mentioned the drawback of including only "healthy" transplant recipients. In addition, all the study patients received an adequate dose of dialysis, either HD or PD, and anemia was corrected with erythropoietin therapy as needed.

The impact of the correction of anemia on the quality of life in ESRD patients has been well documented in the literature. [15] Increased doses of HD [16] or CAPD [17] have not been accompa­nied with significant improvements of quality of life indices. However, in all the large studies such as HEMO, [16] ADEMEX [17] and DOPPS [18] quality of life measures were predictive of adverse events and survival.

We are well aware that our results are diffi­cult to compare with other studies due to case­mix differences, as we studied white patients and only a small number of diabetics. Evans et al [9] have reported that dialysis patients' out­comes are affected by not only case-mix and treatment approaches, but also by particular characteristics of dialysis centers; for example the way patients are rehabilitated and trained for home dialysis- the famous center effect. If we add domestic financial and social support policies applied by the local economy, it can be explained why the rate of the unemployed or prematurely retired patients is lower than in other European or American studies. The fi­nancial support of the national insurance com­panies in Greece is rather low to make living acceptable and the most competent patients are forced to work part- or full-time.

Finally, there are indications that caregivers tend to underestimate the adaptive capabilities of patients coping with ESRD and this may have an impact on treatment or communica­tion. The conceptualization and measurement of the relationships of clinical variables to parameters of quality of life may facilitate physicians to identify risk factors for poor health status and the degree to which they can be altered or modified. Nevertheless, as quality of life perceptions tend to change overtime, there is a need for prospective studies in order to examine whether modifications of these risk factors benefit our patients.

   References Top

1.Deyo RA. The quality of life, research and care. Ann Intern Med 1991;114:695-7.  Back to cited text no. 1  [PUBMED]  
2.Devins GM. Illness intrusiveness and the psychosocial impact of lifestyle disruptions in chronic life threatening disease. Adv Renal Replac Ther 1994;1;251-63.  Back to cited text no. 2    
3.Calman KC. Quality of life in cancer patients: A hypothesis. J Med Ethics 1984;10:124-6.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Testa MA, Simonson DC. Assessment of quality of life outcomes. N Engl J Med 1996; 334:835-40.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Gokal R. Quality of life. In: Gokal R, Nolph KD, (eds). The textbook of peritoneal dialysis. Kluwer Academic Publishers 1994 pp 679-98.  Back to cited text no. 5    
6.Zigmund AS, Snaith RP. The hospital anxiety and depression scale. Acta Phychiatr Scand 1983;67:361-70.  Back to cited text no. 6    
7.Karnofsky DA, Burcherval JH. The clinical evaluation of chemotherapeutic agents in cancer. In: Macleod CM. (ed) Evaluation of chemotherapeutic agents. New York Columbia University Press 1949 pp191-205.  Back to cited text no. 7    
8.Gutman RA, Stead WW, Robinson RR. Physical activity and employment status of patients on maintenance dialysis. N Engl J Med 1981;304:309-13.  Back to cited text no. 8  [PUBMED]  
9.Evans RW, Manninen DL, Garrison LP, et al. The quality of life of patients with end-stage renal disease. N Engl J Med 1985;312:553-9.  Back to cited text no. 9    
10.Wilson IB, Clearly PD. Linking clinical variables with health-related quality of life. JAMA 1995;273:59-64.  Back to cited text no. 10    
11.Unruh ML, Weisbord SD, Kimmel PL. Health­related quality of life in nephrology research and clinical practice. Semin Dial 2005;18:82­90.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]
12.Kaitelidou D, Maniadakis N, Liaropoulos L, et al. Implications of hemodialysis treatment on employment patterns and everyday life of patients. Dial Transplant 2005;34:138-44.  Back to cited text no. 12    
13.Juergensen E, Wuerth D, Filkenstein SH,et al. Hemodialysis and peritoneal dialyis: Patients assessment of their satisfaction with therapy and the impact of the therapy on their lives. Clin J Am Soc Nephrol 2006;1:1191-6.  Back to cited text no. 13    
14.Mollaoglu M. Depression and health-related quality of life in hemodialysis patients. Dial Transplant 2004;33:544-9.  Back to cited text no. 14    
15.Valderrabano F. Quality of life benefits of early anemia treatment. Nephrol Dial Transplant 2000;15(suppl 3):23-8.  Back to cited text no. 15    
16.Unruh M, Benz R, Green T, et al. Effects of hemodialysis dose and membrane flux on health related quality of life in the HEMO study. Kidney Int 2004;66:355-66.  Back to cited text no. 16    
17.Paniagua R, Amato D, Vonesh E, et al. Health­related quality of life predicts outcomes but is not affected by peritoneal clearance. Kidney Int 2005;67:1093-104.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]
18.Mapes DL, Lopes AA, Satayathum S, et al. Health-related quality of life as a predictor of mortality and hospitalization: The Dialysis Outcomes and Practice Patterns Study (DOPPS). Kidney Int 2003;64:339-49.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]

Correspondence Address:
Costas Fourtounas
Department of Internal Medicine-Nephrology, University Hospital of Patras, Rio-Patras 26500
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Source of Support: None, Conflict of Interest: None

PMID: 19237806

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]

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