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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2013  |  Volume : 24  |  Issue : 3  |  Page : 519-526
Health-related quality of life in patients on hemodialysis and peritoneal dialysis

Division of Nephrology and Hypertension, Groote Schuur Hospital and University of Cape Town Observatory, Cape Town, South Africa

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Date of Web Publication24-Apr-2013


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.

How to cite this article:
Okpechi IG, Nthite T, Swanepoel CR. Health-related quality of life in patients on hemodialysis and peritoneal dialysis. Saudi J Kidney Dis Transpl 2013;24:519-26

How to cite this URL:
Okpechi IG, Nthite T, Swanepoel CR. Health-related quality of life in patients on hemodialysis and peritoneal dialysis. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2021 Aug 5];24:519-26. Available from: https://www.sjkdt.org/text.asp?2013/24/3/519/111036

   Introduction Top

The increasing global epidemic of chronic kidney disease (CKD) and resultant end-stage renal disease (ESRD) continues to present se­rious challenges for many developing countries. Because chronic renal replacement therapy (dialysis) imposes a dependency and consi­derable burden on patients and their families, handicaps associated with comorbidities asso­ciated with CKD may worsen the situation. The care of patients on dialysis, which is usually focused on the medical and technical aspects of patient care, is expanding to ensure that psychosocial factors (such as quality of life and patient satisfaction) that affect the pa­tients' health is equally covered. Factors in ESRD, like sleep disturbance, sexual dysfunc­tion, anemia, clinical manifestations of comorbid disease, nutritional status, inflamma­tion and relationship with dialysis staff, prooundly impact the patient health-related qua­lity of life (HRQOL). [1],[2],[3]

Several studies have been conducted using different instruments to assess HRQOL in pa­tients receiving dialysis therapy, and have attempted to provide evidence of which moda­lity is superior from a quality of life perspective. [4],[5] Results obtained from many such studies have varied, with some reporting no difference in HRQOL and others showing better HRQOL in peritoneal dialysis (PD) or hemodialysis (HD) patients. [6],[7],[8],[9]

Although HD and PD are thought to provide similar benefits to ESRD patients, compa­risons of HRQOL between the two modalities is currently lacking in South Africa. We there­fore used the kidney disease quality of life short form (KDQOL SF-36) questionnaire to compare HRQOL between HD and PD pa­tients from a single dialysis center in Cape Town, South Africa.

   Subjects and Methods Top

The study was approved by the joint Groote Schuur Hospital and the University of Cape Town Research Ethics Committee. Patients (HD and PD) attending the renal unit of the Groote Schuur Hospital and with working knowledge of English participated in the study. All participants had given a written in­formed consent and none had recent history of hospitalization or of acute illness. Baseline de­mographic and clinical details including age, gender, marital status, smoking and use of alcohol, employment status, years of educa­tion, total household income, cause of ESRD and average of three blood pressure recordings were obtained from the patients. All blood for biochemical tests were drawn pre-dialysis in all the hemodialysis subjects. In PD patients, blood was drawn on the morning of their assessment in the clinic.

HRQOL was assessed using the KDQOL-SF 1.3. [10] The KDQOL-SF, which has been vali­dated in the ESRD population, includes 43 kidney disease-targeted items as well as 36 items that provide a generic core and overall health rating. [11] The disease-targeted items focus on particular health-related domains of pa­tients on dialysis [Table 1].
Table 1: Domains assessed in the kidney disease quality of life (KDQOL-SF 1.3) questionnaire.

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The data were analyzed using SPSS statistical software (SPSS version 11.0 Chicago, IL, USA) and presented as means ± SE. Chi-square test was used for comparisons between groups with categorical variables and an unpaired t test was used to compare groups with normally distributed variables. Univariate ana­lysis was performed with the 36-item health survey and the ESRD-targeted items domains as categorical variables in order to find varia­bles (factors) associated with these items in the HD and PD patients. A P-value of <0.05 was taken as significant.

   Results Top

Characteristics of the studied dialysis patients

The demographic, clinical and biochemical features of the patients are shown in [Table 2]. The mean age of all the patients was 37.8 ± 1.2 years and there was no difference in age, gen­der, smoking and educational status between the HD and PD patients. Hypertension was a common cause of ESRD but there was no significant difference in the causes of ESRD between the two dialysis groups. Duration on dia­lysis therapy was significantly higher in HD patients (49.8 ± 71.5 months vs 14.5 ± 11.6 months; P = 0.001). Diastolic blood pressure was significantly higher in the PD group (80.7 ± 3.2 mmHg vs 89.3 ± 1.7 mmHg; P = 0.003). Also, the serum calcium and parathyroid hormone levels were higher and approached signi­ficant levels in the PD patients (P = 0.071 and P = 0.084, respectively). The mean hemo­globin level was low in both groups as only 9.1% and 15.4% of the HD and PD patients, respectively, had hemoglobin levels within the target range (10.0-12.0 g/dL).
Table 2: Comparison of demographic, clinical and biochemical features between HD and PD patients.

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Comparison of HRQOL (36-item health survey and ESRD-targeted items)

In the 36-item health survey between the HD and PD patients [Table 3], the PD patients generally had better HRQOL scores. These scores however never attained to levels of significant difference from those of the HD patients. The domains in which both groups had low scorers were: Physical functioning, role physical, gen­eral health, role emotional and energy/fatigue. [Table 4] summarizes the comparison of the scores in the ESRD-targeted areas for the two groups. Again, there were no significant diffe­rences in all the assessed domains between pa­tients in the HD and PD groups in the ESRD-targeted areas.
Table 3: Comparison KDQOL-SF 1.3 scores of 36-item health survey between HD and PD patients.

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Table 4: Comparison of KDQOL-SF 1.3 scores of the ESRD-targeted areas between HD and PD patients.

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Univariate regression analysis for the 36-item health survey in PD and HD patients

Univariate analysis was performed for the different domains of the 36-item health survey to identify factors associated with these do­mains in PD and HD patients. The result of the univariate analysis is summarized in [Table 5]. Factors related to anemia [such as use of an erythropoiesis-stimulating agent (ESA) and le­vel of ferritin and hemoglobin] were found to be significantly contributing to the domains in the 36-item health survey in PD and HD pa­tients. For instance, use of an ESA signifi­cantly contributed to the emotional well-being of PD patients (r 2 = 0.267; P = 0.01) and to the domain of pain (r 2 = 0.073; P = 0.049), emo­tional well-being (r 2 = 0.258; P <0.0001) and energy/fatigue (r 2 = 0.390; P <0.0001) in HD patients. Serum ferritin (r 2 = 0.441; P = 0.002) and level of hemoglobin concentration (r 2 = 0.180; P = 0.006) were factors associated with the domain of role emotional in PD and HD patients, respectively [Table 5]. Other factors like parathyroid hormone (PTH) level and calcium involved in mineral bone disease were found to significantly influence the domains' physical functioning, general health and energy/fatigue in HD patients [Table 5].
Table 5: Univariate regression analysis for the 36-item health survey in PD and HD patients.

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Univariate regression analysis for ESRD-targeted items in PD and HD patients

There were fewer variables associated with the ESRD-targeted domains in the HD and PD patients. The hemoglobin concentration and use of an ESA were associated with the symptom and cognitive function domains in HD patients. In PD patients, the systolic blood pressure and the diastolic blood pressure were associated with the cognitive function domain (P = 0.015 and P = 0.002, respectively) while the serum level of inorganic phosphate was associated with the quality of social interaction (r 2 = 0.226; P = 0.019) [Table 6].
Table 6: Univariate regression analysis for the ESRD-targeted items in PD and HD patients.

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   Discussion Top

In Africa, where the epidemic of HIV/AIDS, malaria, tuberculosis and many other infec­tious diseases take up most of the available funding for health care, the scarcity and ra­tioning of resources required for renal replace­ment therapy continues to be a major factor limiting the availability of renal care. [12],[13] Such is the extent of the problem that HRQOL of dialysis patients receives very little attention. As studies on HRQOL are currently lacking in South Africa, we conducted this study to iden­tify factors that affect HRQOL in our patients and to compare HRQOL between the two arms of dialysis offered to our patients.

Our study has shown that HRQOL as mea­sured by the KDQOL-SF instrument is not dif­ferent between HD and PD patients in our population. It also highlights the importance of certain clinical factors (such as anemia and mineral bone disease) and socio-demographic factors (such as employment issues and po­verty) that dialysis patients have to constantly deal with.

Our main findings in this study relate to: (i) the lack of difference in HRQOL between HD and PD patients in our population, (ii) the high prevalence of unemployment in our dialysis population, (iii) the high prevalence of anemia in our dialysis population and (iv) the low res­ponse rate of our patients to an ESA, given that the majority of our patients are treated with an ESA.

Anemia, either directly through a low hemo­globin level or indirectly through use of an ESA, played a significant role in our patients' HRQOL [Table 5] and [Table 6]. The mean level of hemoglobin concentration and the number of patients reaching target hemoglobin was parti­cularly low despite several of these patients being on an ESA [Table 2]. The reason for this poor hemoglobin level was inadequate dosing of an ESA (hospital restrictions due to finan­cial constraints); in some cases, noncom­pliance with the use of an ESA was also docu­mented.

Anemia is associated with poor HRQOL and is a strong predictor of complications and death from cardiovascular causes in patients with CKD. [14] Several observational data indi­cate that correction of anemia is associated with improved outcomes. [15],[16] The Spanish co­operative groups have shown that a higher hemoglobin level (in patients aged ≤65 years without existing cardiovascular disease) is associated with reductions in the physical, psychosocial and global impact of sickness. [17] The poor quality of life observed in our pa­tients may therefore be closely linked to the low levels of hemoglobin documented in most of them.

Other important clinical parameters that were observed to be associated with HRQOL were those that are linked to mineral bone disorder (serum calcium, phosphate and parathyroid hormone levels) [Table 5] and [Table 6]. In HD pa­tients, PTH level was associated with physical functioning (P <0.0001) and energy/fatigue (P <0.0001) and calcium was associated with general health (P = 0.019); in PD patients, phosphate was associated with the quality of social interaction (P = 0.019) [Table 5] and [Table 6]. In a study to determine the extent to which CKD-mineral bone disorder is associated with HRQOL in incident dialysis patients, high and low serum phosphate and low PTH levels were associated with a poorer self-reported physical functioning while serum calcium was not asso­ciated with physical component summary. [18]

Although our study has shown that HRQOL is not different between HD and PD patients in our population, we found that PD patients often had better HRQOL scores in many of the tested domains. Many other studies have pre­viously shown better HRQOL in PD patients than in HD patients. Juergensen et al in assessing satisfaction to therapy and the effects of therapy in HD and PD patients have reported that PD patients have a higher mean satis­faction score (P = 0.15) and less impact of the dialysis treatment on their lives globally (P = 0.019) compared with HD patients. [19]

The difference between studies that have shown better HRQOL in PD patients and studies that have failed to show difference (or shown better HRQOL in HD patients) might arise from: (i) the type of instrument used in assessing HRQOL; (ii) the prevalent socio-economic conditions in the general population; and (iii) whether patients were allowed to choose the dialysis modality or not. In our center, once patients are accepted for renal re­placement therapy, the modality of dialysis is usually selected for them based on availability of space and the opinion of the attending nephrologist.

We also observed that less than a quarter of the PD patients were gainfully employed while almost half of the HD patients were unem­ployed, and that over half the patients in both groups were from households with low total earnings. This is in contrast to the unemploy­ment rate in the general population of South Africa, which is currently 24.0%. [20] The low employment rate in the dialysis population could be due to the loss of jobs soon after being accepted for renal replacement therapy either because of the need to frequently attend HD sessions and be absent from work or the need for frequent PD fluid exchanges at work. Moosa and Kidd have previously shown the odds for a number of variables of being accepted for renal replacement therapy in Cape Town. [13] Among the factors they reported, being employed was shown to significantly increase a patient's chances of being accepted for the renal replacement therapy (OR: 5.42, 95% CI: 3.12 to 9.39, P <0.01).

The main limitation of our study is the small sample size of the PD patients, which mirrors the numbers utilizing PD as a dialysis option worldwide. The number of PD patients we are "allowed" to treat (by the Health Authorities) in our unit is less than half of the number of all dialysis patients in our center. This accounts for the low number of PD patients who participated in this study. Another limitation relates to the study being conducted in a public hos­pital. Patients who attend our hospital for dialysis do so because they do not have health insurance and therefore cannot afford the cost of dialysis in a private care setting. This obviously means that most of our patients were probably of low socio-economic status from the time of starting dialysis. However, we do not consider that this could have significantly affected our findings, given that there are generally few patients who able to afford private dialysis therapy.

HRQOL is low among South African dialysis patients but is similar between the HD and PD patients, and this should therefore encourage the use and availability of PD as a dialysis modality. Clinical and demographic factors that were have found to be associated with HRQOL need to be aggressively addressed if the HRQOL of our patients is to be lifted. Specifically, treatment of anemia and the mineral bone disorder need to be targeted. We might see a significant improvement in the HRQOL of our patients.

   References Top

1.Kalantar-Zadeh K, Kuwae N, Wu DY, et al. Associations of body fat and its changes over time with quality of life and prospective mortality in hemodialysis patients. Am J Clin Nutr 2006;83:202-10.  Back to cited text no. 1
2.Mittal SK, Ahern L, Flaster E, Mittal VS, Maesaka JK, Fishbane S. Self-assessed quality of life in peritoneal dialysis patients. Am J Nephrol 2001;21:215-20.  Back to cited text no. 2
3.Valderrabano F, Jofre R, Lopez-Gomez JM. Quality of life in end-stage renal disease patients. Am J Kidney Dis 2001;38:443-64.  Back to cited text no. 3
4.Marti F, Catherine H, Duboies MF. Compa­rative assessment of three different indices of multimorbidity for studies on health-related quality of life. Health Qual Life Outcomes 2005;3:74-7.  Back to cited text no. 4
5.Walters BA, Hays RD, Spritzer KL, Fridman M, Carter WB. Health-related quality of life, depressive symptoms, anemia, and malnu­trition at hemodialysis initiation. Am J Kidney Dis 2002;40:1185-94.  Back to cited text no. 5
6.Wasserfallen JB, Halabi G, Saudan P, et al. Quality of life on chronic dialysis: Comparison between hemodialysis and peritoneal dialysis. Nephrol Dial Transplant 2004;19:1594-9.  Back to cited text no. 6
7.Wu AW, Fink NE, Jane VR. Changes in Quality of Life during Hemodialysis and Peritoneal Dialysis Treatment: Generic and Disease Specific Measures. J Am Soc Nephrol 2004;15:743-53.  Back to cited text no. 7
8.Merkus MP, Jager KJ, Dekker FW, De Haan RJ, Boeschoten EW, Krediet RT. Quality of life over time in dialysis: The Netherlands Cooperative Study on the Adequacy of Dialysis. NECOSAD Study Group. Kidney Int 1999; 56:720-8.  Back to cited text no. 8
9.Manns B, Johnson JA, Taub K. Quality of life in patients treated with hemodialysis or peritoneal dialysis: What are the important determinants? Clin Nephrol 2003;60:341-51.  Back to cited text no. 9
10.Hays RD, Amin N, Alonso J, et al. Kidney Disease Quality of Life Short Form (KDQOL-SF), Version 1.3: A manual for use and sco­ring. 1997. Available from: http://www.rand. org/pubs/papers/2006/P7994.pdf (Last accessed on 2010 Oct 10).  Back to cited text no. 10
11.Korevaar JC, Merkus MP, Jansen MA, Dekker FW, Boeschoten EW, Krediet RT, NECOSAD-study group: Validation of the KDQOL-SF: A dialysis-targeted health measure. Qual Life Res 2002;11:437-47.Naicker S. Challenges for nephrology practice in Sub-Saharan Africa. Nephrol Dial Transplant 2010;25:649-50.  Back to cited text no. 11
12.Moosa MR, Kidd M. The dangers of rationing dialysis treatment: The dilemma facing a deve­loping country. Kidney Int 2006;70:1107-14.  Back to cited text no. 12
13.Weiner DE, Tighiouart H, Vlagopoulos PT, et al. Effects of anemia and left ventricular hypertrophy on cardiovascular disease in patients with chronic kidney disease. J Am Soc Nephrol 2005;16:1803- 10.  Back to cited text no. 13
14.Collins AJ. Anaemia management prior to dialysis: Cardiovascular and cost-benefit o­bservations. Nephrol Dial Transplant 2003;18: (Suppl 2):2-6.  Back to cited text no. 14
15.Locatelli F, Aljama P, Bárány P, et al. Revised European best practice guidelines for the management of anaemia in patients with chronic renal failure. Nephrol Dial Transplant 2004;19:(Suppl 2):1-47.  Back to cited text no. 15
16.Moreno F, Sanz-Guajardo D, López-Gómez JM, Jofre R, Valderrábano F. Increasing the hematocrit has a beneficial effect on quality of life and is safe in selected hemodialysis patients. Spanish Cooperative Renal Patients Quality of Life Study Group of the Spanish Society of Nephrology. J Am Soc Nephrol 2000;11:335-42.  Back to cited text no. 16
17.Johansen KL, Chertow GM. Chronic kidney disease mineral bone disorder and health-related quality of life among incident end-stage renal-disease patients. J Ren Nutr 2007;17: 305-13.  Back to cited text no. 17
18.Juergensen E, Wuerth D, Finkelstein SH, Juergensen PH, Bekui A, Finkelstein FO. Hemodialysis and peritoneal dialysis: 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. 18
19.Central Intelligence Agency (CIA). The World FactBook: South Africa unemployment rate. Available from: https://www.cia.gov/library/publications/the-world-factbook/geos/sf.html (Last accessed on 2010 Dec 06).  Back to cited text no. 19

Correspondence Address:
Ikechi G Okpechi
E13 Renal Unit Groote Schuur Hospital, University of Cape Town Observatory, 7925 Cape Town
South Africa
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DOI: 10.4103/1319-2442.111036

PMID: 23640624

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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