Quality of life in patients on continuous ambulatory peritoneal dialysis in an African setting

Enajite I Okaka; Sagren Naidoo; Momina M Ahmed; Malcolm Davies; Saraladevi Naicker

doi:10.4103/1319-2442.157436

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Year : 2015 | Volume : 26 | Issue : 3 | Page : 631-637

Quality of life in patients on continuous ambulatory peritoneal dialysis in an African setting

Enajite I Okaka¹, Sagren Naidoo², Momina M Ahmed³, Malcolm Davies², Saraladevi Naicker²
¹ Renal Unit, Department of Medicine, University of Benin Teaching Hospital, Benin City, Nigeria
² Division of Nephrology, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
³ Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia

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Date of Web Publication

20-May-2015

Abstract

To determine the quality of life (QOL) of patients on continuous ambulatory peritoneal dialysis (CAPD), we studied all the CAPD patients attending their monthly follow-up care clinics at three tertiary hospitals in Johannesburg by administering the World Health Organization QOL-Bref questionnaire. The patients were grouped according to age, duration of peritoneal dialysis and gender. Data were analyzed to determine the significant differences in the QOL scores among the subgroups. There were 114 patients [64 males (56.1%), with a mean age of 42.4 ± 11.3 years) and 38 healthy control subjects (22 males (57.9%), with a mean age of 42.1 ± 12.4 years]. Twenty-one patients (18.4%) had hemoglobin <10 g/dL, while 16 patients (14%) had serum albumin <3 g/dL. The mean QOL scores in the physical, psychological, social relationships and environment domains of the CAPD patients were 55.7 ± 15.0, 56.6 ± 16.4, 55.3 ± 24.7 and 56.3 ± 16.6, respectively. The CAPD patients had significantly lower QOL scores compared with controls, and those aged <30 years had better scores in the physical and psychological domains, gender and hemoglobin concentration. Serum albumin levels did not have a significant impact on the QOL of the CAPD patients.

How to cite this article:
Okaka EI, Naidoo S, Ahmed MM, Davies M, Naicker S. Quality of life in patients on continuous ambulatory peritoneal dialysis in an African setting. Saudi J Kidney Dis Transpl 2015;26:631-7

How to cite this URL:
Okaka EI, Naidoo S, Ahmed MM, Davies M, Naicker S. Quality of life in patients on continuous ambulatory peritoneal dialysis in an African setting. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 Jan 20];26:631-7. Available from: https://www.sjkdt.org/text.asp?2015/26/3/631/157436

Introduction

Quality of life (QOL) is now recognized as an index of treatment outcomes in the management of persons with chronic disease conditions. Although subjective, it reflects an appreciation of the importance of patients' feelings and satisfaction with medical treatment. ^[1],[2]

The World Health Organization (WHO) defines QOL as an individual's perception of his or her position in life within the cultural context and value system that he/she lives in and in relation to his or her goals, expectations, parameters and social relations; a broadranging concept affected in a complex way by the person's physical health, psychological state, level of independence, social relationships and relationship to salient features of the environment. ^[3]

Health-related QOL in chronic kidney disease (CKD) patients is impaired most significantly in terms of levels of physical function, ^[4] and the QOL tends to worsen with the decline in renal function. Advancing age, female gender, presence of diabetes, anemia and cardiovascular disease are associated with lower QOL scores among CKD patients. ^[5]

In end-stage renal disease (ESRD), low QOL is associated with increased morbidity and mortality. ^[6] The modality of renal replacement therapy may affect QOL in ESRD, although previous studies comparing the QOL in patients on continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis (HD) showed conflicting results. ^[7],[8],[9] Predictors of QOL among patients on HD and peritoneal dialysis (PD) include age, co-morbidities, vintage of dialysis treatment and socioeconomic issues. ^[10] There is a paucity of QOL studies among patients on CAPD in Africa.

We aim in this study to assess CAPD patients in an African setting and the influence of gender, duration of treatment, age, serum albumin and hemoglobin (Hb) levels on their QOL.

Subjects and Methods

We studied patients from the PD clinics of three hospitals affiliated to the Division of Nephrology, University of Witwatersrand, Johannesburg. PD care in these centers is sponsored by the government of South Africa, including dialysis fluid, catheters and medications. Healthy volunteers without kidney disease were recruited as control subjects. Ethical approval was obtained from the University Ethics Committee and official permission to carry out the study was granted by the management of the three hospitals participating in the study. Data collection was carried out between June and August 2011.

All CAPD patients attending the monthly follow-up clinic aged ≥18 years were approved for the study. Patients on CAPD for <1 year and those with an acute illness were excluded from the study.

In a cross-sectional design, we used for the measurement of QOL a generic questionnaire, the WHOQOL-Bref. The study patients were approached to fill out the questionnaire after granting their consent. The questionnaires were self-administered by the majority of the patients and those who required assistance had the questionnaire administered by the investigators.

The demographic data of the patients included age, gender, ethnicity, marital status, vintage of treatment and cause of kidney disease. The average hemoglobin blood levels and serum albumin in the preceding three months were obtained from patient records.

Assessment of QOL

The WHOQOL-Bref questionnaire is a generic, health-related questionnaire developed by the World Health Organization Quality of Life Group. It is a well-validated trans-cultural QOL instrument. It consists of 26 items, two of which measure overall QOL and satisfaction with health status on a five-point Likert scale. The remaining 24 items fall into four domains of QOL, namely physical health, psychological wellbeing, social relationships and environment. The WHOQOL-Bref requires the patients to rate their QOL in the preceding four weeks, with item scores ranging from 1 to 5. Domain scores are multiplied by four and transformed to a score range of 4-20 or 0-100. The 0-100 score range was used for this study.

Statistical Analysis

Descriptive statistics were expressed as frequencies and percentages for categorical variables and means ± standard deviations, minimum and maximum values for continuous variables. Mean QOL scores of the patient and control groups were compared using the independent samples "t" test. The patients were grouped according to vintage of PD treatment, using a cut-off of four years, which has been used in a previous study ^[7] on the premise that patient adjustment to diagnosis and treatment would have occurred.

The five-point Likert scale was collapsed into a 2 point scale for ease of analysis. Cross tabulation and Chi square analysis were used to compare the overall QOL of patients grouped according to gender, age and PD vintage. Pvalues <0.05 were considered as statistically significant.

Results

A total of 150 patients on CAPD attended the monthly PD follow-up clinics during the period of the study. Thirty-six patients were excluded from the study; 26 who started CAPD <1 year ago and 10 patients who were ill during the period of the study. The study participants consisted of 114 patients (64 males and 50 females) and 38 healthy control subjects (22 males and 16 females). Of the study patients, 96% were black and 52% were married, and their average duration of CAPD treatment was 3.3 ± 2.5 years, while all the control subjects were black and 71.1% of them were married. Sixteen (14.0%) patients had mean serum albumin level <3 g/dL, while 21 patients (18.4%) had mean Hb levels <10 g/dL [Table 1].

Table 1: Demographic, clinical and biochemical characteristics of the participants (patients and controls) in the study.

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The five-point Likert scale for the overall QOL and satisfaction with health status showed "Good overall QOL" when collapsed into a three-point scale, as reported by 61.4% and 86.8% of PD patients and control subjects, respectively, while 48.2% of patients and 76.3% of control subjects reported "satisfaction" with health status [Table 2].

Table 2: Overall QOL, satisfaction with health status of the PD patients and the controls.

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The mean QOL domain scores for the control subjects were significantly higher than those of the PD patients [Table 3].

Table 3: Comparison of mean QOL domain scores of PD patients and controls.

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There was no significant difference in the QOL domain scores between male and female patients. Patients less than 30 years of age had significantly higher QOL scores in the physical and psychological domains. Patients on PD vintage <4 years had higher total QOL domain scores compared with those on PD for >4 years [Table 4].

Table 4: Comparison of mean QOL domain scores of PD patients according to gender, PD duration and grouped age.

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When grouped according to gender, PD vintage and age, there was no significant difference in the proportion of patients who reported good QOL and poor or neither good nor poor QOL [Table 5].

Table 5: Comparison of perceived overall QOL of PD patients when grouped according to gender, duration of PD treatment and age.

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There was no significant difference between the mean QOL domain scores of patients with Hb blood levels <10 g/dL and serum albumin <3.0 g/dL compared with patients with Hb levels >10 g/dL and serum albumin >3.0 g/dL [Table 6].

Table 6: Comparison of the mean of the QOL domain scores of PD patients according to the means of serum albumin and the means of the hemoglobin blood levels.

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Discussion

The proportion of patients who reported "good" overall QOL (61.4%) and satisfaction with health status (48.2%) was low when compared with 86.8% and 76.3% of controls who reported "good" QOL and "satisfaction" with health status, respectively. The mean QOL domain scores of patients was significantly lower than those of the controls. In a study among healthy individuals, patients on maintenance hemodialysis and asthmatic patients, the healthy group had mean domain scores ranging from 61.3-71.1. ^[11] Skevington et al also found in their study among persons with diverse diseases and healthy persons that domain scores in the healthy group ranged from 68.79-77.38 compared with a range of 57.0-64.86 in sick individuals. ^[12] Patients with chronic disease tend to have reduced QOL, and CAPD patients are no exception. They have peculiar challenges that include body image issues, episodes of peritonitis and restricted employment options due to the need for peritoneal bag exchanges during the day.

We found no difference between the QOL scores of male and female patients in all domains Previous workers on QOL have reported worse QOL in females, while others reported worse QOL in males. In a report by Rocco et al, ^[13] the female gender correlated negatively with overall quality of wellbeing score among patients with chronic renal disease, while Bakewell et al ^[14] reported a significant association between male gender and poorer QOL scores.

In our study, patients aged <30 years had better QOL scores in the physical (P = 0.049) and psychological (P = 0.047) domains. It is possible that this group of patients was still single and under the care of parents with available psychological support as opposed to the married and older patients with family responsibilities in addition to the health problems. Older patients may also have other comorbidities that further worsen the physical well-being. Lin et al reported lower QOL scores in patients on CAPD above 65 years of age, ^[15] while Al Wakeel et al found a negative relationship between age and QOL. ^[16]

In our study, the patients on CAPD for <4 years had significantly higher sum of QOL domain scores compared with those on CAPD for ≥4 years (P = 0.015), but there was no difference in the individual domain scores of the two groups. In a previous QOL study among patients on HD and PD, those on treatment for more than four years had lower QQL scores in all domains than those on PD for <4 years. ^[7] A possible reason for this finding could be reduced dialysis adequacy, reduction in residual renal function or the development of other complications of therapy among patients on CAPD for more than four years. Furthermore, the patients on PD treatment for more than four years have been reported to have a lower survival rate when compared with those on HD for less than four years. ^[17] Residual renal function decreases with time in patients on PD and results in a reduction in dialysis adequacy, which may reduce the physical well-being. This is supported by the report of Bohlke et al, who found that the vintage of PD was a predictor of the physical domain of QOL. ^[10] Nevertheless, there have been reports of patients on CAPD for 10 years with good clinical and physical condition. ^[18]

In our study, 14% of the patients had Hb blood levels <10 g/dL, and there was no difference in their QOL scores and those of the patients with Hb blood levels of ≥10 g/dL. Similar findings have been reported by other investigators, ^[7],[19] but earlier studies before the widespread use of erythropoietin therapy reported higher Hb levels to be associated with better QOL among patients on dialysis. ^[20] Finally, although higher serum albumin levels have been reported to be associated with better QOL, ^[21] we found no difference between the QOL scores in all domains of patients with low and normal levels. A low level of serum albumin is a marker of malnutrition and inflammation; thus, patient selection in this study could be responsible for this result as we excluded patients with intercurrent illnesses.

In conclusion, the QOL of the PD patients was low when compared with that of the healthy subjects. PD patients on treatment for <4 years had higher total QOL scores compared with those on treatment for ≥4 years. PD patients <30 years of age had higher QOL scores in the physical and psychological domains. Gender, hemoglobin and serum albumin levels did not impact on the QOL scores of the PD patients.

Conflicts of interest: None

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