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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2017  |  Volume : 28  |  Issue : 1  |  Page : 133-140
A comparison of health-related quality of life in patients with renal failure under hemodialysis and healthy participants

1 Department of Biostatistics and Epidemiology, Babol University of Medical Sciences, Babol, Iran
2 Department of Internal Medicine, Ayatollah Rohani Hospital, Babol University of Medical Sciences, Babol, Iran
3 Department of Orthodontics, Faculty of Dentistry, Guilan University of Medical Sciences, Rasht, Guilan, Iran

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Date of Web Publication12-Jan-2017


The objective of this study was to evaluate the health-related quality of life (QoL) of patients under hemodialysis (HD) and to compare this to healthy participants. We compared 154 patients on HD to 308 healthy age- and sex-matched controls recruited from Shahid Beheshti Hospital in Babol, Northern Iran in 2014. The data of health-related QoL in eight subscales were collected with interview using a standard short-form questionnaire of short form-36. The demographic data and dry weight and height were measured. The scores of each subscale were transformed from 0 (the worse state) to 100 (the best state). In univariate analysis, Wilcoxon and Kruskal-Wallis tests were used to compare the distribution of scores between cases and controls according to gender, and multiple linear regression analysis was used to adjust the regression coefficient for possible potential confounding factors. The mean overall score of health-related QoL for men was 44.7 ± 23.2 and 74.3 ± 18.1 in patients and controls, respectively, and for women was 37.1 ± 20.8 and 62.1 ± 18.7, respectively. In all subscales, the mean score of patients was significantly lower than controls (P = 0.001) in both sexes. In all eight subscales, after adjusting for demographic characteristics, the patients had significantly lower QoL than controls (P = 0.001). In addition, the independent effect of age, gender, and educational level as predictors of QoL was significant across various subscales (P = 0.001).

How to cite this article:
Hajian-Tilaki K, Heidari B, Hajian-Tilaki A. A comparison of health-related quality of life in patients with renal failure under hemodialysis and healthy participants. Saudi J Kidney Dis Transpl 2017;28:133-40

How to cite this URL:
Hajian-Tilaki K, Heidari B, Hajian-Tilaki A. A comparison of health-related quality of life in patients with renal failure under hemodialysis and healthy participants. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2022 Sep 25];28:133-40. Available from: https://www.sjkdt.org/text.asp?2017/28/1/133/198165

   Introduction Top

Worldwide, it is estimated about 200 million people have chronic kidney disease (CKD), and the burden of CKD continues to increase in low- to middle-level income countries globally.[1] The annual mortality rate of CKD was 14.8%-15.7% in the United States (US) in the period of 2006-2008.[2] While end-stage renal disease (ESRD), which is more devastating medical, social, and economic problem, needs more supervision and medical cares. It is associated with 1-year mortality of 23.5% in the US with the cardiac causes consist of 50% of all deaths.[3] ,[4] Globally, more than one million people die annually from ESRD.[1]

Instead of traditional end points assessment for the effect of interventions on patients, the quality of life (QoL) measures have become increasingly used in the recent decades with changing the pattern of illness in developed and developing countries.[5] ,[6] Traditional moralitybased measures present information about the lowest levels of health only, but reveal little about the important aspects of health and wellbeing.[7] On the other hand, the different domains of health-related QoL that measure the state of well-being including perception of general health (GH) in three dimensions of physical, psychological, and social states that is primary interested as an indicator of efficacy of receiving therapeutic cares.[8]

In the management of patients of ESRD, although the progress has been achieved in therapeutic agents. Using dialysis process in passing off superfluous, the longevity of patients has been increased, but several metabolic complications threat the health-related QoL in the process of dialysis. Thus, the limitations would be arisen on different aspects of daily activities. Many of these patients are unable to cope with possible limitations, and therefore the psychological along with physical and social problems would threat their health states.[9] ,[10] ,[11] In addition, in turn, the depression might be arisen that limits and interferes the interrelationship with others, and thus it would be an obstacle for vitality of life. On the other hand, the costs of management and family economic crises are additional issues to the family and community as well.[1] Although mortality of patients with renal failure has been decreased substantially during the recent decades because of advanced therapeutic agents; nevertheless, the decreasing mortality rate did not show evidence in improving the QoL. Published studies have reported some evidences of poor QoL,[9] ,[10] ,[11] ,[12] ,[13] but a significant difference in QoL has been observed with ethnicity and culture.[14] ,[15] In spite of long duration in managing patients of ESRD under hemodialysis (HD) in the North of Iran, no data are available regarding healthrelated QoL. The objective of this study was to evaluate the health-related QoL of patients under HD and to compare with healthy participants.

   Methods and Subjects Top

We conducted a case-control study of 154 patients with ESRD under HD and 308 healthy participants as controls. The patients were recruited from dialysis centre of Shahid Beheshti Hospital in Babol, northern Iran, in 2014. The inclusion criteria of patients were the end stage of renal failure with at least three months duration of dialysis and aged 20-80 years with dialysis adequacy dose of 250 ± 10 Kt/V. The controls were selected from healthy participants of patients' visitors or from outpatients clinic. In control selection, participants with debilitating conditions such as diabetes, renal failure, history cardiovascular atherosclerosis, heart surgery, cancers, dementia, overt disability and congenital disorders were excluded. Additionally, those who lost their close relatives within the previous six months were also excluded from control selection. For each case, two sex and age matched controls) were selected from patients' visitors or outpatient clinics of the hospital. The demographic data were collected using face to face interviews conducted by trained nurses and a short form (SF-36) of standard questionnaire of health-related QoL was used. The validity and reliability of this questionnaire were assessed in several reports.[16] ,[17] This questionnaire included 36 items that assess the health-related QoL in eight dimensions including physical functioning (10 items), role limitation due to physical health (4 items), role limitation due to emotional health (3 items), bodily pain (2 items), social functioning (2 items), mental health (5 items), vitality (4 items), and GH perception (6 items). SF-36 questionnaire is designed to detect positive as well as negative states of health. In each dimension, the score of items was transformed as a subscale from 0 (worse health) to 100 (best health). In addition, the internal consistency of items within each subscale was evaluated by Cronbach's α as a reliability coefficient for rating data. The calculated Cronbach's ranged from 71.7% for subscale of social functioning to 95.5% for role limitation due to physical health. The duration of dialysis and the demographic data such as age, sex, marital status, educational level, and residence area were collected. The dry weight and height were measured just after dialysis, and the body mass index was calculated.

For statistical analysis, we used Statistical Program for Social Sciences (SPSS) software version 18.0 for Windows (SPSS Inc., Chicago, IL, USA). The descriptive statistic of mean ± standard deviation (SD), median, and interquartile range of QoL in different dimensions was estimated also. The overall QoL as weighted QoL of specific subscales were calculated according to case status, gender, age group, educational level, and duration of dialysis (<2 years/≥2 years). Mann-Whitney and Kruskal-Wallis tests were used to avoid any distributional assumption in comparison of QoL between cases and healthy participants. In addition, the multiple linear regression model was applied to adjust the effect of possible potential confounding factors such as age, sex, educational level, marital status, residence area, and BMI on various dimensions of QoL. The independent predictors and the adjusted regression coefficients with 95% confidence interval (CI) were determined a P <0.05 was considered as significant level. The adjusted regression coefficients of multiple linear regression show the adjusted mean difference between groups of binary predictor factors that entered into the model. The regression analysis was accomplished for each dimension of QoL once at a time as dependent variable and the independent variables were case (vs. control), gender (female vs. male), age group (≥60 vs. <60 years), educational level (≥ high school vs < high school), marital status (couple vs. alone), residence area (rural vs. urban), and BMI (BMI ≥25 vs. <25 kg/m2). The P <0.05 was considered statistically significant.

   Results Top

[Table 1] shows that the prospective mean age of patients and controls was 54.2 ± 16.3 and 51.6 ± 16.0 years, respectively (P = 0.12), and 85 (55.2%) of patients and 70 (55.2%) of controls were male. The percentage of controls who were residence of urban area was significantly higher than patients (63.6% vs. 52.9%, P = 0.03). A rather similar distribution of marital status was observed between cases and controls. While among patients, the majority of the participants (64.9%) were illiterate compared to 36.8% of controls and only the educational level of 4.9% of patients and 21.8% of controls were at the university level (P = 0.001). The mean BMI was revealed significantly higher in control than patients (P = 0.03). The mean duration of dialysis of patients was 46.6 ± 42.8 months. The observed mean dose of dialysis was 253 ± 11.8 Kt/V. [Table 2] shows the mean (SD), median, and interquartile range of score of health-related QoL between patients and controls according to various subscales in men and women. In all subscales, the mean and median score of patients was significantly lower than controls (P = 0.001) in both sexes. The overall score of QoL in men was 44.7 ± 23.2 and 74.3 ± 18.1 for patients and controls, respectively, whereas in women, it was 37.1 ± 20.8 and 62.1 ± 18.7, respectively. The poorer QoL has been observed among women than men in patients and controls as well. In both sexes, among patients, the poorest QoL was observed in subscale of physical role (PR) limitation. Our patients spent more time in their usual daily activities compared with healthy counterparts (the data were not shown separately for each item of daily activity in [Table 2]). [Table 3] compares the mean and median score of overall QoL with demographic characteristics according to case status. The QoL was significantly higher in males than females (74.3 ± 18.1 vs. 62.1 ± 18.7, P = 0.001) in controls while the difference did not reached at a significant level between sexes among patients (P = 0.07). By increasing age to 60 or over, the QOL was significantly lower in both patients and controls (P = 0.001). A significant improvement in QoL was observed with higher educational level among controls, whereas the poorest QoL was found in illiterate and primary level among patients, but it was not reached at significant value. In relation to marital status, a higher level of QoL was significantly associated with participants who were couple and those with dead husbands/wives had the poorer QoL in both groups. While a significant lower score of QoL was associated with BM ≥25 in controls, but no significant difference was observed in patients. In addition, we did not found a significant difference of QoL between those with a history of duration of dialysis of ≥24 months versus <24 months.
Table 1. The distribution of demographic characteristics of patients with renal failure and control group.

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Table 2. The comparison of mean score (±SD) and median (IQR) of health-related QoL according to various subscales between cases and controls with respect to gender

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Table 3. The mean scores ±SD and median (interquartile range-IQR) of overall health-related QoL of patients of hemodialysis and controls according to demographic characteristics.

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[Table 4] shows that for all eight subscales of QoL after adjusting demographic characteristics, patients had significantly lower QoL than controls. In addition, the independent effect of age, gender, and educational level as predictors of QoL was significant consistency across various subscales. While living in the rural area significantly inversely associated with QoL in GH subscale only. None of subscales, the independent influence of BMI, and marital status were significant in predicting of QoL after controlling the effect of sex, age, educational level, and case status.
Table 4.The adjusted regression coefficients with 95% CI of predictors of various subscales of health-related QoL using multiple regression model.

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   Discussion Top

The findings of the present study show that the mean score of QoL of dialysis patients was significantly lower than healthy participants in all subscales after adjusting for age, sex, marital status, educational level, and BMI. Moreover, the results revealed that older age, female gender, and lower educational level were significantly associated with a lower score of all physical, psychological, and social domains of QoL. The lowest score of QoL being in PR limitations (35.7% and 27.5% for men and women, respectively). Low scores of physical, psychological, and social domains demonstrated that all aspects of daily activities, social relationships, and vitality and GH perception are influenced by end-stage renal failure. Similar findings have been reported in other studies.[18] ,[19] Perhaps because of comorbidity with other health conditions such as metabolic disorders and cardiac problems, they have a low score of QoL in bodily pain. In addition, they have more limitations in emotional role playing compared with healthy counterparts. Thus, the vitality score comes down significantly. Their physical limitations, impact negatively, their social functioning, and their relation and interaction with family and their friends in workplace.

Our finding of lower QoL scores in females is in accordance with those reported in other studies.[18] ,[20] One possible explanation for this is the higher prevalence of anxiety and depression symptoms in women in our general population.[21] ,[22] ,[23] There are also some cultural factors contributing to lower QoL in females as, in eastern culture, the female patients may feel that they are burden to their family when they become chronically ill.[18] Men spend more time in outdoor activities for their occupation and thus have more social interaction with others. Depression has a strong effect on QoL in patients under dialysis.[5] However, many instruments used to measure QoL are not able to detect subclinical of depression.[24] Using back depression inventory, one study showed that up to 70% of dialysis patients has some degree of depression. However, using the criteria of the American society of psychiatry, it has been appeared that 10%-18% of patients have some degree of depression.[25] ,[26]

In the present study, we found an inverse and significant association between age and QoL. Older participants in both patient and control groups had a lower score of QoL. This is likely explained by the association of age with other comorbid conditions such as diabetes mellitus.[27]

We also found that higher educational level was significantly and positively associated with scores of QoL in both patient and healthy participants for all subscales. These results are in accordance with previous reports.[21] This may be due to the fact that higher educational level is associated with higher disease awareness and healthier life style practices.

Although we found that some demographic influence of QoL, we also found that the negative influence of comorbidity as.

One limitation of our study is that our data were collected by self-reported responses through interview. This may exaggerate the poorer QoL in patients, but this might operate similarly in controls. The direction of bias of this non-differential misclassification is toward the null, and it does not create a distorted association. Nevertheless, the strengths of our study were using a well-validated standard instrument and a similar instruction in data collection, particularly when comparing patients from healthy controls. In addition, patients and controls were selected from a similar catchment area with equal referral pattern. In conclusion, the results of the presence study show poor QoL among HD patients. Thus, further psychological, emotional, and social supports are required with HD therapy.

   Acknowledgment Top

The authors would like to acknowledge the Deputy of Research of Babol University of Medical Sciences, for supporting this research. We also would like to thank the director of Division of Hemodialysis of Shahid Beheshti hospital/Babol and the nurses and the students of Babol University of Medical Sciences who assisted in data collection.

Conflict of interest: None declared.

   References Top

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Correspondence Address:
K Hajian-Tilaki
Department of Biostatistics and Epidemiology, Babol University of Medical Sciences, Babol
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.198165

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

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