Saudi Journal of Kidney Diseases and Transplantation

: 2012  |  Volume : 23  |  Issue : 5  |  Page : 953--957

Assessment of quality of life in patients on hemodialysis and the impact of counseling

Suja Abraham1, Anju Venu2, Anju Ramachandran2, Praseetha Mundapurath Chandran2, Saraswathi Raman3,  
1 Department of Pharmacy Practice, Amrita School of Pharmacy, Amrita Viswavidyapeetham University, Kochi, Kerala; Research Scholar, Karpagam University, Coimbatore, Tamil Nadu, India
2 Department of Pharmacy Practice, Amrita School of Pharmacy, Amrita Viswavidyapeetham University, Kochi, Kerala, India
3 Al-Shifa College of Pharmacy, Perinthalmanna, Kerala, India

Correspondence Address:
Suja Abraham
Senior Lecturer, Department of Pharmacy Practice, Amrita School of Pharmacy, Kochi, Kerala


Chronic renal failure is an irreversible progressive condition responsible for high morbidity and mortality. Because it requires life-long treatment in the form of renal replacement therapy, the quality of life (QOL) of patients may significantly impair. Studies have revealed that patient education can play a significant role in improving the QOL in these patients. The primary objective of this study was to assess the QOL of patients on hemodialysis by using the World Health Organization Quality of Life assessment scale and also to study the impact of patient counseling in these patients. Fifty patients were selected for the study and they were randomly divided into two groups, control and test; counseling was given to the test group of patients. There was an increase in score in all the four domains (physical, psychological, environmental and social) among the test group when compared with the control group. Also, we found that the psychological domain showed significant increase in score compared with others. Our findings demonstrate that patient counseling plays an important role in improving the QOL by changing their psychological thinking and bringing them toward spirituality.

How to cite this article:
Abraham S, Venu A, Ramachandran A, Chandran PM, Raman S. Assessment of quality of life in patients on hemodialysis and the impact of counseling.Saudi J Kidney Dis Transpl 2012;23:953-957

How to cite this URL:
Abraham S, Venu A, Ramachandran A, Chandran PM, Raman S. Assessment of quality of life in patients on hemodialysis and the impact of counseling. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2022 Jun 28 ];23:953-957
Available from:

Full Text


The number of patients with chronic renal failure (CRF) is increasing steadily globally with its associated poor quality of life (QOL) and high economic burden. CRF has become one of the most expensive diseases to treat in present times. This is particularly true in the developing world where the resources are limited. [1] The National Kidney Foundation has classified CRF into five stages according to the glomerular filtration rate (GFR), and the fifth stage with GFR less than 15 mL/min is called end-stage renal disease (ESRD). [2] The prevalence of ESRD in India has increased in the last two decades. It has become a global threat with significant morbidity and mortality. ESRD also decreases the overall QOL among the affected patients. The treatment option at this stage is renal replacement therapy, which includes dialysis and transplantation. According to various studies, the cost of dialysis is between Rs. 15,000 and 20,000 per month, and will have to be continued lifelong. The cost of renal transplantation and the medicines to prevent rejection is very high when compared with dialysis. Thus, it is very difficult for the average patient to afford dialysis and it becomes mandatory to ensure good QOL while on such expensive treatment. [3]

It has been proven that the QOL is very poor among ESRD patients. The QOL is used to evaluate the general wellbeing of individuals and societies. It may vary according to the patient as well as the disease condition. The WHO has defined QOL as "an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns." [4] Various tools have been developed to measure different aspects of life. Many studies have been carried out for measuring the QOL with generic as well as disease-specific instruments. [5] However, such studies are limited in the Indian scenario, although this aspect requires particular attention in developing countries. The assessment of QOL is an essential element of health-care evaluation and helps in taking suitable measures to increase the QOL of ESRD patients.

According to the study conducted by Zhang et al, patients on dialysis [both hemodialysis (HD) and peritoneal dialysis] experience complications such as cardiovascular disease, peritonitis, etc., which in turn decreases the QOL. The study concluded that because of the lack of awareness, the patient will not come for timely dialysis until more severe co-morbidities develop. [6] Several studies have shown that regular pre-dialysis attendance helps to provide the patient with proper education and thereby achieve better QOL. [7],[8] These findings were supported by the study conducted by Lii et al who concluded that patients who received psychosocial intervention showed reduced depression and better QOL compared with the control group. [9],10,[11] Co-morbidities such as anemia, diabetes, hypertension, dyslipidemia, thyroid disorders, etc. significantly impair the QOL of patients on HD. [12],[13],[14] This emphasizes the significance of patient counseling, which helps the patient to understand the lifestyle modification to be made in order to reduce the prevalence of such co-morbidities. Also, through patient counseling, the patient will be in good rapport with the pharmacist thereby increasing compliance. The main aim of this study is to evaluate the QOL of patients on HD and to compare the impact of counseling in these patients.

 Patients and Methods

A hospital-oriented prospective, longitudinal, observational comparative study was conducted for six months in the nephrology department of a tertiary care hospital. Patients who were receiving HD regularly and aged between 20 and 80 years were included in the study. Patients who were not interested in counseling and those who had voluntarily withdrawn from dialysis as well as those having severe illness, psychoses, infection with the human immunodeficiency virus (HIV) and pregnant and lactating women were excluded from the study. Only patients who had completed at least three months of HD were selected for the study.

At the beginning of the study, there were 172 patients undergoing HD in this hospital. Of these, 81 met the inclusion criteria, but only 50 patients were chosen for the study because of the time constraint. Detailed data could be obtained and analyzed only in these 50 patients during the limited time available for the study, which was six months. Of these 50 patients, 25 were selected randomly as the control group and the other 25 were considered as the test group. Patient counseling was provided to the test group patients using verbal and written materials regarding diet, exercise, life style modification and the importance of regular dialysis and follow-up.

The patients' data relevant to the study was obtained from the patient and bystanders, and the data collection was made by questionnaire (WHO-BREF) administration and the patients' medical records. Using data collection forms, information about the cases was collected from the file of the admitted patients. It contained information concerning each patient's hospital number and socio-demographic data, history of allergy, principal diagnosis, co-morbid conditions, medications, etc.

Assessment of quality of life

For this study, we adopted the WHO-BREF assessment questionnaire (short form of WHO-100), which has been used worldwide. This questionnaire contains about 26 questions dealing with patient's QOL, health and other areas of their life. This scale assesses four main domains, namely, physical health, psychological, social and environmental relationship of the patient. After the initial administration of WHO-BREF to the test and control groups, counseling was given to the patients in the test group. Specific scores for each domain were computed. After six months, the same questionnaires were given to both groups and the domain scores were calculated. By comparing the score values for the test and control groups, QOL assessments were done by using the Statistical Package for Social Sciences (SPSS) software. Results are given as mean ± SD.


In this prospective observational study, various parameters like age distribution, sex, duration on dialysis, duration of disease and comorbidities were analyzed. Fifty patients were randomly assigned to the test and control groups (25 patients each). The mean age of the study population in the test and control groups was 49.72 ± 13.2 and 51.5 ± 11.6 years, respectively. The socio-demographic data and socio-economic status of the patients are given in [Table 1].{Table 1}

It was found that the overall QOL of patients on HD was significantly impaired. In this study, the domain scores of both the test and the control group of patients were calculated after the initial administration of the questionnaire. The domain scores were calculated by using the formula that is given in the WHO-BREF scale.

The study revealed a remarkable difference in the QOL of HD patients in the test group during their first and second visits, while the control group showed only a slight or no change. There was an increase in the overall QOL of the test group patients when compared with the control group, although the baseline values are similar. The QOL of patients in the test group was compared with the control group using the independent t test. It showed that all the domain scores of the test group was significantly higher than the control group (P <0.001) [Table 2]. Thus, patient counseling seemed to play an important role in improving the QOL by changing their psychological thinking and initiating them toward spirituality.{Table 2}


The studies on the QOL of patients with chronic disease have increased these days. It has become an integral parameter to assess patient satisfaction and improvement with therapy. This is very true, especially in conditions like CRF.

Improvement in the QOL has become the major treatment goal in ESRD patients. Because ESRD patients have several other comorbidities such as hypertension, diabetes, dyslipidemia, etc., they have to take different medications. These may have significant adverse effects and may be associated with drug interactions. Moreover, the patients are prone to non-compliance and all these will affect the QOL of the patients. [6]

The QOL can be measured from different angles, sometimes using generic instruments, in some cases disease-specific instruments, or measuring physical and laboratory parameters. It is very essential to measure the psychological domain, as the patient may experience depression or anxiety. That is the reason why we selected WHO BREF where psychological and spiritual domains were included in the assessment. This study mainly concentrated on the physical, psychological, social and environmental domains of the patient and how it affects the overall QOL of ESRD patients undergoing HD. Our study strongly predicts the association between spirituality and psychological issues and the QOL. According to the various studies available, the number of male patients with ESRD is higher than the female patients. [6],[10] This may be because of the smoking and alcoholic habits of men, which might aggravate the renal failure.

Majority of the previous studies were conducted in developed countries where patient counseling is mandatory. These studies showed that patient education provides better health outcomes, improves adherence and decreases health-care cost. [15],[16] Various studies have also shown that patient counseling is associated with positive impact on health and it decreases the mortality and morbidity. [17],[18],[19] This study also suggests that patient counseling improved the QOL of patients with renal failure.

Our study has several findings worth emphasizing. We observed that there is an increase in the average score of the test group when compared with the control group in all the four domains. The increase in average domain score was highest in the psychological domain followed by physical, environmental and social relationship domains. As most of the ESRD patients were depressed and worrying about their health condition, by removing their misconceptions about the disease, we observed an increase in the positive feelings of the patient. The spirituality level of the patients was also found to be increased; thereby, their concentration levels, thinking and learning power were also increased. As a result, they became more involved in their self-activities without any negative feelings.

The main limitation of our study was its duration. Follow-up was only for a period of six months. The results could have been much more authentic if the follow-up duration was two to three years and included a healthy group also as controls. From that data, we would have been able to quantify the impairment of QOL better in ESRD patients. Our study suggests that patient counseling can improve health-related QOL by improving the awareness and removing the misconceptions about the disease. QOL is becoming an important outcome measure after the initiation of dialysis therapy. ESRD is a progressive disease, and early recognition and prevention are the only ways of improving the QOL in these patients.


1Prabahar MR, Chandrasekaran V, Soundararajan P. Epidemic of Chronic Kidney Disease in India -What Can Be Done? Saudi J Kidney Dis Transpl 2008;19:847-53.
2Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice Guidelines for Chronic Kidney Disease: Evaluation, Classification and Stratification. Ann Intern Med 2003;139:137-47.
3Mani MK. Management of End Stage Renal Disease in India. Artif Organs 1998;22:182-6.
4WHOQOL Group. Measuring Quality of Life: The development of the World Health Organization Quality of Life Instrument (WHOQOL). Geneva: World Health Organization; 1993.
5WHOQOL Group. The development of the WHO quality of life assessment instrument (WHOQOL). In: Orley J, Kukyen W, (eds). Quality of Life Assessment: International Perspectives. Heidelberg: Springer-Verlag; 1994.
6Zhang AH, Cheng LT, Zhu N, et al. Comparison of quality of life and causes of hospitalization between haemodialysis and peritoneal dialysis patients in China. Health Qual Life Outcomes 2007;5:49.
7White CA, Pilkey RM, Lam M, et al. Predialysis clinic attendance improves quality of life among haemodialysis patients. BMC Nephrology 2002;3:3.
8Sesso R, Yoshirro MM. Time of diagnosis of chronic renal failure and assessment of quality of life in haemodialysis patients. Nephrol Dial Transplant 1977;12:2111-6.
9Lii YC, Tsay SL, Wang TJ. Group intervention to improve quality of life in haemodialysis patients. J Clin Nurs 2007;16:268-75.
10Khaled AK, Larissa M, Karpov I, et al. Individual quality of life in chronic kidney disease: Influence of age and dialysis modality. Clin J Am Soc Nephrol 2009;4:711-8.
11Peter P, Paul LK. Aspects of quality of life in haemodialysis patients. Clin J Am Soc Nephrol 2010;5:163-6.
12Gabbay E, Meyer KB, Griffith JL, Richardson MM, Miskulin DC. Temporal trends in health related quality of life among Haemodialysis patients. Clin J Am Soc Nephrol 2010;5(2):261-7
13Wasserfallen JB, Halabi G, Saudan P, et al. Quality of Life on chronic dialysis: Comparison between haemodialysis and peritoneal dialysis. Nephrol Dial Transplant 2004;19: 1594-9.
14Spiegel BM, Melmed G, Robbins S, Esrailian E. Biomarkers and Health Related Quality of Life in End stage renal disease: A Systemic Review. Clin J Am Soc Nephrol 2008;3:1759-68.
15Mercus MP, Jager AJ. Quality of life on patients on chronic dialysis: Self assessment 3 month after the start of treatment. Am J Kidney Dis 1997;29:584-92.
16Deniston OL, Carpentire PA. Assessment of Quality of Life in End Stage Renal Disease Health Serv Res 1989;24:555-78.
17Samir SP, Viral SS. Study on psychosocial variables, Quality of Life and religious beliefs in ESRD patients treated with haemodialysis. Am J Kidney Dis 2002;40:1013-22.
18Sathvik BS, Parthasarathy G. An assessment of Quality of Life in Haemodialysis patients using WHO-BREF Questionnaire. Int J Nephrol 2008;18:141-9.
19Thomas D, Joseph J, Francis B, et al. Effect of patient counseling on quality of life of haemodialysis patients in India. Pharm Pract 2009;7: 181-4.