Assessment of Health-Related Quality of Life in Patients Receiving Regular Hemodialysis

Copyright: © 2016 Abdelghany MA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction
End-stage renal disease is a non-curable condition imposes a considerable burden on patients and their families [1,2]. It's been proven that the patient's perception is more important than the clinical assessment in determining HRQOL. Culture and values plays a vital role in shaping perception of HRQOL [3]. Although advances in HD treatment have contributed to improved patients' survival, they're still subjected to multiple threats and stressors that may worsen their HRQOL [4]. Lower HRQOL scores were strongly associated with higher morbidity and mortality [3]. The aim of the present study was to assess self-perception of patients with ESRD undergoing regular hemodialysis of HR-QOL, to study their epidemiological features, assess HR-QOL scores and explore its clinical correlates.

Patients and Methods
This cross-sectional descriptive study was carried out in September 2015 at the hemodialysis unit of Karmouz Health Insurance Hospital, Alexandria, Egypt. Among all adult ESRD patients aged >18 years and maintained on regular hemodialysis treatment for ≥ 1 year, 81 eligible patients joined the study. (As exclusion criteria were: dementia, psychotic disorder, malignancy, active infection(s), acute medical or surgical condition, hospitalization within the prior month and physical or mental handicaps). A validated Arabic form of kidney disease quality of life short form (KD QOL SF-36) version 1.3 questionnaire was used as a self-report instrument to measure HR-QOL. Patients were encouraged to complete the questionnaire at the field of study and not at home, however some patients insisted to take it home and bring it back the next session. Most patients completed the questionnaire on their own, some patients -for various reasons e.g. being illiteratecompleted the survey with assistance of the researcher or a coworker. The KDQOL Instrument is a self-report measure developed for individuals with kidney disease and on dialysis. It captures their perceptions about concerns of symptoms or problems, effects and burden of kidney disease, work status, sleep, cognitive, social and sexual function. It also measures additional quality of life scales include: social support, dialysis staff encouragement and patient satisfaction [5]. The item related to sexual activity was considered it as an optional item to respect patients' privacy. It was missing in half of the patients yet we took that into consideration while doing analysis of the data. All collected data checked for validity. Scoring was done to obtain universal scores ranging from 0 to 100, as higher scores indicate better QOL. Data entry and statistical analysis were performed using SPSS 18.0 statistical software package (SPSS Inc., Chicago, IL, USA). The distributions of quantitative variables were tested for normality using Kolmogorov-Smirnov test, which revealed that the data were normally distributed. Correlation between quantitative variables done using Pearson correlation test. Comparing quantitative variables between 2 groups of cases was conducted using independent t-test. Comparing quantitative variables between 3 groups or more of cases was conducted using oneway ANOVA. Kruskal Wallis test was used when sample size per group was small. Statistical significance was set at P <0.05.
(MHC) = 36.76 ± 10.22. Regarding the ESRD-targeted areas, the mean total score was 54.48 ± 25.65, the highest score was for dialysis staff encouragement scale (73.15 ± 23.64) followed by social support scale (72.22 ± 25.14) and quality of social interaction (71.52 ± 18.74). However, burden of kidney disease and work status scales yielded the lowest scores (25.62 ± 26.62 and 30.86 ± 37.56 respectively). Sleep scale score was 50.22 ± 21.27. Only 40 patients responded to sexual activity inquiries and scored 66.88 ± 32.71 on sexual function scale (Table 1). On the 36-item health survey, the mean total score was 36.5 ± 25.67. Emotional well-being and physical functioning scales yielded the highest score but were below 50 (48.3 ± 23.04 and 46.91 ± 27.79 respectively). The lowest scores represented the role limitations caused by physical and emotional health problems (21.6 ± 31.56 and 24.69 ± 35.27). Pain scale score was 40.31 ± 23.18. Finally, the score overall heath rating scale was 53.09 ± 16.63. On comparing scores in both sexes (Table 1), females' scores were lower than males in mean total score (44.9 ± 23.7 and 49 ± 25.7 respectively) and all scales, except for the sexual function, social support scales and overall health rating item where female scores were relatively higher (Figures 1 and 2).
Unemployed and/or anemic patients had statistically significant reduced HRQOL (P = 0.03, P = 0.02 respectively) ( Table 2). Scores varied according to age, sex, marital status, education level, presence of co-morbidities, dyslipidemia and hypoalbuminemia but without statistical significance. Multiple linear regression analysis for scores demonstrated that working status was the only significant predictor (employed patients' scores were higher than unemployed ones by 8.648 units, while controlling other predictors (p = 0.028) ( Table 3).

Discussion
Long-term HD treatment often results in financial troubles, loss of freedom, dependence on health care personnel and caregivers, negative impacts on marital status, family, and social activities. Thus, quality of life should be measured and monitored for better understanding of patients' condition [6]. This can also help to identify subgroups with relatively poor perceived health and guide interventions to improve their situations and avoid further serious consequences [4]. Over the years, consensus has been established that HRQOL is a multidimensional concept. As such, assessment of HRQOL generally covers physical, social, and psychological domains [4]. Several studies proved that HD patients suffer poor HRQOL, despite continuing advancements in the treatment [3,4,[7][8][9][10][11][12][13][14]. Their HRQL is still much lower than general population [12,15]. Baseline measures of HRQOL were reduced in CKD patients in proportion to the severity grade of CKD [16]. Caregivers for ESRD patients may be affected as well, having a family member on maintenance dialysis therapy creates family burdens greater than those experienced by having a family member with several other chronic conditions [17]. Sexual function item left optional in our study for social issues and expressed by half of the patients. Its score was relatively high (66.8 ± 23). The Dialysis Outcomes and Practice Patterns Study (DOPPS) study in 2004 noticed variation in sexual function scores worldwide with mean scores 66.7, 63.3 and 60.5 for Europe, Japan and USA respectively with statically significant difference between Europe and USA [15]. In the present study, the mean of HRQOL scores were relatively higher in younger age groups in all domains, yet there was no statistically significant difference. The association of age with HRQOL is quite complex and illustrates the complexity of the QOL concept [4]. Some studies conducted in different countries also demonstrated        that age was strongly inversely associated with the physical domain scores. As age increases in the elderly, physical function of the body decreases [2,4,14,[18][19][20][21][22]. A recent Saudi showed that age was a negative predictor of HRQOL score [2]. Concerning gender, many studies of QOL in patients with ESRD have shown that women have lower scores on different QOL tests than men. This was observed in both pre-dialysis and dialysis patients. The reasons for poor QOL in women are not clear and seem to be related to psychological and social factors, rather than the illness itself [12,23,24]. This was consistent with the present study.
It is of interest that Bayoumi et al 2014 showed reduced QOL scores in male patients and male sex was a negative predictor of QOL score [2]. Various factors such as geographic areas, ethnicity, sample size may explain this gender differences of QOL in HD patients [25]. Regarding work status, the current study revealed that HD patients' perception for work function and role of physical limitation scores were relatively low (30.86 ± 37.6 and 21.6 ± 31.6 respectively). Only 28% of patients were employed (working full time or part time), the remaining were not working either due to being retired, in working-age and searching for a suitable job or can't work due to physical limitation. Whatever the cause the HRQOL scores were higher among the working group of patients in mean total score and ESRD targeted areas. Retired group ranked the least score. This difference was statistically significantly. And on applying a multiple Linear regression model to predict total scores, working group's scores were higher than non-working group by 8.648 units of total score while controlling for anemia state, (anemic/non-anemic), patient age, duration of being on hemodialysis treatment (p=0.028). The potential to increase the number of dialysis patients who are employed exists if the barriers to employment that have been identified can be removed [26]. Patients who are satisfied with hemodialysis treatment and accepting it have better working capacity [22]. Directing rehabilitation efforts toward the population of dialysis patients who identify themselves as willing and able to work seems a worthwhile strategy to improve their QOL [26]. Many sociodemographic and clinical factors can influence HRQOL of HD patients. Current study findings proved that future studies with more comprehensive and informative tools to focus on these variables and help us improve our knowledge about HRQOL determinants and in turn this will reflect on clinical practice to enhance their poor QOL status.

Conclusion
All domains of HRQOL were reduced in HD patients. Anemia and unemployment adversely affected HRQOL scores.