Health-related quality of life of dialysis patients during early COVID-19 lockdowns: a snapshot from a public hospital in Malaysia

Background

End-stage renal disease is the last stage of chronic kidney disease and can affect the quality of life (QOL) of dialysis patients. The aim of this study was to assess the quality of life and examine its determinants.

Methods

A cross-sectional survey involving patients on dialysis in a tertiary hospital was conducted from July 2020 to September 2020. Demographic data were collected using a predesigned questionnaire. QOL was measured using the 36-item KDQOL questionnaire, and statistical analysis was carried out using SPSS version 25.

Results

Of the 108 patients, 59 were men and 49 were women, and the mean age was 48.15 ± 15.4 years. The results showed that there was no significant difference in the mean score of all components of health-related quality of life in different types of dialysis. The demographic data, which included age, gender, ethnicity, marital status, education level, occupation, and monthly income, did not significantly affect the QOL of dialysis patients. Patients with a dialysis duration of more than 5 years had a better QOL compared to other groups. Laboratory parameters such as low albumin and low hemoglobin showed a significant correlation with the health-related quality of life of dialysis patients.

Conclusion

The quality of life among patients on dialysis was impaired, especially in terms of burden of the kidney disease. Hypoalbuminemia and anemia were the two factors that influenced QOL.

Health-related quality of life among patients with end-stage renal disease undergoing hemodialysis in Ethiopia: a cross-sectional survey

BACKGROUND

Measurement of health-related quality of life (HRQOL) enables identification of treatment-related side effects of a disease. Such aspects may negatively impact on patients' lives and should be taken into consideration in medical decision-making. In sub-Saharan Africa, research from the perspective of patients with chronic kidney disease is scarce, and it is almost non-existent in patients undergoing hemodialysis. We aimed to determine HRQOL among end-stage renal disease patients undergoing maintenance hemodialysis in Ethiopia and to identify factors associated with HRQOL.

METHODS

A multi-center cross-sectional study was conducted in Addis Ababa, Ethiopia directed to all patients receiving hemodialysis due to kidney failure at 11 randomly-selected government and private hospitals/dialysis centers in the capital of Ethiopia. Data were collected by trained nurses using the KDQOL-36 instrument with five subscales measuring generic and disease-specific HRQOL. Study-specific items were used to collect socio-demographic and clinical data. Factors associated with HRQOL were examined using multivariable linear regression models.

RESULTS

Four hundred eighty-one patients completed the survey through face-to-face interviews (response rate 96%; mean age 45.34 ± 14.67). The mean scores of the subscales ranged from 25.6 to 66.68 (range 0-100), with higher scores reflecting better health. Factors associated with low HRQOL included older age, female sex, no formal education, poor medication adherence, > 2 hemodialysis sessions/week, lower body mass index (< 18.5), longer duration of hemodialysis treatment (≥ 12 months), and poor social support.

CONCLUSION

Patients with kidney failure undergoing hemodialysis in Addis Ababa, Ethiopia, had low HRQOL across all subscales compared to previous studies. Therefore, the implementation of guidelines is crucial to improve patients' adherence to their prescribed medications. Furthermore, establishing patient support groups and encouraging patients to use the available support resources from family members, neighbors, and friends have the potential to improve patients' HRQOL.

Psychometric properties of the kidney disease quality of life-36 (KDQOL-36) in Ethiopian patients undergoing hemodialysis

Background

Health-related quality of life (HRQOL) has a direct association with increased morbidity and mortality among end stage renal disease patients. Valid and reliable instruments to measure the HRQOL of patients with end stage renal disease are therefore required. This study aimed to translate, culturally adapt and evaluate the psychometric properties of the Amharic version of the Kidney Disease Quality of Life-36 (KDQOL-36) instrument in Ethiopian patients with end stage renal disease undergoing hemodialysis.

Methods

The KDQOL-36 instrument was developed for individuals with kidney disease who are being treated with dialysis and includes both generic and disease-specific components. The KDQOL-36 was translated to Amharic language and distributed to a cross-sectional sample of 292 hemodialysis patients. The psychometric evaluation included construct validity through corrected item-total correlation, confirmatory factor analysis and known group analysis. Convergent validity was evaluated by correlations between each of the three kidney disease targeted scales (symptoms/problems list, burden of kidney disease and effects of kidney diseases) and the European Quality of Life 5D-5L and Visual Analog Scales. Regarding reliability, internal consistency and test–retest reliability were assessed.

Results

Two hundred ninety-two patients with a mean age of 48 (SD ± 14.7) completed the questionnaire. Corrected item- total correlation scores were > 0.4 for all items. Confirmatory factor analysis revealed a two χ² /df was 4.4, Root Mean Square Error of Approximation (RMSEA) = 0.108 (90% CI 0.064–0.095), Comparative Fit Index (CFI) = 0.922, Tucker Lewis Index (TLI) = 0.948 and Standardized Root mean-squared residual (SRMR) = 0.058) and three χ² /df = 3.1, RMSEA = 0.085 (90% CI 0.064–0.095), CFI = 0.854, TLI = 0.838 and SRMR = 0.067) factor models for the generic and disease specific components respectively. The mean scores of the three kidney disease targeted domains were correlated to the EQ-5D-5L & VAS with correlation coefficients of large magnitude (0.55–0.81). The reliability of the instrument was satisfactory (Cronbach’s alpha = 0.81–0.91) and Intra-class correlation (ICC) = 0.90–0.96).

Conclusion

The Amharic version of the KDQOL-36 is a reliable and valid instrument recommended for assessment of HRQOL of Ethiopian patients on hemodialysis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-01932-y.

Is malnutrition a determining factor of health-related quality of life in hemodialysis patients? A cross-sectional design examining relationships with a comprehensive assessment of nutritional status

PURPOSE

To identify relationships between health-related quality of life (HRQOL) and nutritional status in hemodialysis (HD) patients.

METHOD

Secondary data from a cross-sectional survey was utilized. HRQOL was assessed for 379 HD patients using the generic Short Form 36 (SF-36) and disease-specific Kidney-Disease Quality of Life-36 (KDQOL-36). Malnutrition was indicated by malnutrition inflammation score (MIS) ≥ 5, and presence of protein-energy wasting (PEW). The individual nutritional parameters included the domains of physical status, serum biomarkers, and dietary intake. Multivariate associations were assessed using the general linear model.

RESULTS

MIS ≥ 5 was negatively associated with SF-36 scores of physical functioning (MIS < 5 = 73.4 ± 8.0 SE vs MIS ≥ 5 = 64.6 ± 7.7 SE, P < 0.001), role-limitation-physical (MIS < 5 = 65.3 ± 14.3 SE vs MIS ≥ 5 = 52.9 ± 14.0 SE, P = 0.006), general health (MIS < 5 = 53.7 ± 7.5 SE vs MIS ≥ 5 = 47.0 ± 7.1 SE, P = 0.003), and PCS-36 (MIS < 5 = 40.5 ± 3.3 SE vs MIS ≥ 5 = 35.9 ± 3.1 SE, P < 0.001); and KDQOL-36 score of symptoms/problems (MIS < 5 = 78.9 ± 5.6 SE vs MIS ≥ 5 = 74.8 ± 5.4 SE, P = 0.022), but not with PEW by any tool. Of individual nutritional parameters, underweight (68.1 ± 5.4 SE, P = 0.031), normal weight (63.8 ± 2.8 SE, P = 0.023), and overweight (64.3 ± 2.9 SE, P = 0.003) patients had significantly higher physical functioning scores compared to obese patients (44.8 ± 5.5 SE). Serum albumin levels were positively associated with physical functioning (P = 0.041) score. HGS was also positively associated with physical functioning (P = 0.036), and vitality (P = 0.041) scores. Greater dietary phosphorus intakes were significantly associated with lower scores for role limitation-physical (P = 0.008), bodily pain (P = 0.043), and PCS-36 (P = 0.024).

CONCLUSION

Malnutrition diagnosis by MIS, but not PEW, indicated associations with HRQOL in HD patients. Individual nutritional parameters that related to higher HRQOL were BMI < 30 kg/m², better dietary phosphorus control, greater muscle strength and higher visceral protein pool.

In-center nocturnal hemodialysis improves health-related quality of life for patients with end-stage renal disease

BACKGROUND

Conventional in-center hemodialysis (HD) is associated with significant symptom burden and reduced health-related quality of life (HRQOL). The HRQOL effects of conversion to in-center nocturnal hemodialysis (INHD) remain unclear, especially amongst those with poor HRQOL.

METHODS

Prospective cohort study of HD patients converting to INHD. Linear regression models summarized the mean score at baseline and at 12 months for the cohort. To assess whether patients with low baseline HRQOL derive greater benefit, we compared values before and after by levels of baseline score for each domain (below vs equal to or above the median) using a formal interaction test (t test).

RESULTS

36 patients started INHD, 7 withdrew (5 transplanted, 1 death, 1 moved) and 5 declined follow-up. After 12 months the mental component score (MCS) increased by 7.1 points to a value of 51.0 (95% CI + 1.5 to 10.9, p = 0.01). Amongst patients with baseline scores below the median, improvements were seen in: Symptoms/Problems of Kidney Disease (+ 15.2, 95% CI + 5.5 to + 24.9, p = 0.003), Effects of Kidney Disease (+ 16.9, 95% CI + 2.2 to + 31.7, p = 0.026), Physical Component Score (+ 9.4, 95% CI + 1.69 to + 17.2, p = 0.018), MCS (+ 10.7, 95% CI + 2.4 to + 19.1, p = 0.013). Burden of Kidney Disease domain change was not significant (+ 15.1, 95% CI - 2.1 to + 32.3, p = 0.083).

DISCUSSION

INHD is a potential intervention for HD patients who struggle with reduced HRQOL, especially for those who struggle with poor mental health. Medical benefits of reduced pill burden and improved phosphate control occur with transition to INHD.

Health-related quality of life in patients with chronic kidney disease

Introduction: In the last three decades, health systems have continued to pay increasing attention to the quality of life (QOL) due to definitional changes in the concept of health and disease. The health-related quality of life (HRQOL) in patients with chronic kidney disease (CKD) is significantly affected, regardless of the stage of CKD. Areas covered: We attempt to thoroughly explore how CKD affects HRQOL domains with a quick primer on HRQOL assessment instruments in patients with CKD. Also, we pointed out the factors affecting HRQOL in patients with CKD as well as the clinical application of HRQOL in CKD management. Expert opinion: The general population enjoys higher HRQOL than patients with CKD in all domains. Similarly, pre-dialysis and kidney-transplant patients have better HRQOL than dialysis population. There are many factors which negatively impact HRQOL in CKD which include for example depression, anxiety, and cognitive impairment for the social domain, inactivity, and frailty for the physical domain as well as lack of social support and extroversion in the social domain. Additionally, social disparities and CKD-related factors would influence HRQOL. Of note, there is no global standard HRQOL assessment tool. Finally, HRQOL should be included in future CKD management guidelines.

Impact of chronic kidney disease and anemia on health-related quality of life and work productivity: analysis of multinational real-world data

Background

Reductions in health-related quality of life (HRQoL) in patients with chronic kidney disease (CKD) are thought to be exacerbated by the low hemoglobin (Hb) levels that define anemia, a common complication of CKD. The current analysis evaluated the impact of anemia on HRQoL and work productivity in patients with non-dialysis dependent and dialysis-dependent CKD using real-world data.

Methods

Data were collected in France, Germany, Italy, Spain, the UK, the USA and China in 2012–2018 in the Adelphi Real World Disease Specific Programme™ for CKD, a large, cross-sectional, survey of physicians and their patients. Patients completed three patient-reported outcomes (PRO) instruments: the EuroQol 5-Dimension 3-level (EQ-5D-3 L), the Kidney Disease Quality of Life (KDQOL-36) instrument and the Work Productivity and Activity Impairment questionnaire. PROs were assessed by CKD stage and Hb levels, and regression analyses were performed with CKD stage and Hb level as independent variables and PROs as outcome variables, while adjusting for age, sex, CKD stage, comorbidities and cardiovascular risk.

Results

Overall, 5276 patients participated in the survey, including 28% stage 4 and 36% dialysis patients. Patients with lower Hb levels more often reported problems/issues on all EQ-5D-3 L domains (p < 0.0001). Regression analyses showed significant associations between lower Hb levels and the probability of low (< 0.8) EQ-5D-3 L utility scores (p < 0.0001) and low visual analog scale scores (p < 0.05), indicating poorer health status. Associations were seen even when adjusting for CKD stage and other potential confounding factors. Significant associations were observed between Hb level and the 12-Item Short-Form Health Survey (SF-12) Physical Component Summary, SF-12 Mental Component Summary and the three KDQOL-36 subscales (all p < 0.0001), and were confirmed using linear regression analyses adjusting for CKD stage and other potential confounders. Numerically greater work productivity losses and greater activity impairment were observed with lower Hb levels.

Conclusions

Lower Hb levels worsen the impact of CKD on HRQoL, and are associated with lower work productivity in patients with CKD. Assessment and treatment of anemia should be recognized as a key component of integral CKD management throughout all stages of the disease.

Mapping the kidney disease quality of life 36-item short form survey (KDQOL-36) to the EQ-5D-3L and the EQ-5D-5L in patients undergoing dialysis

OBJECTIVES

To develop algorithms mapping the Kidney Disease Quality of Life 36-Item Short Form Survey (KDQOL-36) onto the 3-level EQ-5D questionnaire (EQ-5D-3L) and the 5-level EQ-5D questionnaire (EQ-5D-5L) for patients with end-stage renal disease requiring dialysis.

METHODS

We used data from a cross-sectional study in Europe (France, n = 299; Germany, n = 413; Italy, n = 278; Spain, n = 225) to map onto EQ-5D-3L and data from a cross-sectional study in Singapore (n = 163) to map onto EQ-5D-5L. Direct mapping using linear regression, mixture beta regression and adjusted limited dependent variable mixture models (ALDVMMs) and response mapping using seemingly unrelated ordered probit models were performed. The KDQOL-36 subscale scores, i.e., physical component summary (PCS), mental component summary (MCS), three disease-specific subscales or their average, i.e., kidney disease component summary (KDCS), and age and sex were included as the explanatory variables. Predictive performance was assessed by mean absolute error (MAE) and root mean square error (RMSE) using 10-fold cross-validation.

RESULTS

Mixture models outperformed linear regression and response mapping. When mapping to EQ-5D-3L, the ALDVMM model was the best-performing one for France, Germany and Spain while beta regression was best for Italy. When mapping to EQ-5D-5L, the ALDVMM model also demonstrated the best predictive performance. Generally, models using KDQOL-36 subscale scores showed better fit than using the KDCS.

CONCLUSIONS

This study adds to the growing literature suggesting the better performance of the mixture models in modelling EQ-5D and produces algorithms to map the KDQOL-36 onto EQ-5D-3L (for France, Germany, Italy, and Spain) and EQ-5D-5L (for Singapore).

Validity and Reliability of the Indonesian Version of Kidney Disease Quality of Life (KDQOL-36) Questionnaire in Hemodialysis Patients at Hasan Sadikin Hospital, Bandung, Indonesia

BACKGROUND

the prevalence of chronic kidney disease (CKD) and dialysis patients is increasing every year in Indonesia. The impact of CKD and dialysis on patient quality of life (QOL) has been recognized as an important outcome measure in the management of CKD. The Kidney Disease Quality of Life (KDQOL-36) has been validated and is widely used as a measure of QOL for CKD and dialysis patients in many countries, but not in Indonesia. The aim of this study is to determine the reliabity and validity of the Indonesian version of KDQOL-36 on hemodialysis patients in Indonesia.

METHODS

the KDQOL-36 was translated into Indonesian language by a certified translator and then it was back-translated into English. The translated questionnaire was further reviewed by an expert panel. The final questionnaire was administered to hemodialysis patients in Hemodialysis Unit at Hasan Sadikin General Hospital. Validity was measured using Pearson's correlation between the kidney disease-targeted scores, generic dimensions (SF-12) scores and each scale score in KDQOL-36. The internal consistensy was assessed using Cronbach's Alpha and reliability was examined using test-retest.

RESULTS

out of 103 patients, we found that most subjects were male (52.4%) with median age of 51 (22-75) years. The duration of hemodialysis was 3.4 (SD 2.1) years. The validity test showed a significant correlation (p<0.001) on kidney disease-targeted total score, SF-12 and each score of the scale within it. All of the KDQOL-36 scales showed good test-retest reliability. Internal consistency reliability values were acceptable, with Cronbach's Alpha >0,7 for all scales.

CONCLUSION

the Indonesian version of the KDQOL-36 questionnaire is valid and reliable for evaluating QOL in reguler hemodialysis patients.

Health-Related Quality of Life in Patients with Chronic Kidney Disease in Hemodialysis in Medellín (Colombia)

PURPOSE

Hemodialysis is a treatment that is essential for the survival of patients with terminal chronic kidney disease. However, it is highly invasive, non-curative, and physically, psychologically, socially, and financially demanding, which has an impact on the patient's health-related quality of life (HRQL). In Colombia, research from the point of view of patients undergoing hemodialysis is scarce.

PATIENTS AND METHODS

We conducted a cross-sectional study involving 142 patients undergoing hemodialysis. We used an instrument that included the demographic and clinical information as well as the Charlson Comorbidity Index and Karnofsky Performance Status Scale. HRQL was assessed using EQ-5D-5L and KDQOL-36. The analysis was done using measures of central tendency for quantitative variables and relative frequencies for qualitative variables, in addition bivariate and multivariate regression analyses were conducted.

RESULTS

Based on the scores of the EQ-5D-5L scale, it was found that 14.5% subjects showed severe mobility problems, 5.8% were unable to bathe or dress by themselves, 12.9% were unable to perform usual activities, 13.5% were experiencing pain or discomfort (between strong and extreme), and 58.6% showed a certain degree of anxiety or depression. The KDQOL-36 scores were 67.4 ± 19.4 for the symptoms domain and 35.0 ± 27.5 for the disease burden domain. Results of the linear regression analysis showed that the main factors associated with HRQL were the Karnofsky Index and serum albumin levels (p < 0.05).

CONCLUSION

The result of this study revealed the impact on the quality of life of Colombian patients undergoing hemodialysis with chronic kidney disease who were highly affected by the disease burden. KDQOL-36 has excellent properties of reliability, internal consistency, and discriminant power; thus, its use is recommended in subsequent studies to monitor HRQL in this population.

Negligible impact of differential item functioning between Black and White dialysis patients on the Kidney Disease Quality of Life 36-item short form survey (KDQOLTM-36)

PURPOSE

Black dialysis patients report better health-related quality of life (HRQOL) than White patients, which may be explained if Black and White patients respond systematically differently to HRQOL survey items.

METHODS

We examined differential item functioning (DIF) of the Kidney Disease Quality of Life 36-item (KDQOL^TM-36) Burden of Kidney Disease, Symptoms and Problems with Kidney Disease, and Effects of Kidney Disease scales between Black (n = 18,404) and White (n = 21,439) dialysis patients. We fit multiple group confirmatory factor analysis models with increasing invariance: a Configural model (invariant factor structure), a Metric model (invariant factor loadings), and a Scalar model (invariant intercepts). Criteria for invariance included non-significant χ² tests, > 0.002 difference in the models' CFI, and > 0.015 difference in RMSEA and SRMR. Next, starting with a fully invariant model, we freed loadings and intercepts item-by-item to determine if DIF impacted estimated KDQOL^TM-36 scale means.

RESULTS

ΔCFI was 0.006 between the metric and scalar models but was reduced to 0.001 when we freed intercepts for the burdens and symptoms and problems of kidney disease scales. In comparison to standardized means of 0 in the White group, those for the Black group on the Burdens, Symptoms and Problems, and Effects of Kidney Disease scales were 0.218, 0.061, and 0.161, respectively. When loadings and thresholds were released sequentially, differences in means between models ranged between 0.001 and 0.048.

CONCLUSION

Despite some DIF, impacts on KDQOL^TM-36 responses appear to be minimal. We conclude that the KDQOL^TM-36 is appropriate to make substantive comparisons of HRQOL between Black and White dialysis patients.

Psychometric Properties of the Kidney Disease Quality of Life 36-Item Short-Form Survey (KDQOL-36) in the United States

BACKGROUND

The Centers for Medicare & Medicaid Services require that dialysis patients' health-related quality of life be assessed annually. The primary instrument used for this purpose is the Kidney Disease Quality of Life 36-Item Short-Form Survey (KDQOL-36), which includes the SF-12 as its generic core and 3 kidney disease-targeted scales: Burden of Kidney Disease, Symptoms and Problems of Kidney Disease, and Effects of Kidney Disease. Despite its broad use, there has been limited evaluation of KDQOL-36's psychometric properties.

STUDY DESIGN

Secondary analyses of data collected by the Medical Education Institute to evaluate the reliability and factor structure of the KDQOL-36 scales.

SETTINGS & PARTICIPANTS

KDQOL-36 responses from 70,786 dialysis patients in 1,381 US dialysis facilities that permitted data analysis were collected from June 1, 2015, through May 31, 2016, as part of routine clinical assessment.

MEASUREMENTS & OUTCOMES

We assessed the KDQOL-36 scales' internal consistency reliability and dialysis facility-level reliability using coefficient alpha and 1-way analysis of variance. We evaluated the KDQOL-36's factor structure using item-to-total scale correlations and confirmatory factor analysis. Construct validity was examined using correlations between SF-12 and KDQOL-36 scales and "known groups" analyses.

RESULTS

Each of the KDQOL-36's kidney disease-targeted scales had acceptable internal consistency reliability (α=0.83-0.85) and facility-level reliability (r=0.75-0.83). Item-scale correlations and a confirmatory factor analysis model evidenced the KDQOL-36's original factor structure. Construct validity was supported by large correlations between the SF-12 Physical Component Summary and Mental Component Summary (r=0.40-0.52) and the KDQOL-36 scale scores, as well as significant differences on the scale scores between patients receiving different types of dialysis, diabetic and nondiabetic patients, and patients who were employed full-time versus not.

LIMITATIONS

Use of secondary data from a clinical registry.

CONCLUSIONS

The study provides support for the reliability and construct validity of the KDQOL-36 scales for assessment of health-related quality of life among dialysis patients.

Cross-sectional survey in CKD patients across Europe describing the association between quality of life and anaemia

BACKGROUND

Deteriorating renal function in chronic kidney disease (CKD) patients is commonly associated with reduced haemoglobin levels, adding to the already considerable humanistic burden of CKD. This analysis evaluated the impact of anaemia on disease burden in patients with CKD stages 3-4, and in those on dialysis.

METHODS

This was a descriptive, cross-sectional analysis of European data from an Adelphi CKD Disease-Specific Programme. This programme collected data from patients and their treating nephrologists/endocrinologists; patient- and physician-reported data were matched for each patient. Health-related quality of life (HRQoL) data were obtained through patient completion of the EQ-5D, SF-12 and KDQOL-36. Additional information was obtained via physician reporting of patient symptoms, and patients' reports of impaired activity. Anaemia was defined by haemoglobin level and/or current use of erythropoiesis stimulating agents.

RESULTS

Significant, but modest Spearman's rank correlations were observed between haemoglobin levels and extent of HRQoL impairment, regardless of instrument used (range 0.19-0.23; all P-values < 0.0001). When stratified by anaemia status, impairment was consistently lower for anaemic than non-anaemic CKD patients across measurement scales (e.g. EQ-5D index value [standard deviation {SD}] 0.72 [0.31] vs 0.83 [0.23], respectively; P < 0.0001). Physician-reported patient tiredness was associated with increased disease burden at all levels of CKD studied (total EQ-5D index value [SD] in patients reporting no tiredness vs tiredness 0.81 [0.26] vs 0.70 [0.30] respectively; P < 0.0001) with P < 0.0001 for no tiredness vs tiredness at all stages of CKD. The presence of anaemia was associated with impaired activity levels at CKD stages 3 (37.5 % vs 28.4 %, respectively; P = 0.0044) and 4 (48.1 % vs 39.9 %, respectively; P = 0.0292), and in patients on dialysis (52.0 % vs 45.0 %, respectively; P = 0.0732).

CONCLUSIONS

The analysis found that CKD patients with anaemia typically had a lower HRQoL than those without anaemia. The impairment correlated with anaemia was more apparent in non-dialysis patients with CKD stages 3 or 4 than in those receiving dialysis. Coexisting CKD and anaemia may have an impact on patient HRQoL similar to other chronic conditions such as diabetes, epilepsy or certain forms of cancer.