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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2020  |  Volume : 31  |  Issue : 2  |  Page : 460-472
Quality of life and its determinants among hemodialysis patients: A single-center study

1 Department of Nephrology, Bahrain Defense Force Hospital, Manama, Bahrain
2 Department of Medicine, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
3 Department of Community Medicine, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain

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Date of Submission22-Apr-2019
Date of Acceptance29-May-2019
Date of Web Publication09-May-2020


The purpose of this study was to investigate the relation between selected demographic and clinical characteristics and quality of life (QOL) scores in patients with end-stage renal disease who receive dialysis. We conducted the study at one hemodialysis (HD) unit in Bahrain from May 2018 to July 2018. We used standard QOL Index (QOLI) score instrument in Arabic form. This study included 100 patients (66 men and 34 women), aged 22 to 80 years on treatment with maintenance HD for four to 190 months. Inclusion criteria were as follows: those aged >18 years with no severe morbidities or psychological diseases and were on dialysis for at least three months. The following QOL scores were recorded: the health and functioning domain (64.8 ± 15.3), the social and economic domain (65.6 ± 14.1), the psychological/spiritual domain (74.9 ± 14.3), and the family subscale domain (75.9 ± 14.5). Male patients had reduced QOL though not statistically significant and younger patients had better QOL scores. The QOL scores revealed a decreasing trend with decreasing level of education, and they were higher among those who were not working and stayed at home. In addition, the family subclass scores were significantly higher among the married patients. Correlations between the demographic characteristics and QOL scores showed that there was a significant negative correlation between family domain and educational level and marital status, while there was a significant positive correlation between residence and psychological domain. Age, gender, marital status, residence, ethnicity, education level, employment status, income, and duration on HD nonsignificantly affected one or more domains of QOLI scores in such patients. Adequate management of these factors could influence patient outcomes.

How to cite this article:
El-Habashi AF, El-Agroudy AE, Jaradat A, Alnasser ZH, Almajrafi HH, Alharbi RH, Alanzy A, Alqahtani AM. Quality of life and its determinants among hemodialysis patients: A single-center study. Saudi J Kidney Dis Transpl 2020;31:460-72

How to cite this URL:
El-Habashi AF, El-Agroudy AE, Jaradat A, Alnasser ZH, Almajrafi HH, Alharbi RH, Alanzy A, Alqahtani AM. Quality of life and its determinants among hemodialysis patients: A single-center study. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2022 Dec 4];31:460-72. Available from: https://www.sjkdt.org/text.asp?2020/31/2/460/284022

   Introduction Top

Chronic kidney disease (CKD) affect several aspects of life of these patients. The life of those treated with dialysis is characterized by many restrictions.[1] The major psychological and physiological stressors experienced by dialysis patients are pain, restriction of fluids, itching, discomfort, limitations in physical activity, fatigue, weaknesses, paying for the care, feelings of inadequacy, sexual dysfunction, and negative moods.[1],[2] Quality of life (QOL) is an important parameter that needs to be considered when evaluating the experience and outcome of patients receiving health care. Although no consensus exists between experts in defining the QOL, there is a general agreement that in CKD patients, particularly in those receiving dialysis, QOL most commonly affects the physical domains (e.g., physical abilities and vitality) and least commonly affects the mental functioning (e.g., mental, behavioral, and psychological health) and social health.[3]

According to the World Health Organization Global Burden of Disease project, CKD contributes to approximately 850,000 deaths every year, and it is the 12th leading cause of death and 17th leading cause of disability in the world. Moreover, the burden of CKD continues to increase in the low- to middle-income countries globally.[3] Instead of the traditional end points for the assessment of the effect of interventions on patients, QOL measures have become increasingly used in the recent decades with changing pattern of illness in developed and developing countries.[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14]

Published studies have reported some evidences of poor QOL, but a significant difference in QOL has been observed with ethnicity and culture.[1],[3],[13] In spite of long duration in managing patients with end-stage renal disease (ESRD) under hemodialysis (HD) in Bahrain, no data are available regarding health-related QOL.

The aim of our work was to evaluate the QOL of CKD patients undergoing dialysis treatment in terms of their physical, psychological, social, and environmental health dimensions, and to identify the correlation between the overall QOL and the diverse domains of Quality of Life Index (QOLI).

   Materials and Methods Top

We conducted a cross-sectional study among HD patients at one big center, Bahrain Defense Force Hospital, Manama, Kingdom of Bahrain, Between May and July 2018, we recruited 135 dialysis patients to participate in this study; however, we could analyze only 100 patients who completed the questionnaire.

Inclusion criteria comprised adults over 18 years old who had undergone at least three months of dialysis and had not changed their treatment modality over the past three months. We excluded patients if there were cognitive dysfunction; a history of hospitalization in the past two months; presence of coexisting morbidities such as stroke, chronic liver diseases, malignancy, multi-organ system failure, and major hearing impairment, as these factors could potentially affect their QOL.

We obtained ethical approval for this study from the Ethical Committee of the Institutional Review Board at Arabian Gulf University and Bahrain Defense Force Hospital before the start of the study. We informed all participants that their participation was voluntary and the study results would be confidential. We obtained a written informed consent from all participants to participate in the study.

Demographic data as well as data on duration of dialysis, marital status, level of education, income, employment, ethnicity, duration on dialysis, and cause of CKD were collected for all respondents. We used structured questionnaire for collecting data, and QOL was measured using the QOLI questionnaire. We encouraged educated patients to fill the questionnaire by themselves, however, the investigators read it for patients who were not educated, and they noted down their responses.

Description of the Quality of Life Index

The QOLI is a well-established multidimensional, reliable, and validated questionnaire intended for dialysis. Ferrans and Powers developed the QOLI to measure QOL in terms of satisfaction with life.[15] The QOLI measures both satisfaction and importance of various aspects of life. We used important ratings to assess the satisfaction responses so that scores reflect the respondents’ satisfaction with those aspects of life they value. Items that are rated as more important have a greater impact on scores than those of lesser importance. We calculated scores for QOL overall and in the following four domains: health and functioning, psychological/spiritual, social and economic, and family.[16] The QOLI scores ranged from 0 to 30, with 30 as the highest score. For an accurate and easy comparison of the two tools, we transformed the QOLI scores to 0-100. On this scale, 100 is the highest score.

   Statistical Analysis Top

We used initially Excel Spreadsheet for data entry and verification, and then we exported it to IBM SPSS Statistics for Windows version 22.0 software (IBM Corp., Armonk, NY, USA). We presented the results of descriptive analysis as mean ± standard deviation (SD). Univariate relationships between sociodemographic (age, gender, marital status, working status, monthly income, level of education, ethnicity, religion, and residing area), ESRD-related variables (duration of dialysis and type of co-morbidity) were analyzed. We used one-way analysis of variance method and Student’s /-test to analyze QOL scores. We used Pearson’s correlation coefficient to assess the interdomain correlation and the correlation between various demographic variables and domain scores. We performed post hoc analysis for variables with more than two groups. Differences with P <0.05 were considered statistically significant.

   Results Top

A total of 100 respondents were included in this study. Sixty-six percent were males. The mean age was 60.8 ± 12.3 years, and 22% were >70 years. The mean duration on dialysis was 40.3 ± 33.3 months (median = 36). Among the studied patients, 18% of patients were not educated, 68 were married, and 10% were unemployed. The monthly income was <200

Bahrain Dinar (BD) (1 BD = 2.6 US$) in 21% of the patients. Diabetic mellitus was the common cause of ESRD (85%). The mean number of drugs taken was 7.4 ± 3.3. The mean number for hospital days during the previous six months was 3.6 ± 8.7 days. The demographic characteristics of the study patients (n = 100) are summarized in [Table 1].
Table 1: Characteristics of the study population (n =100).

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In our study patients, we observed the highest QOL score in the family subscale (75.9 ± 14.5) followed by the psychological/spiritual subscale (74.9 ± 14.3), social and economic subscale (65.6 ± 14.1), and physical domain QOL scores (64.8 ± 15.3) [Table 2]. Most of the patients have faith of God in their life, and this helped them to cope with their disease. Table 2 shows the mean scores and SDs in each category of the main domains.
Table 2: The mean scores for each domain of the KDQOL instrument among the studied HD patients (n = 100).

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We assessed various demographic factors and their association to QOL, and we tabulated it in [Table 3]. Data show that the female patients reported statistically insignificantly (P <0.05) higher QOL scores in the psychological [67.9 (13.6)] and family domains (77.5 ± 13.5) compared to male patients (64.5 ± 14.3 and 75.0 ± 14.9, respectively). Health/functioning scores, psychological/spiritual score, and social/economic score were insignificantly higher among patients aged <30 years. Level of education affected the QOL score. We found a statistically significant difference between QOL scores in psychological/spiritual score P = 0.042) and social/economic score dimensions (P = 0.030) of patients. We found that patients with higher professional degrees scored statistically significant higher scores compared to patients who were not educated (post hoc analysis). Patients from rural areas reported statistically significantly (P = 0.049) higher scores in the family domain [98.6 ± (12.1)] and social/economic scores (98.9 ± 11.4) compared to patients from urban areas (75.4 ± 14.3 and 64.7 ± 14.2, respectively). In addition, we found that family subclass scores were statistically significantly higher among the married patients compared to other patients (P = 0.027). There were insignificant higher scores in all domains among those who were not working and stayed at home compared to other patients. Scores were not affected significantly by religion, monthly income, and ethnicity, cause of ESRD or duration of HD [Table 3].
Table 3: Comparison of domain mean scores, standard deviations, and significance based on sociodemographic variables.

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[Table 4] shows the details of Pearson’s correlations among various domains. We found that there was a statistically significant association between overall perception of QOLI and general health and scores obtained from different domains P <0.05 in all cases). Analysis of the strength of association among various domains showed moderate interdomain correlation between social and family domains (Pearson’s r >0.3 and <0.5) and strong inter- domain correlation among rest of the domains (Pearson’s r >0.5).
Table 4: Pearson's correlation among the domain scores.

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[Table 5] shows correlations between the demographic characteristics and QOL scores in different domains. We observed a statistically significant negative association between family subscale and educational level (Pearson’s r = 0.191, P = 0.048) and marital status (Pearson’s r = 0.231, P = 0.021). In addition, we observed a statistically significant positive correlation between residence and psychological subclass (Pearson’s r = 0.177, P = 0.049). In our study, however, the duration of dialysis, age, gender, ethnicity, employment, and religion had no significant correlation with QOL domains P >0.05). When the correlation between total QOL scores and patients’ characteristics was assessed, only gender was statistically significant negatively correlated. We revealed weaker and negative correlations between total QOLI and ethnicity, educational level, marital status, and the causes of ESRD, which did not reach statistical significance [Table 5].
Table 5: Pearson's correlation between characteristics and the domain scores.

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   Discussion Top

Our study provides a detailed description of the QOL scores of CKD patients on maintenance HD in Bahrain and the effect of certain variables on their QOL. Given that the subscale components of the two tools (KDQOL-SF and QOLI) are not directly comparable, we compared scores of the two instruments based on the total scores. Our results showed that the overall mean score was 69.1 ± 12.1 (range 40.8-98.6). Compared to studies from other different countries, Bahraini HD patients had lower scores than study from the UAE with total score of the QOLI of 77.2 for dialysis patients.[10] However, it was higher than Saudi patients (total score of 60.3 using KDQOL-SF instrument)[4] and another study by Parker et al[14] who reported a total score of 61.4. We could explain the differences in our findings from other studies to several factors. The first factor may be that the ethnicity and the culture of the patients are different. The second factor may be that strength of the family relationships may affect the level of social and family support received by patients. The third factor may be that the QOL scores could be influenced by the severity of comorbidities associated with dialysis patients.

In our study, when we compared the scores in the four domains in our patients, we found that the highest score (75.9 ± 14.5) was observed in family domain followed by the psychological/ spiritual domain (74.9 ± 14.3). Low scores (<60) were seen in the “work status,” “changes in daily life,” and “sexual life” (scores 58.9, 55.5, and 54.6, respectively). We could attribute this to the fact that most of the patients had chronic comorbidities and most of them were currently not working. High scores (>90) were observed only in “faith in God” sub-category of psychological/spiritual subscale, which may be related to religious beliefs among Arabic Muslim people. This was supported by the argument that Arab and Muslim people receive considerable support from their families when they become ill.[10],[11],[12]

We did not observe the impact of gender on QOLI in the HD patients in our study. These results were in agreement with the study of Saad et al.[17] In their study, they found that males and females had no significant difference in QOL scores. However, several other studies have observed a significant influence of gender on QOL. Sayin et al[18] found that males have worse QOL than females, whereas Valderrabano et al[5] reported quite the opposite. We could explain this by differences in the biological factors and biases in the provision of care, as female patients get more support from their families, and they are not the main source for income for their families.

Our findings showed that older participants had a lower score of QOL although statistically nonsignificant. These findings were in line with the results of Bohlke et al,[19] who reported the association of higher scores with younger age, and they suggested that elderly patients have more comorbid conditions that linked to lower scores. These findings were in contrast to the results of Greene,[20] who used the same tool and observed that increasing age was associated with higher values of some of the QOLI scores. They suggested that elderly patients have a greater level of comfort with their health and social life.

In this study, we found that statistically, the total scores of the QOLI were not significantly correlated with length of time on dialysis. These results were in agreement of the study done by Esmaeli et al,[21] but were in contradictory to the results of Bohlke et al,[19] who found that patients who had been on HD for shorter lengths of time had higher QOLI scores. Possible explanations for this diversity of findings could include with the start of dialysis, many patients may become depressed with less satisfaction for their life and with time on dialysis, more patients may have comorbidities that affect their QOL.

Employment status found to influence the QOL in many studies.[10],[22],[23] We did not find that employment status have any impact on QOLI, yet, there was a trend to be higher in all domains among those who were not working and stayed at home. This was in line with one study,[24] which reported that employed and unemployed HD patients had differences in the QOLI scores. However, it was in contrast to other studies where the employed patients had better overall QOL score than the retired and the unemployed patients.[10],[18],[22] One explanation may be that in Bahrain, we offered dialysis treatments during the daytime in most of HD units, making it difficult to maintain their job during normal working hours. Moreover, HD patients who have full-time employment have more physical and emotional stress in their life.

Our study showed that most of the patients had faith in God (91.8 ± 13), and there was a positive association between spiritual beliefs scale and global QOL measures and satisfaction with life. These findings were in agreement with some other studies.[6],[23] Patel et al[23] suggested that there is a positive association between spiritual belief scores and global QOLI scores, their satisfaction with life, and perception of depression. Religious beliefs may affect HD patients, making them able to cope with life.

The finding that ethnicity did not have any significant impact on the QOL total scores in the HD patients was not expected. Respondents with Indian ethnicity had nonsignificant lower scores than Bahraini patients and generally have lower socioeconomic status than Bahraini people. However, because our study included only small number of patients from this ethnic group (3%), a bigger sample size may be required before we can draw a definite conclusion in our study. In one study from the UAE,[10] their results showed that patients with a UAE nationality had a significant higher QOLI total score (P = 0.023), and this may be explained by free medical care and government aids offered for these patients.

Our results showed that marital status did not affect statistically the total scores of the QOLI in our patients, except in family relations domain, which was in line with other studies that have measured the QOL of dialysis patients using the SF-36 tool.[8],[19],[23] In Bahrain, due to strong family ties, even unmarried people usually get adequate social and financial support from their families that help people to cope with their illnesses.

Our results showed that the level of education did not have an impact on the total scores of QOL in HD patients, and this was not expected. However, it differs from the results of other studies; moreover, there was a statistically significant negative association between higher professional education level and both psychological/spiritual and social domains [Table 3].

Many studies have linked better QOL with higher educational level.[7],[24] However, our results have been supported by one study,[25] who linked the ability to adjust to physical incapability with higher level of education and acquired skill used at work.

Income was nonsignificantly associated with all domains and overall score of QOLI. Our study findings are consistent with the results of one study that reported a positive correlation between QOL scores and total family income.[26] This is because higher income would lead to better self-esteem, feeling of satisfaction, and less worry about the future, all of which result in better QOL.

Limitations of the study are that the sample size is relatively small, patients from other major facilities were not added, and biochemical parameters and adequacy of dialysis that also affect the QOL of dialysis patients were not evaluated. We also did not use control groups to make appropriate comparisons of the findings obtained from HD patients with other patients such as peritoneal dialysis and kidney transplant patients.

We conclude that in spite of these limitations, the present study provides an understanding of factors that are associated with QOL in Bahraini HD patients. Studying and understanding the factors which may affect the QOL in HD patients is useful to HD health-care professionals when developing individualized interventions based on their personal needs to provide better treatment and dialysis care delivery in future.

   Acknowledgments Top

The authors would like to thank the nursing staff and junior doctors, Bahrain Defense Force Hospital, who participated in this study.

Conflict of interest: None declared.

   References Top

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Correspondence Address:
Amgad E El-Agroudy
Medicine Department, College of Medicine and Medical Sciences, Arabian Gulf University, Manama
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.284022

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