Comparison of quality of life between haemodialysis and renal transplant patients.

INTRODUCTION

Quality of life is a broad concept encompassing many factors related directly and indirectly to health status (World Health Organization, 1948). It is of particular importance in trials comparing treatments with similar or no impact on disease progression and survival. However, the term quality of life is often used vaguely and without clear definition (Gill & Feinstein, 1994). Health economic studies may use quality of life as an indicator of the benefit and utility of certain interventions (such as medical and surgical therapies). Moreover, research on quality of life is also an issue in clinical practice (Patrick & Chiang, 2000).

Many serious medical conditions are associated with increased poor physical and mental health. One such condition is chronic renal disease, which has increased substantially in recent years (Testa & Simonoson, 1996). Chronic kidney disease is now recognised as a significant and rapidly growing global health burden (Valderrabano et al., 2001). In recent decades, kidney replacement therapy such as haemodialysis, peritoneal dialysis, and kidney transplantation have lengthened the life of many patients with end-stage renal disease (Reimer et al., 2000).

End-stage renal disease and its treatment profoundly affect health related quality of life not only for the patient but the family also. Although renal replacement therapy ameliorates some of the symptoms of end-stage renal disease they may not be completely alleviated. Moreover, with treatment often comes significant life style changes, all of which impact on quality of life (Franke et al., 2003). Quality of life of patients with end renal disease is influenced by the disease itself and by the type of replacement therapy (Oberbaue et al., 2003). Dialysis must be repeated frequently and continued life-long until death or transplant (Laupacis et al., 1996; Naughton et al., 1996).

Transplantation is a highly successful treatment modality, but it is not a curative procedure. Transplantation can alter quality of life in many ways, both positively and negatively (Fallon et al., 1997). However, this is often at a personal cost, for example transplant patients have to face the side effects of immunosuppressive drugs, noncompliance, and rejection of the transplanted organ, psychosocial stress and excessive financial burdens (Hariharan et al., 2000). There is also a risk of graft rejection this may mean a return to dialysis and/or re-graft, with attendant health and cost implications (Aulakh et al., 2003). This also has an emotional toll on families.

A study which followed pre-transplant patients for up to two years post-transplant found employment rates increased by 50% with a functioning transplant (Evans et al., 1985). On the other hand, more than a third of the haemodialysis group and a sixth of the transplantation group reported that they had accompanying chronic physical disorders. The national kidney dialysis and kidney transplant study found that while 79.1% of transplant recipients had almost normal physical function, only approximately half of dialysis patients reported being able to function at the same level (Afayin et al., 2003).

Renal transplantation is a chronic condition that involves the total human environment for supportive care and self care (American Nurses Association, 1995). It not only affects the patients but also the family and society. Nursing as a discipline aims to address actual and potential patient health problems and nurses must be able to educate patients about self care skills (Wolfgang et al., 2004).

With advanced and improved renal replacement therapy, such as haemodialysis and renal transplantation, patients' survival rates have increased and quality of life has become an increasingly important parameter quality of life in haemodialysis and renal transplantation patient has been studied extensively in recent decades (Bullinger, 1991).

METHODS

This research was a descriptive, cross-section and analytical study. Its purpose was to determine and comparison of quality of life in haemodialysis and renal transplantation patients.

Sample

The study participants included 213 patients who were undergoing haemodialysis and were not on the waiting list for transplantation and patients who had received a renal transplant at least six months ago. Inclusion criteria were: age 17-45 years; educational level; haemodialysis or renal transplantation duration of about six months. Exclusion criteria were: any illness or malignancy, or patients who were on the waiting list for renal transplantation.

The first 114 patients were selected randomly from the haemodialysis unit records of the university hospital. They were asked to complete the research scales on the days that they came into hospital for dialysis. Similarly, the first 99 patients who had undergone renal transplantation six months previously were selected randomly from the clinic or nephrologist's office. They completed their scales on the days they came to either the clinic or nephrologist's office.

Comparison of quality of life between haemodialysis and renal transplantation patients was performed at three and six months after initial baseline, this included: assessment of physical status, mental status, activities of daily living, and social function.

Data collection

The Short Form 36 (SF-36) questionnaire was used to assess quality of life annually for kidney transplantation and haemodialysis patients. The SF-36 is the most well known general health questionnaire, which was developed from the work of the Rand Corporation in the late 1970s and 1980s (Gill & Feinstein, 1994). Its use is reported in more than 2000 publications, and it is one of the most widely used quality of life instruments worldwide (Ware & Sherbourne, 1992; Hemingway et al., 1997).

The SF-36 questionnaire is a self administered survey that contains 36 items that take a few minutes to complete. It includes one multi-item scale that assesses eight health domains (Matas et al., 1998):

* limitations in physical activities because of health problems

* limitations in social or physical activities because of physical or emotional problems

* limitations in usual role activities because of physical health problems

* bodily pain

* general mental health

* limitations in usual role activities because of emotional problems

* vitality

* general health problems

Items are evaluated using either a subjective or an objective rating. All scales are scored from 0 (worst case) to 100 (best case) (Tomasz & Piort, 2003).

In addition to the SF-36, a visual analogue scale (0-5) was used to gather socio-demographic and health data (physical health and renal transplant and haemodialysis information expectation levels) using a 10-item multiple-choice questionnaire, which was constructed for this study (Matas et al., 1998).

Data analysis

The Statistical Package for Social Sciences (SPSS) was used for statistical analysis in this study. In comparing the groups, the Chi-square test for categorical variables, and the t-test and co-variance analysis for continuous variables, were used. For determination of the variables, which predicted the level of general compliance, mental health, physical function and quality of life, logistic and multiple regression analysis was used for non-normally distributed continuous variables. Statistical significance was set at p < 0.05.

Ethical considerations

The study protocol was approved by the university and local hospital medical ethics committee. In accordance with standard ethical procedures, patients were informed that participation was entirely voluntary and would not affect their future treatment. They were assured of full confidentiality and anonymity. The data collector was available to patients and their families to discuss the study and answer any concerns expressed.

RESULTS AND DISCUSSION

Sample

213 patients were included in the study (see table 1), of whom 122 (57%) were male and 91 (43%) were female. There were 114 patients (63 male, 51 female) in the haemodialysis group, whose mean age was 33.88 years (SD 10.72). In the renal transplantation group there were 99 patients (59 male, 40 female), whose mean age was 32.39 years (SD 9.5). The average age of patients in this study was significantly younger than those in Tomasz and Piort's (2003) study of quality of life in haemodialysis and renal transplantation patients, whose average age was 44 (SD 12) years. In this study, the two groups were similar in size and gender distribution and there were no significant differences between haemodialysis patients and renal transplantation patients regarding their age, gender, level of education, and their primary disease (see table 1). However, there was a statistically significant difference in marital status between the two groups (p < 0.001), although the majority in both groups was married and unemployed. Although Tomasz and Piort's (2003) study did not reveal any demographic differences between haemodialysis and renal transplant subjects, the study by Blake et al. (2000) showed significant differences in age and marital status between the two groups.

The most common chronic disease in both groups was hypertension, followed by glomerulonephritis and diabetes. Other diseases included rheumatism, heart failure and gastritis. This is consistent with other research that shows that diabetic glomerulonephritis and hypertension are the most common diseases (Harrison, 2005).

Quality of life

The SF-36 scores revealed statistically significant differences (p < 0.05) between the haemodialysis and the renal transplantation groups in all domains except social functioning, with the renal transplant patients reporting higher quality of life scores than haemodialysis patients in all domains (see table 2). This was particularly true for their physical and psychological status, but not for their social functioning. However, some significant differences in some aspects of social functioning were observed between the groups: bodily pain and discomfort, positive feeling, and activities of daily living. This is consistent with earlier research by Bermer et al. (1989) who reported better quality of life scores in transplant patients' quality of life in several domains. Reimer et al. (2000) reported that transplanted patients and healthy controls reported similar quality of life, which was significantly better than in dialysis patients.

Using the SF-36, overall quality of life was rated more highly by the transplant patients (see figure 1). When assessing overall quality of life using visual analogue scores (VAS) there was a statically significant difference between the two groups (p < 0.001). In the haemodialysis group the mean VAS was 2.84 (SD 1.04) compared to 3.22 (SD 0.85) in the renal transplant group. The overall VAS was 2.93 (SD 0.95). Comparison of overall quality of life by using VAS in both groups showed a significant difference between the groups. These findings are consistent with previous research which demonstrated that overall, kidney transplantation improved to quality of life in end-stage renal disease patients (Franke et al., 2003) and transplant patients with functioning grafts had a better quality of life than patients treated with various dialysis techniques (Fisher et al., 1998). However, research in France and Japan with renal transplant patients reported lower physical and general health than the general population (Motzahn et al., 1997).

[FIGURE 1 OMITTED]

CONCLUSIONS

In general, quality of life improved after successful kidney transplant compared to dialysis. Although initially expensive, renal transplantation is a cheaper renal replacement therapy in the long term and is associated with reduced mortality. The high cost of the operation and the lifelong immunosuppressive medications present a significant economic challenge for society. Although quality of life has been shown to improve following transplant, the intensive follow-up regimen influences renal transplant patients' daily and social activities and employment, and in turn, increases their economic burden (Lewis et al., 1990). Patients are concerned about possible rejection and have distress related to side effects of medications, economic burden, and their family (Taskapan et al., 2005).

REFERENCES

Afayin SA, Vesile A, Siren S, Remzi EM, Roazlu HE, Savgi A (2003). Psychiatric problems, life quality and compliance in patients treated with hemodialysis and renal transplantation. Turkish Journal of Psychiatry 17 (1), 22-31.

American Nurses Association (1995). Nursing's Social Policy Statement. Washington DC: American Nursing Publications.

Aulakh BS, Singh SK, Khanna S, Kaura R (2003). Erectile dysfunction in uremia patients and the effect of renal transplantation--our experience. Transplantation Proceedings 35 (1), 315-319.

Bermer BA, McCauley CR, Wrona RM, Johnson JP (1989). Quality of life in end-stage renal disease: a reexamination. American Journal of Kidney Disease 13 (3), 200-209.

Bullinger M (1991). Quality of life definition, conceptualization and implications--a methodologist's view. The Journal of Urology 158 (3), 143-149.

Blake C, Codd MB, Cassidy A, O'Meara YM (2000). Physical function, employment and quality of life in end-stage renal disease. Journal of Nephrology 13 (12), 1-8.

Evans R, Manninen DL, Garrison LP, Hart LG, Blagg CR, Gutman LP (1985). The quality of life of patients with end-stage renal disease. New English Journal of Medicine 312 (9), 553-559.

Fallon M, Gould D, Wainwright SP (1997). Stress and quality of life in the renal transplantation patients: a preliminary investigation. Journal of Advanced Nursing 25 (3), 562-570.

Fisher R, Gould D, Wainwright S, Fallon M (1998). Quality of life after renal transplantation. Journal of Clinical Nursing 7 (6), 553-563.

Franke GH, Reimer J, Philipp T, Heemann U (2003). Aspects of quality of life through end stage renal disease. Psychology of Rehabilition 12 (2), 103-115.

Gill TM, Feinstein AR (1994). A critical appraisal of the quality of life measurements. JAMA 272 (8), 619-626.

Hariharan S, Johnson CP, Bresnahan BA, Taranto SE, Stablein D (2000). Improved graft survival after transplantation in the United States. New England Journal of Medicine 342 (24), 605-612.

Harrison A (2005). Disorders of the kidney and urinary tract. In: Kasper DL, Braunwald E, Hauser S, Long D, Jameson LJ, Fauci AS (Editors), Harrison's Principles of Internal Medicine, 16th edition. USA: McGraw-Hill.

Hemingway H, Stafford M, Stansfeld S, Shipley M, Marmot M (1997). Is the SF-36 a valid measure of change in population health? Results from the Whitehall II study. BMJ 315 (7118), 1273-1278.

Laupacis A, Keown P, Pus N, Krueger H, Ferguson B, Wong C, Muirhead N (1996). A study of the quality of life and cost-utility of renal transplantation. Kidney International 50 (1), 235-420.

Lewis VT, Starr A, Ketefian S, White JM (1990). Stress, coping and quality of life in family members of kidney transplant recipients. Journal of the American Nephrology Nurses Association 17 (6), 427-431.

Matas AJ, McHugh L, Payne WD, Wrenshall LE, Dunn DL, Gruessner RW, Sutherland DE, Najarian JS (1998). Long-term quality of life after kidney and simultaneous pancreas-kidney transplantation. Clinical Transplantation 121 (3), 233-242.

Motzahn E, Northcott C, Dossetor B (1997). Quality of life of individuals with end stage renal disease: perceptions of patients, nurse, and physicians. Journal of the American Nephrology Nurses Association 24 (3), 325-333.

Naughton MJ, Shamaker SA (1996). Assessment of health related quality of life. In: Furberg CD, Demets DL (Editors), Fundamental of Clinical Trials, 3rd edition. St. Louis: Mosby Press.

Oberbauer R, Hutchison B, Eris J, Arias M, Claesson K, Mota A, Kreis H, Kleinman L, Wang F, Chen J, Revicki DA; Rapamune Maintenance Regimen Study Group (2003). Health-related quality of life outcomes of sirolimus-treated kidney transplant patients: results of a 2-year randomized clinical trial. Transplantation 75 (8), 1277-1285.

Patrick DL, Chiang YP (2000). Measurement of health outcome in treatment effectiveness evolution: conceptual and methodological challenges. Medical Care 38 (9), 104-250.

Reimer J, Franke GH, Lutkes P, Kohnle M, Gerken, G, Heemann U (2000). Quality of life in patients before and after kidney transplantation. Psychological Health 52 (1), 16-23.

Taskapan H, Ateay F, Kaya B (2005). Psychiatric disorders and long inter dialysis weight gain in patients on chronic haemodialysis. Nephrology 10 (4), 15-20.

Testa MA, Simonson DC (1996). Assessment of quality of life outcomes. The New England Journal of Medicine 334 (13), 835-840.

Tomasz W, Piort A (2003). Trial of objective comparison of quality of life between chronic renal failure patients treated with haemodialysis and renal transplantation. Annals of Transplantation, 8 (2): 47-53.

Valderrabano F, Jofre R, Lopez-Gomez JM (2001). Quality of life in end-stage renal disease patients. American Journal of Kidney Disease 38 (3), 443-464.

Ware JE, Sherbourne CD (1992). The MOS 36-item short form health survey (SF-36). Conceptual framework and item selection. Medical Care 30 (7), 473-483.

World Health Organization (1948). Preamble to the constitution of the world Health organization as aborted by the international Health conference. New York, 19-22 June 1946. Signed on 22 July by the representatives of 61 states; official records of the WHO; 2:100.

Wolfgang F, Christa M, Rainer O (2004). Health-related quality of outcomes after kidney transplantation. Health and Quality of Life Outcomes 8 (2), 1-6.

Sedigheh Fayazi RN; MSN, Department of Medical Surgical Nursing, Nursing and Midwifery College, Ahwaz Jondishapour University of Medical Sciences, Ahwaz, Iran

Marziyeh Asadizaker RN; MSN, Department of Medical surgical Nursing, Nursing and Midwifery College, Ahwaz Jondishapour University of Medical Sciences, Ahwaz, Iran

Athary Shahrouz RN; MSN, Sabzevar Hospital, Sabzevar, Iran

E-mail: [e-mail]

Table 1: Socio demographic data

     Socio demographic variables      Haemodialysis       Kidney
                                         patients        transplant
                                                          patients
               Mean age               33.88 (SD 10.7)   32.3 (SD 9.5)

Gender                  Male            63 (55.3%)       59 (59.6%)

                       Female           51 (44.7%)       40 (40.7%)

Educational            Primer           34 (29.8%)       38 (38.4%)
level
                     High school        35 (30.7%)       19 (19.2%)

                  Vocational school     24 (21.1%)       29 (29.3%)

                       College          21 (18.4%)        13 (13.1)

Marital status         Single           18 (16.2%)       32 (33.3%)

                       Married          93 (83.8%)       64 (66.7%)

Employment            Employed          22 (19.6%)       23 (23.5%)
status
                     Unemployed         88 (78.6%)       71 (72.1%)

                       Student           2 (1.8%)         4 (4.1%)

Primary disease     Hypertension        40 (35.1%)       23 (23.5%)

                     Glomerulo-         18 (15.8%)       15 (15.3%)
                      nephritis

                      Diabetes          12 (10.5%)        6 (6.1%)

                    Other disease       44 (38.6%)       54 (55.1%)

Table 2: Comparison of mean quality of life domains between
haemodialysis and kidney transplantation patients

 Quality of life     Haemodialysis     Kidney      Significance
    dimension          patients      transplant
                                      patients

Physical                 58.77         79.29          < 0.05
functioning

Role--physical           67.10         73.73          < 0.05

Role--emotional          57.75         63.13          < 0.05

Vitality                 48.24         62.03          < 0.05

Social functioning       59.21         64.03      Not significant

Bodily pain              61.57         71.96          < 0.05

General health           32.89         50.50          < 0.05

Mental health            53.38         66.66          < 0.05