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NDT Advance Access published online on September 15, 2008
Nephrology Dialysis Transplantation, doi:10.1093/ndt/gfn506
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© The Author [2008]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org


Factors affecting the quality of life of haemodialysis patients from Romania: a multicentric study

Anca Seica1, Liviu Segall1, Constantin Verzan2, Nina Vaduva2, Maria Madincea3, Simona Rusoiu4, Sorina Cristea5, Maria Stefan6, Daniela Serbanescu7, Petronela Morosanu8, Luminita Grajdeanu9, Roxana Andronache10, Maria Nechita11, Dorina Dragos12, Paul Gusbeth-Tatomir1, Gabriel Mircescu2, Adrian Covic1 and Anca Dronca13

1 Nephrocare Dialysis Center, Iasi 2 Nephrocare Dialysis Center Carol Davila, Bucuresti 3 Timisoara Dialysis Center 4 Craiova Dialysis Center 5 Floreasca Bucuresti Dialysis Center 6 Tîrgu-Mures Dialysis Center 7 Nephrocare Dialysis Center, Constanta 8 Piatra Neamt Dialysis Center 9 Focsani Dialysis Center 10 Petrosani Dialysis Center 11 Baia-Mare Dialysis Center 12 N.C. Paulescu Institute Dialysis Center, Bucuresti, Romania 13 Deva Dialysis Center

Correspondence and offprint requests to: Anca Seica, Nephrocare Dialysis Center, University Hospital, ‘C.I. Parhon’, 50 Carol 1st Blvd, 700503 Iasi, Romania. Tel: +40-727-889089; Fax: +40-232-211752; E-mail: ancagusbeth{at}yahoo.com



   Abstract
Top
 Abstract
Introduction
 Subjects and methods
 Results
 Discussion
 References
 
Background. The quality of life (QoL) is an important predictor of outcome in end-stage renal disease (ESRD) patients. Therefore, QoL needs to be regularly assessed in this setting. Our study describes QoL, as well as demographic and clinical variables associated with QoL in chronic haemodialysis (HD) patients in Romania.

Methods. All prevalent chronic HD patients (N = 709; mean age 51.7 ± 12.6 years) in 12 dialysis centres from the three main regions of Romania were included in the study. Six hundred and six of these completed the Short-Form Health Survey (SF-36) and the Kidney Disease Quality of Life Questionnaire—Short Form (KDQOL-SF).

Results. The mean physical component summary (PCS) score was 46.3 ± 19.2, and the mean mental component summary (MCS) score was 55.1 ± 19.3. These figures were lower than those previously described in non-dialysis age-matched Romanian individuals. The mean kidney disease summary component (KDSC) score was 68.3 ± 11.3, similar to other studies. The worst dimension of QoL was work, whereas the best ones were cognitive function and quality of social interaction. We found older age, female gender, lower socio-economic status and higher educational level to be associated with lower QoL scores.

Conclusions. The QoL of HD patients in Romania is lower than that in the general population. Our results suggest that at least one-third of these patients might be considered for rehabilitation therapy, in order to try and prevent complications and mortality.

Keywords: end-stage renal disease; haemodialysis; quality of life



   Introduction
Top
 Abstract
 Introduction
Subjects and methods
 Results
 Discussion
 References
 
‘Adding life to years and not just years to life’ is as true for ESRD patients as for any other individuals. In maintenance HD population, health-related QoL is usually poorer than that in the age-matched general population, because of the typically high burden of comorbidity and complications of ESRD [1–3]. Therefore, attaining a good QoL in these patients is a difficult task, requiring significant efforts from nephrologists and support from social workers and psychologists.

Several large studies have demonstrated QoL, as assessed with the SF-36, to be a consistent and powerful predictor of death and hospitalization in HD patients [3–5]. The Dialysis Outcomes and Practice Patterns Study (DOPPS) [4] found the PCS score of SF-36 to predict mortality better than serum albumin. Lowrie et al. [3] showed that a PCS score <43 and a MCS score <51 significantly increase the risk of death and hospitalization; a one-point increase in PCS is associated with a 2% reduction in mortality, independently of demographic and comorbid variables. Moreover, a MCS score under 43 is highly specific and sensitive for depression [2].

In Romania, as well as in other Central and Eastern European countries, dialysis centres have dramatically developed and expanded during the past 20 years. The current policy of employment of psychology specialists in dialysis care teams is aimed at improving QoL in ESRD patients in our country. Romanian specialists have recently settled regular psychonephrology national summits, validated two QoL evaluation instruments in HD subjects and created a set of guidelines for rehabilitation and psychology practice in chronic kidney disease and ESRD patients.

The present study is in line with these efforts. For the first time in the Romanian dialysis population, we investigated QoL in a wide survey, analysed demographic and clinical factors influencing QoL and compared our results with those from similar Western European research.



   Subjects and methods
Top
 Abstract
 Introduction
 Subjects and methods
Results
 Discussion
 References
 
Patients
All prevalent HD patients (N = 709) in 12 dialysis centres from the three main geographic regions of Romania (Moldavia, Walachia and Transylvania) were included in the study. The 12 centres represent ~17% of all dialysis centres, comprising roughly 10% of the total chronic HD population in our country. We selected only those centres employing full-time psychologists who are the only qualified professionals in performing QoL assessment in Romania.

Thirty-eight patients were excluded from the study because of concomitant acute illnesses (that may have acutely influenced their QoL). Of the remaining patients, 65 did not complete the QoL questionnaires either because they did not understand the questions or because they refused to answer.

We analysed the following socio-demographic and clinical factors: (1) age; (2) gender; (3) dialysis vintage; (4) educational level (low level was defined as secondary school graduate or less; medium level—as high-school undergraduate or graduate; high level—as college graduate); (5) socio-economic level (i.e. net family income: low level—was defined as ≤400 euros/month; high level—as >400 euros/month); (6) living status (i.e. living within family versus living alone); (7) serum haemoglobin (Hb); (8) Kt/V; (9) diabetes and (10) heart failure.

Instruments
QoL was assessed by SF-36 [1], a generic QoL instrument adapted for the Romanian population [6]. SF-36 evaluates QoL on eight dimensions: physical functioning, social functioning, role-functioning emotional, role-functioning physical, vitality, pain, mental health and general health perceptions. Two summary scores were calculated: (1) the physical component summary score (PCS), as the mean of physical functioning, role-functioning physical, vitality, pain and general health perceptions scores and (2) the mental component summary score (MCS), as the mean of social functioning, role-functioning emotional, mental health, vitality and general health perceptions scores. Scores range from 0 to 100; the higher the score, the better the QoL.

A total of 117 patients completed the 11 kidney disease-specific scales of the Kidney Disease Quality of Life Questionnaire (KDQOL-SF), also validated in the Romanian population [7]: symptoms/problems list, effects of kidney disease on daily life, burden of kidney disease, work status, cognitive function, quality of social interaction, sexual function, sleep, social support, dialysis staff encouragement and patient satisfaction. Scores range again from 0 to 100; the higher the score, the better the QoL. To exclude potential bias in the assessment of QoL, both instruments were self-administered [8].

Data analysis
Statistical analysis was performed with SPSS 12.0 for Windows. Based on other studies, we used in our analysis the cut-off scores of 43 for PCS [3], and 51 [3] and 43 [2] for MCS. Pearson correlation was used to assess the relationship between QoL and continuous variables (age, dialysis vintage, Kt/V, and Hb). Comparisons were made using Student's t-test for independent variables. All demographic, socio-economic and clinical variables were included in a multivariate analysis. A P-value of 0.05 or less was considered to indicate statistical significance.



   Results
Top
 Abstract
 Introduction
 Subjects and methods
 Results
Discussion
 References
 
Demographic, socio-economic and clinical characteristics are shown in Table 1. We found no significant differences between geographic regions for any of these variables.


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  		Table 1 Demographic and clinical data

 
QoL results are presented in Table 2. A PCS score of <43 was found in 44.9% of patients, and a MCS score of <52 was found in 43% of patients, while 35.5% of patients had both PCS and MCS below these critical scores. Depression (i.e. MCS < 43 [2]) was found in 27.7% of patients. The analysis of the ESRD-targeted areas showed that the most affected dimension of QoL in our patients was work, whereas the best results were observed for cognitive function and quality of social interaction. Only 42.7% of patients answered the questions about sexual function.


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  		Table 2 SF-36 and KDQOL scores

 
Differences between SF-36 scale scores by demographic, socio-economic and clinical factors are illustrated in Tables 3 and 4. Women scored lower in all QoL dimensions, but significantly so only for physical functioning and vitality (P = 0.004 and P = 0.03, respectively). Patients aged 65 or more had poorer QoL scores, but significantly so for PCS (P = 0.001), social support (P = 0.03) and patient satisfaction (P = 0.01). Patients’ educational level and socio-economical status had a significant influence on PCS, but not on MCS; better PCS scores were associated with lower educational (P = 0.03) and with higher income levels (P = 0.01). The presence of diabetes was a significant factor for worse physical functioning (P = 0.05). There were no significant differences in QoL scores by geographic regions.


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  		Table 3 Comparisons of SF-36 scores by demographic variables

 

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  		Table 4 Comparison of SF-36 scores based on socio-economic and educational levels

 
PCS and MCS correlated positively with Hb (P < 0.001 and P < 0.05, respectively) and negatively with age (P < 0.001). In multivariate analysis, PCS was predicted only by age (R2 = 0.03; P = 0.001; 95% CI = –12.82 to –3.22), whereas no significant predictors were found for MCS.



   Discussion
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
References
 
Little data is available concerning the QoL of Eastern European HD patients in general. We used both a generic (SF-36) and a specific tool (KDQOL-SF) for QoL assessment, as recommended by Rettig et al. [9] and Cagney et al. [10]. Our study showed that QoL scores of HD patients in Romania are lower than those in the general population (Figure 1). About 35% of HD patients in our study have both PCS and MCS scores lower than the critical scores, as established by Lowrie et al. [3].


Figure 1
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  		Fig. 1 SF-36 composite summary scores of the study group and the general population from Romania (Mihaila et al., QoL Newsletter, 2000 [6]).

 
MCS scores were higher than PCS scores in our patients, similar to other studies in HD patients [11]. The difference between MCS and PCS was larger (+7.7) than that reported by Mihaila et al. [7] in a Romanian non-dialysis population (–6.6). In other words, despite the worsening of the physical health status, the mental health of dialysis patients is relatively preserved. This was previously explained by dynamic adaptation of patients’ expectations to their chronic illness [12,13]. The prevalence of depression (MH ≤ 42) was 21.5%, similar to the findings of DeOreo et al. [2], which reported a prevalence of depression of 25%.

Among demographic factors, we found older age, female gender, low socio-economic status and high educational level to be associated with lower QoL scores. Patients <65 years old had significantly higher PCS scores, but similar MCS scores, compared with those ≥65 [2,14–16]. In multiple regression analysis, age had a significant impact on PCS (R2 = 0.03; P = 0.001), which is in agreement with other studies [5,17,18], but not on MCS. However, when looking at the R2 value, age explains <3% of the variation of QoL. This means that QoL is influenced by a lot of other unrecognized factors. Therefore, a close psycho-social follow-up of dialysis patients becomes even more crucial, as they all should receive personalized attention.

Women had lower QoL scores than men, as already reported by others [19,20]; this may be explained by women's multiple domestic tasks and responsibilities that, unlike men, they cannot circumvent [21].

Similar to other studies [22], we showed a low socio-economical level to be associated with lower QoL in our HD patients. In contrast, we found that a lower educational level was associated with better PCS scores. Possibly, the explanation is that less educated patients rely completely on physical labour for a living even after starting on dialysis, which may help them maintain a better physical functioning compared to their more sedentary highly educated counterparts.

Another particular finding in our patients was a lower burden of kidney disease than that reported by the DOPPS [4]. This may be due to specific aspects of Romanian policy of compensation for disability, resulting in a paradoxical switch from lowly paid and harsh work to a better living standard for a large number of patients and their families.

A parallel between QoL scores of our population and those from other studies is presented in Table 5. In comparison with Western European HD patients [23], our subjects had a similar kidney disease summary composite (KDSC) score, but better PCS and MCS scores; this is probably because our population was younger (51.7 versus 59.9 years old, on average), and had a lower prevalence of diabetes (8.2% versus 13.8%) and heart failure (5.9% versus 24.1%). When compared with other Eastern European HD populations, our patients also did better; for example, Romanians had higher QoL than Russian patients [18], in spite of older age (51.7 versus 43.5).


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  		Table 5 QoL scores in various HD populations

 
We believe that patients with lowest PCS and MCS scores might benefit from rehabilitation programmes, in order to try and reduce their morbidity and mortality risks. We suggest that future studies in Romanian ESRD patients should focus on the impact of comorbidity burden on QoL, comparisons between various renal replacement modalities (HD, peritoneal dialysis and renal transplantation) and interventions to improve QoL.

Conflict of interest statement. None declared.



   References
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 

  1. Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). Med Care (1992) 30:473–483.[Web of Science][Medline]
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  3. Lowrie EG, Zhang H, LePain N, et al. The association of SF-36 quality of life scales with patient mortality. CQI Memorandum, Fresenius Medical Care, 1997.
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  7. Verzan C, Mircescu G, Vaduva N, et al. Reliability and validity of the Romanian version of Kidney Disease Quality of Life Questionnaire (KDQOL-SF). Nefrologia (2007) 30:A94.
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  10. Cagney KA, Wu AW, Fink NE, et al. Formal literature review of quality of life instruments used in end-stage renal disease. Am J Kidney Dis (2000) 36:327–336.[Web of Science][Medline]
  11. Kutner NG. Assessing end-stage renal disease patients’ functioning and well-being: measurement approaches and implications for clinical practice. Am J Kidney Dis (1994) 24:321–333.[Web of Science][Medline]
  12. Dolan P. Modelling valuations for health states: the effect of duration. Health Policy (1996) 38:189–203.[CrossRef][Web of Science][Medline]
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Received for publication: 12. 6.08
Accepted in revised form: 18. 8.08


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This Article
Right arrow Abstract Freely available
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