Comparing quality of life in dialysis patients and patients after kidney transplantation: a questionnaire survey

Overview

Purpose:
The aim of the survey was to determine and compare quality of life in patients with chronic kidney failure treated with dialysis and those after kidney transplantation.

Methods and Results:
The group comprised 199 patients with chronic kidney failure (99 dialysis patients and 100 patients after kidney transplantation). Data were collected using the WHOQOL-BREF questionnaire for assessing quality of life. Patients after kidney transplantation had statistically significantly higher quality of life scores in all domains than dialysis patients (p<0.001). When compared with the general population, patients after transplantation showed lower quality of life only in the physical health domain (p<0.001) and separate item measuring satisfaction with health (p<0.01). Dialysis patients had lower quality of life than the normal population in all domains and separate items, the only exception being the environment domain (p<0.001). Dialysis patients’ quality of life significantly decreased in all domains with time from initiation of dialysis therapy (p<0.05).

Conclusions:
Information about QoL of patients with renal failure treated by different approaches may help both doctors and patients and their families when making decisions about therapy selection.

Key words:
quality of life, kidney transplantation, dialysis, WHOQOL-BREF questionnaire.

Introduction

Chronic kidney failure is a condition when renal function is decreased to such a degree that the kidneys are unable to maintain the normal composition of the internal environment even under basal conditions, with special dietary and medical measures and in a balanced metabolic situation of the organism (1). The term refers to patients with terminal kidney failure requiring replacement of renal function by dialysis or transplantation (2). 

In the Czech Republic, a total of 8,761 kidney transplantations were performed between the beginning of the programme and the end of 2010, with 364 transplantations in the year 2010 alone. As of 31 December 2009, there were 3,771 Czech patients with a functional renal graft, with the proportion of patients with irreversible kidney failure treated by transplantation being about 40% in the recent years (3). In 2009, a total of 5,763 patients were treated by haemodialysis in the Czech Republic, with only 458 (8%) patients receiving peritoneal dialysis (4).

In current health care, quality of life (QoL) has become one of the criteria for evaluating the efficiency of treating various pathological conditions and diseases (5). Today, there is a general consensus in many areas of clinical medicine about the need to assess QoL as one of the basic components of various medical interventions (6). Most frequently, the term “health-related QoL” is used. Specifically, the term refers to subjective well-being associated with illness, treatment and its side-effects. It means that, apart from the clinical measures of therapy success or failure, both subjective and objective data on the patient’s physical and mental condition are assessed (6). From the perspective of current medicine, QoL means that health care is sensible to the extent that it positively influences patients’ lives. The main goal of medicine is not health or prolonged life as such but maintained or improved QoL (7). 

Dialysis significantly interferes with patients’ lives. On the one hand it saves lives, on the other hand it is undoubtedly a burden (8). Dialysis patients’ lives are complicated not only by their dependence on regular haemodialysis and attending staff, exposure to numerous stressful situations, adherence to a diet and limited fluid intake. Due to high sickness rates, patients often lose their jobs. Changes in appearance and sexual dysfunction may contribute to loss of partners. For most patients, the only hope is successful kidney transplantation (2,9). According to Šabaková et al. (10), however, there is a small group of patients who consider dialysis sessions the only opportunity to meet other people. For them, dialysis is a social event.

Despite advances in dialysis therapy, dialysis patients’ QoL remains low (11, 12, 13). Only some factors may be influenced, such as early detection, anaemia management, exercise and depression treatment (14). Overbeck et al. (15) found significantly lower QoL in terms of physical functioning, social functioning, general health perceptions and physical summary value in patients awaiting kidney transplantation as compared with those after renal transplant.

Successful kidney transplantation changes numerous, mainly physiological, parameters affecting patients’ QoL. For example, erythropoietin production by the transplanted kidney corrects anaemia associated with its deficient production in individuals with irreversible kidney failure. Increased haemoglobin concentration and haematocrit adjustment improve cognitive functions and various electrophysiological parameters. Kidney transplantation is also better at correcting uraemia symptoms than dialysis treatment, resulting in better quality of sleep and management of loss of appetite (16). Parker et al. (17) reported an association between QoL in patients with chronic kidney failure and quality of sleep. According to Eryilmaz et al. (18), sleep disturbances are not common in patients after transplantation but are more frequent than in the general population (approximately 30% of patients).

Patients after kidney transplantation are not subject to sudden changes in body fluid volume. Also dietary restrictions are less stringent than in dialysis patients. Their daily regime is not dependent on devices which may consequently mean a deeper feeling of autonomy and freedom. However, transplantation also has some adverse effects on health. These are especially side effects of immunosuppressive drugs, including the development of metabolic disorders, increased risk of infectious diseases and changes in physical appearance of persons after kidney transplantation (16). White and Gallagher (19) studied a relationship between QoL following kidney transplantation and certain sociodemographic measures. Being younger, attaining a higher education level, being in employment and being married were associated with higher QoL.

In their literature review, Landreneau et al. (20) analyzed 16 studies on differences in QoL between patients after transplantation and dialysis patients. They found significantly better QoL in patients after transplantation in the following domains: general QoL, physical functioning and psychosocial functioning.        

Objective

The aim was to determine and compare QoL in patients with chronic kidney failure treated with dialysis and those after kidney transplantation. The other goal was to compare QoL in patients with kidney failure with the normal Czech population.

Methods

The group comprised patients with kidney failure treated in several dialysis centres (St. Anne’s University Hospital in Brno, University Hospital Olomouc and University Hospital Ostrava) and patients with kidney failure after renal transplantation followed up in outpatient counselling centres in all of the above hospitals. The inclusion criteria were as follows: participation in a chronic dialysis program for at least 6 months, a minimum time from kidney transplantation of 6 months and willingness to cooperate. A total of 204 patients were enrolled in the study. Of those, 5 patients were excluded due to incomplete questionnaires later as the data were processed. The patients signed their informed consent, which was written according to general principles, based on the ethical guidelines. The normal population was defined using two representative samples of a population selected by multistage random sampling (7).     

To asses QoL, the World Health Organization quality of life instrument WHOQOL-BREF was used. The questionnaire comprises 24 items grouped into four broad domains (physical health, psychological health, social relationships and environment) plus two separate items rating the overall quality of life and health status. Domain 1 (physical health) measures physical pain, dependence on health care, fatigue, mobility, daily living activities and capacity for work. Domain 2 (psychological health) is concerned with enjoying life, meaning of life, concentration, acceptance of bodily appearance, self-esteem and negative feelings. Domain 3 (social relationships) focuses on personal relationships, sex life and support from friends. Domain 4 (environment) assesses security, physical environment, financial resources, access to information, leisure activities, home environment, access to health care and transport.

The WHOQOL-BREF results were assessed as (a) a domain score, represented by the mean raw score calculated from the relevant items including transformation to a scale of 4 to 20, and (b) scores for two separate items q1 and q2 assessing the overall quality of life and general health. The domain raw scores were calculated and transformed using methods described by Dragomírecká (6). The scores ranged from 1 to 5 for individual items and from 4 to 20 for the domains. The higher the domain score was the better quality of life. In Graphs 1 to 4, the separate items q1 and q2 are transformed to the scale from 4 to 20 to facilitate comparison.      

The data were statistically processed using the Statgraphics Plus package. For descriptive analysis of the WHOQOL-BREF questionnaire, basic statistical characteristics were used, such as the frequency count, arithmetic mean and standard deviation. To test differences in the QoL scores between dialysis patients, patients after transplantation and the general population, a t-test for the significance of the difference between the means of two independent samples was used at a significance level of 5%. To test for trend in the mean QoL scores with respect to time from initiation of dialysis/ kidney transplantation, a trend test for ordinal data was used.   

Results

Sociodemographic characteristics of patients

The group comprised a total of 199 patients with chronic kidney failure, of which 99 were dialysis patients and 100 were patients after kidney transplantation. The sociodemographic data are shown in Table 1.

Table 1. Sociodemographic characteristics patients with kindney failure

Assessment of the WHOQOL-BREF domains

Patients after kidney transplantation had significantly higher QoL scores in all domains as well as in separate items assessing the overall QoL and health than dialysis patients. When compared with the normal population, patients after kidney transplantation had significantly lower QoL only in the physical health domain (p=0.000) and the separate overall health item (p=0.006). By contrast, dialysis patients’ QoL was significantly lower in all domains and separate items as compared with the general population, the only exception being the environment domain (see Table 2).

Table 2. Comparison WHOQOL-BREF domains by dialysis patients, patients after kidney transplantation and standard population

s – standard deviation

Assessing QoL in individual items

In the physical health domain, patients with chronic kidney failure had statistically significantly lower QoL scores for pain (p<0.001), dependence on health care (p<0.001) and mobility (p<0.01) than the normal population. Patients after transplantation had worse pain and health care dependence scores than dialysis patients. On the other hand, dialysis patients reported not enough energy, greater fatigue and mobility and sleep problems.

In the psychological health domain, both dialysis patients and those after transplantation had statistically significantly lower QoL scores for negative feelings (p<0.001) and capacity for work (p<0.05). For the other items, the quality of life of patients after transplantation was similar to that of the general population. Their mean score for enjoying life (3.99) was even slightly higher than that of the normal population (3.83). Dialysis patients stated less satisfaction in all psychological health domain items.  

In the social relationships domain, the most significant difference was noted for the sex life item. Patients with chronic kidney failure were less satisfied with their sex life than the normal population (p<0.05). There was a significant difference especially in dialysis patients. The scores for personal relationships and support from friends were consistent with those in the general population.

Finally, in the environment domain, both dialysis patients and patients after transplantation were more satisfied with their physical environment, financial resources, access to information, home environment, access to health care and transport than the normal population. The results are shown in Graph 1.

Assessing QoL in individual items by gender

Although women reported more frequent negative feelings, they were more satisfied with the meaning of life, concentration, security and capacity for work than men. Moreover, women were more satisfied with themselves, personal relationships, sex life and support from friends, as seen from Graph 2. As for the domains, women had statistically significantly higher QoL scores for the social relationships domain than men (p=0.030). There were no statistically significant differences in the other domains. 

Assessing QoL with respect to the time from transplantation/ initiation of dialysis

There were no significant changes in patients’ quality of life between individual periods of time following transplantation, the only exception being the physical health domain. In this domain, QoL scores slightly increased over individual time periods. By contrast, dialysis patients were found to have mildly decreasing mean QoL scores with increasing duration of their dialysis program in all the WHOQOL-BREF domains. (see Table 3)  

Table 3. Assessing QoL according to the time from transplantation/ initiation of dialysis

*a trend test for ordinal data, s – standard deviation, n.s. – no significant  

Discussion

Chronic diseases and therapy itself mean a significant change in life, being a burden not only for patients but also for those around them. The above results suggest that the presence of chronic kidney disease is not the crucial factor for decreased QoL in the environment domain in which our patients had significantly better scores than the normal population. There were better scores for physical environment, home environment, transport, access to health care and information and, surprisingly, financial resources. Similar results were also reported by Dragomírecká and Bartoňová (7), Bužgová et al. (21) and Coelho-Marques et al. (13).

Patients with chronic kidney failure and treated by dialysis perceived that therapy had a negative impact on their QoL. Dialysis patients had significantly worse scores for all WHOQOL-BREF domains than patients after transplantation and the general population (with the exception of environment). Similarly, Sathvik et al. (22) when comparing QoL of dialysis patients with that in the normal population found significantly lower patients’ QoL in the physical health, psychological health and social relationships domains. Bužgová et al. (21) reported lower scores only in the physical health domain and two separate items rating the overall QoL and health status.

Significantly better QoL scores were observed in patients after kidney transplantation. When compared with the normal population, they only showed decreased QoL in the physical health domain and overall health status. Lee et al.23 stated that despite the overall benefit of kidney transplantation for all studied parameters, these patients did not achieve the same QoL in the physical health domain as the general population. Similar results were published in a study by Sathvik et al. (22) who found significantly higher QoL scores in patients after transplantation for all WHOQOL-BREF domains with the exception of physical health. This was probably due to the patients’ belief in considering successful kidney transplantation as a panacea. Many authors compared QoL of dialysis patients and those after kidney transplantation (11, 15, 16, 22, 24-29). They were consistent in finding higher QoL scores for all the studied parameters in patients after kidney transplantation as compared with individuals undergoing dialysis therapy.

The more optimistic assessment of QoL of patients after kidney transplantation as compared with dialysis patients is also apparent from QoL scores with respect to the length of therapy. Patients after transplantation were found to have increasing mean QoL scores in the physical health domain. In dialysis patients, on the other hand, QoL in all the domains was gradually perceived as worse. According to Hilbrands et al. (29) QoL scores in patients after kidney transplantation in both physical and psychosocial dimensions improved continuously and were identical to those in the general population 12 months after transplantation. Ginieri-Coccossis et al. (30) studied QoL in dialysis patients in terms of length of treatment. In accordance with our results, they found lower QoL in all WHOQOL-BREF domains 4 years after dialysis therapy, particularly in haemodialysis patients as compared with peritoneal dialysis patients.

Despite significantly higher QoL scores for all domains in patients after kidney transplantation in our study, they had lower scores for the physical pain, dependence on health care and negative feelings items than dialysis patients. Gulášová (31) thinks that in these patients, the psychological domain may be dominated by frequent anxiety about the transplanted kidney since its failure means that they would have to restart dialysis. Further, there are changes in experiencing, behaviour, interests and life values. Things considered non-essential by healthy individuals are at the top of the hierarchy of values in patients’ quality of life. According to Kong and Molassiotis (32), the main stressors in patients after transplantation are uncertainty about the future, compliance with and side-effects of medication and fear of infection.                      

In our study, patients after transplantation were significantly more satisfied with their capacity to work than dialysis patients. Evans et al. (11) reported differences in the capacity to work, with 75% of kidney transplant recipients being able to work as compared with only 25% of patients undergoing analysis.

In the social relationships domain, patients with kidney failure had similar scores for support from friends and personal relationships to that of the general population. The hypothesis that dialysis patients become isolated and have increasingly fewer friends was not confirmed (31). However, patients with kidney failure, especially if treated by dialysis, were less satisfied with their sex life. According to Coelho-Marques et al. (13), female patients undergoing dialysis were significantly more sexually dysfunctional than healthy women.

When comparing the scores of men and women with kidney failure, there was a significant difference only in the social relationships domain. In our study, women had higher QoL scores in this domain than men. This phenomenon may be associated with the social roles of males in the family and society. Bužgová et al. (21), reported significantly higher QoL scores in women not only in the social relationships domain but also in physical health when compared with men. By contrast, Sathvik et al. (22) found lower QoL scores in women with kidney failure in the psychological health and environment domains as compared with men. The authors assumed that female patients felt that they were a burden to their families and were much more apprehensive about their bodily image and appearance than males.     

Conclusion

The results of this survey confirmed the previous studies on the topic. It showed significantly better perception of QoL in patients after kidney transplantation than in dialysis patients. Lower scores were stated by patients after transplantation only in the physical health domain. However, QoL in this domain slightly increased with time after transplantation. Information about QoL of patients with renal failure treated by different approaches may help both doctors and patients and their families when making decisions about therapy selection.