Peritoneal dialysis and health-related quality of life

Research has shown that patients on dialysis rate their health-rated quality of life (HRQOL) much lower than the general population.1,2 This is a concern, as diminished HRQOL is associated with increased risks of morbidity and mortality.3 While those using peritoneal dialysis (PD) reported their HRQOL as much higher than patients receiving conventional in-center hemodialysis (IHD),4 frequent hospitalizations and administering daily treatments can increase the burden of therapy, impacting patients and care partners alike.2,5

Factors associated with greater quality of life (QOL) in PD patients

PD has been associated with greater HRQOL during the initial period after dialysis and for up to two years as compared to IHD, even after adjusting for clinical and socioeconomic characteristics.8

  • Scores of three clinical domains (effects of kidney disease, burden of kidney disease, and dialysis staff encouragement) and two socioeconomic domains (sexual function and dialysis staff encouragement) were higher in patients on PD compared with those on IHD at one and two years after dialysis initiation.8
  • Patients with stage 5 chronic kidney disease or ESRD treated with PD had better general HRQOL than IHD patients, specifically in subdomains of physical functioning, role limitations due to emotional problems, side effects, and burden of kidney disease.9
  • A separate analysis of modified kidney disease QOL survey data showed that although PD patients experienced identical dialysis-related symptoms as IHD patients, they were to a lesser degree.4 Highly affecting parameters were the ability to continue work or studies, fewer disruptions of life plans, and the will to live.4

Factors associated with diminished QOL in PD patients

Initiation of renal replacement therapy has a strong impact on HRQOL in comparison with other stages of chronic kidney disease.10

  • Emotional aspects of HRQOL were significantly associated with heightened states of anxiety (26.6%) and depression (27%).10
  • Lower physical role scores were significantly and independently associated with lower emotional role, energy fatigue, and social function scores.10

Chronic fluid overload, inflammation, malnutrition, and multimorbidity (commonly, cardiovascular disease and diabetes mellitus) are common factors negatively affecting PD patients’ HRQOL and increasing their risk of death.11-14

  • Overhydration was independently associated with lower physical component (PCS) and mental component scores (MCS), and kidney disease component scores.8,15
  • Lower HRQOL was significantly associated with lower serum albumin and sodium levels, higher BMI, and lower subjective global assessment.12,16,17

The most affected QOL dimensions were effects of the disease, burden of the disease, occupational status, sleep, and satisfaction.18

More strategies are needed to reduce burden of care on patients and caregivers

Patients on dialysis often need caregiving and assistance from family members and/or others to attend hospital visits and supervise therapy administration. This places a considerable burden on caregivers, which can in turn influence their QOL.19

  • The physical component of the QOL questionnaire was negatively associated with the number of hospital admissions over the previous year and positively associated with social support.3 Lower mean scores of HRQOL physical functioning domain have been associated with increased risk of death.12,20  
  • Compared to national norms, caregivers and dialysis patients tended to have poor physical HRQOL but normal MCS; lower caregiver MCS revealed nearly a sevenfold correlation to dialysis duration and tenfold for burden of kidney disease.21
  • Caregivers also tended to have lower physical HRQOL if their loved one had higher social HRQOL, and lower mental health-related QOL during the early stage of the patient’s dialysis treatment and when patients experienced low disease-targeted QOL.21

Conclusion

As compared to IHD, PD patients have greater autonomy and better HRQOL. Social support is observed to be a key factor in perceived QOL. Greater symptomology corresponded to worse HRQOL and to perceiving the disease as a burden. The worse the HRQOL, particularly in PCS domains, the more a lower PCS should be considered a predictor of death. 

References

  1. Jung HY, Jang HM, Kim YW, et al. Depressive symptoms, patient satisfaction, and quality of life over time in automated and continuous ambulatory peritoneal dialysis patients. Med (United States). 2016;95(21):1-10. doi:10.1097/MD.0000000000003795
  2. Thaweethamcharoen T, Noparatayaporn P, Sritippayawan S, Aiyasanon N. Kidney Disease–Specific Scores and Health Utility of Continuous Ambulatory Peritoneal Dialysis Patients, Automated Peritoneal Dialysis Patients, and Caregivers. Value Heal Reg Issues. 2020;21:194-200. doi:10.1016/j.vhri.2019.12.001
  3. Aguiar R, Pei M, Qureshi AR, Lindholm B. Health-related quality of life in peritoneal dialysis patients: A narrative review. Semin Dial. 2019;32(5):452-462. doi:10.1111/sdi.12770
  4. Dąbrowska-Bender M, Dykowska G, Żuk W, Milewska M, Staniszewska A. The impact on quality of life of dialysis patients with renal insufficiency. Patient Prefer Adherence. 2018;12:577-583. doi:10.2147/PPA.S156356
  5. Weinhandl ED, Gilbertson DT, Collins AJ. Mortality, Hospitalization, and Technique Failure in Daily Home Hemodialysis and Matched Peritoneal Dialysis Patients: A Matched Cohort Study. Am J Kidney Dis. 2016;67(1):98-110. doi:10.1053/j.ajkd.2015.07.014
  6. Mitema D, Jaar BG. How Can We Improve the Quality of Life of Dialysis Patients? Semin Dial. 2016;29(2):93-102. doi:10.1111/sdi.12467
  7. USRDS Annual Data Report. Reference Table H.9: Annual Mortality Rates in CAPD/CCPD Patients, Adjusted for Age, Sex, Race, Ethnicity, Primary Cause of ESRD, and Patient Vintage.; 2019. www.usrds.org
  8. Jung HY, Jeon Y, Park Y, et al. Better Quality of Life of Peritoneal Dialysis compared to Hemodialysis over a Two-year Period after Dialysis Initiation. Sci Rep. 2019;9(1):1-10. doi:10.1038/s41598-019-46744-1
  9. Chuasuwan A, Chuasuwan A, Pooripussarakul S, et al. Comparisons of quality of life between patients underwent peritoneal dialysis and hemodialysis: A systematic review and meta-analysis. Health Qual Life Outcomes. 2020;18(1):1-11. doi:10.1186/s12955-020-01449-2
  10. Rebollo Rubio A, Morales Asencio JM, Eugenia Pons Raventos M. Depression, anxiety and health-related quality of life amongst patients who are starting dialysis treatment. J Ren Care. 2017;43(2):73-82. doi:10.1111/jorc.12195
  11. Zhou W, Hu W, Han G, Wang H, Zhang J, Mei C. The impact of residual renal function on quality of life in patients with peritoneal dialysis. Clin Nephrol. 2018;90(2):106-111. doi:10.5414/CN109064
  12. Pei M, Aguiar R, Pagels AA, et al. Health-related quality of life as predictor of mortality in end-stage renal disease patients: An observational study. BMC Nephrol. 2019;20(1):1-10. doi:10.1186/s12882-019-1318-x
  13. Dekker MJE, Marcelli D, Canaud BJ, et al. Impact of fluid status and inflammation and their interaction on survival: a study in an international hemodialysis patient cohort. Kidney Int. 2017;91(5):1214-1223. doi:10.1016/j.kint.2016.12.008
  14. Vrtovsnik F, Verger C, Van Biesen W, et al. The impact of volume overload on technique failure in incident peritoneal dialysis patients. Clin Kidney J. Published online 2019:1-8. doi:10.1093/ckj/sfz175
  15. Yoon HE, Kwon YJ, Song HC, et al. Overhydration negatively affects quality of life in peritoneal dialysis patients: Evidence from a prospective observational study. Int J Med Sci. 2016;13(9):683-695. doi:10.7150/ijms.16372
  16. Dudar I, Shymova A, Gonchar Y, Loboda O, Krasiuk E. Quality of life in peritoneal dialysis patients and its relationship with nutrition disorders. Ukr J Nephrol Dial. 2019;4(1(61)):45-52. doi:10.31450/ukrjnd.1(61).2019.06
  17. Günalay S, Oztürk YK, Akar H, Mergen H. The relationship between malnutrition and quality of life in haemodialysis and peritoneal dialysis patients. Rev Assoc Med Bras. 2018;64(9):845-852. doi:10.1590/1806-9282.64.09.845
  18. Sitjar-Suñer M, Suñer-Soler R, Masià-Plana A, Chirveches-Pérez E, Bertran-Noguer C, Fuentes-Pumarola C. Quality of life and social support of people on peritoneal dialysis: Mixed methods research. Int J Environ Res Public Health. 2020;17(12):1-15. doi:10.3390/ijerph17124240
  19. Kang A, Yu Z, Foo M, Chan CM, Griva K. Evaluating burden and quality of life among caregivers of patients receiving peritoneal dialysis. Perit Dial Int. 2019;39(2):176-180. doi:10.3747/pdi.2018.00049
  20. de Oliveira MP, Haas VJ, Ribeiro RDCHM, de Oliveira Oller GASA, de Oliveira Oller GASA. Health-related quality of life as a predictor of mortality in patients on peritoneal dialysis. Rev Lat Am Enfermagem. 2016;24. doi:10.1590/1518-8345.0786.2687
  21. Nagasawa H, Sugita I, Tachi T, et al. The relationship between dialysis patients’ quality of life and caregivers’ quality of life. Front Pharmacol. 2018;9(JUL):1-10. doi:10.3389/fphar.2018.00770