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ABSTRACT
Little is known about the quality of life and survival in the patients on maintenance hemodialysis (HD) in India. Poor nutrition
and dialysis noncompliance is common. This study investigates the factors that affect the quality of life (QoL) in HD patients in
India. This cross-sectional study included 78 patients on HD for two months. Demographic, nutritional, functional subjective
global assessment and Kidney Disease Quality of Life (KDQOL-36) assessments were done. Predictors of QoL were assessed
by regression analysis. The mean calorie and protein intake were 1245116.9 kcal and 0.860.19 g/kg/day respectively. Male
gender (OR=9.68), serum parathyroid hormone PTH <150 pg/ml (OR=0.03), age 65 years (OR=1.25), no catheter use
(OR=1.9) and hospitalizations (OR=0.11), were independent predictors of total score 50. Independent predictors of physical
component summary (PCS) >25 were male gender (OR=5.06) and urine output at start of dialysis (OR=1.05). Independent
predictors of mental component summary (MCS) 25 were male gender (OR=11.02), serum PTH>150 pg/ml (OR=0.15),
daily protein intake of >0.8 g/kg and caloric intake >20 K.cal/kg (OR=10.8). Patients with urine output >1 liter per day had more
hypotensive episodes during dialysis (r=0.56, P=0.045), more headaches (r=0.63, P=0.006) but that did not affect the PCS
significantly. Low PTH (<150 pg/ml) (OR=1.29), multiple access failures (OR=3.36) and total score 50 (OR=0.09) were
independently associated with increased hospitalization. Males, patients with serum PTH >150 pg/ml and those not on catheter
had better total score. Though patients with higher urine output had better PCS, those with output >1 liter had higher incidence
of hypotension and dialysis-related headache. Protein-energy malnutrition affected the MCS significantly. Dialysis noncompliance
seen in one-fourth of the population did not affect the scores significantly.
Key words: Hemodialysis, kidney disease quality of life-36, malnutrition, noncompliance, quality of life
Introduction
The average incidence of chronic kidney disease Stage5
(CKD5) in developing countries is 150 per million
population, an incidence lower compared to the developed
nations.[1] In India, an estimated 100-220 per million
population reach CKD5 and approximately 10% of these
Address for correspondence:
Dr. Ilangovan Veerappan, Assistant Professor, Department of Nephrology,
Pondicherry Institute of Medical Sciences, Ganapathichettikulam,
Village No. 20, Kalapet, Puducherry 605 014, India.
E-mail: ilangovanv@gmail.com
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Website:
www.indianjnephrol.org
DOI:
10.4103/0971-4065.91185
18
Results
Of the 131 patients studied [Figure1], the mean age was
52.3513.53 years and 77% were males [Table1] and the
mean duration of dialysis was 14.314.3 (median=12,
range 2-60) months. The commonest cause of CKD was
diabetic nephropathy (53.4%). Final analysis included 91
patients as 24 did not give consent for the study and 16
patients were excluded after applying the exclusion criteria.
The baseline parameters were comparable in the patient
population that was studied and those that were excluded
[Table1]. For the QoL analysis 78 patients were eligible.
Twenty four refused consent, 16 had atleast on exclusion
criteria, two patients had severe dementia, five patients
did not have a qualified medical translator and six patients
did not complete the KDQOL-36 questionnaire [Figure1].
The dialysis prescription was empiric and the frequency
of dialysis varied between less than once weekly to thrice
weekly (once weekly or less eight, twice weekly 80 and
thrice weekly 43 patients). Nineteen patients (24.4%)
were noncompliant with regard to frequency or duration
of dialysis. We defined noncompliance as skipping one or
more HD sessions in a month or shortening by 10 or more
min one or more HD sessions in a month. Over the period
of three months six patients died, four left for another
center and four had live related renal transplantation.
The mean calorie intake on a non-dialysis day was
1245116.9 kcal calculated by recall technique. The
estimated daily protein intake was 0.860.19 g/kg/day
as calculated by PNA. The mean serum albumin was
3.520.43 g/dl and 24.4% had serum albumin less than
3.5 g/dl [Table1].
19
Age (Years)
Sex (M/F)
Diabetes mellitus (Pre-dialysis)
Diabetic nephropathy
PTH (pg/ml)
Sr. calcium (mg/dl)
Sr. calalb (mg/dl)
Sr. phosphorus (mg/dl)
Sr. albumin (g/dl)
Calorie intake (Kcal/day)
PNA (g/kg/day)
Phosphate binder use
Vitamin D use
Kt/V (n=103),
Dialysis duration
Dialysis noncompliance
Hospitalizations (per year)
PCS score
MCS score
SGA (A/B/C)
All patients
(n=131)
Patients included
(n=78)
Patients excluded
(n=53)
55.312.8
62 (79.5%)/16 (20.5%)
46 (59%)
40 (57.1%)
223.7185.6
51.1 13.8
39 (73.6%)/14 (26.4%)
30 (56.6%)
30 (42.9%)
187.9185.1
NS
NS
NS
8.60.7
9.090.8
6.00.2
3.50.49
1245 116.9 (800 1750)
0.860.19 (0.44 1.2)
65 (83.3%)
22 (28.2%)
1.250.2
15.114.4
19 (24.4%)
1.331.2 (0 4)
36.2912.25 (19.3 75)
33.294.91 (18.2 50.3)
17/112/2
8.60.8
9.080.9
5.61.8
3.540.55
Not done
Not done
42 (79. 2%)
16 (30.1%)
1.310.3
14.613.1
Not done
Not done
Not done
Not done
Not done
NS
NS
NS
NS
NA
NA
NS
NS
NS
NS
NA
NA
NA
NA
NS
PNA=Protein nitrogen appearance; KT/V=Measure of dialysis adequacy; PCS Score=Physical component summary score; MCS Score=Mental component
summary score; Calalb=Serum calcium corrected for serum albumin; SGA=Subjective global assessment. KT/V was calculated for 103 patients. Of the remaining
28 patients, 20 were on irregular schedules and eight were on once weekly. NS=Not significant; NA=Not applicable
Clinical characteristics
Age (years)
>65 (ref)
65
Gender
Male (ref)
Female
Kidney disease
Diabetic nephropathy
(ref)
Unknown
Chronic
Glomerulonephritis
Renal calculi disease
Current urine output (ml)
<1000 (ref)
>1000
Hospitalization
1
Nil (ref)
Nutrition
PNA (g/day)
0.8 (ref)
>0.8
Calorie intake (Kcal/kg/
day)
<20 (ref)
20
Sr. Albumin (g/dl)
< 3.5 (ref)
3.5
Blood biochemistry
Hemoglobin (g/dl)
< 8 (ref)
8-11
11-13
Sr. PTH (pg/ml)
>300
150-300
<150 (ref)
Sr. calcium (mg/dl)
<8
8-10
>10 (ref)
Physical
Mental
component component
summary
summary
Total score
2526.9
38.522.3a
25.56.2
34.99.2c
43.712.3
55.710.6c
38.223.7
28.618.6a
35.39.1
25.25.3c
55.611.8
46.18.3b
33.222.4
33.68.9
52.111.7
35.625
37.512.2
34.710.1
24.65
55.711.9
49.37.8
39.627.6
26.26.1
46.65.1
40.226.2
27.18.5a
32.410.4
35.75.8
5511.9
55.67.3
30.224.3
42.421.2a
32.99.3
33.79.6
50.713.1
56.89.4a
38.421.8
35.226.5
35.19.9
3310
55.911.6
52.712.9
39.626.6
39.420.3
34.611.3
32.89.7
53.813.3
56.28.9
39.225.9
3522.4
32.89.1
33.59.6
55.110.6
53.212.3
27.318.6
38.423 a
755c,*
35.110.5
33.28.2
30.714.4
50.812.2
54.711.4
80.55.9b
33.410.6
33.99.4
27.36.1
55.813.4
53.611.9
52.39.8
Contd...
Physical
Mental
component component
summary
summary
Total score
39.322
33.622
32.89.7
33.89.2
54.611.3
52.912.2
37.522
39.228.5
31.819.8
36.59.7
32.29.3
30.38.1a,*
56.111.5
53.313.2
51.110.5
21.316.8
39.426.6
38.619.3a
5521.4c,*
31.29.1
348.9
34.710.5
33.18.9
46.610.4
55.213
55.511.3a
61.24.5c,*
31.319.5
42.925.8b
4525.8c
21.914.6
34.24.4
3410.4
28.35.9
31.24.4
53.111.6
55.612.9
56.59.9c
46.59.7
37.115.2
27.114.1a
33.99.3
26.98.4
54.311.8
47.39.7
32.422
42.424.8
3510
30.67.8a
52.812.2
55.310.9
36.123.5
37.525
339.2
3611
53.311.9
57.310.8
43.521.6
23.621.4c
34.79.8
30.88.1
57.39.6
47.412.7c
37.124
41.124.2
33.17.1
34.713
50.111.1
56.99.8
4221.6
31.324.1a
33.79.4
339.5
56.710.28
51.112.6a
3823.3
31.923.7
34.28.7
30.810.8
54.511.5
51.512.3
37.125
35.622.4
328.6
34.310
52.812.2
54.411.4
=P < 0.05 > 0.005, b=P < 0.005 > 0.001, c=P<0.001. *=P<0.05 after
Bonferroni correction ref=reference variable used in analysis; PNA=Protein
Nitrogen Appearance; Sp Kt/V=Single Pool Kt/V; IDWG=Inter-Dialytic
Weight Gain
a
21
Discussion
There is limited information available on the QoL in
Table3: Predictors of total score KDQOL-36
Age65 years
Male gender
Dialysis duration
Serum PTH<150 ng/ml
Current catheter use
Serum calcium (Alb)
Urine output_start
Hospitalization
Dialysis noncompliance
IDWG
Serum albumin>3.5 mg/dl
Travel time
Transfusion requirement
Multiple access failures
Dry body weight
Odds
ratio
Confidence
interval
1.25
9.68
0.16
0.03
1.9
0.80
1.001
0.11
3.27
0.67
2.33
1.01
0.77
4.53
1.04
1.11 1.89
1.56 56.6
0.015 1.66
0.002 0.48
1.23 2.1
0.21 3.05
0.99 1.003
0.012 1.019
0.46 22.79
0.35 1.27
0.42 12.96
0.98 1.044
0.58 1.039
0.45 45.20
0.97 1.12
0.027
0.021
0.12
0.013
0.002
0.74
0.32
0.05
0.23
0.22
0.33
0.25
0.08
0.19
0.20
Dialysis duration
Serum PTH<150 pg/ml
Serum calcium (Alb)
Calcitriol use
Cal. PNA
Urine output_start
Any hospitalization
Male gender
Dialysis noncompliance
IDWG
Odds
ratio
Confidence
interval
0.32
0.99
1.02
1.72
3.86
1.05
0.48
5.06
0.90
0.73
0.07 1.37
0.24 4.07
0.42 2.51
0.35 8.33
0.54 27.44
1.00 1.2
0.10 2.21
2.04 32.48
0.16 4.95
0.50 1.07
0.13
0.99
0.95
0.49
0.17
0.027
0.35
0.008
0.91
0.11
22
Hospitalization
Serum albumin>3.5 mg/dl
Age65
Calorie intake (Kcal/Kg/Day)
Cal. PNA
Male gender
Travel cost
Urine output_start
Dialysis noncompliance
Serum PTH<150 ng/ml
Odds
ratio
Confidence
interval
0.34
1.71
2.62
1.15
10.80
11.02
0.99
1.00
1.32
0.15
0.06 1.93
0.21 13.5
0.28 24.1
0.96 1.39
1.13 102.5
1.04 116.6
0.99 1.0
0.99 1.002
0.19 9.09
0.02 0. 93
0.22
0.61
0.39
0.11
0.038
0.046
0.057
0.99
0.77
0.042
Cal. PNA=Nutrition intake with at least >20 Kcal/kg of calories and >0.8 g/kg
of protein; Urine output_start=Urine output at start of dialysis
Odds ratio
95% CI
NS
NS
1.29
3.36
NS
NS
0.09
0.02, 1.11
0.99, 1.0
1.1, 2.3
1.88, 6.01
0.66, 1.01
0.82, 1.23
0.02, 0.43
0.06
0.56
0.046
0.001
0.11
0.34
0.03
Age, serum PTH <150 pg/ml, current urine output, multiple access failures,
lower body weight, IDWG >5 % of body weight, total score 50 with P value
<0.2 by univariate analysis were included in the multivariate regression model
Correlation r
0.56
0.63
0.045
0.006
0.271
0.249
0.234
0.014
0.458
0.466
0-099
0.195
0.021
0.253
0.101
0.097
0.244
0.183
0.2
0.016
0.028
0.04
0.9
<0.001
<0.001
0.389
0.088
0.86
0.025
0.508
0.398
0.031
0.108
0.079
0.184
0.27
0.107
0.017
0.368
0.181
0.111
0.049
0.097
0.103
0.001
0.113
0.335
0.681
0.398
0.37
23
Conclusion
All the five subscales of KDQOL SF-36 were worse in
females. Patients with serum PTH>150 pg/ml and not
on catheter had a better total score. Though patients with
higher urine output had better PCS, those with output>1
liter had higher incidence of hypotension and dialysisrelated headache. Protein-energy malnutrition is rampant
is our cohort and it affected the MCS significantly. Dialysis
noncompliance seen in one-fourth of the population did
not affect the scores significantly.
References
1.
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Indian Journal of Nephrology
25
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