Health-related quality of life in endstage renal failure

Psychometric properties of the Arabic version of the hospital anxiety and depression scale in hemodialysis patients

The literature lacks a rigorous psychometric evaluation of the Arabic version of Hospital Anxiety and Depression Scale (HADS) in hemodialysis (HD) patients. This study aims to evaluate reliability, determine the underlying factor structure of the Arabic version of HADS and assess its suitability as screening tool for depression and anxiety among Arabic HD patients.A sample of 370 HD patients were recruited from all health districts in Kuwait. Reliability for HADS (all items) and its subscales HADS-A (anxiety) and HADS-D (depression) were estimated using Cronbach's alpha and item analysis was conducted. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted to extract and test the factor structure for the Arabic version of HADS. Eight models were tested using CFA to determine goodness-of-fit.The Cronbach α for the Arabic HADS (all items), HADS-A and HADS-D were 0.884, 0.852 and 0.764, respectively. Pearson correlation coefficient between HADS-A and HADS-D subscales indicated significant correlation (r = +0.69, PV < 0.001). EFA indicated two factors with eigenvalues >1, which accounted for 48.5% of the total variance. CFA revealed the one-factor model had the poorest fit, the two-factor models with acceptable fit, and three-factor models showed good fit.The Arabic HADS has good reliability and internal consistency, which warrants its use in screening for anxiety and depression among Arabic HD patients. Furthermore, the three-factor structure has shown a better fit which warrants further exploration in HD patients with the advancement in theory of psychological models for anxiety and depression.

Analysis of influencing factors on quality of life in patients with chronic kidney disease undergoing maintenance haemodialysis

Objective

To investigate and analyse the quality of life (QoL) of patients with chronic kidney disease (CKD) undergoing maintenance haemodialysis (MHD), explore influencing factors and provide a basis for formulating corresponding intervention measures.

Methods

A cross-sectional study was conducted on 190 patients with CKD undergoing MHD in hospital between March 2021 and March 2022. A general information questionnaire and the Kidney Disease Quality of Life Short Form were used to collect data. The QoL scores of patients with CKD undergoing MHD were calculated and compared by t-test and analysis of variance. Pearson correlation analysis was used to analyse the correlation between QoL scores and related factors. Stepwise multiple linear regression analysis was used to screen the influencing factors of QoL.

Results

The total score of QoL of patients with CKD undergoing MHD was 59.32 ± 11.67, and the scores of physical component summary, mental component summary and kidney disease component summary were 50.21 ± 9.32, 48.76 ± 10.81 and 66.34 ± 12.76, respectively. The QoL scores of patients with CKD undergoing MHD were significantly different in age, education level, marital status, employment status, monthly income, dialysis frequency, dialysis duration and complications (p < 0.05). The QoL scores were positively correlated with education level, monthly income and dialysis frequency, and negatively correlated with age, dialysis duration and blood phosphorus level (p < 0.05). Stepwise multiple linear regression analysis showed that age, education level, employment status, dialysis frequency, dialysis duration and blood phosphorus level were the main influencing factors of QoL (p < 0.05).

Conclusion

The QoL of patients with CKD undergoing MHD is low, and it is affected by multiple factors. We suggest that healthcare workers should pay attention to the physical and mental health of patients with CKD undergoing MHD, provide individualised and comprehensive nursing interventions and improve their QoL.

Anxiety-depression levels and coping strategies among renal transplant waitlisted and non-waitlisted hemodialysis patients

Background/Aim: Although hemodialysis provides prolonged survival, patients face major challenges, including conflicts about life decisions, limited physical, mental, and lifestyle activities, psychological distress, high prevalence of anxiety and depression symptoms, and compromised health-related quality of life. This study aimed to compare anxiety-depression levels and coping strategies between renal transplant waitlisted and non-waitlisted hemodialysis patients. Methods: A total of 75 hemodialysis patients were enrolled in this case-control analytical study, including renal transplant waitlisted (n = 35) and non-waitlisted (n = 40) patients. Patients were asked to fill out a questionnaire including socio-demographic characteristics, duration of hemodialysis, the Hospital Anxiety and Depression Scale, and the Ways of Coping Questionnaire. Comparative analyses were performed via Student's t-test and Pearson Correlation test. Results: The mean age was 57.1 (15.3) years; 56% were males, and being under hemodialysis treatment was 7.3 (5.9) years. Waitlisted and non-waitlisted patients were matched. Overall, 28 patients (37.3%) had anxiety, and 34 patients (45.3%) had depression. There was no significant difference between the two groups regarding depression scores. Anxiety was more common among non-waitlisted than waitlisted patients (P = 0.043). The fatalistic approach was the most common coping strategy applied, and there was a significant negative correlation between anxiety scores and the problem-solving approach (P = 0.034) and a significant positive correlation between depression scores and the helplessness approach (r = 0.234, P = 0.043). Conclusion: Both waitlisted and non-waitlisted hemodialysis patients have significantly higher levels of depression, with anxiety being higher in non-waitlisted patients. Since coping strategies differed concerning anxiety and depression but not transplant candidacy, psychiatric evaluation and counseling would be essential in hemodialysis patients to control the stressors.

Psychological Well-Being of Living Kidney Donors and Recipients

OBJECTIVES

Previous research has indicated that kidney transplantation is associated with longer and better quality of life and can also have psychological impacts to both recipients and living donors. This study aimed to examine the psychological well-being of kidney transplant recipients and living donors in the first Ethiopian kidney transplant program using a psychological well-being framework developed by Ryff.

MATERIALS AND METHODS

All 82 kidney recipients and living donors who underwent medical screening for transplantation or living donation at the St. Paul's Hospital Millennium Medical Transplant Center between the establishment of the Center (September 2015)and the data collection end date (December 2018) were selected using medical records. Seventyfive recipients and 64 donors participated in the study. This study used a cross-sectional study design. Demographic questionnaires and Ryff's 84-item psychological well-being assessment were used. Collected data were analyzed through frequency, percentages, means, t tests, and analyses of variance.

RESULTS

Approximately 83% of study recipients scored in the upper 3 quartiles for composite psychological well-being scores, and 50% of study donors scored in the middle 2 quartiles for composite psychological well-being scores, with roughly 20% in the highest quartile. We found no significant mean difference between recipient and donor subscales, excluding the Personal Growth Subscale, which showed a significant mean difference between recipients (mean [SD] of 69.01[8.39]) and donors (mean [SD] of 65.89 [8.84]). This study revealed no significant psychological mean differences between kidney recipients and donors regarding the demographic characteristics of sex, age, marital status, and education.

CONCLUSIONS

Our single-center study cohort of kidney transplant recipients and living donors revealed overall psychological well-being scores similar to established transplant centers in other countries. Psychological well-being subscore data can provide meaningful information about the experiences of recipients and donors.

Effectiveness of a Breathing Training Program on Quality of Life in Patients with Predialysis Chronic Kidney Disease: A Randomized Controlled Trial

Context:

Chronic kidney disease (CKD) patients have suboptimal quality of life (QOL). Various studies/researches have revealed that breathing exercises have a positive and favorable impact on different systems of the body.

Aims:

This study aims to assess the effect of a breathing training program on QOL in patients with predialysis CKD.

Settings:

The study was a single-center study conducted at PGIMER, Chandigarh.

Design:

Randomized controlled trial.

Methods:

Sixty individuals were enrolled and randomized using lottery method. QOL was assessed or evaluated by Kidney Disease and QOL questionnaire (KDQOL™-36). Breathing exercises were taught to the intervention group. Patients included in control group continued with the routine care. Assessment of QOL was done after 4 weeks in both the groups.

Results:

Change in KDQOL™-36 scores showed significant difference between control and the intervention group. The mean scores of control group in the subscale effects of kidney disease, SF-12 Physical functioning (Physical Health Composite) and SF-12 Mental functioning (Mental Health Composite) were 84.79, 39.16 and 37.40, respectively, whereas in intervention group, the respective mean scores were 91.88, 43.92, and 44.16. The difference was statistically significant (P = 0.04, P = 0.01, and P = 0.003, respectively).

Conclusions:

Breathing training program improves QOL in patients with predialysis CKD.

Quality of Life in Predialysis End-Stage Renal Disease Patients at the Initiation of Dialysis Therapy

Objective

To assess health-related quality of life (QL) in a group of Dutch predialysis end-stage renal disease (ESRD) patients prior to the initiation of dialysis, and to compare QL between patients with different intended initial dialysis treatments.

Design

In a prospective cohort study, demographic, clinical, and QL data were obtained from Dutch adult patients who were consecutively enrolled from 27 different centers 0 – 4 weeks prior to the beginning of their chronic dialysis treatment.

Patients

Of the 301 patients who completed the QL questionnaires (of a possible 337 enrolled patients), 152 intended to start with hemodialysis (pre-HD) and 149 patients with peritoneal dialysis (pre-PD).

Main Outcome Measure

Perceived QL of pre-HD and pre-PD patients. Quality of life was assessed with two generic health assessment instruments: the SF-36 and the EuroQol.

Results

After correction for group differences, pre-HD patients scored consistently, but not significantly, lower for all separate dimensions of the SF-36 and the overall health score of the EuroQol compared to pre-PD patients. However, analyzing the dimensions of the SF-36 together, adjusted for case-mix, pre-HD patients scored significantly lower than pre-PD patients. Mean difference was 6.5 points ( p = 0.04).

Conclusion

Multivariate adjustment for known case-mix differences at the start of dialysis therapy was not sufficient to adjust for all patient selection effects on QL. Consequently, published QL comparisons between HD and PD in nonrandomized cohort studies should be interpreted with caution. Assessment of QL just before start of dialysis therapy and subsequent adjustment for baseline values may be the only valid alternative for randomized studies.

Twelve weeks of supervised exercise improves self-reported symptom burden and fatigue in chronic kidney disease: a secondary analysis of the 'ExTra CKD' trial

Background

Chronic kidney disease (CKD) patients experience a high symptom burden including fatigue, sleep difficulties, muscle weakness and pain. These symptoms reduce levels of physical function (PF) and activity, and contribute to poor health-related quality of life (HRQoL). Despite the gathering evidence of positive physiological changes following exercise in CKD, there is limited evidence on its effect on self-reported symptom burden, fatigue, HRQoL and physical activity.

Methods

Thirty-six patients [mean ± SD 61.6 ± 11.8 years, 22 (61%) females, estimated glomerular filtration rate: 25.5 ± 7.8 mL/min/1.73 m²] not requiring renal replacement therapy underwent 12 weeks (3 times/week) of supervised aerobic exercise (AE), or a combination (CE) of AE plus resistance training. Outcomes included self-reported symptom burden, fatigue, HRQoL and physical activity.

Results

Exercise reduced the total number of symptoms reported by 17% and had favourable effects on fatigue in both groups. AE reduced the frequency of ‘itching’, ‘impotence’ and ‘shortness of breath’ symptoms, and the intrusiveness for symptoms of ‘sleep disturbance’, ‘loss of muscular strength/power’, ‘muscle spasm/stiffness’ and ‘restless legs’. The addition of resistance exercise in the CE group saw a reduction in ‘loss of muscular strength/power’. No changes were seen in subjective PF or physical activity levels. AE increased self-efficacy for physical activity.

Conclusions

Supervised exercise had favourable effects on symptom frequency and intrusiveness, including substantial improvements in fatigue. Although the intervention did not improve self-reported physical activity levels, AE increased patients’ self-efficacy for physical activity. These favourable changes in self-reported outcomes support the important role of exercise in CKD.

Economic Evaluation of Kidney Transplantation versus Hemodialysis in Patients with End-Stage Renal Disease in Hungary

Background—

Kidney transplantation is generally acknowledged as the more clinically effective and more cost-effective option in managing patients with end-stage renal disease, compared with dialysis. This study looked for confirmatory evidence in a Hungarian population.

Methods—

Patients (n = 242) with end-stage renal disease who received cadaveric kidney transplantation during 1994 were followed up for 3 years. They were compared with patients (n = 840) receiving hemodialysis who were on a waiting list for transplantation. Data were collected retrospectively. Treatments were compared for clinical efficacy and for cost-effectiveness.

Results—

At month 36, the standard mortality hazard function was 3.5 times higher in the group receiving hemodialysis ( P<.0001) than in the transplant recipients. Average treatment costs per patient over the 3 years were also significantly higher ( P<.0001) in the hemodialysis group than in the group that received transplants. The cost of 1 year gained by transplantation was significantly less ( P<.0001) than the cost associated with hemodialysis.

Conclusions—

Compared with hemodialysis, kidney transplantation provides greater survival benefits to patients with end-stage renal disease, at less cost.

Health-related quality of life assessment in end-stage renal failure

End-stage renal failure (ESRF) is a life-threatening condition and survival can be maintained only with renal replacement therapy. Furthermore, the complications of ESRF, its treatment and co-existing diseases have been found to have a significant impact on the physical health of patients. It is well documented that the health status of the renal patient population is worse than that of the general healthy population; for this reason the assessment of quality of life of ESRF patients has received considerable attention.

During the 1990s, the focus of health assessment moved away from the disease itself towards health status and wellbeing. The widespread use of the 36-item short-form (SF-36) questionnaire has promoted this. In ESRF studies from data using the SF-36 questionnaire it has been shown that it is the physical functional component of health that is most affected by the patient's condition, with co-morbidity having a significant impact.

There is growing consensus that health-related quality of life is more than just an assessment of health status. Rather, it is the relative importance given by the individuals themselves to the impact of the disease on their life. While this approach is emerging, some of the tools which have been developed to measure individualised quality of life require further scientific validation for use with the ESRF population.

Reduction of carbamylated albumin by extended hemodialysis

Introduction Among conventional hemodialysis (CHD) patients, carbamylated serum albumin (C-Alb) correlates with urea and amino acid deficiencies and is associated with mortality. We postulated that reduction of C-Alb by intensive HD may correlate with improvements in protein metabolism and cardiac function. Methods One-year observational study of in-center nocturnal extended hemodialysis (EHD) patients and CHD control subjects. Thirty-three patients receiving 4-hour CHD who converted to 8-hour EHD were enrolled, along with 20 controls on CHD. Serum C-Alb, biochemistries, and cardiac MRI parameters were measured before and after 12 months of EHD. Findings EHD was associated with reduction of C-Alb (average EHD change -3.20 mmol/mol [95% CI -4.23, -2.17] compared to +0.21 [95% CI -1.11, 1.54] change in CHD controls, P < 0.001). EHD was also associated with increases in average essential amino acids (in standardized units) compared to CHD (+0.38 [0.08, 0.68 95%CI]) vs. -0.12 [-0.50, 0.27, 95% CI], P = 0.047). Subjects who reduced C-Alb more than 25% were found to have reduced left ventricular mass, increased urea reduction ratio, and increased serum albumin compared to nonresponders, and % change in C-Alb significantly correlated with % change in left ventricular mass. Discussion EHD was associated with reduction of C-Alb as compared to CHD, and reduction of C-Alb by EHD correlates with reduction of urea. Additional studies are needed to test whether reduction of C-Alb by EHD also correlates with improved clinical outcomes.

Risk of major depression in patients with chronic renal failure on different treatment modalities: A matched-cohort and population-based study in Taiwan

The influence of different treatment modalities on the risk of developing major depression in patients with chronic renal failure (CRF) is not well understood. We aimed to explore the incidence of major depression among patients with CRF who were on different dialysis modalities, who had received renal transplantation (RT), and those who had not yet received any of the aforementioned renal replacement therapies. We conducted a population-based retrospective cohort study using a national health insurance research database. This study investigated 89,336 study controls, 17,889 patients with chronic kidney disease on conservative treatment, 3823 patients on hemodialysis (HD), 351 patients on peritoneal dialysis (PD), and 322 patients who had RT. We followed all individuals until the occurrence of major depression or the date of loss to follow-up. The PD group had the highest risk (hazard ratio [HR] 2.43; 95% confidence interval [CI] 1.26-4.69), whereas the RT group had the lowest risk (HR 0.18; 95% CI 0.03-1.29) of developing major depression compared with the control group. Patients initiated on PD had a higher risk of developing major depression than patients initiated on HD (pairwise comparison: HR 2.20; 95% CI 1.09-4.46). Different treatment modalities are associated with different risks of developing major depression in patients with CRF. Among renal replacement therapies, patients who have had RT have the lowest risk of developing major depression. Patients who initiate renal therapy on PD may have a higher risk of major depression compared with patients who initiate renal therapy on HD.

An appraisal of end-of-life care in persons with chronic kidney disease dying in hospital wards

AIM

To review end-of-life care provided by renal healthcare professionals to hospital in-patients with chronic kidney disease, and their carers, over a 12-month period in Northern Ireland.

METHODS

Retrospective review of 100 patients.

RESULTS

Mean age at death was 72 years (19-95) and 56% were male. Eighty three percent of patients had a 'Not For Attempted Resuscitation' order during their last admission and this was implemented in 42%. Less than 20% of all patients died in a hospital ward. No patients had an advanced care plan, although 42% had commenced the Liverpool Care Pathway for the Dying Patient. Patients suffered excessive end-of-life symptoms. In addition, there was limited documentation of carer involvement and carer needs were not formally assessed.

CONCLUSION

End-of-life care for patients with advanced chronic renal disease can be enhanced. There is significant variation in the recording of discussions regarding impending death and little preparation. There is poor recording of the patients' wishes regarding death. Those with declining functional status, including those frequently admitted to hospital require holistic assessment regarding end-of-life needs. More effective communication between the patient, family and multi-professional team is required for patients who are dying and those caring for them.

Demographic factors affecting quality of life of hemodialysis patients - Lahore, Pakistan

Objective: The objective of the study was to determine the demographic factors affecting Quality Of Life (QOL) of hemodialysis (HD) patients.

Methods: This observational study was conducted at Shalamar Hospital, Lahore. Patients of End Stage Renal Disease (ESRD) and on maintenance HD for more than three months were included during the period March to June 2012. Patient of ESRD not on dialysis and Acute Renal Failure were excluded. One hundred and twenty five patients who fulfilled the criteria were included. Demographic data containing age, sex, residence, socio economic status, education, mode of traveling for dialysis, total time consumed in dialysis were collected by the investigators. QOL index was measured using 26 items, WHO QOL BREF.

Results: There were 89(71.2%) male and 36(28.8%) female patients. Environmental domain score was highest (p=0.000) than all other domains in HD Patients. In overall analysis age, marital status and total time consumed in getting HD effect QOL significantly (p=<0.05). In domain wise analysis, male has better QOL in social relationship domain than female. Age has negative relationship with physical health and psychological health domain. QOL of unmarried and literate patients is significantly better (p=<0.05) in physical health domain. Employed patients have better QOL in physical, psychological and social relationship domain (p=<0.05) than unemployed patients. Patients of residence of rural areas have better QOL in physical and environment domain. Financial status of HD patients affect QOL in social domain. Distance covered to reach hospital effect QOL in psychological domain (p=<0.05). Patients traveling in private transport have better QOL in environmental domain (p=<0.05). Total time consumed in getting HD effect social relation in QOL (p=<0.05). According to linear regression model, marital status is positive predictor and unemployment is negative predictor of QOL in physical health domain. Age is negative predictor of QOL in psychological domain, monthly income is positive predictor of QOL in domain. Unemployment is positive predictor of QOL in social relation domain. Monthly income and place of residence is positive predictor of QOL in environment domain.

Conclusion: Gender, age, marital status, unemployment, residence of rural area, economical status, distance covered to reach hospital, mode of transport, total time consumed in getting HD, effect QOL in HD patient. Education level is a positive factor for improving QOL of HD patients.

Depression and coping in adults undergoing dialysis for end-stage renal disease

INTRODUCTION

Research on depression in local patients with end-stage renal disease (ESRD) is sparse. Thus, this study aims to examine the frequency and severity of depression among ESRD patients and relate depression with their coping skills.

METHODS

A cross-sectional study using universal sampling method was conducted at several dialysis centers in Kuala Lumpur, Selangor and Johor, Malaysia. The Beck Depression Inventory II (BDI-II) and the Brief COPE scale were used to measure depression and coping skill, respectively.

RESULTS

The study involved 274 ESRD patients, comprising of 183 hemodialysis and 91 continuous ambulatory peritoneal dialysis patients. The result showed that 21.1% of the patients experienced moderate to severe depression. Several components of coping skill were associated with depression. However, only two components in the Brief COPE (behavioral disengagement and self-blame) were identified as predictors.

DISCUSSION

This study showed that depression is common in ESRD patients and is related to the types of coping skills adopted by patients. Hence, this study provides some insight into ESRD patients with depression. Appropriate counseling should be given to these patients to empower them to cope with the illness so as to enhance their quality of life.

Economic evaluation of sevelamer for the treatment of hyperphosphatemia in chronic kidney disease patients not on dialysis in the United Kingdom

OBJECTIVES

To determine the cost effectiveness of sevelamer vs calcium carbonate in patients with chronic kidney disease and not on dialysis (CKD-ND) from the perspective of the National Health Service (NHS) in the UK.

METHODS

A Markov decision analytic model was developed to estimate (1) total life years (LYs), quality-adjusted life years (QALYs), and costs for patients treated with sevelamer or calcium carbonate; and (2) incremental costs per LY gained (LYG) and per QALY gained for sevelamer vs calcium carbonate. Data informing probability transitions to all-cause death and dialysis inception in CKD-ND patients were taken directly from the INDEPENDENT-CKD study and were extrapolated beyond the 3-year clinical trial using Weibull regression analysis. Estimates of health utility and costs (in £2011) were derived from the published literature.

RESULTS

Over a lifetime horizon, sevelamer treatment resulted in a gain of 2.05 LYs and 1.56 QALYs per patient, an increase of £37,282 in total costs per patient vs calcium carbonate (3.5% discount), and a per-patient cost of £18,193/LYG and £23,878/QALY gained. Results were robust to alternative assumptions in key parameters; results were most sensitive to alternative assumptions regarding the mean daily dose of sevelamer, impact of sevelamer on dialysis initiation, cost of dialysis, and health utility estimates. The probabilistic sensitivity analysis showed that sevelamer was cost-effective vs calcium carbonate in 93% of simulations at a willingness-to-pay threshold of £30,000/QALY gained.

LIMITATIONS

While the model simulated a real-world clinical setting, this analysis was subject to limitations common to all decision analytic models, in that it used a mix of data sources and relied on several assumptions. Not all variables that impact real-world outcomes and costs were included in this model.

CONCLUSIONS

Sevelamer is a cost-effective option compared to calcium carbonate for the first-line treatment of hyperphosphatemia in CKD-ND patients in the UK.

Quality of life in children with end-stage renal disease based on a PedsQL ESRD module

BACKGROUND

Health-related quality of life (HRQOL) is an essential subject for children with end-stage renal disease (ESRD) and their families.

METHODS

We performed a cross-sectional investigation of HRQOL in children undergoing renal replacement therapies, such as dialysis and renal transplantation, using the 34-item Pediatric Quality of Life Inventory 3.0 End-Stage Renal Disease (PedsQL 3.0 ESRD) module. We assessed 92 ESRD patients aged 2-18 from four Korean university hospitals.

RESULTS

The male:female ratio was 44:48, and the most common cause of ESRD was chronic glomerulonephritis. Fifty-five children were treated by dialysis, and 37 received renal transplantation. Transplant patients had better HRQOL than dialysis patients in two domains in parent proxy reports: "About my kidney disease" and "Worry." In child self-reports, transplant patients had better HRQOL than dialysis patients in one domain: Treatment problems. However, there were no significant differences in total QOL scores between peritoneal dialysis (PD) and transplant patients in child self-reports. In addition, there were differences in the ESRD module scores between child self- and parent proxy reports. Children usually reported better QOL than their parents. Child self-reports showed significantly higher QOL scores than parent proxy reports in the domains of General fatigue, Family & peer interaction, and Worry. Children on PD self-reported a significantly higher QOL than children on hemodialysis (HD).

CONCLUSIONS

The PedsQL 3.0 ESRD module may be useful as an ESRD-specific instrument to evaluate HRQOL in children; however, a larger, longitudinal prospective study is warranted.

Effect on Anxiety of Education Programme about Care of Arteriovenous Fistula in Patients Undergoing Hemodialysis

Purpose

This study investigated the impact of education, provided to individuals, in whom AV fistula was preferred as a vascular access, regarding information and anxiety.

Methods

This experimental study was performed on 32 patients undergoing hemodialysis between November 2009 and February 2010 in the Nephrology Clinic of Sivas Cumhuriyet University Hospital. Patients' data was collected by means of Personal Information Form (PIF), AV Fistula Information Form (AV-FIF), and Beck Anxiety Inventory (BAI); education brochures were used in order to inform the individuals. Collected data were assessed with SPSS. Statistical analyses were used in order to assess the data: percentage account, paired samples t test.

Results

When comparing information and anxiety score of individuals prior to and following education about AV fistula care, it was seen that information and anxiety scores were low and high respectively, prior to the education. Following education, patients' information and anxiety scores became higher and lower respectively. All these results were statistically significant (P< 0.001).

Conclusions

Education about fistula increased the information level about fistula care and decreased anxiety in patients undergoing hemodialysis. It is important to perform patient education regularly, because it increases the level of orientation towards illness and interventions in patients.

Quality of life in end-stage renal disease patients: differences in patient and spouse perceptions

OBJECTIVES

Spouses and other proxies consistently rate patient quality of life (QOL) lower than patients rate it themselves. This pattern has been observed in end-stage renal disease (ESRD), cancer, stroke and other chronic illnesses, but it has not been explained. The purpose of the current paper is to examine similarities and differences in spouse and patient ratings of the QOL of patients with ESRD.

METHOD

Patients with ESRD and their spouses participated in baseline and one-year follow-up interviews. Both patients and spouses rated the patient's QOL, mood, functional ability, subjective health, and kidney disease symptoms. Spouses also rated their own QOL.

RESULTS

Spouses rated all patient characteristics, including QOL, as worse than did the patient. Change in perceptions of patient's mood and their subjective health predicted both patient and spouse ratings of patient QOL. Change in spouse's perceptions of patient's functional ability predicted spouse ratings of patient QOL, but not the patient's own ratings. Finally, change in the spouse's own QOL explained additional variance in their rating of the patient's QOL.

CONCLUSION

Patients and spouses perceive patient QOL and predictors of patient QOL differently. Implications include the need to be aware of negative bias in spouse ratings of patients of QOL and other psychosocial variables, especially when spouse perceptions are considered by health care professionals. Discussing differences in patient and spouse perceptions in clinical settings with both patients and spouses will allow for a more comprehensive understanding of patient status.

In-center nocturnal hemodialysis: another option in the management of chronic kidney disease

BACKGROUND AND OBJECTIVES

Some patients are not optimally treated by conventional in-center hemodialysis (HD) and are unable to perform home HD. We examined the effect of in-center thrice-weekly nocturnal HD (INHD) on patient outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Patients who were not optimally treated on conventional HD were offered INHD. Thirty-nine patients' laboratory data and medication use were analyzed for the 12 mo before and after conversion to INHD until September 1, 2007. Quality of life on conventional HD and INHD was compared.

RESULTS

After conversion to INHD, median values for phosphorus decreased from 5.9 to 3.7 mg/dl (P < 0.01), alkaline phosphatase level increased from 84 to 161 U/L (P < 0.01), and percentage reduction in urea increased from 74 to 89% (P < 0.01). The mean number of antihypertensive drugs prescribed declined from 2.0 to 1.5 (P < 0.05) during the course of INHD, and the mean daily dosage of phosphate binders declined from 6.2 to 4.9 at study end (P < 0.05). There was a significant reduction in erythropoietin-stimulating agent use of 1992 U/wk (P < 0.01). There was no significant change in median hemoglobin, iron saturation, corrected calcium, or parathyroid hormone levels. Overall, quality of life, sleep, intradialytic cramps, appetite, and energy level all improved significantly on INHD.

CONCLUSIONS

INHD offers an effective form of HD for long-term dialysis patients who are unable to perform home HD.

Gender- and age-related benefit of renal replacement therapy on health-related quality of life

OBJECTIVES

The aim of this study was to compare the health-related quality of life (HRQOL) of end-stage renal disease patients on renal replacement therapy with that of subjects of the same gender and similar age from the general population, in an attempt to determine patient subgroup that benefits more from the treatment.

METHODS

A cross-sectional study involving haemodialysis, peritoneal dialysis and renal transplant patients (n = 874) was conducted with subjects providing socio-demographic and disease-related data, and completing the validated Greek Short Form-36 (SF-36) Health Survey. Patient-specific z-scores were calculated using mean SF-36 scores and SD of age- and gender-matched subgroups from the Greek norms.

RESULTS

Males and younger patients generally reported better HRQOL. However, z-scores in these groups generally showed a larger health deficit, i.e. an increased divergence from the HRQOL of their age- and gender-matched counterparts of the general population, compared with the health deficit observed in female and younger patients.

CONCLUSIONS

Health-related quality of life studies involving disease groups may sometimes be inconclusive if results are not compared with population norms, and particularly with subgroups matched for important demographic variables. Otherwise, as this study has shown, it is possible that important information may remain unrevealed.

Patients' views regarding choice of dialysis modality

BACKGROUND

Increasing patient numbers have resulted in pressure on dialysis centres and a need to reorganize dialysis treatment. This study explored patients' experiences with different dialysis modalities and investigated issues related to the patient's choice of modality, especially 'out-of-centre' dialysis (i.e. modalities other than CHD).

METHODS

Six focus group interviews were conducted with 24 dialysis patients, 3 pre-dialysis patients and 18 relatives. Each focus group comprised patients on one type of dialysis, i.e. CHD, self-care CHD, HHD, CAPD/APD, aAPD or pre-dialysis patients. Based on a semi-structured interview guide, the group discussions centred on advantages and disadvantages of dialysis modalities, problems experienced and their (possible) solutions and patient involvement in choice of modality.

RESULTS

The focus groups participants considered that each dialysis modality has its advantages and disadvantages. Flexibility, independence and feelings of security were key factors in determining choice of modality, with maintenance of a normal life being a major goal. Patients and their relatives want to participate in choice of modality, but a genuine offer of out-of-centre dialysis including professional support and appropriate and timely education is needed to encourage a greater use of modalities other than CHD.

CONCLUSIONS

No single dialysis modality emerged as offering the best solution for patients with end-stage renal disease. In the absence of absolute clinical contraindications, the treatment of choice should be the modality that best accommodates the patients' preferences for their daily activities and lifestyle. A move towards more patients on out-of-centre dialysis requires a greater focus on pre-dialysis patients and closer consideration of patients' preferences and current lifestyle.

Utility of health states in chronic kidney disease: a structured review of the literature

PURPOSE

To document published utilities for health states associated with Chronic Kidney Disease (CKD) and End Stage Renal Disease (ESRD) and determine the most appropriate values for use in economic models to evaluate renal treatments in the UK.

METHODS

A structured literature review was conducted (MEDLINE, EMBASE, NHS EED and HTA) in order to identify relevant articles published between January 1990 and January 2006. In addition searches were conducted on websites of Health Technology Assessment (HTA) organizations and the Cost Effectiveness Analysis Registry. Articles were reviewed and those not containing utilities excluded. Results were assessed on the quality of the elicitation studies and their relevance to the UK HTA environment.

RESULTS

Thirty-five studies satisfied the inclusion criteria. Most studies were conducted in Canada (13), the US (10) and the Netherlands (4). Utilities were identified for all/most of the necessary states, but scores for individual states differed widely between studies and very few studies met the quality criteria. The majority of studies used the time trade-off (23) and standard gamble (11) to elicit utilities, while only six used EQ-5D. Seven studies provided community preferences. Two studies were judged to be directly relevant to economic evaluations in the UK.

CONCLUSIONS

Many studies have estimated utilities in ESRD patients, but only a few have estimated utilities based upon public preferences. Further empirical research is needed to produce more reliable utilities for economic modelling in the UK, especially in chronic kidney disease patients who do not require dialysis.

Estimating Preference Scores in Conventional and Home Nocturnal Hemodialysis Patients

Previous studies have reported higher quality of life in patients who receive home nocturnal hemodialysis (HNHD) than conventional in-center hemodialysis (IHD). The optimal method for eliciting preferences from dialysis patients remains undefined, and there may be unique methodologic concerns in this population. Patients' preferences for IHD (n = 20) and HNHD (n = 24) were studied using the standard gamble (SG), time trade-off (TTO), and modified willingness to pay (WTP) methods. This report describes experience with operationalizing these three techniques in this population. A higher preference for HNHD was found with all measures, with significant differences observed with the SG (HNHD: median 0.79 [interquartile range (IQR) 0.67 to 0.95]; IHD: median 0.60 [IQR 0.20 to 0.82]; P = 0.031) and WTP (HNHD: median 0.50 [IQR 0.40 to 0.68]; IHD: median 0.20 [IQR 0.20 to 0.38]; P < 0.001). SG and TTO scores were moderately correlated but not with WTP. In addition, qualitative issues arose during TTO and WTP interviews that seemed to influence the interpretation of these preference scores. In the TTO, time willing to trade became oriented toward the next pivotal life event, with a failure of the requirement for a constant proportional time trade-off. WTP preferences were oriented toward the smallest survival stipend. These issues represent range restriction biases. No significant issues arose during the SG interviews. HNHD patients expressed a greater preference for current health than IHD patients. The operational performance of SG was good in this study, whereas biases and methodologic concerns were identified with the TTO and WTP in this population.

Health-Related Quality of Life of Predialysis Patients with Chronic Renal Failure

BACKGROUND

Health-related quality of life (HQOL) of predialysis patients with chronic renal failure (CRF) has received less attention than that of dialysis patients. We investigated changes in SF-36 over 1 year and examined associations between clinical parameters and SF-36 in predialysis CRF patients.

METHODS

Subjects were 471 predialysis CRF patients. SF-36 and clinical parameters were measured every 8 weeks for 48 weeks. Of the 471 subjects, 294 underwent one or more follow-ups. We analyzed the pooled dataset of the 294 CRF patients and 2002 subjects from Japanese general population using analysis of covariance.

RESULTS

After adjustment for age and sex, the 1-year declines in SF-36 domains were significantly greater in the predialysis patients than in the general population. For a 10% decline in hematocrit from the baseline survey value, the decline in vitality of SF-36 was 4.5 points (p = 0.003), while for a 10% increase in serum creatinine from the baseline survey value, respective declines in physical functioning, role-physical and mental health were 1.2 (p = 0.004), 1.9 (p = 0.035), and 1.0 points (p = 0.008).

CONCLUSION

Among these predialysis CRF patients, the decline in HQOL was faster than that in the general population, and was associated with an increase in serum creatinine and decline in hematocrit.

Predictors of Perceived Health Status in Patients after Kidney Transplantation

BACKGROUND

Patients after kidney transplantation have decreased mortality, morbidity and better quality of life compared to people on dialysis. Major efforts are being directed towards research into graft and patient survival. Research into quality of life is less intensive. The aim of this study was to explore the predictors of perceived health status (PHS) in kidney transplant recipients.

METHODS

Out of 218 patients after kidney transplantation 138 participated in the study. Linear regression analysis was performed to predict PHS, measured with the SF-36 questionnaire, in three age categories (<40, 40-59, >or=60 years). Independent variables included social support (measured with the Social Support List Discrepancies questionnaire), sociodemographic and medical variables, side effects and compliance.

RESULTS

Predictors of better PHS in patients<40 years were better social support (P<or=0.001), lower creatinine (P<or=0.001) and lower stress from adverse effects (P<or=0.001). In the group of patients aged 40-59 years higher education (P<or=0.05), increased housekeeping activities (P<or=0.01) and lower stress from adverse effects (P<or=0.001) predicted better PHS. In the last age group predictors of better PHS were lower rate of dialysis (P<or=0.05) and posttransplant hospitalizations (P<or=0.01), absence of diabetes mellitus (P<or=0.01) and lower stress from adverse effects (P<or=0.05).

CONCLUSIONS

Major differences exist in PHS among kidney transplant recipients depending on their age. Side effects of therapy are the most important predictor of PHS for all age groups. PHS of young patients mostly depends on their renal function and their social support. Education and working activities are most important for middle-aged people whereas in older patients PHS is mostly affected by comorbidity.

Evaluation of the cost effectiveness of sirolimus versus tacrolimus for immunosuppression following renal transplantation in the UK

INTRODUCTION

Immunosuppressive therapy is required to prevent graft rejection. Calcineurin inhibitors such as tacrolimus are paradoxically toxic to the kidney, whereas sirolimus (rapamycin; Rapamune) is not generally associated with the nephrotoxicity of CNIs. The purpose of this study was to evaluate the relative cost utility of sirolimus versus tacrolimus for the primary prevention of graft rejection in renal transplant recipients in the UK.

METHODS

A stochastic simulation model was constructed using clinical trial and observational data comparing the two treatments. Time duration was up to 20 years. Costs were from a UK NHS perspective, valued at 2003 prices and discounted at 6%. Benefits were discounted at 1.5%. Simulated events included patient and graft survival, haemodialysis, peritoneal dialysis, re-transplants and acute rejection. Costs were summed for events and various maintenance therapies. Utility was differentially accredited depending upon survival and using the alternative renal replacement therapies. Outcome was predicted using post-transplant creatinine levels up to 3 years. Extensive statistical economic and sensitivity analyses were undertaken.

RESULTS

Over the 10-year horizon, sirolimus gained 0.72 years (discounted) of functioning graft over tacrolimus, resulting in an incremental cost per year of functioning graft that was dominant. Over a 20-year time horizon, the cost effectiveness of sirolimus over tacrolimus further improved with an average discounted gain in years of a functioning graft of 1.8 years, resulting in an incremental cost-utility ratio that was also dominant. The number of haemodialysis events was 48,243 for sirolimus recipients versus 127,829 for those receiving tacrolimus and peritoneal dialysis events 40,872 versus 105,249, respectively. Similar values were obtained when real-life observational data on tacrolimus use in Cardiff, Wales were entered into the model. Using data from Cardiff, sirolimus remained dominant over tacrolimus under all scenarios.

CONCLUSION

Our study suggests that sirolimus may be more cost effective than tacrolimus for the primary prevention of graft rejection in renal transplant recipients in the UK. Sirolimus was economically 'dominant' under almost all scenarios investigated. This finding was robust using statistical economic analysis and univariate sensitivity analysis.

Evaluation of the cost-effectiveness of Sirolimus versus cyclosporin for immunosuppression after renal transplantation in the United Kingdom

OBJECTIVE

The purpose of this study was to evaluate the cost-effectiveness of sirolimus compared with cyclosporin for the postsurgical management of renal transplant recipients, from the perspective of the UK National Health Service and the Personal Social Service.

METHODS

A discrete event stochastic simulation model was developed to evaluate both cost-effectiveness and cost utility over 10 and 20 years after transplant using historical data on 937 renal transplant recipients from the University Hospital of Wales in Cardiff, United Kingdom. The simulation was designed to forecast the incidence of acute rejection events, graft failure, retransplant, frequency of hemodialysis (HD) and peritoneal dialysis (PD), and death. Cox proportional hazard models were derived from historical transplant data, in which 1-, 2-, and 3-year post-transplant serum creatinine levels were used as the key drivers for predicting graft success and survival. Costs were reported as year-2003 UK pounds sterling (1 UK pound = US $1.76). Probabilistic sensitivity analysis was conducted and results reported with particular attention to 2 threshold values, 30,000/QALY and 20,000/QALY RESULTS: Over a 10-year time horizon, treatment with sirolimus was projected to produce a gain of 0.60 discounted year of functioning graft with a cost savings of 276 UK pounds per patient. Over a 20-year time horizon these benefits increased to 1.59 discounted years of functioning graft and a cost savings of 7405 UK pounds per patient. Using sensitivity analysis of the 10-year model, the only factors found to cause the probability of exceeding a 30,000 ceiling to be >5% were the proportion of subjects maintaining continuous graft function and the use of low-dose cyclosporin. With the 20-year model, sirolimus maintained cost-effectiveness across most scenarios in sensitivity analysis.

CONCLUSIONS

In this model analysis, sirolimus was cost-effective compared with cyclosporin for 10 to 20 years after renal transplantation in the United Kingdom, from the perspective of the UK National Health Service and Personal Social Service.

Quality of Sleep and Quality of Life in Renal Transplantation Patients

INTRODUCTION

Sleep and sleep-related disorders are common among end-stage renal disease patients. In the general population and hemodialysis patients, insomnia impairs health-related quality of life (HRQOL). The aims of this study were to examine the prevalence of sleep problems among renal transplantation patients and the relationship between the quality of sleep and the HRQOL.

METHODS

Pittsburgh Sleep Quality Index (PSQI) for measuring quality of sleep, WHOQOL-BREF for quality of life, and Beck Depression Inventory (BDI) were applied to 100 renal transplant patients.

RESULTS

Thirty (30%) subjects were "poor sleepers" (global PSQI > 5). Poor sleepers were younger (mean age: 31 vs 37); less educated (mean years of education: 7.80 vs 9.55), and more depressed (mean BDI scores 13.63 vs 7.18). There were significant inverse correlations between global PSQI and physical health (r = -0.31; P < .001) and psychological state (r = -.20; P = .04) with a significant correlation with BDI scores (r = .36; P < .001). The BDI score (P < .001) was the only significant factor of physical health, psychological state, and social functioning. BDI score (P < .001) and education (P < .022) were significant predictors of environmental conditions.

CONCLUSION

Sleep problems are not as common among transplant as dialysis patients, but still higher than the general population. Poor sleep seems to be a part of depressive symptomatology. Severity of depression and lower education were more negatively effective factors on the quality of life of these patients than the quality of sleep.

Renal replacement therapy choices for pre-dialysis renal patients

With the numbers of patients developing end-stage renal failure predicted to increase over the coming years, more patients than ever will be expected to choose their future form of renal replacement treatment. This study explored the decision-making processes of pre-dialysis patients to elucidate how these choices were made. Nine pre-dialysis patients were interviewed, transcripts of which were analysed using interpretative phenomenological analysis. Four main themes relating to the decision-making process emerged: maintaining one's integrity, forced adaptation, utilizing information, and support and experiencing illness. While making a decision was an individualized process, contextualized within participants' illness experiences, these core themes emerged for the whole group, irrespective of the chosen treatment modality. For renal services, there is a need to tailor information provided to pre-dialysis patients and to become cognizant of the contexts in which they live and operate.

Effects of an adaptation training programme for patients with end-stage renal disease

AIMS

This paper reports a study investigating the effectiveness of an adaptation training programme (ATP) to help patients with end-stage renal disease (ESRD) to cope with illness-related stresses and, thus, to alleviate depression and improve quality of life.

BACKGROUND

Patients with ESRD who receive dialysis must confront the burdens of long-term illness and numerous treatment-associated stressors. The ability of these patients to cope with and adapt to these stresses, whether related to their medical regimen or to the demands of daily life, has an important influence on physical and psychological well-being.

METHODS

The study was a randomized controlled trial using a convenience sample of 57 eligible, fully informed and consenting patients with ESRD who were assigned to experimental (ATP plus usual care) or control (usual care) groups. Participants in the ATP took part in weekly small group sessions over an 8-week period and monthly follow-up to help them to cope with stressors. A clinical nurse specialist and an experienced psychotherapist led them in three small groups (8-10 per group). Participants in the usual care group received routine care. Instruments comprised the Haemodialysis Stressor Scale, Beck Depression Inventory and Medical Outcomes Study SF-36. Data were collected at baseline and at three months following the intervention.

RESULTS

The major stressors for these patients were limitations on time and place related to employment, limitations on fluid intake, transport difficulties, loss of bodily function, length of dialysis treatment, and limitation of physical activities. The ATP had a beneficial effect on perceived stress (P = 0.005), depression (P = 0.001) and quality of life (P = 0.02) 3 months after the intervention.

CONCLUSIONS

This study supports the effectiveness of an ATP to decrease stress and depression levels, and to improve the quality of life of ATP patients receiving haemodialysis.

Kidney transplantation: determination of the problems encountered by Turkish patients and their knowledge and practices on healthy living

BACKGROUND

Although renal transplantations remove many limitations, dialysis can improve quality life in patients with end-stage renal disease, once transplantation has been performed and the patient has been discharged with a functioning graft, life with a chronic illness continues.

AIMS AND OBJECTIVES

This study was carried out to define problems encountered by patients undergoing kidney transplantation and their knowledge and practices on healthy living.

DESIGN

This study was designed as a retrospective and descriptive survey.

METHODS

This study was performed on 125 patients who were followed at Social Insurance Institute's Ankara Specialty Hospital Transplantation Clinic between March and August 2001. A convenience sample was drawn from the population of renal transplant patients. A questionnaire was prepared based on the literature, which included patients' socio-demographic information, physiological problems, diseases and repeated hospitalizations; side-effects and usage of immunosuppressive drugs, knowledge and practices of patients regarding healthy living and their knowledge needs. Data were collected through interviews. Percentage and chi-square test were used in evaluation of the data.

RESULTS

Physiological problems and diseases after renal transplantations were seen such as 38.4% had infections in urinary and respiratory tract. Some had hypertension (22.4%) hypercholesterolaemia (26.5%) and 5.6% had malignancy. Most (67.2%) developed antirejection drugs side-effects. About 55.2% were admitted to hospital after renal transplantation and 68.8% had not received any training after transplantation from a health professional. Only 35.2% knew the signs and symptoms of rejection entirely or partly. It was determined that 55.2% stated that they avoid sunlight and 56% stated that they exercise regularly. Only 26.8% of female patients do regular breast self-examination. While 52.8% listed the forbidden foods correctly, only 27.2% could list the forbidden beverages accurately.

CONCLUSIONS

According to the results, patients undergoing renal transplantation experience various problems that may influence their quality of life adversely and their knowledge and practice is not adequate for them to continue to lead healthy lives.

RELEVANCE TO CLINICAL PRACTICE

In accordance with the results of the study, offering continuing education and counselling services, preparing training guides, brochures, video cassettes and CDs for patient education, improving the national web sites to inform the public and creation of a home care system were suggested.

Haemodialysis patients and end-of-life decisions: a theory of personal preservation

BACKGROUND

Lack of knowledge about the end-of-life treatment preferences of patients undergoing haemodialysis is problematic in the acute care setting as, often, patients are unable to communicate their treatment wishes effectively and have not previously documented their desires in the form of advance directives. Existing theoretical models offer an incomplete explanation of end-of-life treatment decisions in haemodialysis patients.

AIM

This paper reports a study exploring decisions about end-of-life treatment (e.g. cardiopulmonary resuscitation, mechanical ventilation) in people with kidney failure undergoing haemodialysis.

METHODS

Grounded theory was used. Theoretical sampling led to selection of 20 haemodialysis patients (11 men and nine women with a mean age of 56) who attended three dialysis outpatient centres in central Texas. They were interviewed about end-of-life treatment plans and the use of advance directives (i.e. living wills and durable powers of attorney for health care). Interviews, transcripts and field notes from the first 12 patients were analysed by making constant comparisons. The remaining eight interviews were used for validation purposes. Data collection and analysis spanned the years 1997-2000.

FINDINGS

When prompted to think about and discuss end-of-life treatments, haemodialysis patients chose to focus on living rather than dying. A substantive theory of 'personal preservation' was developed. This consists of three phases: knowing the odds for survival, defining individuality (beating the odds, discovering meaning, being optimistic and having faith in a higher force) and personal preservation (being responsible and taking chances).

CONCLUSIONS

The theory of personal preservation furthers understanding of illness behaviour and the process by which patients make decisions about end-of-life treatments. It can be used to sensitize health care professionals to patients' desires and to enhance patient-professional communication.

Haemodialysis patients' beliefs about renal failure and its treatment

Patients' beliefs about illness are important because they influence adherence and adjustment, but they are often surprising and idiosyncratic. Qualitative research can identify them in ways that are not shaped by psychological theory, but quantification is necessary if clinicians are to be informed about the beliefs that are likely to be prevalent in their patients. Qualitative analysis of interviews with 16 haemodialysis (HD) patients identified beliefs about end-stage renal failure (ESRF) and its treatment that were formed into a questionnaire, completed by 156 similar patients. Patients attributed ESRF to diverse factors including lack of self-care and inadequate medical care. Patients lacked a clear belief in the mechanism of action of dietary control, and its necessity was not readily acknowledged. The common view of haemodialysis as 'cleansing' extended to the reassuring belief that it would purge the body of disallowed food or drink. Many patients regarded haemodialysis and dietary control as externally imposed challenges that dominated life. The findings identify potential targets for educational intervention to improve adherence and adjustment and predictions about effects of patients' beliefs that can be tested in future prospective studies.

Do health causal attributions and coping strategies act as moderators of quality of life in peritoneal dialysis patients?

OBJECTIVE

The present study aimed at testing the relationships between health causal attribution and coping mechanisms with quality of life (QOL) in patients who have end-stage renal disease (ESRD) undergoing a peritoneal dialysis (PD) treatment. It was hypothesized that QOL should be negatively associated with the severity of the disease. Problem-focused coping, internal health-related locus of control (HRLOC) and medical power HRLOC were hypothesized as positive moderators preserving a better QOL, after controlling for the severity of the disease.

METHODS

A total of 47 PD patients completed the Kidney Disease Quality of Life (KD-QOL) scale encompassing the Medical Outcomes Study Short-Form (MOS SF-36) self-administered questionnaire, the Multidimensional Health Locus of Control scale and the Ways of Coping Check-List (WCCL) scale.

RESULTS

Low scores for all QOL scores were found except for pain dimension, as compared with scores available from a general French population. Globally, QOL was not related to the severity of the disease. Univariate analysis showed that the physical component score (PCS) of QOL was positively associated with internal HRLOC (r=.35; P<.05), and negatively with medical power HRLOC (r=-.36; P<.05). Multivariate analysis adjusting for age confirmed these results. Mental component score (MCS) was negatively associated with the use of emotion-focused coping and seeking social support (r=-.45; P=.001 and r=-.30; P<.05, respectively), the first association persisting in multivariate analysis. Neither PCS nor MCS was linked to the use of problem-focused coping.

CONCLUSION

These results suggest that physical QOL is all the more preserved when patients are more convinced that their behaviour can influence their health condition and that psychological QOL is all the more impaired when health condition is perceived as less controllable, requiring emotion-focused coping (avoidance strategies). Health causal attributions and coping act respectively as moderators of physical and psychological components of QOL.

Cost analysis of renal replacement therapies in Finland

BACKGROUND

Costs for treating patients with end-stage renal disease (ESRD) have grown noticeably. However, most of the cost estimates to date have taken the perspective of the payers. Hence, direct costs of treating ESRD are not accurately known.

METHODS

Files of all adult patients with ESRD who entered dialysis therapy between January 1, 1991, and December 31, 1996, were studied retrospectively, and all use of health care resources and services was recorded. Follow-up continued until December 31, 1996.

RESULTS

Two hundred fourteen patients fulfilled the study criteria, 138 patients started with in-center hemodialysis (HD) therapy, and 76 patients started with continuous ambulatory peritoneal dialysis (CAPD) therapy. Patients were followed up until death (72 patients) or treatment modality changed for more than 1 month. Fifty-five patients received a cadaveric transplant, and after transplantation (TX), they were examined as a separate group of TX patients. Direct health care costs for the first 6 months in the HD, CAPD, and TX groups were 32,566 US dollars, 25,504 dollars, and 38,265 dollars, and for the next 6 months, 26,272 dollars, 24,218 dollars, and 7,420 dollars, respectively. During subsequent years, annual costs were 54,140 US dollars and 54,490 dollars in the HD group, 45,262 dollars and 49,299 dollars in the CAPD group, and 11,446 dollars and 9,989 dollars in the TX group. Regression analyses showed 4 variables significantly associated with greater daily costs in dialysis patients: age, ischemic heart disease, nonprimary renal disease, and HD treatment.

CONCLUSION

Compared with HD, CAPD may be associated with lower costs, yet the absolute difference is not striking. After the TX procedure is performed once, annual costs decline remarkably, and cadaveric TX is less costly than both dialysis modalities.

The quality of life and cost utility of home nocturnal and conventional in-center hemodialysis

BACKGROUND

Home nocturnal hemodialysis is an intensive form of hemodialysis, where patients perform their treatments at home for about 7 hours approximately 6 nights a week. Compared with in-center conventional hemodialysis, home nocturnal hemodialysis has been shown to improve physiologic parameters and reduce health care costs; however, the effects on quality of life and cost utility are less clear. We hypothesized that individuals performing home nocturnal hemodialysis would have a higher quality of life and superior cost utility than in-center hemodialysis patients.

METHODS

Home nocturnal hemodialysis patients and a demographically similar group of in-center hemodialysis patients from a hospital without a home hemodialysis program underwent computer-assisted interviews to assess their utility score for current health by the standard gamble method.

RESULTS

Nineteen in-center hemodialysis and 24 home nocturnal hemodialysis patients were interviewed. Mean annual costs for home nocturnal hemodialysis were about 10,000 dollars lower for home nocturnal hemodialysis (55,139 dollars +/- 7651 dollars for home nocturnal hemodialysis vs. 66,367 dollars +/- 17,502 dollars for in-center hemodialysis, P = 0.03). Home nocturnal hemodialysis was associated with a higher utility score than in-center hemodialysis (0.77 +/- 0.23 vs. 0.53 +/- 0.35, P = 0.03). The cost utility for home nocturnal hemodialysis was 71,443 dollars/quality-adjusted life-year (QALY), while for in-center hemodialysis it was 125,845 dollars/QALY. Home nocturnal hemodialysis was the dominant strategy, with an incremental cost-effectiveness ratio (ICER) of -45,932 dollars. The 95% CI for the ICER, and 2500 bootstrap iterations of the ICER all fell below the cost-effectiveness ceiling of 50,000 dollars. The net monetary benefit of home nocturnal hemodialysis ranged from 11,227 dollars to 35,669 dollars.

CONCLUSION

Home nocturnal hemodialysis is associated with a higher quality of life and a superior cost utility when compared to in-center hemodialysis.

Quality of life after kidney and pancreas transplantation: a review

There is an increasing amount of data on quality of life (QOL) in most chronic illnesses; some of the instruments used are generic, but recently, there is a tendency to use disease-specific instruments. We propose that recipients of organ transplants be assessed routinely for QOL by means of the 36-Item Short-Form Health Survey or a disease-specific instrument; for compliance, by means of the Long-Term Medication Behavior Self-Efficacy Scale; and for psychological status, by means of the Beck Depression Inventory Brief Symptom Inventory or the Symptom Checklist. The widespread use of QOL data in recipients of organ transplants will increase accountability of service providers and eventually increase patient satisfaction because these instruments are patient reported.