Formal literature review of quality-of-life instruments used in end-stage renal disease

Health-related quality of life in patients with chronic kidney disease

Introduction: In the last three decades, health systems have continued to pay increasing attention to the quality of life (QOL) due to definitional changes in the concept of health and disease. The health-related quality of life (HRQOL) in patients with chronic kidney disease (CKD) is significantly affected, regardless of the stage of CKD. Areas covered: We attempt to thoroughly explore how CKD affects HRQOL domains with a quick primer on HRQOL assessment instruments in patients with CKD. Also, we pointed out the factors affecting HRQOL in patients with CKD as well as the clinical application of HRQOL in CKD management. Expert opinion: The general population enjoys higher HRQOL than patients with CKD in all domains. Similarly, pre-dialysis and kidney-transplant patients have better HRQOL than dialysis population. There are many factors which negatively impact HRQOL in CKD which include for example depression, anxiety, and cognitive impairment for the social domain, inactivity, and frailty for the physical domain as well as lack of social support and extroversion in the social domain. Additionally, social disparities and CKD-related factors would influence HRQOL. Of note, there is no global standard HRQOL assessment tool. Finally, HRQOL should be included in future CKD management guidelines.

Quality of Life of Elderly Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

Objective

The aim of the present study was to evaluate the impact of continuous ambulatory peritoneal dialysis (CAPD) on the lifestyle of elderly patients.

Patients and Methods

Aspects of health-related quality of life (QL) were studied in 48 patients (16 men, 32 women) in end-stage chronic renal failure (ESRF) undergoing CAPD at the Clinic of Nephrology, Clinical Centre of Serbia. The first group comprised 20 adult patients (8 men, 12 women; age range: 35 – 59 years). The second group consisted of 28 older adult patients (8 men, 20 women; age range: 65 – 75 years). Mean length of CAPD treatment was 5.2 years in the first group and 3.67 years in the second group. Fifteen QL variables were investigated: marital status, family relationships, working ability, sleep, tiredness, appetite, wound healing, hobby, sports, friendships, sexual activity, mood, travel, self management, and happiness.

Results

The results showed that, in the examined groups, marital status and relationships with family members weren't influenced at all by dialysis. In both groups, CAPD had a negative influence on ability to bear cold and to travel, but other life functions were not significantly affected. Elderly patients had a significantly worse appetite ( p = 0.03, Fisher test) and mood ( p = 0.045, Fisher test) than did younger adults. In other examined variables, no statistically significant differences were found between the groups.

Conclusions

Lack of large, statistically significant differences between the groups suggests that CAPD has an equal influence on quality of life in younger and older adult patients.

Impact of First Dialysis Modality on Outcome of Patients Contraindicated for Kidney Transplant

Background

We compared, in patients contraindicated for kidney transplant, outcomes between those patients who were only on hemodialysis (HD) and those who were given peritoneal dialysis (PD) as first renal replacement therapy (RRT).

Design

Prospective, population-based cohort study of incident cases of end-stage renal disease between June 1997 and June 1999.

Setting

A network of dialysis care: NEPHROLOR, that is, all the renal units in Lorraine, one of the 22 French administrative regions (population over 2.3 million people).

Participants

387 patients were contraindicated for kidney transplant during the first 2 years of RRT: 284 were on HD, 103 on PD. Mean age was 67.6 ± 11.3 years for HD patients and 70.8 ± 11.4 years for PD patients ( p = 0.015).

Main Outcome Measures

Mortality until June 2003, hospitalization over the 2 first years of RRT, and Kidney Disease and Quality of Life Short Form (KDQOL-SF) 6 and 12 months after initiation of RRT.

Results

HD patients were more likely to die from cardiac or cerebrovascular causes, PD from cachexia or withdrawal from dialysis. Whatever mode of RRT, the unadjusted 2-year and 5-year survival rates were similar ( p = 0.98). The rate of total duration of hospital stay per month of RRT was similar in HD and PD groups: 2.7 ± 4.5 and 2.9 ± 4.2 days respectively ( p = 0.7). PD was associated with better quality of life than HD. The dimensions Role limitation due to emotional function, Burden of kidney disease, and Role limitation due to physical function ranked first, second, and third for PD.

Conclusion

In Lorraine, end-stage renal disease patients who were given PD as first-line RRT had no excess of death risk or hospitalizations, and better quality of life the first year of RRT.

Measuring health-related quality of life in patients with conservatively managed stage 5 chronic kidney disease: limitations of the Medical Outcomes Study Short Form 36: SF-36

PURPOSE

Chronic kidney disease (CKD) negatively affects health-related quality of life (HRQoL), which is often measured using the Medical Outcomes Study Short Form 36 (SF-36) questionnaire. However, the adequacy of SF-36 in this population has not been reported. We aimed to determine floor and ceiling effects and responsiveness to change of SF-36 in patients with conservatively managed stage 5 CKD.

METHODS

SF-36 data were collected prospectively. Floor and ceiling effects were estimated for each SF-36 scale and summary measure based on raw scores. The minimal clinically important difference (MCID) was estimated using a combination of anchor-based and distribution-based methods. Responsiveness to change was assessed by comparing MCID for each scale and summary measure to its smallest detectable change.

RESULTS

SF-36 data were available for 73 of the 74 study participants. Using baseline data, floor and/or ceiling effects were detected for 3 of the 8 SF-36 scales. The anchor-based estimation of MCID based on differences in baseline functional status yielded the most reliable results. For the physical component summary, MCID was estimated at 5.7 points. Whilst the two SF-36 summary measures were responsive to change and free of floor and/or ceiling effects, six of the eight scales were not.

CONCLUSIONS

This small study of patients with conservatively managed stage 5 CKD found that only the summary measures of SF-36 and 2 of its 8 scales can be used to assess changes in HRQoL over time. These findings suggest that in this population, alternative HRQoL assessment tools should be considered for future studies.

Design and participant baseline characteristics of 'A Clinical Trial of IntensiVE Dialysis': the ACTIVE Dialysis Study

AIMS

Observational reports suggest extended dialysis hours are associated with improved outcomes. These findings are confounded by better prognostic characteristics among people practising extended hours. The aim of this article is to provide an overview of the methods and baseline characteristics for ACTIVE Dialysis Study participants.

METHODS

This multicentre, randomized, open-label, blinded endpoint-assessment trial randomized participants receiving maintenance haemodialysis therapy to either extended (≥24 h) or standard (12-18 h) weekly haemodialysis for 12 months. A web-based randomization system used minimization to ensure balanced allocation across regions, dialysis setting and dialysis vintage. The primary outcome is the change in quality of life over 12 months of study treatment assessed by EQ-5D. Secondary outcomes include change in left ventricular mass index assessed by magnetic resonance imaging and safety outcomes including dialysis access events.

RESULTS

A total of 200 participants were recruited between 2009 and 2013 from Australia (29.0%), China (62.0%), Canada (5.5%) and New Zealand (3.5%). Participants had a mean age of 52 (± 12) years and 11.5% were dialysing at home, with a mean duration of 13.9 h per week over a median of three sessions. At baseline, 32.5% had a history of cardiovascular disease and 36.5% had diabetes.

CONCLUSION

The ACTIVE Dialysis Study has met its planned recruitment target. The participant population are drawn from a range of health service settings in a global context. The study will contribute important evidence on the benefits and harms of extending weekly dialysis hours. The trial is registered at clinicaltrials.gov (NCT00649298).

Patient-Reported Outcome Instruments for Physical Symptoms Among Patients Receiving Maintenance Dialysis: A Systematic Review

BACKGROUND

Patients with end-stage renal disease (ESRD) receiving dialysis have poor health-related quality of life. Physical symptoms are highly prevalent among dialysis-dependent patients and play important roles in health-related quality of life. A range of symptom assessment tools have been used in dialysis-dependent patients, but there has been no previous systematic assessment of the existing symptom measures' content, validity, and reliability.

STUDY DESIGN

Systematic review of the literature.

SETTINGS & POPULATION

Patients with ESRD on maintenance dialysis therapy.

SELECTION CRITERIA FOR STUDIES

Instruments with 3 or more physical symptoms previously used in dialysis-dependent patients and evidence of validity or reliability testing.

INTERVENTION

Patient-reported physical symptom assessment instrument.

OUTCOMES

Instrument symptom-related content, validity, and reliability.

RESULTS

From 3,148 screened abstracts, 89 full-text articles were eligible for review. After article exclusion and further article identification by reference reviews, 58 articles on 23 symptom assessment instruments with documented reliability or validity testing were identified. Of the assessment instruments, 43.5% were generic and 56.5% were ESRD specific. Symptoms most frequently assessed were fatigue, shortness of breath, insomnia, nausea and vomiting, and appetite. Instruments varied widely in respondent time burden, recall period, and symptom attributes. Few instruments considered recall periods less than 2 weeks and few assessed a range of symptom attributes. Psychometric testing was completed for congruent validity (70%), known-group validity (25%), responsiveness (30%), internal consistency (78%), and test-retest reliability (65%). Content validity was assessed in dialysis populations in 57% of the 23 instruments.

LIMITATIONS

Consideration of physical symptoms only and exclusion of single symptom-focused instruments.

CONCLUSIONS

The number of available instruments focused exclusively on physical symptoms in dialysis patients is limited. Few symptom-containing instruments have short recall periods, assess diverse symptom attributes, and have undergone comprehensive psychometric testing. Improved symptom-focused assessment tools are needed to improve symptom evaluation and symptom responsiveness to intervention among dialysis-dependent patients.

Quality of life in dialysis: A Malaysian perspective

There is a growing interest to use quality of life as one of the dialysis outcome measurement. Based on the Malaysian National Renal Registry data on 15 participating sites, 1569 adult subjects who were alive at December 31, 2012, aged 18 years old and above were screened. Demographic and medical data of 1332 eligible subjects were collected during the administration of the short form of World Health Organization Quality of Life questionnaire (WHOQOL-BREF) in Malay, English, and Chinese language, respectively. The primary objective is to evaluate the quality of life among dialysis patients using WHOQOL-BREF. The secondary objective is to examine significant factors that affect quality of life score. Mean (SD) transformed quality of life scores were 56.2 (15.8), 59.8 (16.8), 58.2 (18.5), 59.5 (14.6), 61.0 (18.5) for (1) physical, (2) psychological, (3) social relations, (4) environment domains, and (5) combined overall quality of life and general health, respectively. Peritoneal dialysis group scored significantly higher than hemodialysis group in the mean combined overall quality of life and general health score (63.0 vs. 60.0, P < 0.001). Independent factors that were associated significantly with quality of life score in different domains include gender, body mass index, religion, education, marital status, occupation, income, mode of dialysis, hemoglobin, diabetes mellitus, coronary heart disease, cerebral vascular accident and leg amputation. Subjects on peritoneal dialysis modality achieved higher combined overall quality of life and general health score than those on hemodialysis. Religion and cerebral vascular accident were significantly associated with all domains and combined overall quality of life and general health.

The psychosocial correlates of quality of life in the dialysis population: a systematic review and meta-regression analysis

PURPOSE

The psychosocial correlates of quality-of-life (QoL) research in end-stage renal disease (ESRD) are important in identifying risk and protective factors that may account for the QoL variability. Thus, the present study provides a meta-analysis of these research results.

METHODS

Published studies reporting associations between any psychosocial factors and QoL were retrieved from Medline, Embase, and PsycINFO. Mean effect sizes were calculated for the associations across psychosocial constructs (affect, stress, cognitive appraisal, social support, personality attributes, and coping process). Multiple hierarchical meta-regressions were applied to moderator analyses.

RESULTS

Eighty-one studies covering a combined sample of 13,240 participants were identified resulting in 377 effect sizes of the association between psychosocial factors and QoL. The overall effect size of the association was medium (0.38). Stress, affect, and cognitive appraisal had the largest effect sizes. Location of study, dialysis type, gender, age and QoL domains measured (general well-being, subjective QoL, and health-related QoL) were significant substantive moderators for the associations.

CONCLUSIONS

The present study shows that there is a moderate association between psychosocial variables and QoL in patients with ESRD, consistent across different QoL domains. The psychosocial constructs that have the strongest association with QoL are stress, affect, and cognitive appraisal.

Design and rationale of health-related quality of life and patient-reported outcomes assessment in the Frequent Hemodialysis Network trials

BACKGROUND

End-stage renal disease patients experience significant impairments in health-related quality of life (HRQOL). Testing various strategies to improve patient HRQOL in multicenter clinical trials, such as the Frequent Hemodialysis Network (FHN) trials is vitally important.

AIMS

The aim of this paper is to describe the design and conduct of HRQOL and patient-reported outcomes (PRO) assessment in the FHN trials.

METHODS

In the FHN trials, HRQOL was examined as a multidimensional concept, and the SF-36 RAND Physical Health Composite score was one of the co-primary outcomes. The instruments completed to assess HRQOL included the Medical Outcomes Study Short Form SF-36, Health Utilities Index 3, Sleep Problems Index, Beck Depression Inventory and feeling thermometer. These instruments have been shown to have high reliability, validity and responsiveness to change in the end-stage renal disease population. Additional items evaluating PRO including sexual function, time to recovery after dialysis and patients' self-perceived burden to caregiver were also assessed. All questionnaires were administered by trained interviewers using computer-assisted telephone interviewing to ensure blinding and minimizing selection bias. Interim analysis reveals that these instruments can be used to collect a comprehensive set of HRQOL measures with minimal patient burden.

CONCLUSIONS

Accurate measurement of HRQOL and PRO can help us test whether hemodialysis interventions improve the health and well-being of this compromised patient population. We have shown that a comprehensive set of HRQOL measures can be centrally collected through telephone interviews in a blinded fashion, in a way that is well tolerated with minimum respondent burden.

Evaluation of the methodological quality of systematic reviews of health status measurement instruments

A systematic review of measurement properties of health-status instruments is a tool for evaluating the quality of instruments. Our aim was to appraise the quality of the review process, to describe how authors assess the methodological quality of primary studies of measurement properties, and to describe how authors evaluate results of the studies. Literature searches were performed in three databases. One hundred and forty-eight reviews were included. The purpose of included reviews was to identify health status instruments used in an evaluative application and to report on the measurement properties of these instruments. Two independent reviewers selected the articles and extracted the data. Reviews were often of low quality: 22% of the reviews used one database, the search strategy was often poorly described, and in many cases it was not reported whether article selection (75%) and data extraction (71%) was done by two independent reviewers. In 11 reviews the methodological quality of the primary studies was evaluated for all measurement properties, and of these 11 reviews only 7 evaluated the results. Methods to evaluate the quality of the primary studies and the results differed widely. The poor quality of reviews hampers evidence-based selection of instruments. Guidelines for conducting and reporting systematic reviews of measurement properties should be developed.

Development and validation of a French patient-based health-related quality of life instrument in kidney transplant: the ReTransQoL

BACKGROUND

In the absence of a French health-related quality of life (QOL) instrument for renal transplant recipients (RTR), we developed a self-administered questionnaire: the ReTransQol (RTQ).

METHODS

This questionnaire was developed using classical methodology in the following three phases over a two-year period: Item Generation phase, identifying all possible items having adverse impact on the QOL of RTR, Item Reduction phase, selecting the most pertinent items related to QOL, and Validation phase, analyzing the psychometric properties. All RTR involved in these phases were over 18 and were randomly selected from a transplant registry.

RESULTS

Item generation was conducted through 24 interviews of RTR. The first version of RTQ (85 items) was sent to 225 randomized RTR, and 40 items were eliminated at the end of the item reduction phase. The second version of RTQ (45 items) was validated from 130 RTR, resulting in the RTQ final version. The factor analysis identified a structure of five factors: Physical Health (PH), Mental Health (MH), Medical Care (MC), Fear of losing the Graft (FG) and Treatment (TR). The psychometric properties of RTQ were satisfactory. Comparison between known groups from the literature confirmed the construct validity: patients without employment or living alone have lower QOL scores, and women have lower QOL scores than men. RTQ was more responsive than SF36 to detect changes in the QOL of RTR who were hospitalized secondary to their renal disease in the 4 weeks preceding their inclusion.

CONCLUSION

According to French public health priorities, RTQ appears to be a reliable and valid questionnaire.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Instruments for evaluating shared medical decision making: a structured literature review

The author conducted a structured literature review of instruments for evaluating shared medical decision making. She included relevant instruments that were generalizable beyond specific situations and had been formally evaluated and organized them by domains of values or preferences, information and communication in decision making, and other aspects of decision making. For values or preferences, the author identified 11 instruments, mostly on preferences for roles and information. For information and communication, she found a systematic review of instruments for observational assessment of decision making, 3 additional observational instruments, and 3 questionnaires. For other aspects of decision making, the author identified 3 instruments in domains such as decision self-efficacy and 4 multidimensional instruments. Although instrument development tended to cluster in several areas and there were clear gaps in the literature, the diversity of instruments demonstrates the broad range of constructs involved in assessing shared decision making.

Cross-sectional validity of a modified Edmonton symptom assessment system in dialysis patients: a simple assessment of symptom burden

Subjective symptom assessment should be a fundamental component of health-related quality of life (HRQL) assessment in end-stage renal disease (ESRD). Unfortunately, no symptom checklist has established reliability or validity in ESRD. We report the validation of a modified Edmonton Symptom Assessment System (ESAS) in 507 dialysis patients who concurrently completed the Kidney Dialysis Quality of Life-Short Form (KDQOL-SF) questionnaire. The ESAS demonstrated a mean of 7.5+/-2.5 symptoms. The symptoms reported as most severe were tiredness, well-being, appetite, and pain. The overall symptom distress score was strongly correlated with the KDQOL-SF subscales symptom/problem list (r=-0.69, P<0.01), effects of kidney disease (r=-0.52, P<0.01), and burden of kidney disease (r=-0.50, P<0.01), as well as lower RAND-12 physical health composite (PHC) (r=-0.54, P<0.01) and lower RAND-12 mental health composite (MHC) (r=-0.62, P<0.001). In the multivariate regression analysis, after controlling for potential confounding variables including comorbidity using the modified Charlson Comorbidity Index, the ESAS symptom distress score remained strongly associated with the MHC (slope=-0.82+/-0.07, P<0.01) and PHC (slope=-0.48+/-0.07, P<0.01). The ESAS symptom distress score accounted for 29% of the impairment in PHC and 39% of the impairment in MHC. The intraclass correlation coefficient for the total symptom distress score in a 1-week test-retest was 0.70, P<0.01. Symptom burden is high and adversely affects HRQL in dialysis patients. The modified ESAS is a reliable, valid, simple, and useful method for regular symptom assessment in this patient population.

Changes in physical and psychosocial functioning among adolescents with chronic kidney disease

Little research has been published assessing changes in the functional health status of children and adolescents with chronic kidney disease (CKD). We know little about which clinical parameters influence functional status or health-related quality of life in these young people. In a prospective study using data from semi-annual visits over a 4-year period from 78 adolescents with CKD aged 11 years to 18 years, we detail the impact of several clinical measures (i.e., kidney function, albumin, hematocrit, height) on short-term changes in health-related quality of life. The 50-item Child Health Questionnaire Parent Form, a validated health-related quality of life measure in children, was used to obtain physical and psychosocial functioning summary scores at each visit. After adjustment for the variables mentioned above, the physical summary score on the Child Health Questionnaire (CHQ) declined as glomerular filtration rate declined. Increasing height was associated with a positive change in physical and psychosocial summary scores. We conclude that decline in kidney function is associated with a subsequent decline in health-related quality of life, particularly in terms of physical activity.

Development and Psychometric Properties of the Dialysis Module of the WHOQOL-BREF Taiwan Version

BACKGROUND

Quality of life (QOL) is now considered to be an important part of the assessment of dialysis patients. The aim of this study was to develop and assess the reliability, validity and sensitivity of the dialysis module of the World Health Organization Quality of Life - Brief (WHOQOL-BREF) Taiwan version [WHOQOL-BREF(TW)] in patients undergoing regular hemodialysis (HD).

METHODS

QOL survey was administered to 283 regular HD patients in metropolitan Taipei. The instruments used included: (1) the proposed module - composed of the core part, the WHOQOL-BREF(TW), and the six specific items; (2) the symptom/problem (S/P) scale - composed of 12 items specific for dialysis patients; (3) the utility measure, which was performed with standard gamble (SG) methods; and (4) the rating scale (RS).

RESULTS

Based on the six criteria of validity, reliability and variance of the items, four HD-specific items were selected. Reliability study showed that Cronbach's alphas, composite reliability, and test-retest reliability (intraclass correlation at an average retest interval of 4-8 weeks) of the four domains of physical, psychological, social relationship and environment, ranged from 0.74-0.82, 0.79-0.84 and 0.61-0.79, respectively. Validity study showed that all the correlations between an item and its corresponding domain were highly significant (r>0.4, p<0.01) and larger than the correlations between the item and other domains. SG and psychometric measures showed relatively low correlations (0.12-0.26). The module showed the same construct as the WHOQOL-BREF(TW) under confirmatory factor analysis, whereas the exploratory factor analysis showed mild variation. Convergent and discriminant validity were good. Global QOL, physical, psychological and environment domains had some sensitivity to differentiate the severity of the condition of patients receiving HD. Clinical validity was demonstrated in global QOL, physical and psychological domains to have significant correlations with S/P scores.

CONCLUSION

Besides broader coverage than the core WHOQOL-BREF(TW), the dialysis module of the WHOQOL-BREF(TW) is a valid, reliable and sensitive QOL instrument for the assessment of HD patients in Taiwan.

Health-related quality of life in nephrology research and clinical practice

Physical, psychosocial, and lifestyle disturbances, along with physical and emotional symptoms, have been shown to impact the health-related quality of life (HRQOL) of those dependent on renal replacement therapy. The value of HRQOL measurement as a tool to improve clinical care has been recognized by patients, clinical investigators, and health care providers. The potential importance of HRQOL assessment lies in the additional information it provides and the impact it has on the clinical decision-making process between a patient and a physician. There remain a multitude of challenges facing renal providers who wish to incorporate HRQOL measurement to improve patient care. These challenges include the clinician's understanding of the conceptual model of HRQOL, the quality of the scientific process that contributed to the current literature on HRQOL, a willingness of the clinician to incorporate HRQOL information into clinical practice, and the logistic difficulties of collecting and applying HRQOL data in a busy practice setting. Arguably, optimizing HRQOL may be the most substantial impact the health care team will have on the person with kidney failure. In order to implement HRQOL assessment at the point of care, providers may consider using computer adaptive testing and scoring algorithms using item response theory, which will allow adequate reliability for interpretation of change among individuals. Moreover, the effective assessment and interpretation of HRQOL will be aided by continued publication of norms, outcomes of randomized controlled trials, and continued experience of investigators and clinicians.

Health-related quality of life predicts outcomes but is not affected by peritoneal clearance: The ADEMEX trial

BACKGROUND

We hypothesized that increasing small solute clearance in peritoneal dialysis (PD) would lead to improvements in patient health-related quality of life (HRQOL).

METHODS

Patients were randomized to a control group [standard 4 x 2 L continuous ambulatory peritoneal dialysis (CAPD)] and an intervention group (CAPD with a target creatinine clearance >/=60 L/week/1.73 m(2)). The Kidney Disease Quality of Life Short Form was obtained at baseline and at 6, 12, and 24 months. Physical (PCS), mental (MCS), and kidney disease component summary (KDCS) scores were computed.

RESULTS

The two groups were comparable at baseline with respect to HRQOL. Baseline variables highly predictive of better QOL included absence of diabetes, younger age, higher starting GFR, and serum albumin. Baseline values of QOL were highly predictive of survival and hospitalizations. An unadjusted comparison revealed that patients in the intervention group had significantly higher PCS and KDCS scores at six months. However, there were no significant differences between the intervention and control patients at 12 or 24 months. When similar analyses were carried out adjusting for different patterns of patient dropout, there were no significant differences between the two groups at any time point in terms of PCS, MCS, and KDCS scores.

CONCLUSION

We found no evidence of a long-term benefit in HRQOL of CAPD patients by increasing peritoneal small-solute clearances when HRQOL parameters were adjusted for patient dropout. Measures of HRQOL have a significant predictive value for patient survival and hospitalizations.

Assessing Health Status and Health Care Utilization in Adolescents with Chronic Kidney Disease

Few validated health status measures have been assessed in children with chronic kidney disease (CKD). The objective was to assess the validity of a generic health status measure, the Child Health and Illness Profile-Adolescent Edition (CHIP-AE), in adolescents with CKD. A case-control study was performed (1) to assess scores on the CHIP-AE in adolescents with CKD compared with two control groups of age-, socioeconomic-, and gender-matched peers and (2) to compare health of patients who had chronic renal insufficiency (CRI), were on dialysis, and were posttransplantation. Seven pediatric nephrology centers recruited 113 patients (mean age, 14 yr; 39 CRI, 21 dialysis, 53 posttransplantation). Compared with 226 control subjects, patients with CKD had lower overall satisfaction with health and more restriction in activity. Positively, patients with CKD had more family involvement, better home safety and health practices, and better social problem-solving skills and were less likely to participate in risky social behaviors or socialize with peers who engaged in risky behavior. Patients who received dialysis were less physically active and experienced more physical discomfort and limitations in activities than did transplant or CRI patients. It is concluded that patients with CKD have poorer functional health status than age-matched peers. Among CKD patients, dialysis patients have the poorest functional health status. These results suggest that the CHIP-AE can be used to measure functional health status in adolescent patients with CKD.

Cultural adaptation and validation of the "Kidney Disease and Quality of Life - Short Form (KDQOL-SF™ 1.3)" in Brazil

The objective of the present study was to translate the Kidney Disease Quality of Life -- Short Form (KDQOL-SF 1.3) questionnaire into Portuguese to adapt it culturally and validate it for the Brazilian population. The KDQOL-SF was translated into Portuguese and back-translated twice into English. Patient difficulties in understanding the questionnaire were evaluated by a panel of experts and solved. Measurement properties such as reliability and validity were determined by applying the questionnaire to 94 end-stage renal disease patients on chronic dialysis. The Nottingham Health Profile Questionnaire, the Karnofsky Performance Scale and the Kidney Disease Questionnaire were administered to test validity. Some activities included in the original instrument were considered to be incompatible with the activities usually performed by the Brazilian population and were replaced. The mean scores for the 19 components of the KDQOL-SF questionnaire in Portuguese ranged from 22 to 91. The components "Social support" and "Dialysis staff encouragement" had the highest scores (86.7 and 90.8, respectively). The test-retest reliability and the inter-observer reliability of the instrument were evaluated by the intraclass correlation coefficient. The coefficients for both reliability tests were statistically significant for all scales of the KDQOL-SF (P < 0.001), ranging from 0.492 to 0.936 for test-retest reliability and from 0.337 to 0.994 for inter-observer reliability. The Cronbach's alpha coefficient was higher than 0.80 for most of components. The Portuguese version of the KDQOL-SF questionnaire proved to be valid and reliable for the evaluation of quality of life of Brazilian patients with end-stage renal disease on chronic dialysis.

Factor structure and reliability of the Hungarian version of the Illness Intrusiveness Scale: invariance across North American and Hungarian dialysis patients

OBJECTIVES

The objectives of this study were to compare the factor structure and to assess the reliability of the Hungarian version of the Illness Intrusiveness Rating Scale (IIRS), testing internal validity and employing simultaneous confirmatory factor analysis (SCFA) in two large samples of North American versus Hungarian patients with end-stage renal disease (ESRD).

METHODS

Translation was conducted according to current recommendations. Following pilot testing, 365 maintenance haemodialysis patients completed the scale. Hungarian data were compared with IIRS data from North American ESRD patients undergoing maintenance hemodialysis to evaluate item bias (Group x Item ANOVA).

RESULTS

Confirmatory factor analyses indicated a good fit between the previously hypothesized three-factor model ("relationships and personal development", "intimacy", and "instrumental" life domains) of the original English version and the Hungarian translation. Although statistically significant (P<.05), the effect size for the Groups x Items interaction was not substantial. Internal consistency was very good (Cronbach's alpha=.80) for the total score, and, although somewhat lower than ideal, it was still in the acceptable range for the subscales (.64-.67). These numbers are similar to values reported for the original English version. Test-retest reliability was also acceptable.

CONCLUSION

The Hungarian translation of the IIRS has the same three-dimensional factor structure as the original English-language version does. Furthermore, it is sufficiently reliable for research applications. These features satisfy important requirements of cultural equivalence.

Do we need a nutrition-specific quality of life questionnaire for dialysis patients?

Food, eating, and quality of life are intimately related. Available generic and disease-specific health-related quality of life (HRQOL) instruments address nutrition only with respect to the ability to eat and omit more dynamic components of nutrition such as sensory enjoyment of food and food intake. For improved assessment and monitoring of nutrition-related quality of life in hemodialysis patients, a nutrition-specific questionnaire is recommended, consisting of two tools: the Appetite and Dietary Assessment Tool (ADAT), already used in many dialysis clinics, and the nutrition-specific Food Enjoyment in Dialysis (FED) questionnaire which asks 10 additional questions on sensory changes, thirst, gastrointestinal symptoms, side effects from medications and/or dialysis, and feelings of satisfaction and control. This nutrition-specific information should permit comprehensive evaluation and monitoring of changes in nutrition related quality of life. When coupled with generic and disease specific tools, it will provide a complete picture of quality of life in hemodialysis patients.

Fellows’ Forum in Dialysis

We describe a patient with end-stage renal disease (ESRD) who developed depression over the period of dialysis initiation. Depression is an extremely common but underrecognized disorder in the dialysis population, which is one of the rationales for this case report. Here we present the epidemiology, mechanisms for diagnosis, associations with medical morbidity, and treatment modalities specifically for patients on dialysis.

ESRD patient quality of life: symptoms, spiritual beliefs, psychosocial factors, and ethnicity

BACKGROUND

Recent research suggests that patients' perceptions may be more important than objective clinical assessments in determining quality of life (QOL) for patients with end-stage renal disease (ESRD).

METHODS

We interviewed 165 hemodialysis patients from 3 sites using a QOL questionnaire that included the Satisfaction With Life Scale (SWLS) and the McGill QOL (MQOL) scale, which includes a single-item global measure of QOL (Single-Item QOL Scale [SIS]). The MQOL scale asks patients to report their most troublesome symptoms. We also initiated the use of a Support Network Scale and a Spiritual Beliefs Scale.

RESULTS

Mean patient age was 60.9 years, 52% were men, 63% were white, and 33% were African American. Patients had a mean treatment time for ESRD of 44 months, mean hemoglobin level of 11.8 g/dL (118 g/L), mean albumin level of 3.7 g/dL (37 g/L), and mean Kt/V of 1.6. Forty-five percent of patients reported symptoms. Pain was the most common symptom (21% of patients). There was an inverse relationship between reported number of symptoms and SWLS (P < 0.01), MQOL scale score (P < 0.001), and SIS (P < 0.001). The Spiritual Beliefs Scale correlated with the MQOL scale score, SWLS (both P < 0.01), and SIS (P < 0.05). The Support Network Scale score correlated with the MQOL Existential (P = 0.01) and MQOL Support (P < 0.01) subscales. No clinical parameter correlated with any measure of QOL, spiritual beliefs, or social support.

CONCLUSION

Symptoms, especially pain, along with psychosocial and spiritual factors, are important determinants of QOL of patients with ESRD. Additional studies, particularly a longitudinal trial, are needed to determine the reproducibility and utility of these QOL measures in assessing patient long-term outcome and their association with other QOL indices in larger and more diverse patient populations.

General or disease specific questionnaire? A comparative study in hemodialysis patients

OBJECTIVE

Today questionnaires developed to assess important outcome measures such as health-related quality of life are widely used. In this study we evaluated the construct validity of the Nottingham Health Profile (NHP) and the reliability of its Turkish version in hemodialysis patients.

METHODS

In a sample of patients on renal dialysis (n = 94) the quality of life is measured by the NHP. The validity of this questionnaire is evaluated by using the Kidney Disease Questionnaire (KDQ) in the same patient group. The NHP is administered twice to each patient, at dialysis intervals two weeks apart.

RESULTS

NHP scores at both administrations are similar in both assessments. Pearson's correlation coefficients range from 0.61 to 0.84. Cronbach's alpha coefficients for the NHP sections range between 0.64 and 0.79. The alpha coefficients for three of the NHP scales (energy, sleep and social isolation) are well below 0.7. In the KDQ the mean values obtained for the five dimensions are: 4.2 +/- 1.5 for physical symptoms, 4.8 +/- 1.7 for fatigue, 4.9 +/- 1.9 for depression, 4.2 +/- 1.2 for relationship with others, and 4.8 +/- 1.5 for frustration. In general the correlation between the dimensions of the NHP and KDQ is good and the correlation coefficients varies from 0.18 to 0.73. Clinical validity is assessed by examining the correlation between the results obtained for the two questionnaires (components of the NHP and KDQ) and hemoglobin level, number of the co-morbid conditions and educational level.

CONCLUSIONS

The NHP is shown to have construct validity when used in patients with end-stage renal disease (ESRD) in Turkey. The application of the NHP in patients with ESRD is easy, fast and the questions are not difficult to understand. The multiple-degree scoring in the KDQ causes a complexity in answering. The correlation between the dimensions of the NHP and KDQ is good. Our results show better correlations between disease specific questionnaires and clinical parameters.

Nutritional status affects quality of life in Hemodialysis (HEMO) Study patients at baseline

OBJECTIVE

To evaluate associations between frequently used indicators for assessing nutritional status and health-related quality of life in hemodialysis patients after controlling for demographics, comorbidity, and dialysis dose.

DESIGN

Survey of 1,387 hemodialysis patients enrolled at baseline in the Hemodialysis (HEMO) Study. Nutritional status indicators included dietary energy intake, equilibrated normalized protein catabolic rate (enPCR), serum creatinine (SCr), serum albumin (SAlb), body mass index (BMI), calf circumference, and appetite. Health-related quality of life was measured by the Medical Outcomes Study Short Form-36 (MOS-SF-36) summary measures: the Physical Component Scale (PCS) and Mental Component Scale (MCS).

SETTING

Fifteen clinical sites throughout the United States providing in-center hemodialysis.

RESULTS

The mean PCS score was 36.1 +/- 10 SD, lower than normative data in healthy populations. PCS scores were lower among women, whites, and those with diabetes, severe comorbidities, and poor appetites. Appetite, dietary energy intake, SAlb, and SCr were strongly associated with PCS scores even after controlling for demographics and comorbidity. The sum of the parameter estimates for the effects of nutritional status on PCS was large, 7 points or more depending on the individual's nutritional status indicators. The mean MCS score was 49.7 +/- 10.1 SD, similar to scores in healthy populations, but lower among those with severe comorbidities, poor appetites, advanced age, and more years on dialysis. Appetite, age, and years on dialysis were significantly associated with MCS after controlling for other demographics and comorbidity. Dialysis dose did not significantly alter these relationships.

CONCLUSION

Easy-to-use indicators for assessing nutritional status (appetite, energy intake, SAlb, and SCr) together are strongly associated with health-related quality of life, even after controlling for comorbidities and dose of dialysis in hemodialysis patients, providing an additional reason for maximizing patients' nutritional status and health.

Early quality of life benefits of icodextrin in peritoneal dialysis

Early quality of life benefits of icodextrin in peritoneal dialysis.

BACKGROUND

The impact of new therapies on patient quality of life (QOL) is emerging as an important indicator of the value of these therapies. In patients on dialysis, previous QOL evaluations have focused mainly on comparative approaches between modalities, or on longitudinal trends within a modality, but few have evaluated technical innovations or introduction of new therapies. The aim of the present study was to assess the early effects of a new dialysis solution (icodextrin) on the QOL of peritoneal dialysis patients. The QOL is compared with that of patients on dextrose, and the impact of demographic, and clinical characteristics on patients' QOL is examined.

METHODS

The kidney disease quality of life questionnaire (KDQOL) was administered to patients who participated in a phase III double-blind, parallel group, active-controlled trial to evaluate the efficacy and safety of a peritoneal dialysis (PD) solution containing icodextrin in comparison with dextrose PD solution. A total of 93 patients (58 icodextrin, and 35 dextrose) completed the questionnaire at both baseline and after 13 weeks. In addition to patients QOL, patients' demographic and clinical characteristics were recorded at both baseline and 13 weeks.

RESULTS

Mean change scores from baseline to 13 weeks of icodextrin patients were substantially higher (> or =5) than dextrose, particularly with respect to general health perception, physical functioning, role-physical, and many KDQOL symptom items such as lack of strength, washed out or drained, lack of appetite, faintness or dizziness, dry skin, cramps after an exchange or treatment, cramps during an exchange or treatment, and muscle spasms or twitching. At 13 weeks, icodextrin patients had significantly improved symptoms, and rated their health in general higher than those patients in the dextrose group. Upon multivariate analysis, icodextrin contributed significantly to the improvement of patients' mental health, general health, and symptoms such as muscle spasms or twitching, cramps during an exchange or treatment, cramps after an exchange or treatment, itchy skin, and faintness or dizziness.

CONCLUSIONS

Peritoneal dialysis patients treated with icodextrin experienced substantial quality of life improvement at 13 weeks after the start of treatment when compared to dextrose patients. Further research is necessary to determine patients' quality of life over time in a longitudinal study setting.

Cross-sectional study of health-related quality of life in African Americans with chronic renal insufficiency: the African American Study of Kidney Disease and Hypertension Trial

We measured health-related quality of life (HRQL) by using the Medical Outcomes Study 36-Item Short-Form (SF-36) in a cross-sectional study of 1,094 African American men and women with mild to moderate chronic renal insufficiency (mean glomerular filtration rate, 45.7 mL/min/1.73 m2) caused by hypertension before randomization onto the African American Study of Kidney Disease and Hypertension (AASK) Trial. Scales contributing to physical health and a summary measure, the Physical Component Summary (PCS) score (mean, 43.4 +/- 10.9 [SD]), were significantly lower than scales relating to mental health and the Mental Component Summary (MCS) score (51.3 +/- 10.3). All scales (except Role-Physical) and the PCS and MCS were significantly higher in men (44.3 +/- 10.9 and 51.8 +/- 10.0, respectively) than women (41.9 +/- 10.8 and 50.5 +/- 10.6, respectively). In multivariate analysis, employment status, education level, household income, body mass index, comorbid medical conditions, years of hypertension, number of antihypertensive drugs prescribed, exercise status, and male sex were significant independent predictors of PCS. Fewer factors predicted MCS and included employment status, marital status, current smoking, age, comorbid medical conditions, and male sex. In the entire AASK cohort, mean scores for individual scales, except Mental Health, and the PCS were lower, but the mean MCS score was slightly higher than values for the US general population. Values for individual scales of the SF-36 and the PCS were substantially higher among AASK participants compared with African-American hemodialysis patients. Six of the eight scales were lower in the AASK cohort compared with groups of racially mixed and exclusively African-American hypertensive subjects. We conclude that physical aspects of quality of life are substantially reduced compared with mental components among AASK participants, and a number of demographic and clinical characteristics significantly impact on HRQL.

Antihypertensive treatment with and without benazepril in patients with chronic renal insufficiency: a US economic evaluation

OBJECTIVE

To conduct an economic analysis in the US of antihypertensive treatment with and without benazepril in patients with chronic renal insufficiency.

DESIGN

A four-state Markov model, using clinical data obtained from a 3-year randomised clinical trial [the Angiotensin-Converting-Enzyme Inhibition in Progressive Renal Insufficiency (AIPRI) study] plus its extension study (median 3.6 years), and cost data obtained from published US sources. The period of analysis was 7 years following randomisation.

PERSPECTIVE

Healthcare payer.

SETTING

Clinical data were obtained from multiple medical centres in three European countries as described in the published studies. Key economic data were obtained from the US Healthcare Financing Administration's End Stage Renal Disease programme.

PATIENTS AND INTERVENTIONS

In the clinical studies on which this economic analysis was based, patients with chronic renal insufficiency of various aetiologies were randomised to antihypertensive therapy with or without concomitant benazepril.

MAIN OUTCOME MEASURES AND RESULTS

Over 7 years of analysis, patients randomised to antihypertensive treatment with concomitant benazepril therapy incurred on average USD12991 (1999 values) lower medical costs than patients prescribed antihypertensive treatment without benazepril, and obtained an additional 0.091 quality-adjusted life years (QALYs). Costs and QALYs were greater for the benazepril arm than the placebo arm for all years of analysis after the first. Rank order stability of results favouring the benazepril therapy arm was found in sensitivity analyses of changes in key model parameters. Additional economic and health benefits favouring patients receiving benazepril would be seen if underlying model rates of dialysis and transplantation were increased, as may be appropriate to reflect treatment practice differences in the US relative to European countries.

CONCLUSIONS

Benazepril therapy as a component of antihypertensive treatment of persons with chronic renal insufficiency initially costs money, but investment costs are recouped quickly and return on investment continues to grow. The impact of end-stage renal disease on patient health and healthcare costs is great. Thus, the quality-adjusted survival benefits and overall cost savings seen in benazepril recipients over a prolonged period (2 to 7 years) indicate that the strategy of prescribing benazepril to reduce progression of renal disease in patients with renal insufficiency is both clinically and economically beneficial compared with current antihypertensive regimens without ACE inhibition.

Quality of life in end-stage renal disease patients

Health-related quality of life (QOL) refers to the measure of a patient's functioning, well-being, and general health perception in each of three domains: physical, psychological, and social. Along with survival and other types of clinical outcomes, patient QOL is an important indicator of the effectiveness of the medical care they receive. QOL of patients with end-stage renal disease is influenced by the disease itself and by the type of replacement therapy. Numerous studies have identified the effect of such factors as anemia, age, comorbidity, and depression on QOL. Most of these factors appear during the predialysis period, and the adequate management of some of them could influence patient outcomes. Among replacement therapies, transplantation appears to give the best QOL for large groups of patients. No conclusive data exist to prove differences in QOL between hemodialysis patients and peritoneal dialysis patients. In the case of elderly patients or those with a high degree of comorbidity, the best treatment option should be assessed in each individual case, taking all possible factors into account. Finally, it has been proven that physical and mental function are inversely correlated with the risk for hospitalization and mortality.

Quality of life in end-stage renal disease patients

Health-related quality of life (QOL) refers to the measure of a patient's functioning, well-being, and general health perception in each of three domains: physical, psychological, and social. Along with survival and other types of clinical outcomes, patient QOL is an important indicator of the effectiveness of the medical care they receive. QOL of patients with end-stage renal disease is influenced by the disease itself and by the type of replacement therapy. Numerous studies have identified the effect of such factors as anemia, age, comorbidity, and depression on QOL. Most of these factors appear during the predialysis period, and the adequate management of some of them could influence patient outcomes. Among replacement therapies, transplantation appears to give the best QOL for large groups of patients. No conclusive data exist to prove differences in QOL between hemodialysis patients and peritoneal dialysis patients. In the case of elderly patients or those with a high degree of comorbidity, the best treatment option should be assessed in each individual case, taking all possible factors into account. Finally, it has been proven that physical and mental function are inversely correlated with the risk for hospitalization and mortality.

The impact of dialysis and transplantation on children

Effective methods to treat end stage renal disease (ESRD) in children have become available in the United States during the last 3 decades. Since the United States Congress created the Medicare ESRD Program in 1972, most children with ESRD have the option of Medicare insurance. Medicare expenditures for children with ESRD range from $14,000 for transplant recipients to $43,000 for dialysis patients per year. The tremendous expense of ESRD treatment has led to research to determine which treatment options are associated with the best health outcomes and the best value (quality/cost) for the money spent treating ESRD. The National Kidney Foundation's Dialysis Outcomes Quality Initiative recommends the use of quality of life and health status measures to gauge the impact of renal replacement therapy on quality of life in the ESRD population. In adult patients with renal failure, several generic and disease-specific quality of life measures have been validated and tested for reliability. In contrast, little research using validated and reliable health status measures has been performed in pediatric patients to measure the impact of ESRD. This article summarizes existing literature on how we currently measure the impact of dialysis and transplantation on children, discusses existing health status measures for children and adolescents, and describes how these measures might be used to improve our care of patients and long-term outcomes for children with kidney failure.

The Use of Patient-Based Instruments to Measure, Manage, and Improve Quality of Care in Dialysis Facilities

Continuous quality improvement requires analysis of data and the variation in those data to improve the process of care. Traditionally, physicians assign a higher value to quantitative data gathered from laboratory and physiologic testing than to data gathered from querying patients. There is a growing literature validating the use of patient-assessed health status as primary data in measuring and managing quality improvement. There are a range of patient-assessed data, from simple "complaints" to psychometrically validated health status instruments. Each has its own use. Each are increasingly available for use in the routine conduct of care. Patient-assessed health status predicts important outcomes of care such as death, hospitalization, depression, and physical capacity. Providers can use them to plan and monitor care. The ongoing challenge is to align the patients' expectations for issues related to process of care with issues associated with outcomes of care.

Developing a health-related quality-of-life measure for end-stage renal disease: The CHOICE Health Experience Questionnaire

The Choices for Healthy Outcomes in Caring for End-Stage Renal Disease ([ESRD] CHOICE) Study was designed to evaluate the effectiveness of alternative dialysis prescriptions. As part of CHOICE, we developed an instrument for measuring health-related quality of life (HRQOL) for patients with ESRD that would complement the Medical Outcomes Study 36-Item Short-Form Survey (SF-36) and be sensitive to differences in dialysis modality (hemodialysis [HD] and peritoneal dialysis [PD]) and dialysis dose. The selection of HRQOL domains to be included was based on: (1) a structured literature review of 47 articles describing 53 different instruments; (2) content analysis of five focus groups with HD and PD patients, nephrologists, and other providers; (3) a survey of 110 dialysis providers about features of different modalities that affect patient HRQOL; and (4) a semistructured survey of 25 patients with ESRD on the effects of dialysis on functioning and HRQOL. To help prioritize domains and items identified by these methods, a representative sample of 136 dialysis patients rated each item for frequency and bother. A panel of nephrologists provided advice about the salience of items to modality or dose. Items and scales were selected with a preference for existing measures tested in patients with ESRD and were tested for reliability and validity. The first four steps yielded 22 HRQOL domains that included 96 items: 8 generic domains in the SF-36 (health perceptions, physical, social, physical and emotional role function, pain, mental health, and energy); 8 additional generic domains (cognitive functioning, sexual functioning, sleep, work, recreation, travel, finances, and general quality of life); and 6 ESRD-specific domains (diet, freedom, time, body image, dialysis access [catheters and/or vascular], and symptoms). New items were developed or adapted to assess ESRD-specific domains. Scales for these items showed adequate internal consistency (Cronbach's alpha > 0.70, except for time [alpha = 0.57] and quality of life [alpha = 0.68]), as well as convergent and discriminant construct validity in a sample of 928 patients. The final questionnaire included 21 domains (time was deleted) and 83 items. We have designed a patient-centered instrument, the CHOICE Health Experience Questionnaire, that addresses domains that may be sensitive to differences in dialysis modality and dose and shows evidence for reliability and validity as a measure of HRQOL in ESRD.