Assessment of Quality of Life and Associated Factors in Patients of Non-diabetic Chronic Kidney Disease in Various Stages: Pre-dialysis, Dialysis, and Kidney Transplant Recipients

Dear Editor,

Chronic kidney disease (CKD) is characterized by progressive nephron loss, leading to irreversible decrease in GFR and loss in renal function.¹ Five to ten percent of the world’s population is estimated to be suffering from CKD.² The Global Burden of Disease Study 2015 ranked CKD as the 8^th leading cause of death in India.³ The overall age-adjusted incidence rate of end-stage renal disease in India is 229 million.⁴ Very few studies that assess the quality of life in various stages of CKD, including dialysis and transplantation, have been done in our country. The disease burden has a strong impact on the patient’s quality of life (QOL) and other associated factors.

Our study included 120 subjects: 30 each in CKD, hemodialysis, peritoneal dialysis, and renal transplantation. The mean age of the study participants was 43.31 ± 11.99 years. The male-to-female ratio was 2:1. Of the total number of participants, 86.7% were married and 60.8% belonged to the upper-middle class. Sixty-one percent of the study participants belonged to the normal BMI range, and 28.3% were graduates. The aetiologies for CKD were chronic gloemrulonephritis (55/120; 45.83%), unknown aetiology (51/120;42.5%) and chronic pyelonephritis (14/120; 11%).

The health-related QOL (HRQOL) was studied using Kidney Disease Quality of Life Short Form 36 (KDQOL-SF 36) version 1.3⁵ from RAND corporation, which has been validated in our population. The kidney disease–specific instrument assesses the burden of kidney disease in 11 domains (symptoms or problems of kidney disease, burden of kidney disease, effects of kidney disease, work status, cognitive function, quality of social interaction, sexual function, sleep, social support, patient satisfaction, and dialysis staff encouragement). Each domain is scored on a 100-point scale, with higher scores representing better QOL. The individual scores can be averaged to a kidney disease component summary (KDCS) score.

The SF-36 assesses the HRQOL in eight domains (physical functioning, role limitations caused by physical problems, role limitations caused by emotional problems, pain, general health, energy or fatigue, emotional well-being, and social function). Results from the SF-36 are further summarized into a physical composite summary (PCS) and a mental composite summary (MCS) score.

The QOL in the four groups is listed in Table 1. Symptom burden and problem, effects of kidney disease, burden of kidney disease, and KDCS were highest. Quality of social interaction and sleep was higher in the transplant group. There seemed to be no difference in the dialysis groups. The work status was affected in all the groups, with better scores noted in the dialysis groups.

The SF-36 scores are tabulated in Table 1. Physical functioning, role physical, general health, role emotional, and PCS were well preserved in the transplant group. Emotional well-being and MCS were comparable. In physical functioning, physical role was better in PD compared to hemodialysis (HD). In social functioning, significantly lower scores were seen in the transplant group and peritoneal dialysis group, whereas the highest score was seen in the CKD group. The physical and mental composite scores were better in the transplant group.

The impact of social and demographic parameters (age, gender, marital and socioeconomic status, BMI, and education) is tabulated in Table 2. A significant impact of age, socioeconomic status, and education was observed only on the PCS scores, and there was no impact on the MCS scores and the KDCS scores. PCS showed a significantly declining trend with respect to age, with higher scores noted in the younger age group; this implied a higher threshold and better ways of coping. Men were found to have better PCS, MCS, and KDCS scores. Upper class and higher education had significantly higher scores in the PCS. This data, when analyzed under multiple linear regression, emphasized irrespective of the socioeconomic class of the study subjects, in KDCS domain education plays an important role in raising an awareness on health thus bringing the P value to 0.029, where as it does not seem to affect the PCS and MCS. In the analysis of SF-36, we observed that RT patients scored better results compared to the other three groups. In the dialysis groups, PD patients had better scores in physical and emotional well-being. Overall, the scores were poor in HD in comparison with others. The PCS showed a nonsignificant declining trend from RT to HD, whereas the MCS was comparable in all the groups.

In conclusion, transplant patients had a better QOL with respect to physical functioning, role physical, general health, role emotional, and PCS. CKD patients had better work status and KDCS scores. In the dialysis groups, PD patients had better physical and emotional well-being. Socioeconomic status and education seem to play an important role in influencing the QOL. The higher the education status, the better was the QOL. All four groups required emotional support uniformly.