Quality of Life in Patients with Chronic Renal Failure and Some Affecting Factors

Purpose: This study was conducted to determine the quality of life (QoL) in dialysis patients (DP) and the factors affecting the QoL. Material and Methods: 104 DP patients receiving treatment at a university hospital were included in this research, which was also a cross-sectional study. Data were collected with the Patient Information Form (PIF) and Kidney Disease Quality of Life Form (KDQOL-36). Collected data were evaluated on SPSS. Result: The most affected QoL dimensions in the sampling were disease burden based on kidney disease, physical health-12 and mental health-12, respectively. The QoL was found low in higher ages, women, people with low education level, people living with family and patients undergoing dialysis for a long time (p< 0.05), and mental health was low in single people. Moreover, mental health component scores were especially obtained low in people who didn’t adherence their diet. In our study, the effect on quality of life was not found statistically important in terms of having a comorbid disease and taking erythropoietin (p> 0.05). Conclusion: CRF led to an advanced increase in the disease burden of the patients and infl uenced the areas of physical and mental health negatively. In order to enhance the QoL in patients with CRF, it is necessary to improve the affected areas with a multidisciplinary approach and to handle the factors which infl uence the QoL with the understanding of effective and holistic health services in line with the individualized need for patient care. Research Article Quality of Life in Patients with Chronic Renal Failure and Some Affecting Factors Mukadder Mollaoğlu1* and Gonca Deveci2 1Professor, Department of Nursing, Cumhuriyet University, Health Sciences Faculty, Turkey 2Cumhuriyet University Hospital, Nephrology Departments, 58140 Sivas/ Turkey Dates: Received: 12 April, 2017; Accepted: 25 May, 2017; Published: 29 May, 2017 *Corresponding author: Mukadder MOLLAOĞLU, Professor, Department of Nursing, Cumhuriyet University, Health Sciences Faculty, Turkey, Tel: 0.346.225 23 21; Fax: 0.346.225 18 21; E-mail:


Introduction
Chronic renal failure (CRF) is an important public health problem that has become an epidemic in Turkey [1,2]. CRF threatens the patient health with high rates of disability and death, and the health budget together with expensive dialysis and kidney transplant treatments seriously. Over 2 million people worldwide still maintain their lives with dialysis and kidney transplant treatments. It is estimated that approximately 10% of the adults have kidney disease in the world. This number is expected to double annually by 6-8 % in coming 10 years, and the total treatment cost may reach 1.5 trillion dollars. According to the data of the Turkish Nephrology Association, there are almost 60,000 patients who receive dialysis treatment or had kidney transplant. It is anticipated that this number will exceed 100,000 annually by 10% in 2015, which is almost twice of many developed countries, and the 1.5 billion dollar treatment cost will double [1][2][3][4].
However, important changes occur in lives of the patients who receive hemodialysis treatment despite the developments in this treatment model. Patients encounter many physical, spiritual and social problems [5][6][7][8]. Symptoms such as fatigue, cramp, pain, sleep disorder, dyspnea, piruritis, depression, nausea, vomiting and constipation negatively infl uence all the areas of daily living and the quality of life (QoL) of individuals [10][11][12].
Restrictions in social life and physical activity diffi culties occur together with these symptoms that are frequently experienced by the hemodialysis patients. It was found that especially fatigue infl uenced working, spending free time, nutritional habits, sexual activities, enjoying life, family relations and friendships negatively [13,14] . Some psycho-social diffi culties like the deterioration of the working capacity, decrease in the physical activities, problems inside the family and sexual problems in dialysis patients complicate the maintenance of the treatment and infl uence the disease process and treatment negatively [15][16][17]. http://doi.org/10.17352/2455-5495.000020 Because the patients receiving regular hemodialysis treatment have to deal with the symptoms of the disease, continue a diet, adapt themselves to the changes in their bodies and review their personal, social and professional purposes once again, hemodialysis affects briefl y all the areas of life including social, economic and psychological aspects and the QoL [7,13,17]. Patients might be under the effect of many psychological and physical factors and develop physical and psychological problems while getting used to the changes in their lives and learning to live with them. All these may affect the life qualities of the individuals negatively [18][19][20][21][22] . Planning care attempts that will enable understanding the disease behavior in sick individuals, psychological reactions and adaptation diffi culties and developing appropriate handling methods can be possible with QoL evaluations [20,22]. As in WHO's defi nition, QoL studies must occasionally be carried out for the holistic evaluation including physical, spiritual and mental dimensions of life [15][16][17]20]

Method
Research sampling consisted of patients who underwent dialysis treatment with chronic renal failure diagnosis in the dialysis unit of a university hospital, complied with the criteria and accepted to participate in the study. The criteria applied in the sampling selection were being at and above the age of 18, having undergone dialysis treatment at least for six months, having no psychiatric diseases, open consciousness and cooperation. In compliance with these criteria, 104 patients were included in the study. Eight patients were excluded from the study because they were unwilling, two patients were not included due to conscious changes and four patients were excepted due to the fact that they had been diagnosed for less than six months.

Kidney Disease Quality of Life-Short Form (KDQOL-SF):
The form which is mostly used in the ESKD, a scale specifi c to the disease, is the Kidney Disease Quality of Life Form.
KDQOL was developed by Ron Hays et al. in the USA in 1994 [22] and translated into Spanish, Italian, German, Japanese, French, Chinese, Netherlandish (Dutch) and Turkish. This is a scale that helps monitoring the ESKD patients and in which its various treatment effects and well-being are declared and evaluated by the patient himself.
It has both a general section and a section specifi c to the kidney disease. As a general scale, it is based on SF-36, and as a specifi c scale, it includes questions targeting certain health problems of the individuals with kidney disease or ESKD patients that received renal replacement treatment; it is a self-applicable scale. The survey has 36 articles divided into 5 dimensions. SF-12 (12 articles); articles related to kidney disease (5 dimensions/24 articles): Symptom/problem list (12 articles), Effect of kidney disease (8 articles), Burden of kidney disease (4 articles), SF12 physical component (6 articles), SF12 mental component (6 articles). Likert method was used for each article during the scoring. A program is available on the website of the KDQOL study group which is used for calculating the score. Scores change between 0 and 100 at each dimension, and higher scores refl ect the QoL QoLrelated to better health. Its Turkish translation was made by Yıldırım et al [23]. For the Turkish version of the scale, the Cronbach alpha value was found as 0.80.

Ethics considetation
The study was approved by the Ethics Commitee of the Cumhuriyet University Hospital in addition to the offi cial permissions. The patients were informed that they would end their participation whenever they want, their private information will not be revealed or used in whatsoever form, and utmost confi dentiality will be maintained.

Statistical analysis
SPSS (Statistical Package for Social Sciences) 14.0 statistics packaged software was used for statistical assessments in this research. For the sociodemographic, clinical and laboratory data of the patients, descriptive statistical methods were used. In the analyses including group comparisons, the Chi-square test was applied for categorical variables, the Mann Whitney U test for averages in 2-group comparisons and the Kruskal Wallis test in 3-group comparisons. Results were assessed at 95% confi dence interval and the signifi cance level was accepted as p<0.05.

Results
It was determined that 52.9% of the cases with a 63.05 (SD;12,92) average of age were men, 69.2% were married, 66.3% were primary school graduates, only 5.8% were university graduates, most of them didn't work (97.1%) and 70.2% had living with family. Moreover, 64.6% had another diagnosed chronic disease and people with chronic diseases mostly had diabetes and hypertension problems (95.0%). It was found that 93.3% of the cases underwent hemodialysis, 36.7% had dialysis application less than 1 year, 68.9% went through dialysis procedure 5 years or less, 70% of hemodialysis patients went into dialysis for 3 times 4 hours a week, 84.6% adhered to their diet as they stated and only 25% received erythropoietin treatment (Tables 1,2). http://doi.org/10.17352/2455-5495.000020 It was also detected in the sampling that the disease burden based on kidney disease was the lowest (mean; 28.25, SD; 27.26), and the means of physical health-12 (mean: 30.87, SD: 9.58) and mental health-12 (mean: 37.99, SD: 9.62) were low, too (Table 3).
Considering the relationship between the sociodemographic attributes and QoL of the cases, age differences were found important in terms of symptoms (p<0.01), but unimportant in terms of disease duration, disease effect, SF12 physical component and SF-12 mental component (P>0.05). A negatively oriented (r=-.13) relationship was obtained between ages and symptoms. Even though this relationship coeffi cient is statistically important, it is weak as a relationship criterion.
When QoL functions were compared as per gender, the difference between the genders was found unimportant in terms of disease burden (p>0.05), but important in terms of symptoms, disease effect, SF-12 physical component and SF-12 mental component (p<0.05). As seen, the score of women is lower than that of men at these parameters. When QoL  Chronic obstructive pulmonary disease 5 (7.5)    [12,17]. This dependence leads to troubles in family, professional and social lives of the patients. These problems infl uence the QoL of the patients negatively [13,15]. The quality of life is a signifi cant criterion for the evaluation of quality of life, treatment consequences and level of living [16,18,20].
With this understanding, our study aims at researching the quality of life in the patients who have chronic renal failure and dialysis treatment in our university hospital and factors affecting it.
Subscale scores of QoL scale that belong to the cases were generally found low in our study. In the sampling, mostly the disease burden based on kidney disease, physical health and mental health were infl uenced respectively. It was detected in many studies investigating the QoL of the patients with ESRF that QoL was perceived medium and below medium/low in parallel with our result [24,25]. Patients felt mostly the disease burden of kidney disease in this sampling. Disease burden has been determined as the factor decreasing the QoL of the patients mostly. QoL scores related to physical and mental health were also found low.
When the relationship between the sociodemographic attributes and QoL of the patients with CRF is reviewed, age increase in CRF is generally associated with bad results in QoL researches regarding health [18,[26][27][28]. A negatively oriented relationship was found between ages and symptoms in this study. This result, which was obtained from our study, shows consistency with the previous research results [29][30][31].
Mollaoğlu [30], revealed that the fatigue level rose with the increasing age and there was a signifi cant difference between the age groups and fatigue. It is supposed that the increase in fatigue resulting from the rising age of the hemodialysis patients and the physiological changes that occur with aging may cause this situation and it may also result from the increase in the number of chronic diseases with aging and the psychosocial effects of these diseases Hence, the existence of other chronic diseases other than CRF is also observed in most of our sampling.
Generally, female patients exhibit a worse QoL in the studies [18,22,28]. The score of women is lower than that of men in this study as well. Our study fi nding is similar to some research results [31][32][33]. All the subgroup score means of men in this study except for the disease burden of QoL scale were found higher than those of women. This fi nding draws attention to the need for supporting the women, who have more roles and responsibilities at home, in terms of physical and social aspects.
In our study, mental health status of the married patients was found higher than that of single patients. It was similarly reported in studies made on the hemodialysis patients that the general functional performance status and many dimensions were infl uenced more negatively in married patients compared to the single ones [18,27,28]. The reason behind the fact that married people have better mental health than the single people is attributed to the stronger social support, as determined in some studies [18,28]. Thus, the lower QoL including the mental health in people living alone supports this result in the study.
It was identifi ed in our study that symptom and disease effect was perceived more negatively in people with lower educational level and this decreased the quality of life. The QoL was generally found to increase in parallel with the increase in the educational status. This result supports the literature [18,[27][28][29][30][31]. The rise in the QoL scores together with the increase in educational level was an expected fi nding and it is thought that the health perception will change and develop positively, individuals will take more responsibilities related to health, in this sense, they will learn and use management strategies for their diseases or disease symptoms, and as a result, the QoL will enhance as the educational level increases.
In our study, quality of life in individuals living with their families were found higher than those living alone. It was set forth in the research made by Parkerson and Gutman [34], that social support perception and life qualities of the patients living with their families were higher. Zhang and Liu [35], revealed in their study that the QoL enhanced as the family support increased. Social support is very important in chronic diseases. It is generally anticipated that people living with their families will have more psychological support and their QoL will be higher due to sharing the family roles [34][35][36][37].  [17,38,39].
When the QoL subscales were compared as per the dialysis session frequency in our study, the difference was found important in terms of symptoms and disease burden. QoL score is higher in patients who received dialysis treatment 3 days 4 hours a week. When short-term daily hemodialysis, night, long hemodialysis (5-6 times/week) and conventional hemodialysis (3 times/week) were compared in a study, QoL scales improved in parallel with the improvement in fl uid, blood pressure and mineral metabolism control of the patients to whom dialysis methods were applied frequently. This study supports our results [17,38].
The quality of life in the patients with CRF that adhered to their diet was found high in our study. QoL of the patients that adhered to their diet was found high in previous studies as well [22,31,24]. In patients following their diet, metabolic control (urea, uric acid, creatine etc.) is provided in a better way, incidence of disease/dialysis complications based on gaining excessive weight decreases, and accordingly, the quality of life is affected positively.
When the QoL subscales were compared as per the erythropoietin application in our study, scores were found higher in terms of all the components compared to those who didn't take it, but the statistical difference is unimportant. In the literature, QoL of the cases that took erythropoietin was found signifi cantly high in every area [40][41][42][43]. It is imagined that the limited number of the patients who took erythropoietin may have infl uenced the result in the study.
In conclusion, CRF led to an advanced increase in the disease