Comparison of Quality of Life in patients with advanced chronic kidney disease undergoing haemodialysis, peritoneal dialysis and conservative management in Johannesburg, South Africa: a cross-sectional, descriptive study

Abstract

Introduction: Mental health and quality of life are under-appreciated clinical targets which affect patient and modality survival.  Lack of dialysis slot availability in the resource-constrained public health sector in South Africa, results in assignment to treatment modalities without regard to effects on these parameters.  We assessed the effect of dialysis modality, demographic and laboratory parameters on mental health and quality of life measurements.

Methods: Size-matched voluntary cohorts were recruited from patients on haemodialysis (HD), peritoneal dialysis (PD), and patients on conservative management (with an estimated glomerular filtration rate below 20mL/min/1.73m²), between September 2020 and March 2021.  Responses to the Hospital Anxiety and Depression Scale (HADS) and Kidney Disease Quality of Life Short Form 36 (KDQOL-SF36) questionnaires and demographic and baseline laboratory parameters were compared between treatment modalities using the Student t-test and Pearson Chi-square test.  Linear regression was used to test for independent effect where significant difference was observed.

Results: HADS anxiety score was highest (p < 0.001) and KDQOL-SF36 emotional wellbeing was poorer in HD (p < 0.001). Social functioning (p = 0.011) and physical limitation due to pain (p = 0.030) were poorer in PD.  Unemployment (p = 0.044) was more frequent in HD; fewer PD patients required a social support grant (p = 0.008).  Significant independent effect was found for age (p = 0.009), employment (p = 0.007), and haemoglobin (Hb) (p = 0.025) on anxiety; HD worsened (p = 0.037) and PD improved (p = 0.007) anxiety.  Unemployment (p < 0.001) and low Hb (p = 0.018) worsened depression.  PD improved (p= 0.002) and HD worsened (p < 0.001) emotional well-being.  PD worsened social functioning (p = 0.002).  PD (p = 0.007) and higher phosphate (p = 0.022) worsened and HD (p = 0.01) and higher Hb (p = 0.02) improved physical discomfort / pain.

Conclusion: Advanced chronic kidney disease increases anxiety and depression and limits quality of life.  Peritoneal dialysis improves mental health and emotional wellbeing and preserves the ability to undertake economic activity but limits social functioning and causes greater physical discomfort.  Targeting haemoglobin and phosphate may ameliorate modality effects on mental health and quality of life.

Introduction

A significant burden of communicable and non-communicable diseases, combined with poor access to nephrology services, render chronic kidney disease (CKD) not uncommon in low-to-middle income countries (LMIC); in Africa genetic risks exacerbate this pattern(1, 2). South Africans are at increased risk of CKD due to a combination of these genetic and environmental risk factors (1). Socioeconomic improvements since the advent of democracy are likely to exacerbate this risk as urbanization and lifestyle change increase the prevalence of hypertension and diabetes (2).

Although the majority of South Africans are reliant on the public sector for management of kidney failure (KF), long-term under-resourcing of state-sponsored dialysis units has resulted in disparities in access to treatment, with the dialysis treatment rate in the private sector being 787 per million population (pmp) as compared to 57 pmp in the state sector (3). Patients with KF in the state sector may therefore not be able to access dialysis and may instead receive conservative management. Those patients fortunate enough to receive dialysis often do not have the luxury of choosing a preferred modality; instead, many state facilities pursue a policy of “peritoneal dialysis first”. Lack of participation in treatment planning may adversely affect treatment satisfaction and quality of life (QOL) (4). Increased survival rates on dialysis, combined with declining rates of transplantation in South Africa, (5) contribute to prolonged waitlisting, in turn leading to accrual of aging and dialysis vintage-associated pathologies which may compromise QOL. Indeed, dialysis treatments themselves carry the potential for significant morbidity which may offset improvements in QOL attained through amelioration of uraemic symptoms.

QOL is known to affect future risk of hospitalisation and mortality (6),(7), as well as compliance with therapy (8). In addition, QOL is itself a significant outcome measurement of kidney replacement therapy (KRT) (9). Despite this, QOL remains an underappreciated and under-researched component of KF management, and there is a paucity of data on the quality of life experienced by dialysis patients in the South African context (10),(11),(12). In particular, the effect of non-directed dialytic therapy on QOL has not been contextualised against the QOL of patients receiving conservative management for KF. This study compares the quality of life of patients on peritoneal and haemodialysis against those with advanced CKD not receiving dialysis and considers the effect of comorbidities on quality-of-life scores.

Methods

Study Instruments

Participants were administered the Hospital Anxiety and Depression Scale (HADS) and the Kidney Disease Quality of Life Short-Form 36 (KDQOL- SF36) questionnaires during routine clinical appointments. Participants who were unable to complete the questionnaires independently or who required translation of the questionnaires into their vernacular language were assisted by nursing staff or the primary investigator. KDQOL-SF36 responses were transformed to domain scores using the online RAND health group KDQOL-SF™ 1.3 calculator. Respondent demographics, HADS and transformed KDQOL-SF36 domain scores were entered with most recent laboratory results in an anonymized database which was used for statistical analysis.

Both the HADS and the KDQOL-SF36 surveys are validated for use in patients with advanced CKD (13),(14). The KDQOL-SF36 consists of 36 questions which provide information on quality of life across a number of subdomains, including physical functioning, role-physical, pain, emotional well-being, role-emotional, and social functioning; scoring is from 0–100 with higher scores indicating better function. Physical function and mental health subdomain scores are used to calculate composite physical and mental score, reflective of overall limitation in these respective areas. The HADS scale questionnaire produces a score of 0–21 for both anxiety and depression symptoms, a score of more than 8 correlates with overt clinical disorder, whilst a score of 4–8 is indicative of borderline symptomatology.

Ethics Approval

Approval for this study was obtained from the Human Research Ethics Committee of the University of the Witwatersrand (protocol number M200635). Institutional approval was obtained from Helen Joseph Hospital. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Results

One hundred and fifty patient participants were recruited to this study, comprising 50 patients on haemodialysis (HD) and peritoneal dialysis (PD) each, and 50 patients with advanced kidney dysfunction (eGFR less than 20mL/ min/1.73m²) undergoing conservative outpatient management (CM). Amongst CM participants, 31 (62%) were in stage 5 of CKD (eGFR consistently below 15mL/min/1.73m²). Baseline characteristics are shown in Table 1 below.

Significant differences in age (p < 0.001), haemoglobin (Hb) (p < 0.001), phosphate (p = 0.005), albumin (p < 0.001), parathyroid hormone (PTH) (p < 0.001), and prevalence of diabetes mellitus (p = 0.004) were observed between treatment groups; dialysis vintage was greater in patients on HD (p = 0.002). Sex, level of education, relationship status, prevalence of HIV infection and cardiovascular disease, and serum urea and calcium showed no significant difference between groups.

Unemployment was more frequent in the HD treatment group (p = 0.044). Patients on PD were less frequently supported by a social grant than other treatment groups (p = 0.008), whilst patients on HD were more frequent recipients of a social grant than other groups (p = 0.005).

Mean HADS anxiety score was highest in patients on HD (p < 0.001, Fig. 1, supplementary table 1), a finding which persisted when compared against those CM patients with CKD stage 5 (p = 0.003); anxiety score was lower in patients on PD compared to those on HD (p < 0.001). Patients’ meeting HADS criteria for the presence of anxiety symptoms of significance (score > 4) were significantly more frequent in the HD group (22, 44%) than in the PD (8, 16%) or CM (11, 22%) groups (p = 0.004).

Depression score in patients on HD trended towards being significantly higher compared to other treatment groups (p = 0.083, Fig. 1). Symptoms of depression (HADS score > 4) were, however, not significantly more frequent in the HD group (17, 34%) than the PD (12, 24%) or CM (11, 22%) groups (p = 0.348).

Composite physical score was better in patients on HD compared to those on PD (p = 0.005), and composite mental score was higher in patients on HD compared to those on PD (p = 0.002) (Fig. 2, supplementary table 1).

Subjective assessment of the ability to meet physical activity expectations (role – physical domain) was better in patients on CM compared to those on dialysis modalities (p < 0.001), significance persisted when analysis was restricted to the CM CKD stage 5 group (p = 0.003). Role-physical domain sores were similar between patients on PD and HD (p = 0.574). Patients on PD reported greater physical limitation due to pain than either those on HD (p = 0.030) or those on CM (p = 0.036). Emotional well-being was poorer in HD compared to either the PD (p < 0.001) or CM treatment groups (p < 0.001). Subjective assessment of limitations imposed on meeting emotional roles (role – emotional) appeared to be better in patients on HD compared to those on CM (p = 0.017), however, this positive effect for HD was lost when HD was compared to those patients on CM with stage 5 CKD (p = 0.153). Finally, patients on HD reported being better able to meet their social functioning expectations compared to patients on PD (p = 0.011) but showed no difference in comparison to the CM group (p = 0.288).

Stepwise sigma-restricted multivariate linear regression modelling was used to evaluate the confounding effect of baseline disparities in treatment groups on the scores which showed significant difference between treatment modality (Table 2).

Younger age and prescription of HD were independently associated with an increased anxiety score, whereas prescription of PD and improving Hb levels reduced anxiety. Treatment modality did not exert an effect on depression, but employment and improving Hb reduced depression levels in respondents in this cohort.

Prescription of haemodialysis reduced emotional wellbeing whilst PD improved emotional well-being when compared to CM; somewhat unexpectedly, albumin level showed inverse effect on emotional well-being. Significant independent effect for dialysis modality was shown for the social function domain, with PD reducing social function relative to CM.

Improving Hb level, control of phosphate, and prescription of HD were found to be independent factors in improving pain score, while prescription of PD resulted in a worsening of pain score relative to CM.

Discussion

This study emphasises the significant psychosocial challenges faced by patients living with advanced chronic kidney disease. Underpinning disordered psychological health, patients experience significant physical limitation resulting in distress regarding their ability to meet expected levels of physical function. Whilst disease-dependent physiological factors such as anaemia may contribute to these symptoms, choice of dialysis modality may play an important role in the severity of depression and anxiety and in individual emotional well-being.

Population studies estimate the prevalence of depression amongst South Africans to be 9.8% and that of anxiety disorder to be 15.8% (15); prevalence of symptoms of these disorders as evidenced by HADS scoring was higher in this cohort of patients living with advanced CKD. Prevalence rates of depression and anxiety disorders have been reported to be higher in patients living with CKD than in either the general population (16–18) or in patients living with other chronic diseases (17), and to increase with progression of chronic kidney disease stage (19).

HRQOL scores deteriorate with advancing CKD as uraemic symptoms mount (20),(21). Physical function is prominently affected by CKD due to the limitations imposed on activity by ensuing anaemia, fluid retention, and acidosis (21). Reflecting this, physical functioning was reduced in all treatment groups in this study. Consistent with the high prevalence of mood and anxiety disorders amongst patients in this study, emotional well-being was generally poor in all treatment groups, and patient subjective assessment of ability to meet expected emotional function (role – emotion) was uniformly poor in all respondents.

Proponents of PD cite improved patient satisfaction with the modality arising from reduced impact of dialysis treatments on quality of life (22). Actual evidence for any difference in mental health and quality of life between dialysis modalities depends on few studies with contradictory findings (17),(23),(24). Metanalysis has suggested some improvement in emotional distress and psychological well-being measures for patients on PD compared those on in-centre HD (25). In the present study, anxiety and emotional well-being scores were better in patients on PD compared to those on HD. Despite these salutatory effects, overall composite mental score was lower in PD patients than in patients on HD, reflecting the contribution of lower-scoring domains such as social functioning and the related subjective assessment of emotional role fulfilment (role – emotional) to the composite mental score.

Apparent differences in quality-of-life measurements between dialysis modalities may however arise from confounding effects of therapy-related factors. For example, selection for PD requires home circumstances of a higher socioeconomic status, a known factor in quality-of-life scores (26). PD patients in this study were more likely to be employed than those on HD and were less frequent recipients of social grants than other treatment groups, evidencing better socio-economic circumstances in this group. Haemoglobin concentration, which is known to affect both physical (11),(20) and mental (20),(21) quality-of-life scores, was lower in HD patients, reflecting a host of modality-related factors including blood loss in the extracorporeal circuit and vascular access procedures. Parathyroid hormone (PTH) and phosphate have been linked to reduced physical function quality-of-life scores (11),(27); in the present study, phosphate and PTH levels were higher in those patients on dialysis therapy compared to the CM group, reflecting progressive loss of residual renal function in patients on dialysis. Finally, dialysis vintage results in progressive accumulation of psychological distress (28),(29). Dialysis vintage in this study was significantly greater in patients on HD compared to those on PD, raising the possibility of confounding effect for this parameter on mental health and quality of life scores in HD patients.

In the present study, prescription of PD independently reduced anxiety and improved emotional well-being in patients with advanced CKD. Perhaps reflecting the effect of abdominal discomfort produced by PD indwell, the modality was associated with poorer pain scores. PD was additionally linked to poorer social functioning, which may be explained by the continuous nature of the modality and the need to interrupt social activities frequently to perform exchanges. In comparison, HD was associated with worsened anxiety and poorer emotional well-being, although limitations imposed by physical discomfort were reduced in this group. Dialysis vintage did not appear to affect any of the quality-of-life subdomains analysed in this series.

As expected, haemoglobin concentration showed significant independent negative association with anxiety and depression scores, whilst increasing levels were a significant factor in improving physical discomfort / pain. The effect of phosphate on physical function scores was again shown in this cohort, with lower levels being a significant factor in improving pain. Younger age was a significant factor in increasing anxiety, an association which may reflect the effect of the limitations imposed by CKD diagnosis and treatment on age-related expectations of physical and emotional roles. Employment was a significant factor in reducing depression; maintained ability to undertake meaningful economic activity is likely to contribute to preserved feelings of self-worth amongst participants.

Previous studies have shown an effect for albumin concentration in improving physical quality-of-life scores (30),(31). Further investigation is required to corroborate and analyse the inverse effect of albumin on emotional well-being in this study, but it is conceivable that improving physical health may have led to frustration with persistent treatment-related inability to meet expectations of societal function.

Limitations

There are limitations to the present study. Treatment groups were not well matched for age, dialysis vintage, and comorbidities, and had significant differences in a number of measured laboratory parameters. Although not measured, there is also likely to have been significant variation in eGFR between treatment groups. The systematics of provision of dialytic therapy in the local context, and the effect of different treatments on lab parameters, make these differences unavoidable, and their distribution in this study is reflective of clinical reality. Limitations imposed by the cross-sectional nature of this study should also be acknowledged. Although the exclusion of recently admitted patients and the administration of the questionnaires on routine appointment days were employed to limit the effects of recent perturbations on responses, it may be that long-term pooled data would be better reflective of the burden of mental health disorders in these patients. Finally, the single-centre nature of this study may limit the generalizability of the findings.

Conclusions

The present study confirms the significant prevalence of anxiety, depression, and reduced quality- of-life in patients living with advanced CKD, but also offers hope. In particular, the direct effect of PD on reducing anxiety and improving emotional well-being, and the potential indirect effect of PD on mental health through facilitation of employment, provides reassurance on the “PD-first” programmes adopted by many state units in South Africa and other LMIC. Finally, direct deleterious effects of modality on quality-of-life may be ameliorated through attention to haemoglobin and phosphate targets.

Abbreviations

Declarations

Availability of data and materials

Data is available on request from the corresponding author

Acknowledgements

We acknowledge all participants that were included in this study.

Funding

No funding was required for this study.

Author information

Authors and Affiliations

University of the Witwatersrand, Faculty of Health Sciences, School of Medicine

Neelu Mathew, Malcolm Davies, Zaheera Cassimjee

Department of Psychology, Helen Joseph Hospital, Johannesburg, South Africa

Malcolm Davies, Zaheera Cassimjee

Department of Psychology, Helen Joseph Hospital, Johannesburg, South Africa

Feroza Kaldine

Author contributions

NM and MD contributed toward the design of the study. NM collected the data. MD, FK and ZC acted as Supervisors. MD provided statistical analysis. Data analysis was done by NM, MD, ZC. Manuscript write-up was done by NM, MD. MD, FK, ZC critically reviewed and edited manuscript. All authors contributed significantly and have read and approved the final manuscript

Corresponding Author

Correspondence to : Zaheera Cassimjee

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