Relationship of life-satisfaction and self-efficacy with prognostic markers in patients receiving hemodialysis

doi:10.21203/rs.3.rs-2098018/v1

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Relationship of life-satisfaction and self-efficacy with prognostic markers in patients receiving hemodialysis

https://doi.org/10.21203/rs.3.rs-2098018/v1

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Objective: A questionnaire suggestive of patients’ health status is needed to assess their quality of life and improve their self-management skills.

It is a descriptive, cross-sectional and multicenter study. The aim of this study was to assess the life-satisfaction and self-efficacy questionnaires verified in Japan which was more related to the biochemical and nutritional markers in patients receiving hemodialysis. A total of 196 outpatients receiving hemodialysis in four dialysis centers were included. The responses to the life-satisfaction and self-efficacy questionnaires were collected. Demographic and clinical characteristics of patients were obtained including life circumstances, in addition to nutritional indices such as normalized protein catabolism rate, creatinine generation rate and geriatric nutritional risk index.

Results: Life-satisfaction scores were related to prognostic nutritional markers such as normalized protein catabolism rate and creatinine generation rate. Female sex and non-diabetic patients were more satisfied with the life undergoing hemodialysis. Elderly patients had higher self-efficacy scores, which was related to their life-satisfaction scores. However, self-efficacy scores were not associated with the biochemical and nutritional markers. This life-satisfaction questionnaire was simple and useful to assess the patient’s condition.

Hemodialysis

Self-Management/Self-Care

Nursing

Psychosocial

It is difficult for patients receiving maintenance hemodialysis to accept the lifestyle on hemodialysis. Patients receiving hemodialysis need to take drugs regularly and control their eating and drinking. For them, the high level of life-satisfaction is associated with better medical outcomes, including reduction in hospitalizations and death [1]. Therefore, basic physical status can be related to high life-satisfaction of patients undergoing hemodialysis. Satisfaction with Life Scale is one of the representative scales, which is a short 5-item instrument designed to measure global cognitive judgments of life-satisfaction. However, there were few studies to assess patients receiving hemodialysis using this life scale [2]. Demographic and clinical background factors of patients with high life-satisfaction have not been clarified yet [3].

Self-efficacy is important to improve occupational performance and satisfaction [4]. Higher self-efficacy has been shown to be associated with better adherence to dietary recommendations [5]. In patients receiving hemodialysis, dietary and drug self-efficacy is needed to manage their life. The most common method described was the use of the Dialysis Diet and Fluid Non Adherence Questionnaire, a four item self-report instrument that probes the severity and duration of renal diet and fluid restriction non-adherence [6]. However, this scale has many questions especially for elderly patients [7]. The relationship of the self-efficacy level with nutritional conditions has been poorly investigated. The background factors related to high self-efficacy in patients receiving hemodialysis have yet to be fully elucidated.

The purpose of this study is to know the association of the scores of life-satisfaction or self-efficacy questionnaires verified in Japan with background characteristics and nutritional markers related to prognosis in patients receiving hemodialysis. We need to know the patients’ characteristics related to high life-satisfaction or self-efficacy. In addition, we would like to clarify which is a better and easy questionnaire to evaluate the patients’ health status.

Study design and participants

This is a cross-sectional study. Kawashima hospital has four branch clinics in Tokushima, Japan named Naruto, Kamojima, Wakimachi and Anan clinics. In the clinics, local outpatients can receive hemodialysis. The inclusion criteria were the outpatients who had undergone hemodialysis therapy at their clinic. There were 400 patients included in the criteria. Patients were excluded if their hemodialysis duration was less than 1 year (n = 46): they had difficulty fulfilling the questionnaires because of some disability such as dementia and mental retardation (n = 55): they had been hospitalized in the past year (n = 65): they disagree with the participation of this study (n = 38). Finally, 196 patients were involved in this study.

The questionnaire of life-satisfaction was used and evaluated previously [8]. The detail of the questionnaire is shown in Supplementary file 1.

The original questionnaire to measure self-efficacy, developed by Oka et al. consists of 15 items measured on a 3-point scale from 1 (not confident) to 3 (very confident). Higher scores indicate stronger self-efficacy. This questionnaire was applied and verified previously in patients receiving hemodialysis in Japan. Briefly, the self-efficacy survey using this instrument was conducted for 143 outpatients undergoing hemodialysis. The answers applicable for analysis were collected from 88 patients. Cronbach’s alpha for the original instrument was 0.9125 [9]. The present study employed short version of this Oka et al.’s scale, which included 10 items (Supplementary file 2). We asked the patients to fill the questionnaire sheets to know the levels of life-satisfaction and self-efficacy on dietary and drug adherence.

Finally, we could collect the responses of 196 patients receiving hemodialysis (83 patients at Naruto clinic, 54 at Kamojima clinic, 43 at Wakimachi clinic, and 16 at Anan clinic.) (Table 1). They were aged 35 to 93 years (mean ± SD, 67.1 ± 11.0 years). Hemodialysis duration ranged from 1.0 to 43.4 years (11.3 ± 9.0 years). The clinical diagnoses of primary renal disease were chronic glomerulonephritis (n=65), diabetic nephropathy (n=38), nephrosclerosis (n=33), polycystic kidney disease (n=14), pregnancy (n=3), CAKUT (n=1) and unknown (n=42).

Table 1. Demographic and clinical characteristics of hemodialysis patients enrolled in this analysis
Number of patients	196
Age, years	67.1 ± 11.0
Female, n (%)	65 (33.2%)
Diabetes, n (%)	56 (28.6%)
Hemodialysis duration, years	11.3 ± 9.0
Body mass index, kg/m²	22.0 ± 3.6
Body surface area, m²	1.60 ± 0.19
Height, cm	161.3 ± 8.7
Dry weight, kg	57.5 ± 12.3
Life-satisfaction	13.1 ± 3.7
Self-efficacy	19.9 ± 3.8
Working, n (%)	57 (29.1%)
Live alone, n (%)	19 (9.7%)
Emergent dialysis initiation, n (%)	47 (24.0%)
Late referral, n (%)	90 (45.9%)
Normalized PCR, g/kg/day	0.90 ± 0.20
Creatinine generation rate, %	100.7 ± 23.0
Geriatric nutritional risk index	92.5 ± 8.5
Albumin, g/dL	3.45 ± 0.24
Potassium, mEq/L	4.79 ± 0.59
Phosphate, mg/dL	5.29 ± 0.94
Mean interdialytic weight gain, % of DW	4.00 ± 1.09
PCR: Protein catabolic rate. DW: Dry weight.

Demographic and clinical characteristics were investigated at the collection of questionnaire response. Blood samples for biochemical data were obtained from arteriovenous shunt just before starting the first dialysis session of the week. Biochemical parameters were measured and calculated every month. The values of the parameters shown were the average of the last 12 months’ data before the collection of questionnaire response. Normalized protein catabolic rate (nPCR) and creatinine generation rate (CGR) were calculated using the method of Shinzato [10,11]. Geriatric nutritional risk index (GNRI) was calculated using the following formula:

GNRI = [14.89 × serum albumin (g/dL)] + [41.7 × (actual body weight/ideal body weight)], where ideal body weight was calculated as follows:

ideal body weight (kg) = [height (m)]² × 22 (kg/m²) [12]. Dry weight was determined by considering cardiothoracic ratio, blood pressure, clinical symptoms and physical findings such as edema.

Statistical analysis

All values are expressed as mean ± SD. Statistical analysis was performed using SPSS for Windows version 13.0 (SPSS, Inc., Chicago, IL, USA). The comparison of three groups divided by the tertile was done by Jonckheere-Terpstra trend test and Cochran-Armitage trend test. The difference of two groups were analyzed using student’s t-test or Welch’s t-test, if data were normally distributed. Non-normal data were analyzed by Man-Whitney’s U test. F-test was used for comparing the factors of total deviation. Prevalence data were analyzed by means of chi-square or Fisher’s exact probability test. Correlation was analyzed by Spearman’s rank correlation. Significance was defined by P less than 0.05.　

Reliability of the questionnaires

The reliability of the life-satisfaction questionnaire had been already examined previously [8]. Therefore, we examined the reliability of the questionnaire questions of self-efficacy. In the present study, the value of Cronbach’s alpha, which is regarded as an index of reliability, was 0.840 for the self-efficacy questions. Principal component analysis of variables was performed in order to confirm the construct validity. Based on the eigenvalue greater than 1, the questionnaire questions included two-factors consisting total adherence and drug taking confidence. The first factor accounts for 42.2% of the total variance. The second one accounts for 14.2%.

Relationship of the life-satisfaction score with nutritional parameters

According to the score of the life-satisfaction questionnaire, we divided into three groups which have low, intermediate and high life-satisfaction. Female sex, non-diabetic patients, and working patients had higher life-satisfaction score significantly. The self-efficacy score, nPCR, CGR were better and body mass index (BMI), body surface area (BSA), height, and dry weight were lower significantly if the life satisfaction score was higher (Table 2).

Table 2. Demographic and clinical characteristics of the patients divided by the life-satisfaction scores.
Tertiles of life-satisfaction score (n = 196)
	Low	Intermediate	High
Number of patients	64	62	70
Age, years	65.6 ± 9.9	66.4 ± 10.8	69.1 ± 12.1
Female, n (%)	17 (26.6%)	16 (25.8%)	32 (45.7%) **
Diabetes, n (%)	27 (42.2%)	16 (25.8%)	13 (18.6%) *
Hemodialysis duration, years	11.8 ± 9.2	10.1 ± 8.5	11.8 ± 9.3
Body mass index, kg/m²	22.2 ± 3.8	22.7 ± 3.1	21.1 ± 3.7 **
Body surface area, m²	1.63 ± 0.19	1.63 ± 0.17	1.53 ± 0.19 *
Height, cm	163.2 ± 8.4	162.1 ± 8.1	158.8 ± 9.0 *
Dry weight, kg	59.5 ± 13.0	59.9 ± 10.7	53.5 ± 12.3 *
Life-satisfaction	9.0 ± 1.9	12.9 ± 0.9	17.0 ± 1.6 *
Self-efficacy	19.1 ± 3.9	19.1 ± 2.9	21.4 ± 4.1 *
Working, n (%)	13 (20.3%)	17 (27.4%)	27 (38.6%) **
Live alone, n (%)	8 (12.5%)	6 (9.7%)	5 (7.1%)
Emergent dialysis initiation, n (%)	14 (21.9%)	15 (24.2%)	18 (25.7%)
Late referral, n (%)	27 (42.2%)	30 (48.4%)	33 (47.1%)
Normalized PCR, g/kg/day	0.88 ± 0.14	0.89 ± 0.30	0.92 ± 0.12 **
Creatinine generation rate, %	95.1 ± 23.1	100.4 ± 22.5	105.9 ± 22.4*
Geriatric nutritional risk index	93.7 ± 9.7	93.2 ± 7.8	90.8 ± 7.7
Albumin, g/dL	3.48 ± 0.28	3.41 ± 0.25	3.44 ± 0.21
Potassium, mEq/L	4.72 ± 0.55	4.76 ± 0.63	4.88 ± 0.59
Phosphate, mg/dL	5.15 ± 0.86	5.25 ± 0.92	5.46 ± 1.00
Mean IDWG, % of DW	4.06 ± 0.99	3.97 ± 1.19	3.96 ± 1.11
PCR: Protein catabolic rate. IDWG: interdialytic weight gain. DW: Dry weight. Ordinal variables were analyzed by Cochran-Armitage test. Interval variables were analyzed by Jonckheere-Terpstra test. : p<0.01. *: p<0.05.

Subanalysis of the life-satisfaction score in each clinic

Subanalysis of the life-satisfaction score in each clinic was done to determine whether the relationship between the life-satisfaction score and the patients’ characteristics were common or not. Female sex, non-diabetic patients, and working patients had higher life-satisfaction scores in every clinic. The self-efficacy score was higher if the life-satisfaction scores was higher at all clinics. nPCR and CGR were higher in patients with higher self-satisfaction scores in three clinics (Supplementary file 3: Table S1).

Relationship of self-efficacy on dietary and drug adherence with demographic and clinical characteristics

The enrolled patients were divided into low, intermediate and high self-efficacy groups as well as the analysis of the life-satisfaction score. Elderly and non-working patients had higher self-efficacy scores significantly. The life-satisfaction score was higher and GNRI was lower significantly if the self-efficacy score was higher (Table 3).

Table 3. Demographic and clinical characteristics of the patients divided by the self-efficacy scores
Tertiles of self-efficacy score (n = 196)
	Low	Intermediate	High
Number of patients	65	69	62
Age, years	63.9 ± 10.2	66.7 ± 11.0	71.0 ± 10.9 *
Female, n (%)	24 (36.9%)	21 (30.4%)	20 (32.3%)
Diabetes, n (%)	17 (26.2%)	19 (27.5%)	20 (32.3%)
Hemodialysis duration, years	12.0 ± 8.7	12.0 ± 10.4	9.8 ± 7.6
Body mass index, kg/m²	22.5 ± 3.9	22.2 ± 3.9	21.1 ± 2.7
Body surface area, m²	1.63 ± 0.21	1.60 ± 0.20	1.56 ± 0.16
Height, cm	162.2 ± 8.4	161.3 ± 9.2	160.3 ± 8.5
Dry weight, kg	59.6 ± 13.9	58.2 ± 12.9	54.5 ± 9.1
Life-satisfaction	11.9 ± 3.6	12.9 ± 3.6	14.4 ± 3.5 *
Self-efficacy	15.9 ± 2.2	19.9 ± 0.8	24.1 ± 2.4 *
Working, n (%)	23 (35.4%)	22 (31.9%)	12 (19.4%)**
Live alone, n (%)	8 (12.3%)	2 (2.9%)	9 (14.5%)
Emergent dialysis initiation,n(%)	16 (24.6%)	15 (21.7%)	16 (25.8%)
Late referral, n (%)	33 (50.8%)	30 (43.5%)	27 (43.5%)
Normalized PCR, g/kg/day	0.90 ± 0.13	0.93 ± 0.28	0.86 ± 0.14
Creatinine generation rate, %	103.3 ± 21.0	97.9 ± 24.2	101.0 ± 23.7
Geriatric nutritional risk index	93.3 ± 8.4	93.7 ± 9.6	90.4 ± 6.7 **
Albumin, g/dL	3.45 ± 0.24	3.46 ± 0.26	3.43 ± 0.24
Potassium, mEq/L	4.86 ± 0.61	4.80 ± 0.57	4.71 ± 0.60
Phosphate, mg/dL	5.34 ± 1.06	5.28± 0.90	5.24 ± 0.85
Mean IDWG, % of DW	4.18 ± 1.11	3.94 ± 1.08	3.87 ± 1.08
PCR: Protein catabolic rate. IDWG: interdialytic weight gain. DW: Dry weight. Ordinal variables were analyzed by Cochran-Armitage test. Interval variables were analyzed by Jonckheere-Terpstra test. : p<0.01. *: p<0.05.

Subanalysis of the self-efficacy score in each clinic

Subanalysis of the self-efficacy score in each clinic was done as well. Elderly patients had higher self-efficacy scores in every clinic. The life-satisfaction score was higher in patients with high self-efficacy scores in every clinic. Non-working patients and low GNRI were related to high self-efficacy in three clinics (Supplementary file 4: Table S2). Even when patients were divided to young (67 years old or less) and elderly (68 years old or more) patients by the average age of the participants (Table 1), higher self-efficacy scores were not related to nutritional parameters significantly (Supplementary file 5: Table S3).

In this study, we investigated the relationship between life-satisfaction/self-efficacy and the characteristics of outpatients undergoing hemodialysis. High life-satisfaction scores were observed in female, non-diabetic patients, and working patients. High life-satisfaction scores were associated with high nPCR and CGR. High self-efficacy scores were common in elderly patients. This life-satisfaction questionnaire was a simple and easy method to know patients’ health status.

The most important finding is that the simple questionnaire of life-satisfaction was related to prognostic markers for dialysis patients such as nPCR and CGR compared as the self-efficacy questionnaire [13]. Of note, life-satisfaction scores were higher in female, non-diabetic patients, and working patients. Female, non-diabetic and working people tend to have a good prognosis than male, diabetic and non-working people [14,15]. Physical condition can affect mental status. For example, strong monotonic associations were observed between pruritus severity and lower physical and mental quality of life, increased depressive symptoms, and poorer sleep quality. Compared with the reference group without any pruritus-related symptom, the adjusted mortality for patients extremely bothered by pruritus was higher significantly [16]. Patients who had poor health-related quality of life were more likely to report more subsequent depressive symptoms [17]. Conversely, mental status can affect the patients’ health. Depressive affect in incident hemodialysis patients was associated with higher risk of hospitalization and more hospital days [18]. Depression influences prognosis, complications, quality of life, treatment and costs for dialysis patients worldwide [19]. Our cross-sectional study cannot prove a causal relationship between life-satisfaction scores and health status, but it is meaningful to clarify the close relationship between mental and physical conditions in patients receiving hemodialysis. The improvement of only a simple symptom may change the mental and physical status and influence the prognosis. We need the further randomized interventional studies to identify the effectiveness, costs, and opportunity costs of providing supportive care in patients receiving hemodialysis [20] (Table 2, Supplementary file 3: Table S1).

In our study, female sex had significantly high life-satisfaction score than male. It can explain the reason why BMI, BSA, height and dry weight were lower significantly if the life-satisfaction score was higher. For your information, BMI, BSA, height and dry weight were correlated with each other except BMI and height (Correlation coefficient > 0.6, Supplementary file 6: Table S4) (Table 2, Supplementary file 3: Table S1).

Self-efficacy is reported to be important to manage better physical status in dialysis patients [21]. However, the self-efficacy scores were higher in elderly patients, which were common at all clinics. Elderly patients tend to be confident in controlling their food intake and drug management, which is consistent with the previous reports [22-25). These studies suggested that increasing age was consistently associated with higher adherence to medication and food restriction (Table 3, Supplementary file 4: Table S2).

In our study, the self-efficacy score was not related to nutritional condition, even if the relationship was analyzed in young and elderly patients separately (Supplementary file 5: Table S3). Probably, we should analyze the importance of the self-efficacy questionnaire using more patients according to some age groups [26]. Besides, our study shows that the patients without employment and those with lower GNRI had higher self-efficacy score significantly. These results were inconsistent with the previous studies, probably because high self-efficacy scores were seen in elderly patients who tend to have low GNRI without employment in our study [27].

In conclusion, female, non-diabetic, or working patients receiving hemodialysis were the factors related to higher life-satisfaction scores, which was related to several prognostic factors. Supportive observation will be needed to manage such patients. This simple questionnaire of life-satisfaction is an easy and useful method to know the patients’ physical conditions receiving hemodialysis. The importance of self-efficacy should be analyzed according to the age group.

Limitations

This is a cross-sectional study, which was conducted in the local area in Japan. Our data may be uncommon all over the world. The response rate of the questionnaire was different between each clinic. It can affect the results. The number of the participants was not large enough to analyze the age-dependent relationship of the self-efficacy score with the patients’ characteristics.

nPCR: normalized protein catabolic rate

CGR: creatinine generation rate

GNRI: Geriatric nutritional risk index

BMI: body mass index

BSA: body surface area

Authors’ contributions

KN conceived study, participated in design and coordination, read and approved the final manuscript. KK and NY participated in design and coordination, undertook interviews, helped to draft manuscript, read and approved the final manuscript. HS, NM, YK, and GI analysed the data, helped to draft manuscript and approved the final manuscript. TD and JM supervised the manuscript and approved the final manuscript.

Acknowledgements

We thank Ikuko Kase, Emi Ogata, Miyuki Fujikawa, Sachiko Kikukawa, Naomi Hosokawa, and Masumi Nagata (Kawashima Hospital) for their clinical assistance.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

The datasets generated and analysed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

All clinical investigations were conducted according to the principles expressed in the Declaration of Helsinki. The requirement of written informed consent was waived as this study used the retrospective data. The patient’s right to avoid enrollment was pledged in an opt-out fashion using the poster about this study. This research including opt-out consent has been approved by the Research Ethics Committee of Kawashima Hospital. The registration number by the committee was 647,648,649,650.

Consent for publication

Opt-out consent was obtained from each participant using the aforementioned poster about this study. The poster was approved by the Research Ethics Committee of Kawashima Hospital.

Funding

None.

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No competing interests reported.

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Relationship of life-satisfaction and self-efficacy with prognostic markers in patients receiving hemodialysis

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