Does Hemodialysis or Peritoneal Dialysis Provide a Better Quality of Life for Those with Chronic Kidney Disease? University of New Hampshire

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1 Running head: QUALITY OF LIFE AMONG CKD PATIENTS Does Hemodialysis or Peritoneal Dialysis Provide a Better Quality of Life for Those with Chronic Kidney Disease? University of New Hampshire

2 QUALITY OF LIFE AMONG CKD PATIENTS 2 Background: In 2015, chronic diseases were the leading cause of death worldwide, accounting for 63% of all deaths (Schaepe & Bergjan, 2015). Last year, the estimated prevalence of chronic kidney disease (CKD) globally was between eight and sixteen percent (Schaepe & Bergjan, 2015). Patients are often diagnosed during the latter stages of CKD due to the lack of symptoms earlier on, and as a result, require dialysis or renal transplantation to prolong or sustain their life. Unfortunately, the need for transplants is much greater than the availability of donor kidneys leaving patients with dialysis, an artificial way of filtering the blood, as their only option for sustaining life. Hemodialysis (HD) is typically done three times a week in three to five hour sessions and requires vascular access as a means to filter one s blood, which includes either a fistula, graft, or catheter. Blood is then removed from one s body and once filtered through a dialyzer, is returned to the body. The other dialysis modality, peritoneal dialysis (PD), uses the patient s peritoneal cavity as a membrane to exchange wastes and fluids. Hypertonic dialysate fluid is instilled into the peritoneal cavity, left to dwell, and later drained. PD requires an intact peritoneal membrane without adhesions from infection or surgeries. It is indicated for patients who are unable to tolerate anticoagulation, have difficulty with vascular access, have chronic infections, or are unstable (Sommer et al., 2013). Both modalities can be performed at home; however, HD is most often done in-center, whereas PD is almost exclusively done at home (Harwood & Clark, 2013). Studies have found that patients with CKD have a lower quality of life (QOL) compared to the general healthy population as well as those with other chronic diseases (Timmers et al., 2008). Quality of life (QOL) can be defined as an individual s perception of self within the context of their culture and value system in relation to their goals, expectations, standards, and

3 QUALITY OF LIFE AMONG CKD PATIENTS 3 concerns of daily life (Boudreau & Dube, 2014). While working with patients through renal replacement therapy, nurses have the ability to impact patient s QOL by utilizing the nursing process to promote positive outcomes through physical assessment, the development of care plans, the implementation of nursing interventions, and the evaluation of health care outcomes. The implementation of individualized care plans and effective nursing interventions can be guided by simply gaining insight on the patient s perception of their QOL (Boudreau & Dube, 2014). The QOL of CKD patients receiving dialysis is especially important to nursing due to the prevalence of the disease worldwide, the co-morbidities associated with CKD, and the likelihood of it progressing to end-stage renal disease (ESRD). Dialysis patients commonly experience physical and mental issues including, but not limited to, itching, lack of energy, loss of self-esteem, and uncertainty regarding the future (Timmers et al., 2008). Thus, the goal is to accommodate these patients with their lifestyle modifications and provide the highest quality of life possible. The reports of substantially lower QOL in CKD patients requires research to identify whether dialysis modalities have an effect on this. Therefore, this clinical question must be addressed: Does HD or PD provide a better quality of life for those with CKD? Search Methods: CINAHL Complete and Health Source: Nursing/Academic Edition databases were used to retrieve evidence regarding the effect of HD and PD on the QOL for people with CKD. Key words used for database searches included dialysis, hemodialysis, peritoneal dialysis and quality of life. To narrow the search results further, filter options selected were: research articles, English language, peer-reviewed, evidence-based practice, full text, and PDF full text. The published date was also restricted to January 2000 to May Of the search results available, only three were selected as evidence that were pertinent to answering the clinical

4 QUALITY OF LIFE AMONG CKD PATIENTS 4 question. These three articles directly compared dialysis modalities and their effects on QOL in CKD patients. Studies that discussed symptom burden, rather than directly addressing QOL, were excluded. Others that involved the use of only one dialysis modality were excluded, because no direct comparisons within the study were formulated, introducing more unknown variables. Google search engine was used for gathering basic understanding of research design studies. Critical Appraisal of the Evidence: A cohort study was conducted in 2008 to examine the illness and QOL perceptions of ESRD patients on HD and PD. Participants included had to be at least eighteen years of age and have no previous history of renal replacement therapy (RRT). The Leventhal s Self-Regulation Model (SRM) and Illness Perception Questionnaire revised (IPQ-R) were the instruments used to understand illness perceptions, coping behaviors, as well as functioning and well-being among dialysis patients. The results concluded higher levels of personal control and significantly higher illness coherence in PD patients compared to HD patients. Compared to the general healthy population, dialysis patients reported a significantly lower QOL. However, PD patients reported a better QOL than HD patients and were comparable to the general population with exceptions of mental health, bodily pain, and mental component scores. HD patients often associated their illness to their emotional state, their own behavior, their mental attitude and smoking; whereas PD patients mostly believed in hereditary causes. Regression analysis was performed on the total group of participants in order to obtain a larger sample size and was beneficial in producing more substantial conclusions. A strong illness identity, many negative consequences, and low personal control were found to be associated with a lower well-being, (Timmers et al., 2008). The findings determined that illness perceptions significantly impact aspects of QOL in dialysis

5 QUALITY OF LIFE AMONG CKD PATIENTS 5 patients. A limitation to this cohort study was the cross-sectional design, which caused the inability to collect data over a period of time regarding the patient s illness perception and QOL. An additional limitation was the exclusion of itching, one of the main physical complaints of ESRD patients, in the IPQ-R version and inclusion of this symptom is recommended in future research. The exclusion of this factor could potentially skew the findings of patients perceptions of illness and QOL (Timmers et al., 2008). A systematic review was done in 2011 to further understand the impact of dialysis modality on QOL for ESRD patients. After data extraction, 26 articles met their inclusion criteria and were cross-sectional, longitudinal, or retrospective in design. Generic and diseasespecific tools were considered as their two main QOL tools. The disease-specific tool included eleven dimensions that can influence QOL. Based on the results, there seems to be several factors that influence patients QOL in addition to the RRT modality. Patients with ESRD reported overall lower QOL due to the physical and psychological effects of their illness as well as factors associated with RRT such as time spent, costs, and complications. Mental health scores for HD and PD patients were found to be similar. Over time physical functioning scores decreased for both; however, HD patients had relatively better scores. Relative to the physical health of these patients, as co-morbidities increased, QOL seemed to decrease. Though there are many factors under consideration, results showed differences in the dimensions were in favor of PD overall. The number of HD and PD patients included in the study as well as their duration of treatment varied greatly, potentially altering the significance of the results. The substantial difference of HD to PD patients may be a factor in the favorable scores of QOL in PD patients, though none were found to be statistically significant. A positive correlation was seen regarding knowledge, sense of personal control, and QOL. Though some aspects of QOL represented

6 QUALITY OF LIFE AMONG CKD PATIENTS 6 significant differences, overall HD and PD patients were comparable in terms of QOL. A limitation to this study is the inclusion of only observational studies; therefore, inherent errors need to be taken into consideration when interpreting the results of the studies. The use of different methodologies, participants and outcome measures throughout the included studies made it more difficult to attain an accurate reflection of QOL in ESRD patients (Boateng, 2011). A study was done in 2015 aimed to explain the QOL and self-efficacy of patients receiving in-center HD versus receiving a home dialysis modality, either HD or PD. A correlational cross-sectional design was used along with quota sampling methods. The sample consisted of seventy-seven participants who were recruited from outpatient facilities. Of the seventy-seven participants, twenty-nine were receiving in-center HD, twenty-two were receiving at home HD, and twenty-six were receiving at home PD. Participants had to be between the ages of eighteen to eighty-nine and receiving some form of RRT for at least six months. The Kidney Disease and Quality of Life questionnaire (KDQOL-SF) and the Strategies Used by People to Promote Health questionnaire (SUPPH) were used as tools to measure QOL and self-efficacy. The results showed higher scores in the majority of study domains for patients on PD with regard to QOL and self-efficacy. However, there is lack of statistical difference in these findings, possibly due to patients being more involved in the decisions of their care, causing feelings of self-empowerment. One limitation of the study was the small sample size and the recruitment of patients from the same demographic area. A larger sample of patients with a variety of demographic backgrounds may result in findings that are more statistically significant. Another weakness of the study was that some participants had recently changed their treatment modality; however, there was no regard to the amount of time since they had changed modalities. This

7 QUALITY OF LIFE AMONG CKD PATIENTS 7 presents an issue, because the patient s opinion and perception regarding their new treatment modality may change over time (Wright, 2015). Evidence Synthesis: Through an in-depth analysis conducted on the three research studies presented in this report, there was a strong correlation between patients that received PD treatment and a higher QOL. However, there was often a lack of statistical significance supporting these findings due to small sample sizes, lack of variety in demographics, and the inability to conduct randomizedcontrolled trials (RCTs). Additionally, results are difficult to compare due to the difference of QOL tools used across the studies. Another difficulty in determining an accurate relationship between a dialysis modality and QOL lies in whether the patient is able to decide which modality they prefer. Patients who felt they were more involved in their decisions and management of their care strongly correlated with increased QOL. This sense of control with their treatment and their illness allows patient s perception of their QOL to be greater. Additional factors, apart from the dialysis modality, can influence the patient s QOL, such as co-morbidities, financial concerns, lack of support, or patient s perception of their illness and QOL. The literature reflects better patient outcomes, such as improved compliance, seen in patients who have better QOL and self-efficacy. Nurses gaining insight into patient s beliefs and responses to their illness can guide the development of interventions focused on improving adaptive functioning by altering patients perceptions about their illness and treatment. QOL is a concept that is fundamental in healthcare, in that it recognizes the effects of illness, evaluates treatments, and facilitates resource decisions. It is a multidimensional concept that is patientcentered and dynamic, encompassing physical and mental well-being, social functioning and functional status (Wright, 2015).

8 QUALITY OF LIFE AMONG CKD PATIENTS 8 Clinical and Research Recommendations: Based on this evidence, there are no strong recommendations as to which dialysis modality is better at improving QOL in patients with CKD. Time spent, cost, and complications are additional factors that patients are concerned about. Nurse s assessments of the patient needs, lifestyle, preferences, and abilities allows them to provide patients with the information they need to make an informed decision regarding their dialysis modality. Additionally, guiding patients to be more in control of their decisions and care will improve their outcomes and their perceptions of QOL. Determining whether individual and group based interventions focused on individual perceptions can also enhance perceptions of QOL in dialysis patients (Timmers et al., 2008). Furthermore, a more accurate reflection of QOL in CKD patients are more likely to be provided with cohort studies, since factors that influence QOL change with time (Boateng, 2011). It is also recommended that researchers use a large and broad patient sample to yield results that are statistically significant and generalizable. Researchers should also use widely used QOL tools and adapt them as necessary to allow for the effective comparison of the studies. The concept of QOL should be frequently revised to reflect changes in the health care system and the population s needs (Boudreau, 2014). Nurses are able to understand how the patient is coping by assessing QOL using objective and subjective health indicators and provide individualized care while involving additional team members to help further meet their individual needs. These findings enhance the understanding among nurses and other health care professionals of the importance of improving health care outcomes for patients through their lived experiences. Nurses play a pivotal role in advocating for patient s health care needs while

9 QUALITY OF LIFE AMONG CKD PATIENTS 9 contributing to the innovation of health care strategies to reduce the cost of care related to CKD (Boudreau, 2014).

10 QUALITY OF LIFE AMONG CKD PATIENTS 10 References Boateng, E. A., & East, L. (2011). The impact of dialysis modality on quality of life: a systematic review. Journal Of Renal Care, 37(4), p. doi: /j x Boudreau, J. É., & Dubé, A. (2014). Quality of life in end stage renal disease: A concept analysis. CANNT Journal, 24(1), p. Harwood, L., & Clark, A. M. (2013). Understanding pre-dialysis modality decision-making: A meta-synthesis of qualitative studies. International Journal Of Nursing Studies, 50(1), p. doi: /j.ijnurstu Schaepe, C., & Bergjan, M. (2015). Educational interventions in peritoneal dialysis: A narrative review of the literature. International Journal Of Nursing Studies, 52(4), p. doi: /j.ijnurstu Sommer, S., Johnson, J., Roberts, K., Redding, S. R., Churchill, L., Ball, B. Henry, N. J., Leehy, P. & Roland, P. (2013). Adult medical surgical nursing. Retrieved from Timmers, L., Thong, M., Dekker, F. W., Boeschoten, E. W., Heijmans, M., Rijken, M., &... Kaptein, A. (2008). Illness perceptions in dialysis patients and their association with quality of life. Psychology & Health, 23(6), doi: / Wright, L. S. (2015). CNE. Quality of Life and Self-Efficacy in Three Dialysis Modalities: Incenter Hemodialysis, Home Hemodialysis, and Home Peritoneal Dialysis. Nephrology Nursing Journal, 42(5),