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531
albumin, hemoglobin, comorbidity, but other potentially modifiable predictors of mortality are need to
be identified (4, 5). A question rises about the possible
prognostic role of HRQOL for survival. There are data
demonstrating that HRQOL predicts outcomes among
hemodialysis patients, although not all studies have
confirmed these results (611). To our knowledge,
only few published studies have examined changes
in HRQOL over time as a predictor of mortality (3).
The aim of our study was to assess whether healthrelated quality of life and change of it over time could
be considered an independent predictor of mortality
in hemodialysis patients.
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The association between health-related quality of life and mortality among hemodialysis patients
Table 1. Characteristics of 183 patients on maintenance hemodialysis by survival
All patients
n=183
Surviving patients
n=115
Deceased patients
n=68
Pa
46.928.3
26.935.9
52.329.0
32.515.5
45.421.5
65.624.6
43.943.2
57.421.7
40.618.9
48.919.7
0.64 19.7*
0.3919.8*
54.525.8
33.037.1
58.227.1
34.215.1
49.719.5
69.822.2
54.542.2
60.419.9
45.716.6
53.617.1
7.115.5**
7.715.3**
33.927.8
16.5431.3
42.229.5
29.816.0
38.222.9
58.527.0
25.939.0
52.523.8
31.919.5
40.9721.2
15.818.5***
1419.9***
<0.001
<0.01
<0.001
0.032
<0.001
<0.01
<0.001
0.022
<0.001
<0.001
<0.001
<0.001
56.715.9
51.116.2
64.311.0
<0.001
Gender, men, %
56.3
56.5
55.9
0.53
Hemoglobin, g/L
100.211.5
101.010.3
99.212.8
0.36
Albumin, g/L
38.83.5
39.73.07
37.93.67
<0.01
CRP, mg/L
10.314.0
7.04.5
13.819.0
0.20
843.5240.9
878.6270.0
797.39189.2
0.042
Kt/V
1.30.21
1.250.2
1.290.21
0.22
Dialysis months
28.823.2
27.723.2
30.223.2
0.52
Characteristic
SF-36 score
Physical functioning
Role-physical
Bodily pain
General health
Vitality
Social functioning
Role-emotional
Mental health
PSC
MSC
Change in PSC
Change in MSC
Age, years
Creatinine, mol/L
PSC, physical health component summary; MCS, mental health component summary.
*n=80; **n=53; ***n=27.
a
Comparing the groups of surviving and deceased patients.
1.0
1.0
PSC 35 and >35
0.8
Cumulative survival
Cumulative survival
0.8
0.6
0.4
PSC <35
0.2
0.6
0.4
MSC <45
0.2
Log rank P<0.001
0.0
0
20
40
60
Follow-up months
0.0
80
100
20
40
60
Follow-up months
80
100
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Table 2. Relative risks of death per 1-point higher HRQOL according to the Cox regression analysis
SF-36 domain
Physical functioning
Role-physical
Bodily pain
General health
Vitality
Social functioning
Role-emotional
Mental health
PSC
MSC
Unadjusted RR
of death (95% CI)
0.97 (0.960.98)
0.98 (0.970.995)
0.98 (0.970.99)
0.97 (0.950.99)
0.97 (0.960.987)
0.98 (0.970.99)
0.98 (0.9790.99)
0.98 (0.970.995)
0.96 (0.940.97)
0.97 (0.950.98)
<0.001
<0.01
<0.001
<0.01
<0.001
<0.01
<0.001
<0.01
<0.001
<0.001
0.98 (0.970.99)
0.989 (0.981.00)
0.98 (0.970.995)
0.99 (0.971.014)
0.98 (0.970.99)
0.98 (0.960.99)
0.991 (0.980.998)
0.98 (0.980.997)
0.96 (0.950.99)
0.97 (0.950.98)
<0.01
0.043
<0.01
0.42
0.025
<0.01
0.019
<0.01
<0.01
<0.01
0.97 (0.950.99)
1.05 (1.021.08)
0.74 (0.401.4)
0.88 (0.780.98)
1.00 (0.9981.001)
1.023 (0.991.06)
<0.01
<0.01
0.36
0.018
0.76
0.19
Variable
MSC
Age
Gender
Albumin
Creatinine
Hemoglobin
PSC, physical health component summary; MCS, mental health component summary.
0.98 (0.960.992)
1.05 (1.031.08)
0.75 (0.401.41)
0.87 (0.780.97)
1.00 (0.991.001)
1.02 (0.991.06)
<0.01
<0.001
0.37
0.012
0.95
0.20
The association between health-related quality of life and mortality among hemodialysis patients
HRQOL, had a significant association with prospective mortality in patients on maintenance hemodialysis. Lower HRQOL scores, showing worse quality
of life, were significantly associated with a higher risk
of death. These associations remained statistically
significant after adjustment for several risk factors of
death, including serum albumin concentration, age,
hemoglobin, and other.
Similar to our findings concerning mortality, other
studies found that the self-reported quality-of-life
score was independently predictive for mortality. Data
analysis of the Dialysis Outcomes and Practice Patterns Study (DOPPS) revealed that lower scores for
major components of HRQOL (both physical and
mental health) were strongly associated with a higher
risk of death and hospitalization in hemodialysis
patients, independent of a series of demographic and
comorbid factors. This study enrolled more than
17 000 patients from the United States, Europe, and
Japan (8). Other study of 1000 patients at three dialysis
centers in the United States reported an association
between lower scores in the physical component of
quality of life and higher risk of death at least until
the next 24 months. In this study, SF-36 physical health
dimension score below the median value was twice
as likely to be associated with mortality (6). A large
study, involving 5256 patients in the United States
and Europe, presented evidence that the mental components of quality of life predict death even after taking into account serum albumin concentration and several other risk factors (12). Lowrie et al. found a similar association between both physical and mental
health dimensions of the SF-36 and dialysis mortality
(13).
However, data on self-reported mental health and
hemodialysis mortality are inconclusive. DeOreo in a
previously mentioned study (6) found no significant
association between a mental health component
summary score and mortality. Mercus et al. (9), in a
relatively small study (189 patients), found no association between a mental health component summary
score of 30 or higher and a composite measure of poor
outcome, but the composite measure did not include
mortality. We found that mental health was associated
with mortality similar to or even greater than physical
health.
The reason that poor self-reported mental health
is associated with increased mortality in hemodialysis
population is unknown. Some potential mechanisms
for this association have been proposed. Deficits in
cognition caused by depression may result in diminished adaptive skills in the face of illness, and
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536
The association between health-related quality of life and mortality among hemodialysis patients
Nephrol 2001;12:2797-806.
8. Mapes DL, Lopes AA, Satayathum S, McCullough KP,
Goodkin DA, Locatelli F, et al. Health-related quality of life
as a predictor of mortality and hospitalization: the Dialysis
Outcomes and Practice Patterns Study (DOPPS). Kidney Int
2003;64:339-49.
9. Merkus MP, Jager KJ, Dekker FW, de Haan RJ, Boeschoten
EW, Krediet RT. Predictors of poor outcome in chronic dialysis
patients: the Netherlands Cooperative Study on the Adequacy
of Dialysis. The NECOSAD Study Group. Am J Kidney Dis
2000;35:69-79.
10. Lowrie EG, Curtin RB, LePain N, Schatell D. Medical
outcomes study short form-36: a consistent and powerful
predictor of morbidity and mortality in dialysis patients. Am
J Kidney Dis 2003;41:1286-92.
11. Wight JP, Edwards L, Brazier J, Walters S, Payne JN, Brown
CB. The SF36 as an outcome measure of services for end
stage renal failure. Qual Health Care 1998;7:209-21.
12. Lopes AA, Bragg J, Young E, Goodkin D, Mapes D, Combe
C et al. Depression as a predictor of mortality and
hospitalization among hemodialysis patients in the United
States and Europe. Kidney Int 2002;62:199-207.
13. Lowrie EG, Zhang H, LePain N, Lew NL, Lazarus JM. The
association of SF-36 quality of life scales with patient mortality. Fresenius Medical Care Memorandum to Dialysis
Services Division Medical Directors. Lexington MA, January
16,1998.
14. Covinsky KE, Kahana E, Chin MH, Palmer RM, Fortinsky
15.
16.
17.
18.
19.
20.
21.
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