To the Graduate Council:

I am submitting herewith a thesis written by Cynthia I. Taylor entitled Quality of Life in

Hemodialysis Patients. I have examined the final electronic copy of this thesis for form
and content and recommend that it be accepted in partial fulfillment of the requirements
for the degree Master of Science, with a major in Psychology.

Richard Metzger_______
Major Professor

We have read this thesis and

recommend its acceptance:

Irene N. Ozbek ______

Amye Warren__________

Accepted for the Council:

Stephanie Bellar________
Interim Dean of the Graduate School
Quality of Life in Hemodialysis Patients

A Thesis Presented for the

Master of Science Degree

University of Tennessee at Chattanooga

Cynthia I. Taylor

May 2010
Copyright 2010 by Cynthia Iris Taylor

All rights reserved.

ii
 Acknowledgements

I would like to thank Dr. Richard Metzger for his support and guidance

throughout my time in graduate school, and especially for his help during this research

and during the thesis process. I would also like to express my gratitude to Dr. Musharraf

Navaid and Dr. Terry Melvin, with the University of Tennessee, College of Medicine;

without their ideas and data collection, this thesis would not have been possible. Thanks

also to Dr. Nicky Ozbek and Dr. Amye Warren, who were sources of encouragement and

feedback that were especially critical to the development of this thesis.

iii
 Abstract

The increasing number of patients with end stage renal disease (ESRD) has caused a

substantial rise in the number of individuals receiving hemodialysis. One of the

persistent questions with this group has been the influence of the procedure on quality of

life. The present study explored the important factors that influence quality of life in

hemodialysis patients. Participants were 160 (71 men and 89 women, mean age 62.84

years) community-dwelling, hemodialysis patients. Participants completed the Kidney

Disease Quality of Life questionnaire and mental health and physical health composite

scores were created in order to examine factors that can be considered predictive of

quality of life in these patients. By using backward regression, the scales most predictive

of mental and physical health were determined. For physical health, burden of kidney

disease (p = .006), effects of kidney disease (p = .011), and sleep (p = .017) were the

best-fitting set of predictors. For mental health, burden of kidney disease (p < .05),

cognition (p < .05), and social support (p < .05) were the best-fitting set of predictors.

Using these results from the regression analysis, a model for predicting physical health

was explored, along with a model for predicting mental health. No other studies of this

type have used predictive models; this is the first study of its kind.

iv
 Table of Contents

Introduction ..........................................................................................................................1

Method .................................................................................................................................9

Participants ...................................................................................................9

Materials ......................................................................................................9

Procedure ...................................................................................................11

Results ................................................................................................................................13

Discussion ..........................................................................................................................19

List of References ..............................................................................................................23

Appendices .............................................................................................................29

Appendix A ................................................................................................30

Appendix B ................................................................................................51

Research Compliance.............................................................................................52

v
 List of Tables

Table 1. Participant Characteristics ...................................................................................9

Table 2. KDQOL Scale Reliabilities................................................................................13

Table 3. Descriptive Statistics of Subscales.....................................................................14

Table 4. Descriptive Statistics of Mental and Physical Health

Composite Scores...............................................................................................14

Table 5. Correlation Analysis Results..............................................................................15

Table 6. Full Regression Results......................................................................................16

Table 7. Regression Analysis Results ..............................................................................16

Table 8. Correlation Analysis Results: Burden Subscale and

Physical and Mental Health ...............................................................................17

vi
 The increasing number of patients with end stage renal disease (ESRD) has

caused a substantial rise in the number of individuals receiving hemodialysis. Numbers

are growing worldwide, and there were 1,371,000 people on dialysis treatment by the end

of 2004 (Grassmann, Giobere, Moeller, & Brown, 2005). Gilbertson, et al. (2005)

predicted that by the year 2015, there will be 136,166 incident ESRD patients annually

and 107,760 ESRD deaths annually in the United States alone. Healthcare providers

have seen this increase as an opportunity to be involved in the care of patients with

chronic illness before they reach the end of life. This thesis involves the analysis of data

collected by Dr. Musharraf Navaid and Dr. Terry Melvin, through Dialysis Clinic,

Incorporated, to investigate the factors that predict quality of life in patients receiving

dialysis. The goal is to provide descriptive information and to make recommendations

for further research.

ESRD, for most patients, is the result of kidney function deterioration over a

period of time that is secondary to another chronic medical condition, such as diabetes or

hypertension (Christensen & Ehlers, 2002). Treatments that are currently available for

ESRD include renal transplantation and a number of forms of renal dialysis. The

treatment arrangement for an ESRD patient is usually influenced by nonmedical factors.

These factors include patient and provider preferences and judgments about which type

of treatment is likely to be associated with positive patient adherence and quality of life

(Christensen & Moran, 1998). This study, however, is concerned only with those ESRD

patients who receive hemodialysis.

The problems associated with ESRD are numerous and many patients experience

a list of symptoms that are co-morbid to ESRD. In 2000, Yavuz, Karatas, and Kilinc

1
found that dialysis patients had mental difficulties as well as physical difficulties. They

reported that the ESRD population has difficulty with ambulation, hand movement

coordination, and cognition. In general, hemodialysis patients have significantly reduced

self-assessed physical and mental health compared to the population (Mittal, Ahern,

Flaster, Maeska, & Fishbane, 2001). One of the goals of this study is to find out what

predicts those physical and mental health components in order to improve quality of life.

Tyrrell, Paturel, Cadec, Capezzali, and Poussin (2005) were interested in the

mental health of these patients, finding that between 30-47% of dialysis patients were

cognitively impaired (p.377). Another pertinent finding for Tyrrell, et al. (2005) was

that many dialysis patients can be cognitively impaired and/or depressed and the

symptoms are many times mistaken for one another. In a study conducted by Christensen

and Ehlers (2002), the estimates of depression in ESRD patients were found to be

particularly high, with approximately 12-40% meeting the diagnostic criteria for a mood

disorder (p.716). They also reported that, compared to patients with other chronic

medical conditions, the rate of psychiatric disorders in the ESRD population is

significantly higher. Also, in patients with ESRD, cognitive impairment is associated

with the severity of kidney disease, more frequent hospitalizations and greater utilization

of health care resources (Kurella, Luan, Yaffe, & Chertow, 2004). Patients report sleep

disturbances, insomnia, restless legs syndrome, cognitive impairment, depression, and

many other symptoms (Kurella, Luan, Lash, & Chertow, 2005). In fact, Kutner, Zhang,

Huang, and Bliwise (2007) reported that among dialysis patients, depressed mood and

prescription sleep medication predicted a lower cognitive function score, and higher

educational level and less bodily pain predicted a higher cognitive function score. The

2
increased demands of ESRD are hard for an individual to adjust to, especially because of

the deficits in cognition that are caused by the disease (Bremer, Wert, Durica, & Weaver,

1997). Mittal, et al. (2001) reported that the psychosocial burden placed on patients

because of the need for dialysis includes time commitment, increased dependence on

family members, anxiety, and feeling tired or depressed after treatment. Many factors

contribute to the cognitive or mental aspects of quality of life and should be considered

during the assessment of overall quality of life.

There seems, then, to be substantial evidence that patients experience both

medical and mental health issues during dialysis. There is general consensus that in

addition to survival, the quality of the remaining life is a highly relevant patient outcome

in the evaluation of treatment (Merkus, et al., 1999, p.720). The question remains how

the mental and physical issues influence the patients quality of life, which is of utmost

importance.

Researchers have investigated the effects of dialysis on quality of life. Although

quality of life is related to health, its concept is very distinct from health (Mingardi, et al.,

1999). In 1997, Evans reported that the term quality of life had been used

interchangeably with such terms as well-being, psychological well-being, happiness, life

satisfaction, positive and negative affect, and the good life (p.1). Because there are so

many aspects of quality of life, it is hard to consider everything that might play a role in

it. Evans found that quality of life includes, but is not limited to, material well-being,

physical well-being, personal growth, marital relations, parent-child relations, extended

family relations, extra familial relations, altruistic behavior, political behavior, job

characteristics, occupational relations, job satisfiers, creative/aesthetic behavior, sports

3
activity, and vacation behavior (p.1). Along with the illness and actual health aspects,

quality of life encompasses such domains as housing, employment, standard of living,

and marriage (Bergner, 1989, p.S148). Kimmel, Emont, Newmann, Danko, and Moss

(2003) found that symptoms, especially pain, along with psychosocial and spiritual

factors, are important determinants of quality of life in patients with ESRD (p.713).

There are factors associated with quality of life that should be assessed that are not

always at the forefront of research design.

Social support has been assessed in many studies, including studies of dialysis

patients. Social support includes social companionship, daily emotional support, and

total support, among others. From mortality to compliance and adherence, social support

can be an essential predictor. Tell, et al. (1995) reported that the perceived social support

of ESRD patients held a strong influence on their health-related quality of life. Mortality

is shown to be affected by the amount of social support received. In fact, in dialysis

patients, perceiving a discrepancy between expected and received social support was

associated with increased mortality (Thong, Kaptein, Kredeit, Boeschoten, & Dekker,

2007). Christensen, Wiebe, Smith, and Turner (1994) found that in dialysis patients, the

estimated 5-year mortality rates among low family support patients were approximately

3 times higher than estimated mortality for high support patients (p.524). The process of

dialysis affects more than just one aspect of a patients life; several aspects are affected

by each other which, in turn, create more and more problems for a patient. Kimmel et al.

(1998) assessed psychosocial factors, behavioral compliance, and survival in dialysis

patients. What they found was that lower levels of social support, decreased behavioral

compliance with the dialysis prescription, and increased negative perception of the effects

4
of illness are all independently associated with increased mortality. (p.245) With social

support being such a critical predictor of mortality and so much more, there is a definite

need to understand how social support and all the other aspects of quality of life work

together.

Patients on dialysis are also less likely to have the ability to work. In one group

of dialysis patients that was studied, only 11% of the total sample was currently

employed (Kutner, Brogan, & Fielding, 1991) and other studies report employment rates

in dialysis patients anywhere from 25-30% (Bremer, Wert, Durica, & Weaver, 1997, and

Holley & Nespor, 1994). Employment has been shown to be a significant factor in the

quality of life of dialysis patients. Blake, Codd, Cassidy, and OMeara (2000) reported

that unemployed ESRD patients scored significantly lower than those employed in

physical function, role physical, bodily pain, general health, vitality, and role emotional

scales. (p.145) Along those same lines, Curtin, Oberly, Sacksteder, and Friedman

(1996) found that measures of functional status were positively associated with

employment in dialysis patients. With employment, a type of social support, being such

an important factor in the lives of dialysis patients, it is easy to see how every possible

aspect of quality of life should be studied in order to determine how it affects quality of

life, whether through physical, emotional, cognitive, or social means.

Two primary instruments have been developed to examine quality of life, one

specifically for those with kidney disease and on dialysis. The World Health

Organization Quality of Life (WHOQOL-BREF) questionnaire and the Kidney Disease

Quality of Life Short Form (KDQOL SF) questionnaire were both developed in response

to the need for proper and thorough insight into the quality of life of patients in the

5
healthcare setting. The WHOQOL measurement approach assumes subjective

evaluation of both positive and negative indicators of quality of life and includes areas

not covered in other health-related quality of life instruments, but which are important to

persons throughout the world and are important in evaluating the quality of life of

individuals within their larger social arrangements (Bonomi, Patrick, Bushnell, &

Martin, 2000, p.1). The WHOQOL-BREF was developed as a shortened version of the

WHOQOL and has proven to be a sound, cross-culturally valid assessment of quality of

life, as reflected by its four domains: physical, psychological, social, and environmental

(Skevington, Lotfy, & Connell, 2004, p.307). Because of the different factors that affect

quality of life in ESRD and other kidney patients, the KDQOL SF was developed and is

considered a self-report measure that includes a 36-item health survey as the generic

core, supplemented with multi-item scales targeted at particular concerns of individuals

with kidney disease and on dialysis (Hays, Kallich, Mapes, Coons, & Carter, 1994,

p.329). The KDQOL has been used all over the world and has been translated into

Korean, Danish, Portuguese, and many other languages. The WHOQOL has been

formatted and changed to suit many types of illnesses and diseases other than kidney

disease.

Although there has been a significant amount of research involving dialysis

patients, there has not been definitive evidence on what factors predict quality of life in

these patients. Cleary and Drennan (2005) found that overall, dialysis patients have a

lower quality of life than do those patients suffering from chronic kidney disease (and not

on dialysis). Merkus, et al. (1997) concluded that quality of life in new ESRD patients

was substantially impaired. Timmers, et al. (2008) examined how cognitive and

6
emotional representations held by dialysis patients about their illness related to quality of

life. Those patients with lower quality of life were more likely to attribute their illness to

their emotional state, their own behavior, their own mental attitude, and to smoking

(p.1423). Kimmel, et al. (1995) stated that there are several important variables to be

measured when assessing quality of life, including social support and relationship

satisfaction, because there are so many different dimensions included in the overall realm

of quality of life.

Knowing which factors are most important in determining quality of life could

help improve both physical and mental aspects of dealing with kidney disease. The

mental health aspect of hemodialysis has been researched, along with the physical aspect

and overall quality of life, but what makes up those aspects? What factors can be

attributed to the make-up of physical health and mental health in dialysis patients? By

understanding what factors affect the quality of life in these patients, healthcare

professionals can better treat patients on an individual basis. Drs. Navaid and Melvin,

from the Departments of Hospice, Palliative Care, and Internal Medicine at the

University of Tennessee College of Medicine, Chattanooga, proposed that symptom

burden and length of time on dialysis would be main factors in both the physical and

mental aspects of ESRD, and wanted to determine what other factors might impact the

quality of life in hemodialysis patients. Symptom burden is the degree to which the

symptoms of ESRD are a burden on the patient. It should be noted that symptom burden

is not equal to disease burden. Symptom burden, in this case, is more of a psychosocial

burden. Parfrey, Vavasour, Henry, Bullock, and Gault (1988) reported that the symptom

burden of ESRD is equal to the symptoms of patients with advanced cancer, and a

7
number of these significant symptoms continue to get worse with the number of years on

dialysis. Using data gathered through hospice patients in and around the Chattanooga

area, the present study will explore Navaid and Melvins hypotheses. Most important to

this research, however, will be an examination of factors that can be considered

predictive of quality of life in these patients. A model for predicting quality of life will

be described, and further, the role of longevity of treatment and symptom burden will be

considered.

8
 Method

Participants

The 160 participants (71 men and 89 women, mean age 62.84 years) were

community-dwelling, hemodialysis patients in stage four kidney disease and received

dialysis three times per week. Sixty-one percent of the participants were white, while

39% were non-white. Table 1 shows selected participant characteristics.

Table 1. Participant Characteristics

Characteristic
Mean Std. Dev.
Age (years) 62.84 14.71
Number of Months on Dialysis 43.69 52.09
Frequency %
Gender
Male 89 53.6
Female 71 42.8
Race
White 97 60.6
Non-White 63 39.3
Marital Status
Married 67 40.4
Not Married 92 55.4

The participants received dialysis through Dialysis Clinic, Inc., which serves

patients in Chattanooga and the surrounding areas. Patients did not receive any type of

compensation for their participation, and all participants consented to be a part of this

study. This study was approved by the University of Tennessee College of Medicine

Institutional Review Board (IRB) and the further use of their data was also approved by

the University of Tennessee at Chattanooga IRB.

Materials

The materials used for this research were the KDQOL SF questionnaires that

include a demographic/background information section. The KDQOL evaluates the

9
patients functioning, well-being, and general health perception in physical,

psychological, and social domains, with particular questions about the effects of ESRD

and dialysis on the patients overall quality of life (Hays, et al., 1994). There are 11

subscales that include symptoms (9 items), effects of kidney disease (8 items), burden of

kidney disease (4 items), work status (2 items), cognitive function (3 items), quality of

social interaction (3 items), sexual function (3 items), sleep (4 items), social support (2

items), dialysis staff encouragement (2 items), and patient satisfaction (1 item).

Following is a list of the definitions of each of the 11 subscales:

Symptoms: Assesses the extent to which the patient is bothered by certain

physical symptoms associated with ESRD

Effects of kidney disease: Assesses the extent to which the patient is bothered by

the effects of kidney disease on daily life

Burden of kidney disease: Assesses how much kidney disease interferes with the

patients life, how much time is spent dealing with kidney disease, how frustrated,

and how much of a burden the patient feels like on the family

Work status: Assesses whether or not the patient has worked in the past four

weeks and, if not, whether it was attributable to their disease

Cognitive function: Assesses the patients reaction, concentration, and confusion

Quality of social interaction: Assesses the patients isolation from others,

irritability towards others, and how well the patient has been getting along with

others

10
 Sexual function: Assesses whether or not the patient has had sexual activity in the

past four weeks and, if so, how much of a problem enjoying sex and becoming

sexually aroused might have been

Sleep: Assesses the patients sleep patterns and habits over the past four weeks

Social Support: Assesses how satisfied the patient is with the amount of support

being received

Staff encouragement: Assesses how supportive the patient feels the dialysis staff

has been

Satisfaction: Assesses how satisfied the patient has been with the overall care

received during their kidney disease

There are also eight SF-36 subscales that can be used to create a mental composite score

and a physical composite score. The eight SF-36 subscales include emotional, emotional

role, social function, energy and fatigue, physical, physical role, pain, and general health

(Hays, et al., 1994).

The background information includes current medications, number of days in the

hospital, cause of kidney disease, date of birth, education, gender, weight, and income.

The KDQOL SF has been found to be both reliable and valid in many studies (Korevaar,

et al., 2004; Hays, et al., 1994). A copy of the entire KDQOL SF instrument can be

found in Appendix A.

Procedure

These participants completed the KDQOL questionnaire either by themselves, had

help from a medical professional, or had the medical professional complete it for them.

One hundred and five of the participants had help from the medical professional in

11
completing the questionnaire. A proctor was available to help the patients answer any

questions or respond to any concerns about the questionnaire while it was being

completed.

Participants were given the questionnaire during a dialysis session in one of eight

different dialysis clinic locations, either in Chattanooga or the surrounding area.

Appendix B is a table showing the number of white and non-white participants at each

dialysis clinic site. The questionnaires were given over a period of two weeks, and the

date depended on the patients dialysis schedules.

12
 Results

The KDQOL SF-36 gives us the opportunity to create mental and physical health

variables that describe the current perception of physical and mental health. Using the

physical and mental health variables helps narrow down exactly what factors predict each

of those two main parts of quality of life.

The first result discussed will be a review of the reliability analyses conducted on

the 11 subscales. Then, the typical performance of patients who completed the

questionnaire will be reviewed. Backward regression and a correlation analysis were

used to predict the factors that influenced patients quality of life, and will also be

discussed. Finally, the results of the one-way analysis of variance (ANOVA) analyses to

determine whether other factors (such as dialysis site, having help with the survey,

number of months on dialysis, and number of days overnight or longer in the hospital)

had an influence on physical health, mental health, or overall health will be examined.

The reliabilities of each of the scales were acceptable, with only one reliability

below .70, which was the quality of social interaction scale. Many of the other

reliabilities were more than acceptable, with four of the reliabilities above .80 and two

above .90. Table 2 shows the reliabilities for each of the scales except the satisfaction

scale because it was only a single-item measure.

Table 2. KDQOL Scale Reliabilities

Scale Cronbachs Alpha

Symptoms .850
Effects .794
Burden .744
Work .727
Cognition .815
Quality of Social .610
Sexual .919

13
Sleep .900
Social Support .799
Staff Encouragement .716
Satisfaction N/A*
*Not applicable for a single-item measure

The typical performance of the participants can be shown by looking at the

subscale means and standard deviations. The means of the subscales have possible

ranges of zero to 100, with higher scores meaning more positive assessment. The lower

the score, the worse the participants felt about that particular issue. Like the subscale

scores, the higher score of the mental and physical health composite means that

participants responded more positively. The mental health and physical health composite

score had possible ranges of zero to 400. Table 3 shows those means and standard

deviations. Table 4 shows the means and standard deviations of the mental health

composite scores and the physical health composite scores.

Table 3. Descriptive Statistics of Subscales

Subscale N Mean Std. Dev.

Burden 156 45.31 25.93
Cognitive 105 80.88 22.40
Effects 142 73.20 19.90
Quality of Soc. 104 83.05 16.97
Support
Satisfaction 154 78.13 20.83
Sexual 33 75.76 30.29
Sleep 101 59.91 23.22
Social Support 156 80.13 25.69
Staff 155 88.31 17.13
Symptoms 116 82.67 17.04
Work 155 17.10 27.59

Table 4. Descriptive Statistics of Mental Health and Physical Health Composite Scores

Composite Score N Mean Std. Dev.

Mental Health 157 278.38 91.13
Physical Health 157 178.42 90.13

14
 Correlation analyses helped to determine which of the subscales were most highly

correlated with the mental health and physical health composite scores. Also assessed in

the correlation analysis was the overall health score of the participant with the mental

health and physical health composite scores. The subscales most highly correlated with

mental health were symptoms (r = .608) and burden (r = .648), and the overall health

score also correlated highly with mental health (r = .681). As with the mental health, the

subscales that were most highly correlated with the physical health were symptoms (r =

.518) and burden (r = .519). The overall health score was also highly correlated with

physical health (r = .679). Table 5 shows the correlation analysis results.

Table 5. Correlation Analysis Results

Scale Mental Health p Physical Health p

Symptoms .608 < .001 .518 < .001
Effects .584 < .001 .469 < .001
Burden .648 < .001 .519 < .001
Work .201 < .001 .323 < .001
Cognition .562 < .001 .406 < .001
Quality of Social .498 < .001 .284 < .001
Sexual .579 < .001 .457 < .001
Sleep .453 < .001 .483 < .001
Social Support .440 < .001 .306 < .001
Staff Encourage .048 .590 .099 .259
Satisfaction .118 .183 .090 .305
Overall Health .681 < .001 .679 < .001

A model for predicting physical and mental health was created by using backward

regression, with those factors most important to physical and mental health falling out of

the model last. The first regression analysis included the demographics (age, ethnicity,

gender, and number of months on dialysis) of the participants and the subscales of the

KDQOL, but because none of the demographics proved to be significant, they were

eliminated. Table 6 shows the full regression model results that were not significant.

15
Table 6. Full Regression Results

R Adjusted R F p
Physical Health .981 .773 5.094 .103
Predictive
Model
Mental Health .967 .695 3.892 .099
Predictive
Model

The regression analysis was performed using only the subscales and physical and mental

health variables. The model for predicting physical health included three subscales as

significant predictors. These were burden (p = .006), effects (p = .011), and sleep (p =

.017), R = .43, F(3,73) = 18.50, p < .001. The model for predicting mental health

included three subscales as significant predictors. These were burden (p < .001),

cognition (p < .001), and social support (p = .001), R = .61, F(4,74) = 28.81, p < .001.

The work subscale was included in the model, however, it was not significant (p = .089).

Table 7 shows the regression results for the best models that predict mental and physical

health.

Table 7. Regression Analysis Results

R Adjusted R F p
Physical Health .432 .409 18.499 < .001
Predictors
Burden .006
Effects .011
Sleep .017
R Adjusted R F p
Mental Health .609 .588 28.808 < .001
Predictors
Burden < .001
Cognition < .001
Social Support .001

16
The burden of kidney disease seems to be the most important factor, having an effect on

both the physical and mental aspects of quality of life.

With symptom burden being the only subscale to prove significant in both

predictive models, a correlation analysis was carried out in order to assess which of the

individual symptom burden scale items were correlated with the physical and mental

health composite scores. While all four items were significantly correlated with physical

and mental health, frustration in dealing with kidney disease correlated most highly with

mental health. Table 8 shows the results of the correlation analysis.

Table 8. Correlation Analysis Results: Burden Subscale and Physical and Mental Health

Items Physical Health Mental Health

My kidney disease .403 .445
interferes too much with my
life
Too much of my time is .373 .419
spent dealing with my
kidney disease
I feel frustrated dealing with .421 .676
my kidney disease
I feel like a burden on my .335 .403
family

One-way ANOVA analyses were carried out to assess whether site (location of

the dialysis clinic), receiving help from staff or medical professionals, number of months

on dialysis, and number of days overnight or longer in the hospital had any effect on the

physical or mental composite scores or overall health. It was determined that there was

no difference in physical health composite scores (p = .684, F(5, 84) = .621) or mental

health composite scores (p = .096, F(5,85) = 1.937) as a result of the site of the dialysis

clinic. There was also no difference in overall health when comparing dialysis sites (p =

.173, F(7, 151) = 1.495). Those who received help from staff members or medical

17
professionals when filling out the survey scored significantly higher on the overall health

question (p = .035, F(2,153) = 3.439), but receiving help did not seem to have an effect

on the physical health (p = .314, F(2,91) = 1.174) or mental health (p = .592, F(2, 89) =

.527) composite scores. There was no difference in physical health (p = .705, F(68, 57) =

.874) or mental health (p = .601, F(70, 52) = .939) composite scores when comparing

number of months on dialysis. There was also no difference in the overall health of

patients when comparing number of months on dialysis (p = .502, F(77, 71) = .999).

Also, the number of days overnight or longer in the hospital did not have an effect on

physical health (p = .325, F(22, 112) = 1.132) or mental health (p = .394, F(20, 111) =

1.067) composite scores. There was also no difference in overall health scores when

comparing number of days overnight or longer in the hospital (p = .271, F(22, 132) =

1.186).

18
 Discussion

The findings from this research will help to provide a model for predicting quality

of life in hemodialysis patients. This research is the first to use this type of predictive

modeling with these patients. Though other studies do use the KDQOL in assessing

quality of life in ESRD patients, this research offers a simple predictive model that can

hopefully be used in the dialysis setting. The model can be utilized to determine what

type of intervention a patient needs, whether with sleep, social support, symptom burden,

etc.

While there are different factors that influence mental health and physical health,

there is one factor that has an influence on both: the burden of kidney disease. The

burden of kidney disease has quite an effect on those kidney patients receiving

hemodialysis 3 times per week. Symptom burden may prove to be the most important

factor in determining overall health in these patients.

The results of the present research show that by using the KDQOL to assess the

burden of kidney disease, the effects of kidney disease, and sleep, the physical health

composite score of ESRD patients can be predicted. Likewise, by using the KDQOL to

assess the burden of kidney disease, cognition, and social support, the mental health

composite score of ESRD patients can be predicted. There is also the potential for the

burden of kidney disease to be looked at individually in order to determine physical and

mental health, and that could lead the way to predicting an overall health score. The

models for predicting physical and mental health should be utilized to determine the

individual patients health issues and to determine the optimal treatment program for the

patient.

19
 Intervening in the areas that influence each of the health scores could potentially

be a way to improve the health scores. If patients feel less burdened, feel fewer effects of

kidney disease, and get more sleep, the better their physical health could be and the better

their quality of life could be. The same theory applies to mental health; by intervening

somewhere along the line and helping patients feel less burdened, less cognitively

impaired, and receive more social support, the better their mental health should be.

Specifically, support groups for renal disease patients or hemodialysis patients would be

ideal. While there are support groups for many types of patients, there is definitely a lack

in support when it comes to the renal patient. Since a lack of social support is included in

the predictive model for mental health, by improving social support, the possibility is that

mental health and even overall health and quality of life could improve. Also, a specific

way to improve physical health might be to intervene in the patients sleeping habits.

Currently, sleep is a major issue in these patients and ways to improve sleep are at the

forefront of research.

Knowing that social desirability plays a part in this type of research is extremely

helpful. This is shown by the fact that those patients who had help from a medical

professional when completing the survey had significantly better results when comparing

overall health scores. The answers that patients gave to the survey questions asked by the

medical professional may have been what the patient thought the medical professional

wanted to hear, as opposed to answering the questions honestly.

Interestingly, the number of months on dialysis and the number of days overnight

or longer in the hospital did not play an important role in predicting physical health and

mental health composite scores or in predicting overall health. Drs. Navaid and Melvin

20
hypothesized that symptom burden and length of time on dialysis would both influence

the health scores, and their hypothesis was partially proven to be correct. Symptom

burden definitely plays a role in determining the health of ESRD patients.

The dialysis clinic site did not influence the health scores, which is an ideal

outcome. All patients at all locations should have scores with no significant mean

difference. Patients should all be treated so that their physical health, mental health, and

overall health scores are at the maximum, although treatments should be fitted to the

individual patients.

Although the KDQOL is a valid and reliable instrument, the limitations to the

instrument include there only being one or two questions that makeup some of the

subscales. Also, the depression subscale included in this instrument is only a two-item

scale, and most studies assessing depression and quality of life in these patients use a

supplementary depression instrument. The fact that so many of the patients in the study

had help in completing the KDQOL is a limitation, although the social desirability aspect

makes it important for future research. Also important to future research will be finding

out if the predictive models for the physical health and mental health can be utilized in

the dialysis setting. The more that is known about patients, the better treatment they can

receive, and the better their quality of life will be.

Specific physical and mental components of overall health and quality of life are

many times overlooked, especially in patients who do not report problems or deficits. By

having them complete the KDQOL, the hope is that both mental and physical health in

dialysis patients can be improved, which will, in turn, improve their overall health.

21
 With the number of kidney disease patients increasing, and the number of patients

on hemodialysis increasing as well, improving overall health in these patients is worth the

research time and effort. More research specifically looking at the predictive models of

physical health and mental health composite scores is necessary to maximize quality of

life in patients with ESRD and on hemodialysis.

22
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28
Appendices

29
 Appendix A

KDQOL SF Instrument

30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
 For research assistant or medical professional use only!!

PLEASE REVIEW SURVEY TO MAKE SURE IT IS COMPLETELY

FILLED OUT!!

FILL OUT THIS SHEET AFTER SURVEY HAS BEEN COMPLETED

AND PUT IN AN ENVELOPE WITH THE SURVEY!!

Research Assistant Name _______________________________________

DATE ___________

DCI# ____________

DCI NAME______________________

First Shift Second Third

Mon. Tues. Wed. Thurs. Fri.

How was survey filled out?

Patient Surveyor Patient assisted by surveyor

50
 Appendix B

Number of White and Non-White Participants at Each Site

Dialysis Clinic Site N

A
White 15
Non-White 1
B
White 7
Non-White 13
C
White 41
Non-White 16
D
White 2
Non-White 11
E
White 7
Non-White 0
F
White 2
Non-White 1
G
White 19
Non-White 4
H
White 4
Non-White 20
Total
White 97
Non-White 63

51
Research Compliance

52
THE UNIVERSITY OF TENNESSEE
Health Science Center

College of Medicine, Chattanooga

Institutional Review Board
960 East Third Street
Suite 102
Chattanooga, TN 37403
Tel: (423) 778-3818 Fax: (423) 778-4170
January 28, 2009

Musharraf Navaid, M.D.

4411 Oakwood Drive,
Chattanooga, TN 37416

RE: study number 09-033: What are the key factors that impact Quality of Life in
Hemodialysis patients? (N/A)

Dear Dr. Navaid:

The Chairman of the UT College of Medicine Institutional Review Board reviewed your
application for the new study listed above. This study qualifies as exempt from review
under the following guideline: 45 CRF 46:101 Category 4.

You are free to conduct your study without further reporting to UT-College of Medicine
Institutional Review Board .

Thank you for keeping the board informed of your activities.

Sincerely,

Stacey Hendricks, CIM

IRB Coordinator

53