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Saudi J Kidney Dis Transpl 2012;23(5):953-957

© 2012 Saudi Center for Organ Transplantation Saudi Journal
of Kidney Diseases
and Transplantation

Original Article

Assessment of Quality of Life in Patients on Hemodialysis and the

Impact of Counseling
Suja Abraham1,2, Anju Venu1, Anju Ramachandran1, Praseetha Mundapurath Chandran1,
Saraswathi Raman3
1
Department of Pharmacy Practice, Amrita School of Pharmacy, Amrita Viswavidyapeetham
University, Kochi, Kerala; 2Research Scholar, Karpagam University, Coimbatore, Tamil Nadu;
3
Al-Shifa College of Pharmacy, Perinthalmanna, Kerala, India

ABSTRACT. Chronic renal failure is an irreversible progressive condition responsible for high
morbidity and mortality. Because it requires life-long treatment in the form of renal replacement
therapy, the quality of life (QOL) of patients may significantly impair. Studies have revealed that
patient education can play a significant role in improving the QOL in these patients. The primary
objective of this study was to assess the QOL of patients on hemodialysis by using the World
Health Organization Quality of Life assessment scale and also to study the impact of patient
counseling in these patients. Fifty patients were selected for the study and they were randomly
divided into two groups, control and test; counseling was given to the test group of patients. There
was an increase in score in all the four domains (physical, psychological, environmental and
social) among the test group when compared with the control group. Also, we found that the
psychological domain showed significant increase in score compared with others. Our findings
demonstrate that patient counseling plays an important role in improving the QOL by changing
their psychological thinking and bringing them toward spirituality.

Introduction and high economic burden. CRF has become

one of the most expensive diseases to treat in
The number of patients with chronic renal present times. This is particularly true in the
failure (CRF) is increasing steadily globally developing world where the resources are li-
with its associated poor quality of life (QOL) mited.1 The National Kidney Foundation has
Correspondence to: classified CRF into five stages according to
the glomerular filtration rate (GFR), and the
Suja Abraham, fifth stage with GFR less than 15 mL/min is
Senior Lecturer, called end-stage renal disease (ESRD).2
Department of Pharmacy Practice, The prevalence of ESRD in India has in-
Amrita School of Pharmacy, creased in the last two decades. It has become
Kochi, Kerala, India a global threat with significant morbidity and
E-mail: suja_srmc@yahoo.co.in mortality. ESRD also decreases the overall
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954 Abraham A, Venu A, Ramachandran A, Chandran PM, Raman S
QOL among the affected patients. The treat-
ment option at this stage is renal replacement
therapy, which includes dialysis and transplan-
tation. According to various studies, the cost
of dialysis is between Rs. 15,000 and 20,000
per month, and will have to be continued life-
long. The cost of renal transplantation and the
medicines to prevent rejection is very high
when compared with dialysis. Thus, it is very
difficult for the average patient to afford dia-
lysis and it becomes mandatory to ensure good
QOL while on such expensive treatment.3
It has been proven that the QOL is very poor
among ESRD patients. The QOL is used to
evaluate the general wellbeing of individuals
and societies. It may vary according to the
patient as well as the disease condition. The
WHO has defined QOL as “an individual’s
perception of their position in life in the con-
text of the culture and value systems in which
they live and in relation to their goals, expec-
tations, standards and concerns.”4 Various tools
have been developed to measure different as-
pects of life. Many studies have been carried
out for measuring the QOL with generic as
well as disease-specific instruments.5 However,
such studies are limited in the Indian scenario,
although this aspect requires particular atten-
tion in developing countries. The assessment
of QOL is an essential element of health-care
evaluation and helps in taking suitable mea-
sures to increase the QOL of ESRD patients.
According to the study conducted by Zhang
et al, patients on dialysis [both hemodialysis
(HD) and peritoneal dialysis] experience com-
plications such as cardiovascular disease, peri-
tonitis, etc., which in turn decreases the QOL.
The study concluded that because of the lack
of awareness, the patient will not come for
timely dialysis until more severe co-morbidi-
ties develop.6 Several studies have shown that
regular pre-dialysis attendance helps to pro-
vide the patient with proper education and
thereby achieve better QOL.7,8 These findings
were supported by the study conducted by Lii
et al who concluded that patients who received
psychosocial intervention showed reduced
depression and better QOL compared with the
control group.9-11 Co-morbidities such as ane-
mia, diabetes, hypertension, dyslipidemia, thy-
roid disorders, etc. significantly impair the
QOL of patients on HD.12-14 This emphasizes
the significance of patient counseling, which
helps the patient to understand the lifestyle
modification to be made in order to reduce the
prevalence of such co-morbidities. Also, through
patient counseling, the patient will be in good
rapport with the pharmacist thereby increasing
compliance.
The main aim of this study is to evaluate the
QOL of patients on HD and to compare the
impact of counseling in these patients.
Patients and Methods
A hospital-oriented prospective, longitudinal,
observational comparative study was conduc-
ted for six months in the nephrology depart-
ment of a tertiary care hospital. Patients who
were receiving HD regularly and aged between
20 and 80 years were included in the study.
Patients who were not interested in counseling
and those who had voluntarily withdrawn from
dialysis as well as those having severe illness,
psychoses, infection with the human immuno-
deficiency virus (HIV) and pregnant and lacta-
ting women were excluded from the study.
Only patients who had completed at least three
months of HD were selected for the study.
At the beginning of the study, there were 172
patients undergoing HD in this hospital. Of
these, 81 met the inclusion criteria, but only 50
patients were chosen for the study because of
the time constraint. Detailed data could be ob-
tained and analyzed only in these 50 patients
during the limited time available for the study,
which was six months. Of these 50 patients, 25
were selected randomly as the control group
and the other 25 were considered as the test
group. Patient counseling was provided to the
test group patients using verbal and written
materials regarding diet, exercise, life style
modification and the importance of regular
dialysis and follow-up.
The patients’ data relevant to the study was
obtained from the patient and bystanders, and
the data collection was made by questionnaire
(WHO-BREF) administration and the patients’
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Assessment of quality of life in patients on HD 955

Table 1. Socio-demographic data of the study patients.

Demographics Test Control
Age-group (years) 49.72 ± 13.2 51.5 ± 11.6
Gender
Male 73% 67%
Female 27% 33%
Co-morbid conditions
Diabetes mellitus 20% 22%
Hypertension 42% 45.66%
Both diabetes and hypertension 18% 12%
Diabetic nephropathy 13.33% 11.33%
Other 6.66% 9%
Duration of renal failure
Less than 3 years 5.7% 4.6%
3–5 years 23.4% 26.2%
5–7 years 43.2% 40.1%
More than 7 years 27.7% 29.1%
Socioeconomic status
Upper 26.7% 22.5%
Upper middle 36.7% 39.3%
Upper lower 13.3% 12.8%
Lower 23.3% 25.4%

medical records. Using data collection forms, Results

information about the cases was collected from
the file of the admitted patients. It contained
information concerning each patient’s hospital
number and socio-demographic data, history of
allergy, principal diagnosis, co-morbid condi-
tions, medications, etc.
Assessment of quality of life
For this study, we adopted the WHO-BREF
assessment questionnaire (short form of WHO-
100), which has been used worldwide. This
questionnaire contains about 26 questions dea-
ling with patient’s QOL, health and other areas
of their life. This scale assesses four main
domains, namely, physical health, psycholo-
gical, social and environmental relationship of
the patient. After the initial administration of
WHO-BREF to the test and control groups,
counseling was given to the patients in the test
group. Specific scores for each domain were
computed. After six months, the same ques-
tionnaires were given to both groups and the
domain scores were calculated. By comparing
the score values for the test and control groups,
QOL assessments were done by using the
Statistical Package for Social Sciences (SPSS)
software. Results are given as mean ± SD.
In this prospective observational study, va-
rious parameters like age distribution, sex, du-
ration on dialysis, duration of disease and co-
morbidities were analyzed. Fifty patients were
randomly assigned to the test and control groups
(25 patients each). The mean age of the study
population in the test and control groups was
49.72 ± 13.2 and 51.5 ± 11.6 years, respec-
tively. The socio-demographic data and socio-
economic status of the patients are given in
Table 1.
It was found that the overall QOL of patients
on HD was significantly impaired. In this
study, the domain scores of both the test and
the control group of patients were calculated
after the initial administration of the question-
naire. The domain scores were calculated by
using the formula that is given in the WHO-
BREF scale.
The study revealed a remarkable difference in
the QOL of HD patients in the test group du-
ring their first and second visits, while the con-
trol group showed only a slight or no change.
There was an increase in the overall QOL of
the test group patients when compared with
the control group, although the baseline values
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956 Abraham A, Venu A, Ramachandran A, Chandran PM, Raman S
Table 2. Assessment of the quality of life at the end of the study period in the two patient-groups.
Domains Control
Domain 1 (physical) 20.54 ± 3.21
Domain 2 (psychological) 17.78 ± 3.32
Domain 3 (environmental) 9.44 ± 1.95
Domain 4 (social) 24.58 ± 4.36
are similar. The QOL of patients in the test
group was compared with the control group
using the independent t test. It showed that all
the domain scores of the test group was signifi-
cantly higher than the control group (P <0.001)
(Table 2).
Thus, patient counseling seemed to play an
important role in improving the QOL by
changing their psychological thinking and ini-
tiating them toward spirituality.
Discussion
The studies on the QOL of patients with chro-
nic disease have increased these days. It has
become an integral parameter to assess patient
satisfaction and improvement with therapy.
This is very true, especially in conditions like
CRF.
Improvement in the QOL has become the
major treatment goal in ESRD patients. Be-
cause ESRD patients have several other co-
morbidities such as hypertension, diabetes,
dyslipidemia, etc., they have to take different
medications. These may have significant ad-
verse effects and may be associated with drug
interactions. Moreover, the patients are prone
to non-compliance and all these will affect the
QOL of the patients.6
The QOL can be measured from different
angles, sometimes using generic instruments,
in some cases disease-specific instruments, or
measuring physical and laboratory parameters.
It is very essential to measure the psycho-
logical domain, as the patient may experience
depression or anxiety. That is the reason why
we selected WHO BREF where psychological
and spiritual domains were included in the
assessment. This study mainly concentrated on
the physical, psychological, social and environ-
mental domains of the patient and how it af-
fects the overall QOL of ESRD patients under-
Test P-value
24.92 ± 2.15 <0.001
23.22 ± 2.45 <0.001
12.24 ± 1.87 <0.001
32.08 ± 3.32 <0.001
going HD. Our study strongly predicts the asso-
ciation between spirituality and psychological
issues and the QOL. According to the various
studies available, the number of male patients
with ESRD is higher than the female patients.6,10
This may be because of the smoking and alco-
holic habits of men, which might aggravate the
renal failure.
Majority of the previous studies were con-
ducted in developed countries where patient
counseling is mandatory. These studies showed
that patient education provides better health
outcomes, improves adherence and decreases
health-care cost.15,16 Various studies have also
shown that patient counseling is associated
with positive impact on health and it decreases
the mortality and morbidity.17-19 This study also
suggests that patient counseling improved the
QOL of patients with renal failure.
Our study has several findings worth empha-
sizing. We observed that there is an increase in
the average score of the test group when com-
pared with the control group in all the four do-
mains. The increase in average domain score
was highest in the psychological domain fol-
lowed by physical, environmental and social
relationship domains. As most of the ESRD
patients were depressed and worrying about
their health condition, by removing their mis-
conceptions about the disease, we observed an
increase in the positive feelings of the patient.
The spirituality level of the patients was also
found to be increased; thereby, their concentra-
tion levels, thinking and learning power were
also increased. As a result, they became more
involved in their self-activities without any
negative feelings.
The main limitation of our study was its
duration. Follow-up was only for a period of
six months. The results could have been much
more authentic if the follow-up duration was
two to three years and included a healthy group
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Assessment of quality of life in patients on HD 957

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