Impact of Anemia on Quality of Life Among Patients Undergoing Dialysis with End-Stage Renal Failure
Rosnah Omar1, Annamma Kunjukunju1*,
Nurul Fariza1
1School of Nursing, KPJ Healthcare
University, Nilai, Negeri Sembilan, Malaysia
*Corresponding author: ann@kpjuc.edu.my
Submitted: 18.03.2024 Accepted: 17.04.2024 Published: 24.04.2024
Keywords: Anemia,
quality of life, end-stage renal failure, kidney failure, chronic kidney
disease
Introduction
End-stage
renal Failure (ESRF) is the final stage of chronic kidney disease in which the
kidneys cannot function independently (Gusev, Solomatina, Zhuravleva, & Sarapultsev, 2021).End-stage renal failure is a GFR of less
than 15 mL/min (Scott, Scuffham, Gupta, Harch,
Borchi, 2020). In the last three decades, health systems have paid
increasing attention to the quality of life (QOL). Health-related quality of
life means measuring a dialysis patient's functioning, well-being, and general
health perception in physical, psychological, and social domains. In evaluating
outcomes in end-stage renal Failure (ESRF), quality of life has become as
important as morbidity and mortality indicators (Pei et al., 2019). The quality of life in patients with End-Stage Renal
Failure (ESRF) can be significantly affected due to the chronic nature of the
illness and the need for regular treatment
(Hussien, Apetrii, & Covic,
2021).
Up to 90% of individuals with ESRF
experience anemia at some time throughout the disease (Vestergaard et al.,
2020). The disease influences the quality of life of patients with end-stage
renal disease, and anemia is a major consequence that frequently affects
patients with ESRF and can significantly lower their quality of life (QOL) (Adamczuk & Roszkowska-Blaim,
2017). Anemia in ESRD is associated with further lowering
the quality of life; even a minor reduction in hemoglobin can be associated
with low quality of life. Diagnosis of anemia is made in adults and children over 15 years with
chronic kidney disease (CKD) when hemoglobin (Hb) is below 13.0 g/dL (130 g/L)
in males and below 12.0 g/dL (120 g/L) in females (McMurray et al., 2012). Iron deficiency, decreased erythropoietin synthesis,
and decreased red blood cell lifespan all play a role in the complex
pathophysiology of anemia in ESRF (Portolés, Martín, Broseta, &
Cases, 2021). Anemia can cause various symptoms, such as fatigue,
weakness, shortness of breath, and a decreased ability to tolerate physical
activity, all of which can significantly affect dialysis patients; quality of
life (QOL) (Hussien,
Apetrii, & Covic, 2021). Studies have
demonstrated a significant improvement in quality of life after initiating
replacement supplement medication treatment to treat anemia in dialysis
patients and those with early renal failure (McMurray et al., 2012).
Additionally, it has been
discovered that anemia negatively affects QOL in individuals with chronic
kidney disease who are not yet receiving dialysis (Mathias et al., 2020). Anemia was linked to lower QOL ratings in patients
with chronic renal disease who had not yet started hemodialysis (Portolés et al., 2021). Anemia is linked to worse QOL across various
dimensions, including physical functioning, role functioning, and emotional
well-being in hemodialysis patients with chronic kidney disease (Najafi, Keihani, Bagheri, Jolfaei,
& Meybodi, 2016). This study aimed to determine the impact of anemia
on the quality of life among dialysis patients with end-stage renal failure in
a private dialysis center in Kuantan, Malaysia.
Method
A cross-sectional study design was
adopted and carried out in the hemodialysis unit of the Private Dialysis Centre
in Kuantan from January to February 2023. The study included adult patients
over the age of 18 who had been diagnosed with ESRF and had been on regular
hemodialysis for at least six months. Patients who were younger than 18 years
of age, had been on hemodialysis for less than six months, were unable to
understand the study due to conditions such as dementia or mental retardation,
or those who refused to participate were excluded from the study. Patients with
CKD not on dialysis also were excluded from the study.
The data was collected using a questionnaire
divided into three sub-sections. Section A was on demographic background,
Section B was on the quality of life, and Section C was on the prevalence of
anemia. The quality of life questionnaire with 15 items was adapted and
modified from 2 sources (Kraus et al., 2016; Van Haalen,
Jackson, Spinowitz, Milligan, & Moon, 2020). Section A was on demographics and the information on
age, sex and race was included. Section
C was on prevalence and data was collected from the patient's case notes using
data collection form as a retrospective observational method. Section B was
administered face-to-face to targeted respondents. Informed consent was
obtained from all participants before the administration of the questionnaire.
Anemia was defined as per Kidney
Disease: Improving Global Outcomes (KDIGO) guidelines as Hemoglobin (Hb) <13.0g/dl in males and
<12g/dl in females (McMurray et al., 2012). This study defined mild anemia as Hb10-10.9 g/dL,
whereas moderate and severe anemia was defined as HB 7-10g /dL and <7 gm
/dL, respectively. The IBM SPSS v.25 was used to perform all calculations and
record the data from the samples used in this study. Categorical variables were
analyzed as frequency and percentages. Comparison of continuous variables was
analyzed using correlation and regression analysis.
Ethical approval
The permission to collect data was
obtained from the institution review board (KPJUC/RMC/EC/2022/432) and the
dialysis center’s management.
Results
Demographic profile of the respondents
A total of 113 cases were included
in the study. The highest number of respondents were females (51%) aged 50 and
above (59.8%) from the Malay ethnic group (74%). The patient's demographic data
is shown in Table 1.
Table
1. Demographic profile of study respondents
|
Variables |
Frequency |
Percent |
|
|
Gender |
Female |
57 |
51 |
|
Male |
56 |
49 |
|
|
Age |
32-40 |
2 |
1.8 |
|
40-49 |
43 |
38.4 |
|
|
50 and above |
68 |
59.8 |
|
|
Race |
Malay |
83 |
74 |
|
Chinese |
25 |
21.5 |
|
|
|
Indian |
5 |
4.5 |
Concerning the prevalence of anemia
among patients with ESRF on dialysis, it was found that 46.4% had mild anemia,
38.4% had moderate anemia, and 16.2% had severe anemia, with the highest
percentage in mild anemia. Detail on the prevalence of anemia is provided in
Table 2. Quality
of life was rated by 76% as "Bad," 6% as "Very Bad," and
19% rated as normal. The highest percentage reported that the quality of life
was bad.
Table 2. Prevalence of anemia
|
|
Frequency |
Per cent |
|
|
Prevalence of anemia |
Mild (Hb:10-10.9 g/dL) |
52 |
46.4 |
|
Moderate (Hb: 7-9.9 g/dL) |
44 |
38.4 |
|
|
Severe (<7g/dL) |
18 |
16.2 |
|
|
Total |
113 |
100.0 |
|
Discussion
The study found that the number of
male and female patients with ESRF attending dialysis was equal. This may be
due to the small sample size in the current study. However, in another study,
males reported having a higher incidence of ESRF (Harris & Zhang, 2020). The majority (59.8%) were aged 50 years and above.
Advancing age was reported to be one factor contributing to the increased
incidence of ESRF (Harford, Clark, Norris, & Yan,
2016). The result shows that in the population being
studied for anemia, 46.4% have mild anemia, 38.4% have moderate anemia, and
16.2% have severe anemia. Previous studies have shown that the prevalence of
Anemia varied grossly in different countries. Cameroon reported the highest at
79%, followed by China at 51.5% and India at 39.36%. However, the USA reported
the lowest prevalence of anemia, 14%, among patients with chronic kidney
disease. The prevalence of anemia also highly varied based on the stages of chronic
kidney disease, with 22.4%, 41.3%, and 53.9% in stages 3, 4 and 5,
respectively. The study reported the highest prevalence among stage 5 patients,
ESRF (Bishaw, Belay Woldemariam,
Mekonen, Birhanu, & Abebe, 2023). Anemia is a common complication of Chronic kidney
disease and is associated with many adverse outcomes like cognitive impairment,
sleep disturbances, and cardiovascular and cerebrovascular complications (Bishaw et al., 2023). A Kidney
Disease Outcomes Quality Initiative (KDOQI) study found that approximately 80%
of hemodialysis patients had anemia (Bello et al., 2022). In this study, the prevalence of anemia is lower,
with only 46.4% of the population with mild anemia. This difference in findings
could be due to differences in the study population, sample size, and methodology.
Research objective two was to
determine the quality of life among dialysis patients with end-stage renal
failure in private dialysis centers. The dialysis patients with ESRF in private
hospitals are commonly thought to have a low quality of life. With 76% of
respondents rating the topic as "Bad" and 6% as "Very Bad,"
most respondents rated QOL as either a "Bad" or "Very Bad"
grade. The findings suggest that ESRF and the need for regular dialysis
treatment negatively influence the quality of life of a sizeable section of the
population under study. These findings are consistent with previous research on
the quality of life among dialysis patients. Dialysis patients had lower
quality of life scores than the general population (Bishaw et al., 2023). Dialysis patients in Malaysia had lower quality of
life scores than the general population, and certain factors, such as age and
comorbidities, also contributed to lower quality of life scores (Soon, Lim, Rampal, & Su, 2019).
The results also highlighted the
mean quality of life for individuals with mild anemia is 40.3, for moderate
anemia is 36.3, which is bad or poor quality of life. The findings are in
congruent with similar study findings(Hussein et al., 2021; Najafi et
al., 2016; Pei et al., 2019; van Oevelen et al., 2023) However, for
patients with severe anemia it was 41.9 with a mean± SD of 39.0±6.02 which is
at the borderline of bad to normal. The findings is not a usual pattern in
patients with ESRD (Salman et al., 2016; Van Haalen et
al., 2020). However, the negative findings may be because of the
small sample size in this study and therefore statistically not significant.
The relationship between Anemia and
Quality of life is generally considered strong, with a Pearson correlation of
0.749. The correlation is highly significant, as evidenced by the significance
p value of 0.001 for mild, moderate, and severe anemia. These findings are
consistent with previous research on the relationship between anemia and
quality of life among dialysis patients. Anemia significantly predicted
decreased quality of life among dialysis patients (Van Haalen et al., 2020; Wouters
et al., 2019).
The study was conducted in a few
dialysis centers in Kuantan, Pahang, Malaysia, and most patients were of Malay
ethnicity. Therefore, the findings may not be representative of the
multi-ethnic Malaysian population. It is recommended that the study be conducted
using a large sample size to include the general population. The study can also
be conducted using different scales to measure QOL.
Conclusion
The study findings reveal that the
prevalence of anemia among patients with ESRF is very common among patients
undergoing dialysis and associated with low quality of life. Earlier
identification and proper management of anemia may help improve the quality of
life of patients with ESRF on dialysis. There are many therapeutic
interventions in place to treat anemia among such patients. Adherence to the
treatment regimen and patient education are important factors in improving the
quality of life among patients with ESRD and having anemia.
Conflict of Interest: This study
has no conflict of interest.
Adamczuk, D., & Roszkowska-Blaim, M. (2017). Long-term
outcomes in children with chronic kidney disease stage 5 over the last 40
years. Archives of Medical Science, 13(3), 635–644.
https://doi.org/10.5114/aoms.2017.67283
Bello, A. K.,
Okpechi, I. G., Osman, M. A., Cho, Y., Htay, H., Jha, V., … Johnson, D. W.
(2022). Epidemiology of haemodialysis outcomes. Nature Reviews Nephrology,
18(6), 378–395. https://doi.org/10.1038/s41581-022-00542-7
Bishaw, F., Belay
Woldemariam, M., Mekonen, G., Birhanu, B., & Abebe, A. (2023). Prevalence
of anemia and its predictors among patients with chronic kidney disease
admitted to a teaching hospital in Ethiopia: A hospital-based cross-sectional
study. Medicine (United States), 102(6), 1–6. https://doi.org/10.1097/MD.0000000000031797
Gusev, E., Solomatina, L.,
Zhuravleva, Y., & Sarapultsev, A. (2021). The pathogenesis of end‐stage
renal disease from the standpoint of the theory of general pathological
processes of inflammation. International Journal of Molecular Sciences, 22(21).
https://doi.org/10.3390/ijms222111453
Harford, R., Clark, M. J. o., Norris, K. C., & Yan, G.
(2016). Relationship Between Age and Pre-End Stage Renal Disease Care in
Elderly Patients Treated with Maintenance Hemodialysis. Nephrology Nursing
Journal : Journal of the American Nephrology Nurses’ Association, 43(2),
101–108.
Harris, R. C.,
& Zhang, M.-Z. (2020). The role of gender disparities in kidney injury. Annals
of Translational Medicine, 8(7), 514–514.
https://doi.org/10.21037/atm.2020.01.23
Hussien, H.,
Apetrii, M., & Covic, A. (2021). Health-related quality of life in patients
with chronic kidney disease. Expert Review of Pharmacoeconomics and Outcomes
Research, 21(1), 43–54.
https://doi.org/10.1080/14737167.2021.1854091
Kraus, M. A.,
Fluck, R. J., Weinhandl, E. D., Kansal, S., Copland, M., Komenda, P., &
Finkelstein, F. O. (2016). Intensive Hemodialysis and Health-Related Quality of
Life. American Journal of Kidney Diseases, 68(5), S33–S42.
https://doi.org/10.1053/j.ajkd.2016.05.023
Mathias, S. D.,
Blum, S. I., Sikirica, V., Johansen, K. L., Colwell, H. H., & Okoro, T.
(2020). Symptoms and impacts in anemia of chronic kidney disease. Journal of
Patient-Reported Outcomes, 4(1).
https://doi.org/10.1186/s41687-020-00215-8
McMurray, J. J.
V., Parfrey, P. S., Adamson, J. W., Aljama, P., Berns, J. S., Bohlius, J., …
Wiȩcek, A. (2012). Kidney disease: Improving global outcomes (KDIGO) anemia
work group. KDIGO clinical practice guideline for anemia in chronic kidney
disease. Kidney International Supplements, 2(4), 279–335.
https://doi.org/10.1038/kisup.2012.37
Najafi, A.,
Keihani, S., Bagheri, N., Jolfaei, A. G., & Meybodi, A. M. (2016).
Association between anxiety and depression with dialysis adequacy in patients
on maintenance hemodialysis. Iranian Journal of Psychiatry and Behavioral
Sciences, 10(2), 2–8. https://doi.org/10.17795/ijpbs-4962
Pei, M., Aguiar,
R., Pagels, A. A., Heimbürger, O., Stenvinkel, P., Bárány, P., … Qureshi, A. R.
(2019). Health-related quality of life as predictor of mortality in end-stage
renal disease patients: An observational study. BMC Nephrology, 20(1),
1–10. https://doi.org/10.1186/s12882-019-1318-x
Portolés, J.,
Martín, L., Broseta, J. J., & Cases, A. (2021). Anemia in Chronic Kidney
Disease: From Pathophysiology and Current Treatments, to Future Agents. Frontiers
in Medicine, 8(March), 1–14.
https://doi.org/10.3389/fmed.2021.642296
Salman, M., Khan,
A. H., Adnan, A. S., Sulaiman, S. A. S., Hussain, K., Shehzadi, N., … Jummaat,
F. (2016). Prevalence and management of anemia in pre-dialysis Malaysian
patients: A hospital-based study. Revista Da Associacao Medica Brasileira,
62(8), 742–747. https://doi.org/10.1590/1806-9282.62.08.742
Scott , Scuffham ,
Gupta, Harch , Borchi, R. . (2020). Going digital: a narrative overview of the
effects, quality and utility of mobile apps in chronic disease self-management.
Aust Health Rev., 44(1), 62–82.
Soon, P. G. K.,
Lim, S. K., Rampal, S., & Su, T. T. (2019). A qualitative examination of
barriers and solutions to renal transplantation in Malaysia: Key-informants’
perspective. PLoS ONE, 14(8), 1–20.
https://doi.org/10.1371/journal.pone.0220411
Van Haalen, H.,
Jackson, J., Spinowitz, B., Milligan, G., & Moon, R. (2020). Impact of
chronic kidney disease and anemia on health-related quality of life and work
productivity: Analysis of multinational real-world data. BMC Nephrology,
21(1), 1–15. https://doi.org/10.1186/s12882-020-01746-4
van Oevelen, M.,
Bonenkamp, A. A., van Eck van der Sluijs, A., Bos, W. J. W., Douma, C. E., van
Buren, M., … Krekels, M. M. E. (2023). Health-related quality of life and
symptom burden in patients on haemodialysis. Nephrology Dialysis
Transplantation, 39(August 2023), 436–444.
https://doi.org/10.1093/ndt/gfad179
Wouters, H. J. C.
M., van der Klauw, M. M., de Witte, T., Stauder, R., Swinkels, D. W.,
Wolffenbuttel, B. H. R., & Huls, G. (2019). Association of anemia with
health-related quality of life and survival: A large population-based cohort
study. Haematologica, 104(3), 468–476.
https://doi.org/10.3324/haematol.2018.195552
© 2024 The
Author(s). Open Access. This article is licensed under a Creative Commons
Attribution 4.0 International License (CC BY 4.0), which permits use, sharing,
adaptation, distribution, and reproduction in any medium or format, as long as
you give appropriate credit to the original author(s) and the source, provide a
link to the license, and indicate if changes were made.
To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/