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International Journal of Nursing Practice 2013; 19: 547–556

RESEARCH PAPER

Quality of life in chronic haemodialysis and peritoneal dialysis patients in Turkey and related factors Besey Ören PhD Lecturer, Researcher, Health Science Faculty, Istanbul University, Istanbul, Turkey

Nuray Enç PhD Lecturer, Researcher, Nursing Faculty, Istanbul University, Istanbul, Turkey

Accepted for publication October 2012 Ören B, Enç N. International Journal of Nursing Practice 2013; 19: 547–556 Quality of life in chronic haemodialysis and peritoneal dialysis patients in Turkey and related factors Turkey is the fifth country in Europe with regard to the number of patients receiving haemodialysis (HD). However, only a limited number of studies have comparatively investigated the factors that affect quality of life in haemodialysis and peritoneal dialysis (PD) patients in Turkey. The purpose of the study was to investigate the factors that affect quality of life in haemodialysis and peritoneal dialysis patients, as well as providing a comparison of quality of life between these groups. In this cross-sectional study, Quality of Life Scale and a data form was completed by 300 dialysis patients who received treatment at five hospital-based dialysis units in Istanbul, Turkey. The data were evaluated using arithmetic mean values, standard deviations, minimums, maximums, percentages, independent groups t-tests, Spearman correlation analyses and one-way variance analyses. The quality of life values in peritoneal dialysis patients were found to be higher than those of haemodialysis patients (P < 0.05). It was concluded that the quality of life in chronic dialysis patients was affected by various factors. Key words: haemodialysis, nursing care, peritoneal dialysis, quality of life, SF-36.

INTRODUCTION Renal replacement therapy is a life-saving treatment for patients with end-stage renal disease (ESRD). The two main treatment modalities are transplantation and dialysis (haemodialysis (HD) or peritoneal dialysis (PD) ).1 Dialysis is the most prevalent ESRD treatment throughout the world and in Turkey.2,3 Turkey is the fifth country in

Correspondence: Besey Ören, Health Science Faculty, Istanbul University, Demirkapı Cad. Karabal Sk. Bakırköy Ruh ve Sinir Hastalıkları Hastanesi Bahçesi içi 34740 Bakırköy, Istanbul 34740, Türkiye. Email: [email protected] doi:10.1111/ijn.12098

Europe with regard to the number of patients receiving HD.2 This increase in ESRD rates is related to an aging population, as well as the increase in the incidence of diabetes (DM), hypertension (HT) and other diseases (cerebrovascular diseases, cardiovascular diseases, etc.) that damage the kidney.3 As patients receiving dialysis treatment have to deal with the symptoms of their disease, maintain a certain diet, cope with changes in their body image and re-evaluate their personal and professional goals, dialysis affects those individuals’ lives in almost all aspects.4–8 Those patients might develop psychological, physical and social problems pertaining to their new lifestyle. All © 2013 Wiley Publishing Asia Pty Ltd

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those problems, in turn, might worsen the patients’ quality of life (QOL) by disrupting their adaptation mechanisms.5,9,10 As HD requires a lifelong and constant reliance to dialysis centres, it mostly affects QOL in a more pronounced way than PD, considering the changes this situation causes in a patient’s life and the difficulty with which a patient adapts to such changes.11 Various studies have shown that the QOL in PD patients is higher compared with the HD patients.12–14 On the other hand, in some studies, the QOL in HD and PD patients were found to be similar.15,16 However, it is widely accepted that QOL in these patient groups is affected by various factors pertaining to dialysis. It is also known that these patient groups generally have a lower QOL in comparison with the general population.14,17 Factors that affect quality the life in HD patients include dialysis efficiency, duration of dialysis, other medical conditions (comorbid organic illness), haemoglobin levels and psychological problems (anxiety and depression).9,18 Also, peritoneal dialysis patients have been found that peritonitis, catheter exit site infections, dialysis efficiency, and psychological problems.1,19–21 In addition, in numerous studies, it has been stated that QOL in these patients is affected by demographic variables (age, gender, years of education, marital status, living with family, etc.).12,14,17 It can be concluded that the patients’ QOL is negatively affected in both treatment modalities. Factors that affect QOL are shown to be similar in HD and PD patients, except for peritonitis and catheter exit site infections. QOL mostly improves if an individual’s needs and expectations are met. QOL is associated with one’s satisfaction with life and happiness and goes beyond objective parameters. If an individual is happy and satisfied with his/her life, his/her QOL can presumed to be good.9,22,23 The factors that affect quality should be considered for improving health services pertaining to dialysis.9 The investigation of factors that affect QOL might help renal nurses in improving their care plans. It should be noted that factors that affect QOL in dialysis patients might be changed through technological improvements and new supportive treatments. Therefore, it is important to assess QOL in ESRD patients regularly and determine the factors that have a negative effect on their QOL. In addition, the QOL aspects of treatment modalities should be compared, and the results should be discussed with the patients while informing them about treatment options. © 2013 Wiley Publishing Asia Pty Ltd

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Although there are many studies on QOL, only a limited number of studies comparatively investigate the factors that affect QOL in HD and PD patients.1,13,16,24 Therefore, the study at hand included both HD and PD patients and provided a comparison in QOL scores in these groups. The SF-36 QOL scale is often preferred for both theoretical and practical reasons in the assessment of health related QOL. The utilization of specific scales that measure health-related QOL through disease specific variables provides more valid results.25 The purpose of this descriptive study was to investigate the factors that affect QOL in HD and PD patients, as well as providing a comparison of QOL between these groups.

METHODS Study sample The universe of the study consisted of 595 HD and 220 PD patients who received treatment in five dialysis units in Istanbul. A sample of 300 patients was randomly selected for the study. Inclusion criteria for this study included being 18 years of age or older, being literate, volunteering to participate in the study, being on the same treatment modality for at least 6 months, and not having mental retardation; 175 of which received HD and 125 which received PD. The mean age of the HD group was found to be 47.56 ⫾ 15.32 and 46.44 ⫾ 14.57 in the PD group. Among the HD patients, 58.3% were female, 60.6% were married, 54.9% graduated from primary school and 68% were unemployed. It was observed that 50.4% of the PD patients were female, 65.6% were married and 43.2% graduated from elementary school/high school. The majority of the patients reported a moderate income level (HD: 56.0%; PD: 52.0%) The majority of the patients in both groups were living with a nuclear family (HD: 76.0 %; PD: 84.8%). In addition, the majority of the patients in both groups reported that they received adequate social support from their families (HD: 78.3%; PD: 87.2%) (Table 2) Dialysis centres are grouped under three different statuses in Turkey, namely university, state and private institutions. We recruited patients who received treatment at these three different types of institutions in order to include these three institution groups in our study universe. As the majority of PD units are located in university hospitals, we also included three university hospitals in Istanbul in our study. The study was carried on in the dialysis centres of five institutions. The data were

Quality of life in dialysis and related factors

collected between March and December 2007, using the face-to-face interview method.

Data collection Instruments The patient data form and the Medical Outcomes Study (MOS) Short Form 36 Health Survey (SF-36) were completed by the participants.

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statistical analyses. Descriptive statistics (mean, standard deviations, minimum, maximum and percentiles values) were calculated for the research variables in both groups. For groups comparisons, independent groups t-test and one-way analysis of variance analysis were conducted. For the correlation analysis of the research variables, Spearman’s rho correlation analysis was used. Significance for all statistical tests was based on the P < 0.05 level.

Patient data form The patient data form consisted of two sections. The first section included questions about personal characteristics (age, gender, years of education, marital status, income level, employment status, family structure and the presence of family support) and the second section included questions regarding clinical characteristics of the patient (duration of dialysis, other medical conditions, peritonitis and laboratory data).

Medical Outcomes Study (MOS) Short Form 36 Health Survey (SF-36)

The SF-36, developed by Ware and Sherbourne,26 was designed for use in clinical practice and research, for health policy evaluations and general population surveys. The SF-36 is a 36-item scale and includes eight dimensions: Physical functioning, role–physical, bodily pain, general health, vitality, social functioning, role– emotional and mental health. Two core components of health (the physical component summary and the mental component summary) can be derived from these eight subscales. There is also a single separate item that is used to assess any change in health from the previous year. Subscale and final global scores for the SF-36 range from 0 to 100. Higher scores indicate a better QOL, whereas lower scores indicate a worse QOL in all subscales. We chose to use the SF-36 as it is a well known and widely used instrument in QOL research. It has been shown that the scale has established validity and reliability in numerous studies, languages and groups.25,27,28 The Turkish version of the SF-36 is also available.25 The scale was found valid and reliable for use in chronic diseases.25 It has been used in many clinical studies and is preferred in research that investigate QOL in dialysis patients. The Cronbach alpha coefficient of the Turkish form was 0,92.25 In our study, the Cronbach alpha coefficient for HD patients were 0.94 and 0.92 for PD patients.

Data analysis The SPSS for Windows Version 14.0 data analysis software (SPSS Inc., Chicago, IL, USA) was used for all

Ethical considerations The informed consent of all the patients taking part in the study and the approval of the ethics board of two universities in Istanbul were obtained. The patients were provided with information prior to the study. The purpose of the research was explained to participants. The patients were told that they were not required to write their names on the questionnaires. They were informed that they could leave the study at any time they wished. The study was ultimately conducted with patients who were willing to participate. The research was conducted in line with the rules of the Helsinki declaration.

RESULTS The scores on each subscale of the SF-36 are shown for the HD group, the PD group and for both groups in Table 1. According to this, the mean scores for both groups ranged between 49.73 ⫾ 18.23 and 59.64 ⫾ 19.68. The minimum score was 0, and the maximum score was 100. The HD group obtained higher scores in the general Table 1 SF-36 quality of life subscale scores Whole group (n = 300)

X ⫾ SD

Functional status Well-being General perception of health Global quality of life HD group (n = 175) Functional status Well-being General perception of health Global quality of life PD group (n = 125) Functional status Well-being General perception of health Global quality of life

Min.

Max.

52.70 ⫾ 26.66 59.64 ⫾ 19.68 49.73 ⫾ 18.23 54.02 ⫾ 18.19

0 1 3 6

100 100 100 100

48.64 ⫾ 26.54 57.02 ⫾ 19.83 47.55 ⫾ 18.03 51.07 ⫾ 18.64

4 1 3 6

100 100 100 100

58.39 ⫾ 25.88 63.30 ⫾ 18.94 52.79 ⫾ 18.14 58.16 ⫾ 16.76

0 6 10 7

100 96 100 94

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perception health subscale (47.55 ⫾ 18.03) and lower scores in the well-being subscale (57.02 ⫾ 02). The PD group obtained higher scores in the well-being subscale (63.30 ⫾ 18.94) and lower scores in the general perception health subscale (52.79 ⫾ 18.14). The lowest scores in all groups were acquired from the general perception of health (49.73 ⫾ 18.23) subscale and the highest scores from the well-being subscale (59.64 ⫾ 19.68). This result showed that the mean subscale scores in the PD group were higher (52.79 ⫾ 18.14 and 63.30 ⫾ 18.94) than the HD group (47.55 ⫾ 18.03 and 57.02 ⫾ 19.83). A comparison between groups indicated that the mean scores in the PD group were higher than those in the HD group (Table 1). The demographic and clinical characteristics of the patients are shown in Table 2. The frequency of heart disease were similar in both groups (HD: 10.2%; PD: 8%), whereas DM, HT, and hyperlipidaemia were more frequent in the PD group (DM: 22.4%; HT: 48.0%; HL: 92.0%). The rate of having hepatitis B (HBV) and hepatitis C (HCV) along with other illnesses were higher in the HD group (HBV: 13.1%; HCV: 32.6%; other: 12.0%). The HD (57.7%) and PD (61.6%) groups used high rates of erythropoietin (EPO). The dialysis duration was higher in the HD group (7.87 ⫾ 5.0 years) than the PD group (3.78 ⫾ 2.9 years). When we investigated the blood values, we found that the mean albumin and phosphorus values were similar in both groups (HD: 3.89; PD: 3.69); the mean haemoglobin (HD: 11.43; PD: 10.83) and urea (HD: 91.38; PD: 70.47) values were higher in the HD group, and the mean creatinin value was higher in the PD group (HD: 8.82; PD: 9.46). Table 3 shows specific parameters affecting QOL in HD and PD patients in four subscales of the SF-36. A variety of factors seem to affect QOL in both groups on different levels. In the HD group, we found statistically significant relationships between age and functionality (P < 0.01), well-being (P < 0.05) and the global QOL (P < 0.05). In addition, men had significantly higher scores than women in the functionality (t(173)=2.08, P < 0.05), well-being (t(173)=2.36, P < 0.05) and the global QOL (t(173)=-2.08, P < 0.05) subscales (this finding is not included in Table 3). There was a statistically significant relationship between educational status and functionality (P < 0.05). Although not shown in Table 3, we have also investigated the affect of marital status on QOL in the HD and PD groups. There was no statistically significant © 2013 Wiley Publishing Asia Pty Ltd

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difference between QOL subscales according to marital status (P > 0.05). It was determined that marital status did not affect the QOL in both groups. When we examined the relationship between income levels and QOL, we found that patients in the HD group who had better income acquired higher scores on the QOL subscales. However, there was no statistically significant difference between any subscales according to the income level (P > 0.05). In the PD group, we found a statistically significant difference between the general perception of health and income (P < 0.05) and people who had a average-high income level acquired higher scores on the general perception of health subscale compared with those who had a lower income (Table 3). When we investigated the relationship between the duration of dialysis and the SF-36 subscales, we found a statistically significant and negative relationship between the duration of dialysis and the general perception of health (r = -0.21; P < 0.01). The scores on the general perception of health subscale decreased as the duration of dialysis increased. In the PD group, there was a statistically significant and positive relationship between the dialysis duration and functionality (r = 0.22, P < 0.05). In this group, the functionality score increased with the duration of dialysis (Table 3). When we investigated the difference of the SF-36 scores according to employment status in the HD and PD groups, we observed that none of the QOL subscale scores differed significantly according to employment status (P > 0.05) (Table 3). It has been found that patients who do not have other medical conditions acquired a significantly higher score from the general perception of health subscale compared with those who had other medical conditions in the HD group (P < 0.01). There was no statistically significant difference in the PD group (P > 0.05) (Table 3). There was a statistically significant difference between the general perception of health scores and the global QOL scores according to the presence of peritonitis (P < 0.05) (Table 3). As shown in Table 4, the PD group had significantly higher scores on all SF-36 subscales compared with the HD group (P < 0.01).

DISCUSSION QOL is considered to be an important indicator of healthcare treatment outcomes. It is noted in the literature that the QOL of patients, whether they receive HD or PD, is

Quality of life in dialysis and related factors

551

Table 2 Distribution of personal and clinical characteristics of the study patients (n = 300) Characteristics

Data HD (n = 175)

Age (years) mean ⫾ SD Duration of dialysis (years) mean ⫾ SD Gender n (%) Female Male Educational level n (%) No formal education and primary school Secondary school High school Marital status n (%) Married Single Employment status n (%) Employed Unemployed Income status n (%) High Average Low Family type n (%) Immediate Family Wide Family Social support from the family n(%) Receives Does not receive Additional illness n (%) Diabetes Present Absent Hypertension Present Absent Heart disease Present Absent Hepatitis B Present Absent Hepatitis C Present Absent EPO usage n (%) Uses Does not use Hgb (g/dL) Mean ⫾ SD (Min-Max) Albumin(g/dL) Mean ⫾ SD (Min-Max) Urea (BUN) Mean ⫾ SD (Min-Max) Creatinin Mean ⫾ SD (Min-Max) Phosphorus Mean ⫾ SD (Min-Max)

47.56 ⫾ 15.32 7.87 ⫾ 5.0

PD (n = 125) 46.44 ⫾ 14.57 3.78 ⫾ 2.9

73 (41.7) 102 (58.3)

63 (50.4) 62 (49.6)

96 (54.9) 60 (34.3) 19 (10.9)

37 (29.6) 54 (43.2) 34 (27.2)

106 (60.6) 69 (39.4)

82 (65.6) 43 (34.4)

56 (32.0) 119 (68.0)

53 (42.4) 72 (57.6)

39 (22.3) 98 (56.0) 38 (21.7)

46 (36.8) 65 (52.0) 14 (11.2)

113 (76.0) 42 (24.0)

106 (84.8) 19 (15.2)

137 (78.3) 37 (19.7)

109 (87.2) 16 (12.8)

17 158 37 138 18 157 23 152 57 118

28 (22.4) 97 (77.6) 60 (48.0) 65 (52.0) 10 (8.0) 115 (92.0) 1(0.8) 124 (99.2) 7 (5.6) 118 (94.4)

(9.7) (90.3) (21.1) (78.9) (10.3) (89.7) (13.1) (86.9) (32.6) (118)

101 (57.7) 74 (42.3) 11.43 ⫾ 1,74 (6.60–18.90) 3.89 ⫾ 0.42 (2.70–6.00) 91.38 ⫾ 40.45 (34.00–221.0) 8.82 ⫾ 2.33 (2.70–15.00) 5.31 ⫾ 1.43 (2.00–10.70)

77 (61.6) 48 (38.4) 10.83 ⫾ 1.69 (6.10–17.20) 3.69 ⫾ 0.48 (2.40–4.90 70.47 ⫾ 32.84 (21.00–183.0) 9.46 ⫾ 3.09 (2.00–19.70) 5.08 ⫾ 1.58 (1.70–11.50)

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Table 3 The comparison of quality of life and socio-demographic and clinical characteristics HD (n = 175) Characteristics

Functional status

Well-being

General Perception of health

Global quality of life

Age r/p Educational level mean ⫾ SD No formal education/primary school Secondary school High school

-0.24/0.002**

-0.17/0.033*

-0.06/0.447

-0.19 */0.017

44.18 ⫾ 25.60 52.37 ⫾ 26.99 59.41 ⫾ 26.23

54.60 ⫾ 18.76 58.72 ⫾ 21.33 63.88 ⫾ 18.99

45.98 ⫾ 18,06 47.18 ⫾ 18.00 56.63 ⫾ 16.01

48.25 ⫾ 17.84 52.76 ⫾ 19.34 59.97 ⫾ 17.88

3.616/0.029

2.100/0.126

2.845/0.061

53.76 ⫾ 27.43 48.00 ⫾ 26.89 45.03 ⫾ 24.53

58.95 ⫾ 20.80 58.30 ⫾ 18.41 51.74 ⫾ 21.88

50.22 ⫾ 18.78 47.72 ⫾ 16.89 44.38 ⫾ 20.00

54.31 ⫾ 19.45 51.34 ⫾ 18.10 47.05 ⫾ 18.97

1.107/0.333 0.00/0.965

1.754/0.176 -0.09/0.229

1.019/0.363 -0.21/0.005**

1.491/0.228 -0.10/0.179

49.16 ⫾ 27.66 47.33 ⫾ 23.72

56.51 ⫾ 19.44 58.30 ⫾ 20.92

45.01 ⫾ 17.76 53.91 ⫾ 17.25

50.23 ⫾ 18.92 53.18 ⫾ 17.95

0.413/0.680

0-.538/0.591

-3.019/0.003**

-0.946/0.346

F/p Income status mean ⫾ SD High Average Low F/p Duration of dialysis (years) r/p Additional Illness mean ⫾ SD Present Absent t/p

3.612/0.029

PD (n = 125) Characteristics Age r/p Educational level mean ⫾ SD No formal education and primary school Secondary school High school F/p Income status mean ⫾ SD High Average Low F/p Duration of dialysis (yrs) r/p AdditionaliIllness mean ⫾ SD Present Absent t/p Peritonitis mean ⫾ SD Present Absent t/p SD Standart deviation, * P < 0.05, ** P < 0.01.

© 2013 Wiley Publishing Asia Pty Ltd

-0.06/0.499

-0.09/0.15

-0.14/0.118

-0.12/0.184

48.79 ⫾ 24.14 63.10 ⫾ 23.91 61.35 ⫾ 28.56

57.16 ⫾ 16.84 66.25 ⫾ 19.33 65.30 ⫾ 19.43

18.89 ⫾ 18.89 18.18 ⫾ 18.18 17.73 ⫾ 17,.73

14.92 ⫾ 14.92 16.01 ⫾ 16.01 18.75 ⫾ 18.75

3.828/0.024*

2.877/0.060

0.089/0.915

2.996/0.054*

54.87 ⫾ 26.77 61.18 ⫾ 25.44 56.97 ⫾ 25.31

64.48 ⫾ 18.11 62.08 ⫾ 19.97 65.10 ⫾ 17.51

50.45 ⫾ 15.80 56.32 ⫾ 19.02 44.14 ⫾ 18.20

56.60 ⫾ 16.57 59.58 ⫾ 17.01 55.40 ⫾ 16.53

0.821/0.443 0.22/0.015**

0.285/0.752 0.06/0.527

3.323/0.039* -0.15/0.086

0.718/0.490 0.10/0.269

56.82 ⫾ 24.627 62.42 ⫾ 28.857

62.15 ⫾ 19.091 66.24 ⫾ 18.482

52.44 ⫾ 16.667 53.70 ⫾ 21.716

57.14 ⫾ 15.592 60.79 ⫾ 19.446

-1.088/0.279

-1.085/0.280

-0.348/0.729

-1.095/0.276

53.97 ⫾ 25.98 61.97 ⫾ 25.43

61.78 ⫾ 19.25 64.53 ⫾ 18.73

48.33 ⫾ 19.35 56.41 ⫾ 16.35

54.69 ⫾ 17.15 60.97 ⫾ 16.01

-1.734/0.085

-0.806/0.422

-2.531/0.013**

-2.112/0.037**

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Table 4 The comparison of quality of life in the HD (n = 175) and PD (n = 125) groups SF 36 subscales

Groups

X ⫾ SD

t

P

Functional status

HD PD HD PD HD PD HD PD

48.64 ⫾ 26.54 58.39 ⫾ 25.89 57.02 ⫾ 19.83 63.30 ⫾ 18.94 47.55 ⫾ 18.03 52.79 ⫾ 18.14 51.07 ⫾ 18.64 58.16 ⫾ 16.76

-3.168

0.002**

-2.755

0.006**

-2.476

0.014**

-3.384

0.001**

Well-being General perception of health Global quality of life

** P < 0.01.

negatively affected by many factors such as age, duration of dialysis, economic status, employment status, nutritional status, self-care habits, dialysis efficiency, sleep deprivation, fatigue and depression.1,14,16–19 As ageing causes physical incompetency, a decrease in QOL is an expected outcome with increasing age. In many studies investigating QOL in dialysis patients, a negative relation between age and QOL has been reported, which is consistent with our results pertaining to the HD group.1,10,14,16–18 The mean age of the HD and the PD group in our study were similar; however, QOL subscales did not seem to be affected by age in the PD group. This result might be explained by the facts that PD patients can receive their treatment at home and they do not have to put personal effort into receiving treatment. In the HD group, men scored significantly higher (P < 0.05) in the functionality, well-being and global QOL subscales compared with women. Parallel results have been reported in various studies evaluating QOL in dialysis patients.9,29 In the PD group, it was found that gender did not have a significant effect on QOL. Some studies note that gender is not a significant predictor of QOL, which is consistent with the PD group of the study at hand.30,31 This result might be explained by the facts that PD patients receive their treatment at home and that women in the PD group are more competent in pursuing their daily activities when compared with the HD group, therefore having better life satisfaction ratings. In the study, it was found that QOL increased with increasing levels of education; however, this increase was not observed in all the sub-scores. Many studies report a similar increase in QOL in people with higher educational levels.10,15,30 In another study, however, no meaningful

relationship between educational level and QOL was found.32 Higher educational levels might contribute to the ability to cope with problems and disease management. It has been determined that the patients in the HD group who reported a sufficient income level had higher QOL sub-scores than those who reported a lower income level. On the other hand, there was no significant difference between QOL sub-scores according to income level in the PD group (P > 0.05). However, a statistically significant relationship between the general perception of health subscale and income level was found (P < 0.05) in the PD group, and the patients who described their income as high or medium scored higher in the general perception of health subscale than the group describing their income as low (Table 3). In some studies, a significant relationship between income levels and QOL was found, and the QOL scores of patients with higher income were also found to be higher, which is consistent with our results in the PD group.15,30 A better general perception of health in cases with higher income is an expected outcome. It can be assumed that patients with higher income can reach better means to improve their health, which positively affects their life satisfaction. A decrease in general perception of health with increasing disease duration is an expected outcome. The acute and chronic complications of dialysis might occur with an increased duration of dialysis.30 As the duration of dialysis increases, chronic complications such as cardiovascular diseases, DM and anaemia might increase alongside the expected acute complications of dialysis. This, in turn, can cause a decrease in the general perception of health. The fact that HD patients have longer durations of dialysis might have affected this result in the current study group. © 2013 Wiley Publishing Asia Pty Ltd

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Although no relationship between duration of disease and QOL was found in one study,1 another study reported that dialysis duration significantly lowered QOL, which is consistent with our results30 (Table 3). The positive relationship between duration of dialysis and functionality in the PD group might be explained by the facts that some of the PD patients transferred to the PD treatment from the HD treatment and that PD patients are more independent in their daily activities. One study reported that PD patients were more active than HD patients.32 It has been reported that the ability to work decreases in dialysis patients, dialysis might lead to unemployment and PD patients have higher working capacity than HD patients.10,33 In our study, there were no significant relationship between employment status and QOL in both patient groups. Contrary to our result, some studies report a lower physical sub-score in unemployed patients.9,33 Peritonitis is one of the most important problems in PD. Peritonitis is responsible for 33% of hospital admissions and 1.6% of deaths.19 As it can be seen in the study, a low QOL score is an expected outcome in patients with peritonitis (Table 3). Peritonitis causes many problems such as abdominal pain, fatigue, loss of appetite and malnutrition.33–35 The QOL of dialysis patients, whether they receive HD or PD, is affected negatively by these treatment modalities. Inconsistent results were obtained in studies regarding the QOL in HD and PD patients.1,9,25,29,36 According to a Turkish study, the QOL sub-scores of elderly HD patients was found to be significantly lower than the general population.17 Many studies report that there is no significant difference between the QOL of HD and PD patients.15,24,37 Abreu et al. and Kutner et al. determined that QOL in PD patients were higher than HD patients, although the authors noted that there was a minor statistical difference between these groups.1,16 In most of the similar studies conducted with HD and PD patients, PD patients were reported to have a better QOL than HD patients.9,10,12,38 Gokal et al., in a metaanalysis where they evaluated the results of different studies that used different scales to assess the health related QOL in patients receiving HD and PD, found that the patients receiving home HD and PD had a better QOL than patients receiving HD in a health centre.13 In our study, the QOL in both groups were compared according to the SF 36 sub-scores, and it has been found © 2013 Wiley Publishing Asia Pty Ltd

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that the PD group had significantly higher scores than the HD group (P < 0.01) (Table 4), which is consistent with the literature.9,12,13 This finding might be explained by the facts that PD patients are more independent; they can directly contribute to their own treatment and have fewer dietary limitations.

CONCLUSION AND IMPLICATIONS FOR NURSING PRACTICE It was concluded that the QOL was affected in HD and PD patients and that the PD group had better QOL than the HD group. It was found that QOL values were affected by age, gender, education, employment status, income, duration of dialysis, incidence of peritonitis and additional diseases. Turkish dialysis nurses should have sufficient knowledge about the factors that affect the QOL in dialysis patients. Nurses who work in these units might minimize the negative effects of factors such as peritonitis and anaemia on QOL and prognosis by using more effective care methods and patient training. In addition, they might provide patient training regarding the management of dialysis-related complications and, in turn, improve the patients’ QOL. In the light of our results, we recommend that implementing education programmes for patients about the changeable factors affecting their QOL and resources allotted to those patients should be increased.

STUDY LIMITATIONS This study has a number of limitations. The data were collected in a single city in Turkey. For this reason, the results might not represent all Turkish patients receiving dialysis. In addition, various factors that might affect the QOL were beyond the scope of this study and therefore excluded (i.e. dialysis efficiency, fatigue, sleep problems, nutritional status, depression, social support, etc.). Moreover, during the study period, home-based dialysis was not being conducted in Turkey. Therefore, homebased dialysis patients could not be included in the study sample. In future studies, the factors that might affect QOL can be included and investigated more comprehensively and the QOL in home-based and hospital dialysis patients might be compared.

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