INTRODUCTION:

Chronic Kidney disease (CKD) involves progressive and irreversible loss of kidney function. CKD and End Stage Renal Disease (ESRD) are associated with increase in poor physical and mental health leading to impaired quality of life (QOL)^1,2. ESRD patients display emotional disturbances such asdepression, anxiety, social withdrawal, non-adherence to treatment and fluid and food intake, as well as cardiovascular and other co-existing disease morbidity. Due to which they have very low functional capacity and physical limitations in their daily activities that affect their mortality, morbidity and quality of life³.

QOL has emerged as an important concept and outcome in health and health care⁴. As with other chronic diseases, the goal of therapy for most ESRD patients is not to ensure ‘cure’ but to eliminate uremic symptoms, minimize dysfunction of main organ systems and improve QOL.

Besidessurvival and morbidity, QOL is a vitaldeterminant in selection of Renal Replacement Therapy (RRT) modality for patients. Various studies suggest that Renal Transplant (RT) have the best outcome and cost effective among all RRT options⁴. However, In India this option is severely curtailed due to issues such asshortage of organs, possible exploitation and inefficient cadaver programme. Unfortunately due to challenges faced with inadequate access to dialysis centres in India, patients are required to perform CAPD for survival.

Nurses encounter various challenges when caring for patients with ESRD on treatment or not on treatment⁵. If nurses understand the QOL issues that can be anticipated, it can help them counsel, and educate patients more efficiently to improve QOL by bringing about lifestyle changes, thereby leading toearlier initiation of therapy, adherence to treatment, improved utilization of resources, management of symptoms, better disease control, improvedself-care ability, self-efficacy, adopt appropriate coping skills, reduction in anxiety, depression, fear, mortality and expenditure^{6,7,8, 9,10,11}. Moreover most nursing actions are aimed at improving the quality of life of individuals and community¹³.

THE OBJECTIVES OF THE STUDY:

1. To assess the quality of life of patients on CAPD.

2. To determine the relationship between quality of life of patients on CAPD and selected demographic and clinical variables.

MATERIAL AND METHODS:

Research approach:

A descriptive quantitative approach was used to assess the QOL of patients on CAPD.

Research design:

A Quantitative, descriptive design was used to assess QOL of patients on CAPD.

Setting of the study:

The study was conducted in Artificial Kidney Lab (AK Lab) ata tertiary centre in South India.

Population:

The population consisted of both inpatient and outpatient subjects with ESRD on CAPD at a tertiary centre in South India.

Sample:

The subjects consist of all ESRD patients on CAPD for more than 3 months who met the inclusion criteria and gave their consent to participate.

Sampling criteria:

Inclusion criteria:

1. Patients who are 18 years and above.

2. Patients who are practicing CAPD for more than 3 months.

3. Patients who can read and understand English, Bengali, Hindi and Tamil.

Exclusion criteria:

1. Patients with cognitive impairment.

Method of sampling:

Consecutive Sampling technique was used for the study due to limited number of samples.

Sample size:

The overall health rating from pilot study was calculated around 56. A sample of 25 subjects were needed to estimate mean of overall health of 56(SD=11.92) obtained in pilot study with the precision of 5 units i.e. 10% and 95% CI. A sample size of 33 on CAPD who met the inclusion criteria was included in the study.

Data collection Instrument:

The instrument consists of 2 parts:

Part 1: Demographic and clinical variables.

Section A: Demographic variables include age, gender, marital status, educational status, occupation, locality and family income.

Section B: Clinical variables include cause of disease, duration on CAPD and comorbidities (including number of comorbidities).

Part 2: Kidney Disease Quality of life (KDQOL-SF™ 1.3) questionnaire.

A standardised tool i.e., Kidney Disease Quality of Life (KDQOL-SF™ 1.3) consisting kidney disease specific and general health related question was used, which wasdeveloped for individuals with kidney disease and on dialysis. It is a self-administer questionnaire and includes 43 kidney disease-targeted items (ESRD targeted areas includes 11 subscales, i.e. symptoms, effect of kidney disease, burden of kidney disease, quality of social interaction, work status, cognitive function, social support, sexual function, sleep, dialysis staff encouragement and patient satisfaction) as well as 36 items that provide a generic core and an overall health rating item (36-item health survey (SF-36), which includes 8 subscales, i.e. role-physical, Pain, physical functioning, general health, role-emotional, emotional wellbeing, social function and energy/fatigue).

Scoring:

Precoded numeric values for response was used to calculate and interpret the scores.

Validity and Reliability:

Bataclan and Dial (2009) in their study on “cultural adaptation and validation of the Filipino version of Kidney Disease Quality of Life – Short Form (KDQOL-SF version 1.3)”, the internal consistency reliability estimated using Cronbach’s α was 0.70¹⁴. Pearson’s correlation coefficient was used to measure the construct validity of the overall health rating with the kidney disease-targeted scales and SF-36 scales. The p value was <0.05.

Validity of translated tool was done by reverse translation by another person. The reverse translated tool was compared with the first translation and necessary corrections were made.

Data collection procedure:

The subjects were identified based on the inclusion and exclusion criteria. Explanation regarding the need and importance of the study was provided, and informed written consent was taken after which the self-administered questionnaire was given to be filled in. It involved a single session lasting for 20 to 30 minutes.

Ethical consideration:

The study was conducted after obtaining approval from the College of Nursing Dissertation Committee and Head of Department of Medical Surgical Nursing. Informed written consent was obtained from the subjects after providing information regarding the purpose, risk, benefits of the study, maintenance of privacy, and voluntary participation. Confidentiality and anonymity of the information was maintained.

Data Analysis:

The data was analysed using Statistical Package for windows (SPSS) version 17.0

1. Descriptive statistics i.e. mean, SD and median was used for continuous variables and frequency along with percentage for categorical variables.

2. The mean change in QOL among different groups of demographic and clinical variables and relationship between demographic and clinical variables and QOL was analysed using independent t-test or ANOVA, non-parametric Spearman’s and parametric Pearson’s correlation coefficient test.

3. A ‘p’ value of < 0.05 was statistically significant and p value < 0.01 was considered highly significant.

RESULTS AND DISCUSSION:

The results of the analysis are presented in the following order:

Section A: Distribution of demographic and clinical variables of the subjects.

Figure 1: Distribution of patient based on age (N=33).

Figure 1 reveals that among 33 subjects on CAPD, majority i.e. 22 (66.7%) of the subjects were 46 to 60yrs,

Table 1: Descriptive of demographic variables (N=33)

Sl. No	Demographic variables		Findings
1.	Age^a		53.06(11.806)
2.	Sex^b	Male Female	21(63.60) 12(36.40)
3.	Marital status^b	Single	2(6.1)
		Married	28(84.8)
		Widowed	2(6.1)
		Divorced	1(3)
4.	Educational status^b	Under graduate^c	18(54.5)
4.	Educational status^b	Graduate^d	15(45.5)
5.	Occupation^b	Unemployed^e	7(21.2)
		Employed^f	21(63.6)
		Retired	5(15.2)
6.	Locality^b	Rural	12(36.4)
6.	Locality^b	Urban	21(63.6)
7.	Family income/month^b	<Rs 10,000^g	7(21.2)
		Rs 10,000 to Rs 20,000	10(30.3)
		>Rs 20,000	16(48.5)

a= Mean (SD); b= Frequency (Percentage); c = Primary, High school and Higher Secondary; d = Graduate and Post graduate; e = unemployed and students; f = employed and others; g = <Rs 5000 and Rs 5000 to Rs 10,000. .

Table 1 reveals that majority of the subject were male 21 (63.6%), 28(84.4%) of the participants were married, 18 (54.5%) were undergraduates and majority of them were employed 21(63.6%).It is also evident that majority of the subjects lived in the urban 21(63.6%) and 16 (48.5%) earned an income of more than Rs. 20,000/month.

The mean age in this study was 53.06 + 11.8, similar to the mean age 51 + 14 as reported by Rajpurkar et al., 2012) and that higher percentage of subjects (66.70%) belong to the age group of 46 to 60 years¹⁵. Findings in similar studies indicate that majority of the ESRD patients on CAPD belonged to older adult group^16,17,18,19.

Table 2: Descriptive of clinical variables. (N=33)

Sl. No	Clinical variables		Findings
1.	Cause of Disease^b	Chronic diseases Diabetes mellitus Hypertension Diabetes mellitus and hypertension	22(66.7) 11(33.3) 7(21.2) 4(12.1)
		Infection	3(9.1)
		Inherited disorder	3(9.1)
		Others	5(15.2)
2.	Duration on CAPD^c		12(3,55)
3.	Comorbodities^b	Diabetes Mellitus Hypertension Anemia Cardiovascular diseases Others None	19(57.6) 29(87.9) 6(18.2) 6(18.2) 13(39.10) 1(3.0)

b= Frequency (Percentage); c= Median (Minimum, Maximum)

Table 2 shows that chronic disease i.e. Diabetes mellitus and Hypertension were the most common cause of disease 22 (66.7%) and the participants median duration on CAPD was 12 months, with the minimum duration of 3 months and maximum duration of 55 months. The table also shows that the most common comorbidity was hypertension 29 (87.9%), followed by Diabetes mellitus 19 (57.6%).

An important finding in the present study was that the most common cause of ESRD is chronic disease (i.e. diabetes mellitus, followed by hypertension). This finding is supported by the study of Dash and Agarwal (2006) and they revealed that the most common aetiology of ESRD in India was diabetes and hypertension. Their second study also had similar outcome indicating the most common cause of ESRD as diabetes, chronic glomerulonephritis, and hypertension. They concluded that the most frequent cause was Diabetes mellitus (30–40%) followed by hypertension (14–22%), CGN (16–20%), CIN (5.4–12.7%), hereditary familial disease (8.4%), obstruction including calculus (2.9%)^15,20,21.

The median duration of ESRD patients on CAPD in this study was 12 months. Studies reported the mean duration on CAPD as 20.9+18 months and 14.5+71.5 months respectively. The duration on CAPD can vary as subjects can shift to other treatment modalities as required and available, while some others may die due to associated complications^{15, 22}.

Section B: Description of overall QOL of patients on CAPD.

The distribution of subjects based on QOL scores is shown in Figure 2.

Figure 2: Distribution of subject based on QOL score (N=33)

The overall average quality of life in this present study was 58.28+SD: 11.5, which is satisfactory contrary to the study conducted in Taiwan which showed that patients on PD had a relatively high perception of their quality of life^15,
23.The difference in QOL scores can be influenced with the availability of healthcare facilities, government schemes, older age, presence and number of comorbidities, and subjective perception of satisfaction, lower expectation, experiences and social factors.

Description of overall QOL scores on 19 areas related to ESRD and general health of KDQOL-SF 36 are shown in table 3.

Table 3: Description of overall QOL. (N=33)

Sl. no	Areas of measurement	N	Mini-mum	Maxi-mum	Mean (std. deviation)
A.	ESRD targeted areas
1.	Symptoms	33	45.83	100	83.01(13.69)
2.	Effect of Kidney disease	33	0	100	67.63 (26.32)
3.	Burden of Kidney disease	33	0	93.75	32.27 (25.56)
4.	Work Status	30	0	100	53.33 (34.57)
5.	Cognitive function	33	20	100	70.9 (20.67)
6.	Quality of social interaction	33	0	100	71.91 (25.20)
7.	Sexual function	11	0	87.50	44.31 (31.80)
8.	Sleep	33	40	100	70.75 (16.48)
9.	Social support	33	0	100	65.14 (34.45)
10.	Dialysis staff encouragement	33	50	100	87.50 (16.82)
11.	Patient satisfaction	33	0	100	65.93 (22.58)
B.	36-Items Health Survey(SF-36)
12.	Physical functioning	33	15	95	55.30(25.58)
13.	Role-physical	33	0	100	38.78 (30.67)
14.	Pain	33	22.50	100	66.51 (24.48)
15.	General health	33	5	100	50.36 (21.05)
16.	Emotional well-being	33	0	100	67.27 (22.94)
17.	Role-emotional	33	0	100	40.40 (41.46)
18.	Social function	33	25	100	67.81 (21.41)
19.	Energy/fatigue	33	30	100	59.69 (17.71)

Table 4: Relationship between selected demographic and clinical variables and subscales of QOL.

S. No	Subscale of QOL	Demographic and clinical variables	Mean (SD)	p-value
1.	Role Physical	Gender:
		Male (n=21)	46.54(32.79)	0.032
		Female (n=12)	25.20(21.59)	0.032
2.	Effect of kidney disease	Educational status:
		Undergraduate (n=18)	76.4620.64)	0.040
		Graduate (n=15)	57.0529.08)
3.	Physical functioning	Occupation:		0.006
		Unemployed (n=7)	52.85(25.14)
		Employed (n=21)	63.33(23.25)
		Retired (n=5)	25.00(9.35)
4.	Work status	Locality:		0.037
		Rural (n=12)	37.50(31.07)
		Urban (n=21)	63.88(33.45)
5.	Role-emotional	Locality:		0.048
		Rural (n=12)	22.22(35.76)
		Urban (n=21)	50.79(41.65)
6.	Burden of kidney disease	Cause of disease:		0.000
		Chronic disease(n=22)	42.04(24.00)
		Others (n=11)	12.72(15.77)
7.	Burden of kidney disease	Number of comorbidities:		0.012
		Comorbidities <=1 (n=7)	19.64(30.28)
		Comorbidities 2 (n=15)	25.16(19.05)
		Comorbidities >2 (n=11)	50.00(22.36)
8.	Dialysis Staff encouragement	Number of comorbidities:		0.039
		Comorbidities <=1 (n=7)	80.35(18.89)
		Comorbidities 2 (n=15)	83.33(18.09)
		Comorbidities >2 (n=11)	97.72(7.53)

ANOVA, Coefficient correlation and Independent t test was used to analyse the relationship between demographic and clinical variables and QOL and subscales of QOL.A ‘p’ value of < 0.05 was statistically significant and p value < 0.01 was considered highly significant

On analysing the relationship between demographic variables and subscales of QOL, there was no significant relationship between age and income to subscales of QOL. However there was a significant relationship between gender and role physical (p=0.032) subscale of QOL, where men had better mean QOL scores to women. Graduates had better mean QOL scores in the area of effect of kidney disease (p=0.040), and retired subjects had higher mean QOL scores in the area of Physical functioning (p=0.006) compared to employed and unemployed subjects. Urban subjects had better mean QOL scores in the area of work status (p=0.037) and role-emotional (p=0.048) compared to their counterparts.

On analysing the relationship between clinical variables and subscales of QOL, no significant change in QOL in relation to duration on CAPD was found. But a highly significant relationship was revealed between chronic disease as the cause of ESRD and burden of kidney disease (p=0.000). It also indicated better QOL scores among subjects where the cause of ESRD was chronic disease compared to their counter parts where the causes were other diseases. It was also found that subjects with more than 2 comorbidities has better QOL scores in the area of burden of kidney disease (p=0.012) and dialysis staff encouragement (p=0.039) compared to subjects with 2 or less comorbidities.

The Null hypothesis is not accepted since there is significant relationship between selected demographic and clinical variables with the subscales of QOL.

IMPLICATIONS OF THE STUDY:

This study reveals that encouragement of dialysis staff had statistically significant association with better QOL among CAPD patients, this highlights the essential and influential role of nurses in assisting patients experience better QOL. Periodic assessment of QOL is necessary to understand the areas of challenges faced by patients which can vary over time. This will help nurses to identify areas where education, training, and reinforcement and counselling are necessary.

The findings from this present study help nurses, students’ and general public to develop skills and knowledge regarding the rehabilitation of ESRD patients, skills in measurement of QOL and prevention of ESRD.

The findings generated from this study will also enable wider avenue for further studies related to QOL of patients on CAPD.

CONCLUSION:

Quality of life is considered as a significant outcome and quality indicator of health care. The findings of this study have revealed the areas of life perceived as poor and good by ESRD patients on CAPD. This information helps us to better understand the experiences and needs of our patients. It is also a source of guide to better nursing care, education and research. Patients on CAPD need to be frequently reassessed and supported through education, reinforcement, regular follow up and counselling to attain best possible QOL.

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Received on 04.08.2022 Modified on 18.09.2022

Asian J. Nursing Education and Research. 2023; 13(1):57-62.

DOI: 10.52711/2349-2996.2023.00014