Translate this page into:
Health-related quality of life among the patients undergoing dialysis in a tertiary care teaching hospital in Southern India
For correspondence: Dr Sitanshu Sekhar Kar, Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India e-mail: drsitanshukar@gmail.com
-
Received: ,
Accepted: ,
Abstract
Background & objectives
Dialysis is a therapeutic intervention where it is essential to consider patients’ quality of life (QOL) as a key aspect of care. This study aims to assess the QOL of patients and identify factors affecting QOL in patients undergoing dialysis.
Methods
A cross-sectional analytical study was conducted among 140 participants undergoing dialysis at a tertiary care hospital in South India. Data on socio-demographic characteristics, history of co-morbid conditions, and details regarding the duration and type of dialysis were collected. QOL was assessed using the European Quality of Life assessment instrument, the EuroQOL 5-Dimensional 5-Level (EQ-5D-5L) questionnaire.
Results
The mean age of the participants was 41 yr (SD±12). Of 140 participants, 96 (68.6%) were men; 80 (57.1%) resided in rural areas. Hypertension was the most common co-existing condition, present in (n=136; 97%) participants. In the QOL assessment, participants reported a total of 86 distinct health states. The most frequently reported states were 11111 (8.6%) and 11121 (2.9%). The health state associated with the poorest quality of life was 55544, reported by one study participant. A majority of participants (86.4%) experienced pain or discomfort, and more than three-fourths (78.6%) reported difficulty performing their usual activities. The mean EQ-5D utility score was 0.581 (95% CI: 0.522-0.639), and the mean EQ Visual Analogue Scale (EQ VAS) score was 49.0 (95% CI: 46.6-51.3). Patients undergoing haemodialysis (0.714) reported a significantly higher quality of life compared to those on peritoneal dialysis (0.512), with a P value of 0.005.
Interpretation & conclusions
The mean utility score among participants undergoing dialysis reflects a compromised quality of life.
Keywords
Chronic kidney disease
dialysis
EQ-5D-5L
haemodialysis
peritoneal quality of life
utility
Dialysis is the most common modality of renal replacement therapy because of limited donors for kidney transplantation1. Haemodialysis (HD) and peritoneal dialysis (PD) are the two types of dialysis adopted for patients with end stage kidney disease. HD is the most common RRT in India2, and it is carried out twice in a week, whereas PD is done 3-4 times per day at home by the patients3. Although the dialysis is proven to be effective in reversing the kidney function, the perceived health-related quality of life (HRQoL) of the patient’s undergoing dialysis is found to be compromised4,5.
With ongoing progress in medical care, the focus is gradually shifting toward improving patients’ quality of life (QOL), not just extending their lifespan. Dialysis being a chronic therapeutic intervention, it is crucial that the QOL of patients is regarded with equal importance6. QOL among dialysis patients can be assessed using the two types of instruments; generic and disease specific instrument7. Although Kidney Disease Quality of Life (KDQOL- SFTM) is the broadly used disease specific instrument, it is only helpful in providing the generic scores and it does not quantify the health states8. So, the best method to measure patient’s QOL is to quantify the health states in terms of utility scores. In this study, the QOL of patients undergoing dialysis was assessed using European quality of life assessment instrument ‘EuroQOL 5-Dimensional 5 Level’ (EQ-5D-5L)9.
Since the Indian value set has been released recently for EQ-5D-5L instrument, measuring QOL using Indian value set will be helpful to quantify how much satisfaction does a person gain from a particular action10. We conducted this study to estimate the quality of life of patients undergoing dialysis, using EQ-5D-5L questionnaire and to determine various factors associated with it.
Materials & Methods
This cross-sectional study was conducted by the department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India between February-December 2019. The study was approved by Institute Ethics Committee. An informed written consent was obtained from the participants before enrolment.
Study setting
We conducted this study in a tertiary care public hospital located in the district of Puducherry (between February-December 2019). The nephrology department of the hospital provided inpatient and outpatient services including renal transplantation. Participants visiting the nephrology department mostly belongs to Puducherry and the neighbouring States of Tamil Nadu, Kerala, Andhra Pradesh, and Karnataka.
The hospital’s dialysis centre operates on all working days (Monday to Saturday), providing haemodialysis services to patients. For those undergoing peritoneal dialysis, a dedicated clinic is held once a week, every Wednesday. Both haemodialysis and peritoneal dialysis are offered on an outpatient basis, with patients charged a nominal fee for the procedure and consultation, while medications are provided free of cost. On average, around fifty patients receive dialysis each day at the centre.
Study design and sample size
We included all participants aged 18 yr and above who could communicate in Tamil or English and had been receiving either peritoneal or haemodialysis for more than three months at the hospital. Study participants with severe cognitive impairment were excluded.
Study procedure
Information about the study procedure and purpose was explained and informed written consent was obtained. For those undergoing peritoneal dialysis, interview was conducted in the dialysis clinic. For those undergoing haemodialysis, interview was conducted in the waiting area of dialysis centre before starting their dialysis procedure.
Data collection tool
A pre-tested, structured proforma was used to collect information on patients’ socio-demographic characteristics (including age, gender, marital status, residence, education, employment, and family income) as well as clinical details such as duration of illness, type and duration of dialysis, and history of co-existing conditions. Data collection was carried out by a postgraduate student proficient in local language and English.
Health-related quality of life was assessed using the EQ-5D-5L descriptive system and the EQ visual analogue scale (EQ-VAS)9. The EQ-5D-5L evaluates a patient’s current health status across five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension is rated on five levels ranging from no problems to extreme problems. The combination of responses across these five dimensions forms a five-digit health state code (e.g., 11111, 21111, 12111, etc.). These health states were then converted into a single utility value ranging from -1 to 1, where 1 indicates perfect health, 0 represents a health state equivalent to death, and negative values indicate states perceived as worse than death. The utility scores derived from the EQ-5D-5L reflect a societal perspective, while the EQ-VAS provides a self-rated measure of health from the patient’s perspective. The Indian tariff value set was used to calculate the quality-of-life index.
Statistical analysis
Data were entered in EpiData version 3.03 and the analysis was done using STATA version 14.0 (StataCorp LLC. College Station, TX, USA). Utility scores for health states were calculated using the equation derived from Indian value set10. Categorical variables such as age groups, gender, residence, marital status, education, occupation, etc. were summarized as proportion and continuous variables such as age and utility values were summarised as Mean (SD). Independent t test and ANOVA were performed to assess the difference in the utility values across socio-demographic characteristics of the patients. Multiple linear regression was used to assess the determinants of health related- quality of life among the patient’s undergoing dialysis.
Results
Characteristics of the study population
A total of 140 participants were enrolled. The mean age of participants was 41 yr (±12 yr). The majority of participants were aged between 35 and 60 yr (n=83, 59.3%), were male (n=96, 68.6%), resided in rural areas (n=80, 57.1%), and were unemployed (n=91, 65%). Over 90 per cent of the participants (n=128, 91.4%) had been receiving dialysis for more than five years, and approximately two-thirds (n=92, 65.7%) were undergoing haemodialysis. The most commonly reported co-existing conditions were hypertension (n=136, 97%) and anaemia (n=44, 31%). Additional socio-demographic and clinical characteristics are presented in table I.
| Characteristics |
Number of participants, n (%) |
Mean (SD) EQ5D# score India | P value |
|---|---|---|---|
| Age group (yr) | |||
| 18-34 | 48 (34.3) | 0.6538 (0.3097) | 0.12 |
| 35-60 | 83 (59.3) | 0.5564 (0.3560) | |
| >60 | 9 (6.4) | 0.4272 (0.4588) | |
| Gender | |||
| Men | 96 (68.6) | 0.6141 (0.3019) | 0.10 |
| Women | 44 (31.4) | 0.5104 (0.4345) | |
| Residence | |||
| Urban | 60 (42.9) | 0.6181 (0.3122) | 0.28 |
| Rural | 80 (57.1) | 0.5540 (0.3766) | |
| Marital status | |||
| Married | 95 (67.9) | 0.5551 (0.3585) | 0.19 |
| Unmarried | 45 (32.1) | 0.6371 (0.3306) | |
| Education | |||
| Upto 10 standard | 70 (50) | 0.5080 (0.3963) | 0.05* |
| Higher secondary | 25 (17.9) | 0.6536 (0.2199) | |
| Graduate & above | 45 (32.1) | 0.6558 (0.3142) | |
| Occupation | |||
| Self-employed / business | 13 (9.3) | 0.5603 (0.3952) | 0.83 |
| Unemployed | 91 (65) | 0.5658 (0.3384) | |
| Homemaker | 22 (15.7) | 0.6253 (0.3495) | |
| Daily / monthly waged | 14 (10) | 0.6345 (0.4154) | |
| Income (in Rupees) | |||
| ≤10,000 | 113 (80.7) | 0.5955 (0.3184) | 0.16 |
| >10,000 | 27 (19.3) | 0.5228 (0.4653) | |
| Duration of illness | |||
| ≤5 yr | 95 (67.9) | 0.5798 (0.3609) | 0.53 |
| >5 yr | 45 (32.1) | 0.5850 (0.3322) | |
| Duration of dialysis | |||
| ≤ 5 yr | 128 (91.4) | 0.5946 (0.3486) | 0.07 |
| >5 yr | 12 (8.6) | 0.4420 (0.3580) | |
| Type of dialysis | |||
| Peritoneal dialysis | 48 (34.3) | 0.5120 (0.3938) | 0.005* |
| Haemodialysis | 92 (65.7) | 0.7148 (0.1897) | |
| Comorbid status | |||
| Present | 137 (94.9) | 0.5749 (0.3513) | 0.93 |
| Absent | 3 (2.1) | 0.8840 (0.1368) | |
P*≤0.05, #EuroQOL 5 dimension score
Health-related quality of life
A total of 86 health states were reported by the participants, among which, the most commonly reported health states were 11,111 (8.57%), and 11,121 (2.86%). Among all the health states, the state corresponded to the worst quality of life was 55,544, and was reported by one patient followed by the health state of 55,543 reported by another patient. Among the patients undergoing dialysis, majority (86.4%) had pain or discomfort followed by more than three fourth (78.6%) had problem in performing their usual activities. More than one third (37.9%) of patients reported difficulty in taking care of themselves (Table II).
| Dimensions of EQ5D | Mobility, n (%) | Self-care, n (%) | Usual activities, n (%) | Pain/ discomfort, n (%) | Anxiety/depression, n (%) |
|---|---|---|---|---|---|
| No problem | 62 (44.3) | 87 (62.1) | 30 (21.4) | 19 (13.6) | 39 (27.9) |
| Slight problem | 30 (21.4) | 31 (22.1) | 46 (32.9) | 45 (32.1) | 50 (35.7) |
| Moderate problem | 31 (22.1) | 14 (10.0) | 37 (26.4) | 53 (37.9) | 37 (26.4) |
| Severe problem | 14 (10.0) | 5 (3.6) | 19 (13.6) | 20 (14.3) | 12 (8.6) |
| Extreme problem | 3 (2.1) | 3 (2.1) | 8 (5.7) | 3 (2.1) | 2 (1.4) |
The mean EQ-5D utility score among participants undergoing dialysis was 0.581 (95% CI: 0.522-0.639). A statistically significant difference in mean (SD) utility scores was observed with respect to patients’ educational qualification and type of dialysis. The utility scores were marginally higher among individuals aged 18-34 yr, males, urban residents, unmarried individuals, and those who were employed; however, these differences were not statistically significant when compared with their respective counterparts (Table I).
The mean EQ-VAS score reported by the patients was 49.0 (95% CI: 46.6-51.3), indicating that patients perceived their health-related quality of life (HRQOL) to be lower when assessed subjectively through the EQ-VAS compared to the utility scores derived from the EQ-5D-5L. This underestimation was consistent across different subgroups, regardless of the type of dialysis, duration of illness, or duration of dialysis (Table III).
| S. no. | Parameters | Mean EQ-5D-5L score (95% CI) India | EQ VAS score (95% CI) |
|---|---|---|---|
| 1. | Duration of illness | ||
| ≤5 yr | 0.5798 (0.5194-0.6401) | 49.4 (47.1-51.6) | |
| >5 yr | 0.5850 (0.5294-0.6405) | 48.2 (45.7-50.6) | |
| 2. | Duration of dialysis | ||
| ≤ 5 yr | 0.5946 (0.5363-0.6528) | 49.2 (46.9-51.4) | |
| >5 yr | 0.4420 (0.3821-0.5018) | 46.2 (43.0-49.3) | |
| 3. | Type of dialysis | ||
| Peritoneal dialysis | 0.5120 (0.4461-0.5778) | 49.0 (46.3-51.6) | |
| Haemodialysis | 0.7148 (0.6831-0.7464) | 49.0 (47.2-50.7) | |
After adjusting for confounders, haemodialysis patients showed significantly better quality of life than those on peritoneal dialysis.
Discussion
In this study of 140 dialysis patients, most were middle-aged males from rural areas, with hypertension and anaemia being the common comorbidities. The mean EQ-5D utility score was 0.581, with pain/discomfort and difficulties in usual activities were most frequently reported. The mean EQ-VAS score was 49.0, indicating lower subjective HRQOL. Utility scores varied significantly by education and dialysis type.
As compared to QoL studies in patients from Singapore, Thailand and Indonesia11-13,the QOL of dialysis patients from India is relatively poor. This variation may be due to the differences in the socio-demographic characteristics of the respondents, presence of comorbid condition and the differences in patients’ perspective of health across different population.
The mean utility score for haemodialysis patients in the current study is consistent with Indian data14. The utility score was significantly higher among patients undergoing haemodialysis compared with those on peritoneal dialysis. Most studies from South Africa, Korea, and a systematic review from Malaysia support this finding15-17. Haemodialysis may offer better quality of life as it is done thrice weekly, while peritoneal dialysis requires daily procedures, making it more burden to the patients. However, a study from China reported higher QOL among PD patients18. This difference may reflect variations in socio-economic status and health literacy, as most patients in the current study were from lower-income backgrounds, while the Chinese study included higher-income, more health-literate patients.
In this study, HRQOL among dialysis patients decreased with increasing age, which is consistent with most other studies using the same instrument, as well as studies in India employing different QOL assessment tools19-21. This finding may be largely attributed to the long-term treatment burden and the presence of comorbid conditions in the elderly, leading to lower QOL compared to younger patients. It underscores the need for enhanced healthcare and psychosocial support for older patients, including family involvement and caregiver assistance.
In our study, male patients reported better QOL compared with females, consistent with findings from other developing countries13. This may be due to greater self-imposed restrictions on travel among women, often influenced by perceived social stigma, as well as higher physical activity and a greater prevalence of depressive and anxiety disorders. Patients with higher education levels and those who were employed also had higher QOL, aligning with studies from India, the United States, Palestine, and a multicentric study in China8,15,22. Similarly, a study in Nepal reported that lack of formal education and unemployment were associated with poorer HRQOL23. These findings suggest that education and employment may contribute to a better standard of living, which in turn positively influences QOL.
We also observed that QOL was slightly higher among urban residents, unmarried individuals, and those with higher income, a finding consistent with studies from India and other developing countries4,14.This could be due to the population residing in urban areas could have better accessibility to their dialysis care and may be also due to their increased awareness regarding the chronic disease condition. Whereas the population who are unmarried may does not have much societal responsibility and their better income also be an important factor for their better QOL.
We also observed that there was a decline in both EQ5D5L and EQVAS scores with duration of dialysis of the patients. This was consistent with all earlier studies conducted using EQ5D5L12,13,19. This indicates that the healthcare providers need to assess and address the long-term dialysis related complications, such as back pain, headache and increased blood pressure among the HD patients; and nausea, vomiting, chills and increased temperature among the PD patients in order to promote the QOL of the patients.
In the current study, we found that majority of patients had pain and discomfort followed by difficulty in doing their usual activities. This was almost consistent with the study conducted in Indonesia24,25 where they reported that majority of the population had problem in doing their usual activities followed by pain and discomfort. A study from Palestine19 also reported that majority of the population had pain and discomfort followed by mobility. The minor difference may be due to variation among the population across geographic regions, yet pain is the major concern for the patient’s undergoing dialysis. As dialysis is the invasive procedure, needle insertion into dialysis access and inflammation caused by the process of dialysis may cause pain to the patients. Whereas support by caregiver and pain management by the clinician by using the standard operating protocol can improve the QOL of the dialysis patients.
The strength of this study is, utility score was calculated using Indian specific tariff value10. As the study was conducted in hospital-based setting there could be the chance of reporting bias regarding their perceived QOL. However, interviewed conducted by the trained single investigator and use of standardised EQ5D5L QOL assessing questionnaire would help to minimise the bias.
To conclude, our study indicated an impaired quality of life in patients undergoing dialysis, with the QOL of patients undergoing haemodialysis better than those undergoing peritoneal dialysis.
Financial support & sponsorship
None.
Conflicts of Interest
None.
Use of Artificial Intelligence (AI)-Assisted Technology for manuscript preparation
The authors confirm that there was no use of AI-assisted technology for assisting in the writing of the manuscript and no images were manipulated using AI.
References
- Renal replacement therapy review. Organogenesis. 2011;7:2-12.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- The Indian Chronic kidney disease (ICKD) study: Baseline characteristics. Clin Kidney J. 2021;15:60-9.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Global dialysis perspective: India. Kidney 360. 2020;1:1143-7.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Quality of life and its Associated factors among patients undergoing dialysis in a tertiary care hospital, Puducherry, South India - A cross-sectional analytical study. J Urol Ren Dis. 2020;5:1189.
- [Google Scholar]
- Importance of quality-of-life measurement throughout the disease course. JAMA Netw Open. 2020;3:e200388.
- [CrossRef] [PubMed] [Google Scholar]
- Worldwide access to treatment for end-stage kidney disease: a systematic review. Lancet. 2015;385:1975-82.
- [CrossRef] [PubMed] [Google Scholar]
- Formal literature review of quality-of-life instruments used in end-stage renal disease. Am J Kidney Dis. 2000;36:327-36.
- [CrossRef] [PubMed] [Google Scholar]
- Kidney disease-specific quality of life among patients on hemodialysis. Int J Nephrol. 2021;2021:8876559.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- [EuroQol-5D (EQ-5D): an instrument for measuring quality of life] Monaldi Arch Chest Dis. 2012;78:155-9.
- [CrossRef] [PubMed] [Google Scholar]
- Development of an EQ-5D value set for India using an extended design (DEVINE) study: The Indian 5-level version EQ-5D value set. Value Health. 2022;25:1218-26.
- [CrossRef] [PubMed] [Google Scholar]
- Comparison of EQ-5D-5L, VAS, and SF-6D in Thai patients on peritoneal dialysis. Value Health Reg Issues. 2019;18:59-64.
- [CrossRef] [PubMed] [Google Scholar]
- Dewi NPRA, Kandarini Y, Sajinadiyasa I, Triharnoto T. Assessment of quality of life among chronic kidney disease patients undergoing hemodialysis in Sanglah General Hospital, Denpasar from April-May 2017 using EQ-5D-5L questionnaire. undefined [Internet]. 2020 [cited 2022 Nov 1]; Available from: https://www.semanticscholar.org/paper/Assessment-of-quality-of-life-among-chronic-kidney-Dewi-Kandarini/81aec35bebf784fe70fe3bdb4b1c152055cab30a, accessed on June 3, 2025.
- Comparison of the preference-based EQ-5D-5L and SF-6D in patients with end-stage renal disease (ESRD) Eur J Health Econ. 2015;16:1019-26.
- [CrossRef] [PubMed] [Google Scholar]
- Quality of life of end stage renal disease patients undergoing dialysis in southern part of Kerala, India: Financial stability and inter-dialysis weight gain as key determinants. J Epidemiol Glob Health. 2020;10:344-50.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Comparison of quality of life in patients undergoing hemodialysis and peritoneal dialysis: a systematic review and meta-analysis. Kidney Blood Press Res. 2017;42:717-27.
- [CrossRef] [PubMed] [Google Scholar]
- Health-related quality of life with KDQOL-36 and its association with self-efficacy and treatment satisfaction in Korean dialysis patients. Qual Life Res. 2013;22:753-8.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Quality of life in patients on chronic dialysis in South Africa: a comparative mixed methods study. BMC Nephrol. 2017;18:4.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Quality of life assessment in patients on chronic dialysis: Comparison between haemodialysis and peritoneal dialysis at a national hospital in Vietnam. Trop Med Int Health. 2022;27:199-206.
- [CrossRef] [PubMed] [Google Scholar]
- Factors affecting quality of life in patients on haemodialysis: a cross-sectional study from Palestine. BMC Nephrol. 2016;17:44.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Factors associated with quality of life among chronic kidney disease patients in Nepal: a cross-sectional study. Health Qual Life Outcomes. 2020;18:207.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Quality of life in chronic kidney disease: a community perspective using world health organization quality of life: BREF questionnaire. Int J Comm Med Pub Health. 2020;7:4105-11.
- [CrossRef] [Google Scholar]
- Patterns of health-related quality of life and associated factors in Chinese patients undergoing haemodialysis. Health Qual Life Outcomes. 2015;13:108.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- A cross-sectional study to assess the health-related quality of life of patients on haemodialysis in Chennai. Egypt J Intern Med. 2024;36:89.
- [CrossRef] [Google Scholar]
- Comparing health-related quality of life and utility scores of patients undergoing hemodialysis and continuous ambulatory peritoneal dialysis in Indonesia. Perit Dial Int. 2025;45:162-73.
- [CrossRef] [PubMed] [Google Scholar]
- Health-related quality of life of hemodialysis patients in Indonesia. Value Health. 2013;16:A699.
- [CrossRef] [Google Scholar]