Chapter V Analysis : Quality of Life: Comparison Between Hemodialysis and Continuous Ambulatory Peritoneal Dialysis
Chapter V Analysis :
Quality of Life:
Comparison Between Hemodialysis and Continuous Ambulatory Peritoneal Dialysis
Chapter V Analysis
There are a lot of results generated by Continuous Ambulatory Peritoneal Dialysis (CAPD) and Hemodialysis. Results can be categorized in the following:
Place of Studies. There are numerous studies on the quality of life of Peritoneal Dialysis Patients and Hemodialysis patients. The researches mostly came from Western Parts of the World. Among the ten researches, five were conducted in the United States, one was carried in the Netherlands, one in Italy, one in Russia, one in Belgium and one in South Korea. All of their studies were obtained from their own countries.
Study Design. The examinations and investigations of the studies use longitudinal and cross-sectional studies with the use of Multivariate Cox-Proportional Hazards Model, Cox Regression Analysis, one-way ANOVA and etc,
Sample Size. In all ten studies, the patients that were observed either of Continuous Ambulatory Peritoneal Dialysis or Hemodialysis, six of the studies have a sample size ranging from 100 to 180,000. One study have only ninety-six patients from one hospital and two of the studies have no sample size because the authors used former studies as their references and basis of their study.
Response Rate. The response rate of the patients was to a degree high. The response rates ranges from 70 to 91%. Definitely the results would be more dependable if the response rate is higher. If the response rate is higher it is a sign and indication of the patient’s willingness to participate in the study.
Tools for Measuring Quality of Life
Using questionnaires in measuring the Quality of Life of patients in Dialysis is limited because it usually changes over a period of time. The majority of studies investigating the Quality of Life in End Stage Renal Dialysis Patients used questionnaires that are generic like the Short Form 36 (SF 36), this is a good QOL tool for screening patients that have higher risk in being hospitalized, poor compliance in renal treatment modality and depression. The Kidney Disease and Quality of Life questionnaire short Form is an instrument used in dialysis patients in the Western Countries like the United States and the Continent Europe, few studies have used this instrument.
The Quality of Life in Patients undergoing Continuous Ambulatory Peritoneal Dialysis or Peritoneal Dialysis declines in the long-term. The Quality of Life in Dialysis patients were worsen and a lot of patients were more strained due to their kidney disease, the feeling of frustrations and the time spent in treating the disease and how it becomes a hindrance in their life. But, not all studies have negative take on Peritoneal Dialysis, some have positive results. Some of the articles mentioned gender differences, age of the patients, co-morbidity. While on the contrary, support of the family members which is a great factor in the result of the study in the Quality of Life were not mentioned.
Besides, there are studies that have shown that the survival rate of Peritoneal Dialysis is almost similar to that of Hemodialysis. TermorShuizen et al stated that on the first two-year of dialysis there is no statistical significant difference in adjusted mortality rates between Hemodialyis and Peritoneal Dialysis.
All the results in the study have shown that patients undergoing renal treatment modalities have essential damage on their Quality of Life; moreover patients undergoing Continuous Ambulatory Peritoneal Dialysis (CAPD) and Hemodialysis (HD) have no significant difference. Nevertheless, in studies using disease specific questionnaires, it presents numerous information on patient’s limitation in relation to their health, quality of life are lower in patients having co-morbid diseases and lower educational attainment, dialysis patients complaining pain, discomfort, anxiety and depression have unsatisfactory impact on their quality of life.
In the study conducted by Alloati et al, the authors found out that hypertension is more difficult to control in Peritoneal Dialysis and patients are more prone to hyperhydration. On the other hand, Anemia is better controlled in Peritoneal Dialysis than in Hemodialysis. And both treatment modalities yielded high and low turn-over in bone lesions.
In assessing the Quality of Life, the use generic outcome measures nowadays are increasing. Generic questionnaires are used in comparing the data of the health status of the population. But then disease specific questionnaires are more beneficial in identifying the effects that are usual for that specific disease.
There are over sixty papers generated on Quality of Life, Peritoneal Dialysis and Hemodialysis. Ten papers have particularly focused on dialysis and quality of life. The basis for the selection of papers is the criteria inclusion. The basic criteria are; the patients included in the study, the execution of the study and the data and conclusions of the research. And a total of ten studies were yielded.
Five studies compared Continuous Peritoneal Dialysis and Hemodialysis. Four of those studies used qualitative method while one used the quantitative method. The aim of those five studies is to give a direcxt comparison of Hemodialyis and Peritoneal Dialysis. The four studies used a focus-group method and the one study used case studies and systematic review of related literature. The samples on these studies were of large sizes and were selected from a very reliable data on their countries. In. the methods that were used in interpreting the study of Alloati et al were not defined and described clearly, hence the validity of the study is difficult to judge. Three studies focused on a particular renal replacement therapy which is either Peritoneal Dialysis or Hemodialysis. The other two studies focused on Suicide and Depression as indicators on the Quality of Life.
Mortality and Survival Rate
Among the ten studies investigated all themes related to the mortality and survival of patients emerged from eight of the ten researches. In all of the studies the mortality rates and survival rates of the two different treatment modalities, in Ford et al study (2000), the mortality rate Peritoneal dialysis patients due to suicide in is higher compare to its counterpart, hemodialysis. And peritoneal dialysis was associated with a 19% higher mortality rate. (Bloembergen, 1995). However mortality tends has shown a relevant decrease among diabetic Continuous Ambulatory Peritoneal Dialysis (CAPD) patients whereas Hemodialysis (HD) mortality increased. (Nelson et al, 1992) In some cases, there is no statistical difference in adjusted mortality rates between Hemodialysis and Peritoneal Dialysis on the first two to three years of Dialysis. (Termorshuizen et al, 2003;Tomilina et al, 2000.; Lameire et al, 2006) In addition, high patients with Body Mass Index (BMI) with UCr ≤ 0.55 g/d had higher chances of all-cause and cardiovascular death (Beddhu et al; 2003) and delivered dialysis on both Hemodialysis and Peritoneal Dialysis is significant in the survival of patients. (Churchill et al, 2002)
Undergoing any renal replacement therapy has impact on the physical aspects. Ford et al discussed that Hemodialysis leaves the patient feeling washed out until the next day whereas Peritoneal Dialysis have no washed out feeling. In Termorshuizen et al study they found out that Hemodialysis patients often have co-morbid conditions, have worse nutritional status, lower hemoglobin concentrations and lower residual renal function. The control for anemia is better with peritoneal dialysis than hemodialysis according to Alloati et al. On the other hand, according to Alloati et al it is easier to control hypertension in Hemodialysis than in Peritoneal Dialysis. Peritonitis is a major issue in Peritoneal Dialysis because it is a great factor in the failure and discomfort of the patients. Other factors include catheter problems and inadequate dialysis, failure rate of peritoneal dialysis is 7-11% per year which is higher than Hemodialysis. (Tomilina et al, 2000; Lameire et al, 2006) In some cases, like Bone lesions, Hemodialysis and Peritoneal Dialysis have respectively frequent incidents. (Alloati et al 2000)
In four studies, the impact on the psychological aspects on Continuous Ambulatory Peritoneal Dialysis (CAPD) and Hemodialysis (HD) patients was discussed. Ford et al mentioned that Hemodialysis provides the opportunity for patients to interact with other patients because it is administered in the clinic, while peritoneal dialysis may produce the feeling of isolation since it is administered at home. The time that the patients spent in the dialysis clinics have therapeutic effects especially if they are interacting with persons having similar problems. In the study conducted by Jung et al, the researchers identify that depression as the most common psychological problem that has a great influence on the Quality of life of patients having End Stage Renal Disease (ESRD). A number of studies approximately calculated that around 20% to 49% of dialysis patients, majority of them under hemodialysis therapy, experience depression. Studies reported that Continuous Ambulatory Peritoneal Dialysis (CAPD) patients having extreme manifestations of depression have greater rate of acquiring peritonitis. According to Jung et al 70% of Continuous Ambulatory Peritoneal Dialysis (CAPD) patients experienced depression and CAPD patients have more negative ideas and thoughts about the future than the common population. Negative thoughts are closely associated with hopelessness, Continuous Ambulatory Peritoneal Dialysis Patients depression is due to psychological factors like hopelessness and internal individual stress. By contrast depression and demographic factors have no significant correlation.
Having renal disease totally affects the patient and its family in terms of financial. The two methods of renal replacement therapy exhibit different costs, due to this difference some patients shifted from the more costly procedure to the less expensive ones. But shifting to less expensive procedures results in the deterioration of the quality of life of the patients. Recent figures have shown that hemodialysis is more expensive renal replacement treatment modality. On present, in the United States the average cost of Hemodialysis is $104 per treatment $66 for a unit of peritoneal dialysis. (Ford et al, 2000) Recently the cost reduction for starting a Peritoneal Dialysis first therapy was calculated in the United States based on Medicare expenditures. The average Medicare expenditures for Peritoneal Dialysis as a first treatment modality were $53,277 while Hemodialysis was $72,189. “Peritoneal Dialysis, no switch” is lower in expenditures compared to “Hemodialysis, no switch.” In addition, “Peritoneal Dialysis with at least one switch” had a lower or similar expenditure to “Hemodialysis with at least one switch.” Financial and reimbursement factors play a very significant role in the preference of the first renal replacement treatment modality and its next application. In implementing Peritoneal Dialysis, a necessary step is having an early referral of patients with kidney disease. Second is providing adequate training for nephrologists regarding Peritoneal Dialysis. Finally, having financial incentives given for caregivers for promoting peritoneal dialysis.
Quality of Life
In relation to the quality of life on Continuous Ambulatory Peritoneal Dialysis (CAPD) and Hemodialysis patients, the ten articles gave contradictory results. Some of the studies are in favor for Continuous Ambulatory Peritoneal Dialysis (CAPD) and some studies are more inclined in Hemodialysis (HD). Studies on suicide rates as an indicator of Quality of life among dialysis patients indicated that the quality of life is better under hemodialysis as renal replacement therapy. Hemodialysis provides patients complete accounting and full social cost benefits, and 141 fewer suicides for every 1000 patients occur in hemodialysis. Hemodialysis has lower mortality risk compare to peritoneal dialysis.(Ford et al, 2000; Bloembergen et al, 1995) On the other hand studies conducted observed that there is a significant renal replacement therapy in favor for Peritoneal Dialysis during the first two years of treatment for younger diabetic patients and Continuous Ambulatory Peritoneal Dialysis (CAPD) has favorable effects on metabolic control. Better mental performance and cognitive function were reported to occur in Peritoneal Dialysis Patients. (Termorshuizen et al, 2003; Alloati et al, 2000; Tomilina et al, 2000.; Nelson et al 1992) In the study conducted by Beddhu et al body size and composition is a great indicator of survival of a dialysis patients and delivered dialysis in Continuous Ambulatory Peritoneal Dialysis (CAPD) and Peritoneal Dialysis (Churchill et al, 2002), in addition, Jung et al discussed that depression an id the most common psychological problem that occurs whether the patient is in Continuous Ambulatory Peritoneal Dialysis (CAPD) or Hemodialysis (HD).