|Year : 2019 | Volume
| Issue : 3 | Page : 53-58
Relationship between blood flow rate and quality of life in patients undergoing hemodialysis
Pringgodigdo Nugroho1, Jeremia Immanuel Siregar2, Rudi Putranto3, Cleopas Martin Rumende4
1 Department of Internal Medicine, Division of Nephrology and Hypertension, Faculty of Medicine, Cipto Mangunkusumo Hospital, Universitas Indonesia, Jakarta, Indonesia
2 Department of Internal Medicine, Faculty of Medicine, Cipto Mangunkusumo Hospital, Universitas Indonesia, Jakarta, Indonesia
3 Department of Internal Medicine, Division of Psychosomatic and Palliative Care, Faculty of Medicine, Cipto Mangunkusumo Hospital, Universitas Indonesia, Jakarta, Indonesia
4 Department of Internal Medicine, Division of Respirology and Critical Care, Faculty of Medicine, Cipto Mangunkusumo Hospital, Universitas Indonesia, Jakarta, Indonesia
|Date of Web Publication||14-Jan-2020|
Jeremia Immanuel Siregar
Apartment Capitol Park Residence, Tower Emerald, Unit 1049, Jl. Salemba Raya No. 16, Central Jakarta 10430
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: A low quality of life (QoL) score in patients undergoing hemodialysis (HD) is associated with an increased risk of mortality. However, no study has evaluated a direct relationship between the blood flow rate (BFR) and QoL in patients undergoing twice-weekly HD. Materials and Methods: This cross-sectional study was conducted on patients undergoing HD (twice weekly) at the HD Unit in Cipto Mangunkusumo Hospital, Jakarta. The patients were divided into two groups: those with a BFR of >250 ml/min and those with a BFR of ≤250 ml/min. QoL was assessed using the Kidney Disease QoL-Short Form questionnaire, which is divided into physical composite summary (PCS), mental composite summary, and kidney disease composite summary (KDCS) scores. The relationship between the BFR and QoL scores was analyzed using the Chi-square test and logistic regression analysis to determine the adjusted prevalence ratio (PR). Results: In total, 132 patients were included in the analysis. Patients with a BFR of >250 ml/min were more likely to have a higher PCS score (PR, 1.86; 95% confidence interval [CI], 1.15–2.99) and KDCS score (PR, 1.41; 95% CI, 1.03–1.92) than those with a BFR of ≤250 ml/min. After the multivariate analysis, the BFR was still associated with the PCS score (adjusted PR, 1.75; 95% CI, 1.12–2.36) and KDCS score (adjusted PR, 1.31; 95% CI, 1.04–1.49). Conclusion: Higher BFR values were significantly associated with higher PCS and KDCS scores in patients undergoing twice-weekly HD.
Keywords: Blood flow, hemodialysis, quality of life, questionnaire
|How to cite this article:|
Nugroho P, Siregar JI, Putranto R, Rumende CM. Relationship between blood flow rate and quality of life in patients undergoing hemodialysis. J Nat Sc Biol Med 2019;10, Suppl S1:53-8
|How to cite this URL:|
Nugroho P, Siregar JI, Putranto R, Rumende CM. Relationship between blood flow rate and quality of life in patients undergoing hemodialysis. J Nat Sc Biol Med [serial online] 2019 [cited 2020 May 30];10, Suppl S1:53-8. Available from: http://www.jnsbm.org/text.asp?2019/10/3/53/275583
| Introduction|| |
Patients with chronic kidney disease (CKD) experience a decrease in the quality of life (QoL) along with deterioration of their CKD condition until the occurrence of end-stage renal disease (ESRD), for which hemodialysis (HD) therapy is needed., Based on the 2016 Indonesian Renal Registry (IRR) data, the prevalence of patients undergoing HD continued to increase, but two-thirds of these patients died <1 year after beginning HD. A study conducted by Lowrie et al. showed that a high QoL score was significantly associated with lower mortality in patients undergoing chronic HD. QoL in patients with CKD can be assessed using a scoring system with a QoL questionnaire such as the Kidney Disease QoL-Short Form (KDQOL-SF™). The KDQOL-SF™ questionnaire has been validated in Indonesia with a Cronbach's value of 0.78 (good internal consistency). HD therapy was reported to be associated with QoL in patients with ESRD.
Factors affecting QoL in patients undergoing HD have been widely studied and include dialysis adequacy (Kt/V) and the blood flow rate (BFR). The BFR is stated on the dialysis machine and indicates the speed of blood flow pumped from the body to the dialyzer, allowing the dialysis process to occur. A higher BFR can reflect higher urea clearance in the blood, indicating more adequate dialysis (higher Kt/V). Borzou et al. reported a significant association of an increased BFR with an increased Kt/V and urea reduction ratio. Kt/V of >1.2 in patients undergoing three-times-weekly HD was significantly associated with a higher QoL score. Other studies indicated that a BFR of ≥300 ml/min correlated with a higher dialysis adequacy and better QoL score., However, these studies were carried out on patients undergoing HD three times a week, which differs from the situation in Indonesia, where almost all patients undergo HD twice a week due to government insurance regulations. No studies to date have revealed a relationship between the BFR and QoL scores in patients undergoing twice-weekly chronic HD. Moreover, the 2016 IRR data showed that most patients in Indonesia underwent HD with a BFR of ≤250 ml/min, which is lower than that in other countries., The purpose of this study was to determine the power of the relationship between the BFR and QoL in these patients.
| Materials and Methods|| |
This cross-sectional study was carried out at the HD Unit in Dr. Cipto Mangunkusumo Hospital (RSCM), Jakarta, from July to August 2018. The inclusion criteria were treatment with twice-weekly chronic HD for ≥3 months, willingness and ability to cooperate during the study, and the ability to read and write. The exclusion criteria were a lack of cooperation, an altered mental status or neurocognitive impairment, deterioration of the clinical condition (hemodynamic instability, severe infection, or critical illness), New York Heart Association (NYHA) Class III or IV chronic heart failure, and any other chronic impairment that can influence QoL such as blindness or immobilization.
The demographic and clinical characteristics (sex, age, duration of HD, comorbidities, access type, HD adequacy (Kt/V), ultrafiltration volume, dry weight, and intradialytic hypotensive events) were obtained from all the patients who met the study criteria. The latest serum hemoglobin and albumin levels measured within the past month were also collected. The BFR of each patient was based on the average BFR from the previous month until the time of study enrollment. Patients with a BFR of >250 ml/min were included in Group 1, while those with a BFR of ≤250 ml/min were included in Group 2. The Indonesian version of the KDQOL-SF™ version 1.3 questionnaire was used to determine the QoL score. The KDQOL-SF™ is divided into three domains: the physical composite summary (PCS), mental composite summary (MCS), and kidney disease composite summary (KDCS). The score of each domain was then divided into two groups based on cutoff values from previous studies that showed lower mortality risks with higher QoL scores (PCS score of ≥44. MCS score of ≥50, and KDCS score of ≥52).
Numerical variables with a normal distribution are presented as mean ± standard deviation, while other variables without a normal distribution are presented as median with interquartile range as appropriate for the type of variables. The relationships between these two groups and the QoL scores in each domain were assessed using the Chi-square test to obtain the prevalence ratio (PR). Furthermore, multivariate analysis of the related confounding factors was performed to obtain the adjusted odds ratio (OR) in each domain of the QoL score. The adjusted OR was then converted for the final adjusted PR using the formula proposed by Schiaffino et al. The statistical analysis in this study was performed using the Statistical Package for the Social Sciences software. The study was approved by The Health Research Ethics Committee, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital (No. 0599/UN2.F1/ETIK/2018).
| Results|| |
In total, 156 patients at the HD Unit in Dr. Cipto Mangunkusumo Hospital underwent twice-weekly chronic HD for ≥3 months during the study period. Twenty patients were excluded due to deterioration of cognitive function, NYHA Class III or IV chronic heart failure, critical ill conditions, blindness, and immobilization. In addition, four patients refused to participate. Finally, 132 patients who met the study criteria were included in the analysis.
Group 1 comprised 85 patients (64.4%) and Group 2 comprised 47 patients (35.6%). Comparison of the basic and clinical characteristics of these two groups is shown in [Table 1]. The percentage of men was higher in Group 1 than 2 (62.4% vs. 37.6%, respectively). The mean age of the patients in Groups 1 and 2 was 48.10 ± 12.26 and 49.60 ± 16.55 years, respectively. The proportion of patients with hypertension was higher than that of patients with diabetes mellitus (72.7% vs. 25.8%, respectively). Moreover, the percentage of patients with HD duration of ≥24 months was higher in Group 1 than 2 (89.4% vs. 61.7%, respectively).
The mean Kt/V in the patients in Groups 1 and 2 was 1.93 and 1.82, respectively. Their percentage of intradialytic hypotensive events was lower in Group 1 than 2 (22.4% vs. 31.9%, respectively). Moreover, the mean hemoglobin concentration of patients in Groups 1 and 2 was 10.2 ± 1.51 and 9.5 ± 1.59 g/dl, respectively, while the mean albumin concentration of patients in Groups 1 and 2 was 4.1 ± 0.43 and 3.9 ± 0.41 mg/dl, respectively. With respect to QoL, the median PCS and MCS scores were higher in Group 1 than 2 (45.40 vs. 36.99 and 48.41 vs. 47.64, respectively). Furthermore, the mean KDCS score was higher in Group 1 than 2 (57.1 vs. 53.0, respectively).
The analysis of the relationship between the BFR and QoL scores in each domain is presented in [Table 2], [Table 3], [Table 4]. Patients with a BFR of >250 ml/min had 1.86-fold higher chance of having a higher PCS score (P = 0.005; 95% confidence interval [CI], 1.15–2.99] [Table 2]. Likewise, these patients also had 1.41-fold higher chance of having a higher KDCS score (P = 0.017; 95% CI, 1.03–1.92) [Table 4]. However, the MCS score was unrelated to a higher BFR (P = 0.665) [Table 3].
|Table 2: Relationship between blood flow rate and physical composite summary score|
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|Table 3: Relationship between blood flow rate and mental composite summary score|
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|Table 4: Relationship between blood flow rate and kidney disease composite summary score|
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Both the PCS and KDCS scores were further included in the multivariate analysis using logistic regression. [Table 5] shows that a BFR of >250 ml/min was still significantly associated with a higher PCS score, even after adjustment with covariates (adjusted PR, 1.75; 95% CI, 1.12–2.36; P = 0.017). Similarly, a higher KDCS score was also significantly associated with a higher BFR after the PR was adjusted (PR, 1.31; 95% CI, 1.04–1.49; P = 0.025) [Table 6].
|Table 5: Multivariate analysis between blood flow rate groups and physical composite summary score|
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|Table 6: Multivariate analysis between blood flow rate groups and kidney disease composite summary score|
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| Discussion|| |
The demographic characteristics of the patients in this study were not substantially different from those of patients in other reports from Indonesia and other countries. The mean age of our patients was 48.1 years, and a larger percentage were male than female (53.8% vs. 46.2%, respectively). This is consistent with previous reports in both Indonesia , and abroad,, in which the age range of patients undergoing HD was 45–54 years and the percentage of male patients was greater.
The percentage of patients who underwent HD for >24 months was higher than that of patients who did not (79.5%). This result is similar to that of a study involving patients undergoing twice-weekly HD in China, in which the mean duration of HD was 3.51 years (≥24 months) with a standard HD length per week (≥10 h). However, the 2016 IRR data reported different results: >50% of patients in Indonesia underwent HD <12 months before death. The probable cause of this difference is the lack of an appropriate HD length per session (>50% of patients in the IRR report had a ≤4-h HD length per session, which was inadequate).
The proportion of patients who developed intradialytic hypotension was lower in Group 1 than 2 (22.4% vs. 31.9%, respectively). El-Sheikh and El-Ghazaly  and Mc Causland et al. found that intradialytic hypotension was more common in patients with diabetes mellitus or severe heart failure, but it was not related to the BFR. Diabetes mellitus itself can cause endothelial dysfunction and autonomic neuropathy resulting in compromised HD access and increased intradialytic hypotensive events., In addition, other studies have shown no correlation between an increased BFR and the incidence of intradialytic hypotension., These previous findings are also in line with the results of the present study, which showed no increase in intradialytic hypotensive events as the BFR increased. Another factor that can be considered in this study is the small proportion of patients with diabetes mellitus and the exclusion of those with severe heart failure.
The Kt/V was higher in patients in Group 1 than 2 (1.92 vs. 1.82, respectively). Patients in Group 1 also had a higher mean serum hemoglobin level (10.2 vs. 9.5 g/dl) and higher mean albumin level (4.1 vs. 3.9 mg/dl). These results are consistent with previous studies, in which a higher BFR was associated with an increase in the Kt/V (P < 0.05)., This finding of higher mean hemoglobin and albumin concentrations is also in accordance with previous studies, in which these parameters were correlated with a higher Kt/V.,
QoL scores in this study were obtained from the KDQOL-SF™ questionnaire, in which the calculated scores are further divided into three domains: the PCS, MCS, and KDCS. In the PCS domain, the median score was higher in Group 1 than 2 (45.40 vs. 36.99, respectively). As previously explained, a higher BFR is associated with a higher Kt/V and urea clearance., The results of the present study are consistent with previous reports, in which patients with a higher Kt/V also had a higher PCS score. Similarly, Ebrahimi et al. found that patients with a higher Kt/V had a higher QoL score (P < 0.001).
In accordance with the PCS score, the mean KDCS score was higher in patients in Group 1 than 2 (57.1 vs. 53.0, respectively). Manns et al. obtained similar results in that a higher dialysis adequacy was significantly associated with higher KDCS scores for the subdomains of symptoms, effects, and burden of kidney disease (P < 0.05 for each domain). The higher urea clearance associated with a higher BFR may decrease the patient's uremia-related symptoms, such as nausea, vomiting, pruritus, and lack of appetite. Therefore, patients' QoL scores may be higher in this domain.
In the subsequent analysis, patients with a BFR of >250 ml/min were more likely to have higher QoL scores in the PCS and KDCS domains (PCS domain: PR, 1.86; 95% CI, 1.15–2.99; P = 0.005 and KDCS domain: PR, 1.41; 95% CI, 1.03–1.92; P = 0.017). The strength and significance of these results did not change despite multivariate analysis of the PCS and KDCS scores. Previous studies had similar results in that the dialysis adequacy was correlated with the PCS domain QoL score (r = 0.303, P = 0.002)., A study of patients undergoing HD three times a week in Malaysia also showed that a higher BFR was correlated with the PCS scores (r = 0.641, P < 0.001). In another report, the KDCS scores were also significantly higher in patients with a high Kt/V (P < 0.05). The results of the present study support these previous reports, with the addition of a PR of 1.86 for the PCS score and 1.41 for the KDCS score. Thus, the BFR was a factor that played an important role in achieving higher PCS and KDCS scores in this study.
In contrast, no significant association was found between the BFR and MCS scores. Previous studies have shown that neither the BFR nor Kt/V was associated with the MCS scores., In previous research reports, sociodemographic factors such as age and male sex had a significant relationship with higher MCS scores in patients undergoing chronic HD., In addition, the patients included in the present study had undergone chronic HD for ≥3 months. Thus, they appeared to have adapted to high levels of uremia, possibly preventing an increased BFR from affecting the MCS score. Yadla  also found no association between the duration of dialysis and MCS scores, and as in the present study, they enrolled only patients undergoing chronic HD. In contrast, Broers et al. reported an increase in MCS scores within the first 120 days of undergoing HD compared with before starting HD.
With respect to the frequency of HD per week, Imelda et al. found no substantial differences between the PCS and KDCS scores in patients who underwent HD three versus two times a week. Likewise, the Dialysis Outcomes and Practice Patterns Study in China  showed that the mean BFR was similar between the two groups. Thus, the BFR can contribute to high PCS and KDCS scores in patients undergoing HD twice a week as well as in those undergoing HD three times a week.
The interesting findings of our study were the cutoff value of the QoL scores that we use, based on studies by Lacson et al. and Mapes et al., wherein higher scores were associated with lower risks of mortality., Our study showed that 79.5% of the patients had HD for more than 24 months. On the contrary, the 2016 IRR report  revealed that more than 50% of patients undergoing HD in Indonesia died within <12 months after undergoing their first HD session, leaving approximately 10% of patients who survived for >3 years after undergoing HD. More than half of these patients underwent HD with a BFR of 200–249 ml/min. About 19% of the patients even used a BFR of <200 ml/min. Based on the results of this study, an increase in the BFR to >250 ml/min seems to be associated with an improved QoL in patients undergoing HD in Indonesia and lower mortality rates.
Based on our knowledge of previous reports, this is the first study in Indonesia to investigate the relationship between the BFR and QoL in patients undergoing twice-weekly HD. This study also used a cutoff QoL score that was associated with the mortality risk; therefore, this higher QoL score may have an effect on the mortality risk. Moreover, this research was performed using a cross-sectional method, and the data obtained were thus quite complete with no loss to follow-up. QoL in this study was assessed using the KDQOL-SF™ questionnaire, which has been validated in Indonesia; thus, its use can be applied to patients in Indonesia.
Nevertheless, this study had two main limitations. First, it was a single-center study; the patients were enrolled from only one hospital, which was a tertiary referral center. Therefore, further research in multiple centers may be needed. Second, the number of patients included in this study was relatively small compared with previous studies on QoL of patients undergoing HD. However, considering the similar HD protocols that are carried out in every unit in Indonesia and abroad, the results of this study can still be applied to patients who undergo HD twice a week.
| Conclusion|| |
Higher BFR values were significantly associated with higher PCS and KDCS scores in patients undergoing twice-weekly HD. An increase in the BFR to >250 ml/min might be considered in such patients to achieve better QoL.
This research was supported by grants from HIBAH PITTA Universitas Indonesia. All authors contributed equally in conduction of the study and writing of the paper, while the fourth author provided the statistical support. We are grateful to all staff members of the Hemodialysis Unit Cipto Mangunkusumo Hospital for supporting this research.
Financial support and sponsorship
This research was supported by grants from HIBAH PITTA Universitas Indonesia. The 3rd ICE on IMERI committee supported the peer review and manuscript preparation of this article.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cruz MC, Andrade C, Urrutia M, Draibe S, Nogueira-Martins LA, Sesso Rde C. Quality of life in patients with chronic kidney disease. Clinics (Sao Paulo) 2011;66:991-5.
Aggarwal HK, Jain D, Pawar S, Yadav RK. Health-related quality of life in different stages of chronic kidney disease. QJM 2016;109:711-6.
Indonesian Renal Registry. 9th
Report of Indonesian Renal Registry 2016. Indonesian Renal Registry; 2016. p. 1-46.
Lowrie EG, Curtin RB, LePain N, Schatell D. Medical outcomes study short form-36: A consistent and powerful predictor of morbidity and mortality in dialysis patients. Am J Kidney Dis 2003;41:1286-92.
Jos W. Life of patients who underwent routine Hemodialysis in Tarakan hospital, Kalimantan Utara, 2014. eJournal Kedokteran Indones 2016;4:87-91.
Broers NJ, Usvyat LA, Kooman JP, van der Sande FM, Lacson E Jr., Kotanko P, et al.
Quality of life in dialysis patients: A retrospective cohort study. Nephron 2015;130:105-12.
Golper TA, Fissell R, Fissell WH, Hartle PM, Sanders ML, Schulman G. Hemodialysis: Core curriculum 2014. Am J Kidney Dis 2014;63:153-63.
Borzou SR, Gholyaf M, Zandiha M, Amini R, Goodarzi MT, Torkaman B. The effect of increasing blood flow rate on dialysis adequacy in hemodialysis patients. Saudi J Kidney Dis Transpl 2009;20:639-42.
] [Full text]
Ebrahimi H, Sadeghi M, Khatibi M. The relationship between quality of life with dialysis efficacy and laboratory parameters in Shahroud hemodialysis patients. Iran J Crit Care Nurs 2015;8:109-16.
Md Yusop NB, Yoke Mun C, Shariff ZM, Beng Huat C. Factors associated with quality of life among hemodialysis patients in Malaysia. PLoS One 2013;8:e84152.
Bieber B, Qian J, Anand S, Yan Y, Chen N, Wang M, et al.
Two-times weekly hemodialysis in China: Frequency, associated patient and treatment characteristics and quality of life in the china dialysis outcomes and practice patterns study. Nephrol Dial Transplant 2014;29:1770-7.
Lacson E Jr., Xu J, Lin SF, Dean SG, Lazarus JM, Hakim RM. A comparison of SF-36 and SF-12 composite scores and subsequent hospitalization and mortality risks in long-term dialysis patients. Clin J Am Soc Nephrol 2010;5:252-60.
Mapes DL, Lopes AA, Satayathum S, McCullough KP, Goodkin DA, Locatelli F, et al.
Health-related quality of life as a predictor of mortality and hospitalization: The dialysis outcomes and practice patterns study (DOPPS). Kidney Int 2003;64:339-49.
Schiaffino A, Rodríguez M, Pasarín MI, Regidor E, Borrell C, Fernández E. Odds ratio or prevalence ratio? Their use in cross-sectional studies. Gac Sanit 2003;17:70-4.
Imelda F, Susalit E, Marbun MB, Rumende CM. Clinical overview and quality of life of end-stage kidney disease patients who have hemodialysis compared to three times a week. J Penyakit Dalam Indones 2017;4:128-36.
El-Sheikh M, El-Ghazaly G. Assessment of hemodialysis adequacy in patients with chronic kidney disease in the hemodialysis unit at Tanta university hospital in Egypt. Indian J Nephrol 2016;26:398-404.
] [Full text]
Mc Causland FR, Brunelli SM, Waikar SS. Dialysis dose and intradialytic hypotension: Results from the HEMO study. Am J Nephrol 2013;38:388-96.
Tonelli M, Hirsch DJ, Chan CT, Marryatt J, Mossop P, Wile C, et al.
Factors associated with access blood flow in native vessel arteriovenous fistulae. Nephrol Dial Transplant 2004;19:2559-63.
Flythe JE, Kunaparaju S, Dinesh K, Cape K, Feldman HI, Brunelli SM. Factors associated with intradialytic systolic blood pressure variability. Am J Kidney Dis 2012;59:409-18.
Schytz PA, Mace ML, Soja AM, Nilsson B, Karamperis N, Kristensen B, et al.
Impact of extracorporeal blood flow rate on blood pressure, pulse rate and cardiac output during haemodialysis. Nephrol Dial Transplant 2015;30:2075-9.
Teixeira Nunes F, de Campos G, Xavier de Paula SM, Merhi VA, Portero-McLellan KC, da Motta DG, et al.
Dialysis adequacy and nutritional status of hemodialysis patients. Hemodial Int 2008;12:45-51.
Manns BJ, Johnson JA, Taub K, Mortis G, Ghali WA, Donaldson C. Dialysis adequacy and health related quality of life in hemodialysis patients. ASAIO J 2002;48:565-9.
Johnson RJ, Feehally J, Floege J. Comprehensive Clinical Nephrology. 5th
ed. Philadelphia: Elsevier-Saunders; 2015. p. 2-27.
Yadla M. Quality of life assessment using Sf-36 questionnaire in maintenance hemodialysis patients supported by government funded cashless scheme. J Clin Nephrol Res 2017;4:1069.
Germin-Petrović D, Mesaros-Devcić I, Lesac A, Mandić M, Soldatić M, Vezmar D, et al.
Health-related quality of life in the patients on maintenance hemodialysis: The analysis of demographic and clinical factors. Coll Antropol 2011;35:687-93.
Guerra-Guerrero V, Sanhueza-Alvarado O, Cáceres-Espina M. Quality of life in people with chronic hemodialysis: Association with sociodemographic, medical-clinical and laboratory variables. Rev Lat Am Enfermagem 2012;20:838-46.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]