Quality of Life of Patients with End-stage Renal Disease Undergoing Hemodialysis in Morocco: Cross-sectional Study

Abstract

Background:

End-stage chronic renal disease and its long-term treatment by hemodialysis (HD) affect several aspects of life. This is a cross-sectional, descriptive, and analytical study of 80 patients undergoing chronic HD at the only public sector HD center in the Meknes prefecture of Morocco. This study’s objectives are to evaluate the quality of life (QOL) of patients receiving chronic HD and to determine the factors associated with these patients’ decreased QOL.

Subjects and Methods:

To achieve the aims of this study, the short form of the Kidney disease quality of life short form (KDQOL-SF1,3), translated and validated in the Moroccan context, was the data collection instrument utilized to gauge these patients’ QOL.

Results:

The overall mean KDQOL-SF™ score was 39.31 (standard deviation [SD] 7.56). The kidney disease component, mental component, and physical component scores were 47.84 (SD 11), 33.91 (SD 10.22), and 36.19 (SD 8.30), respectively. Scores considered satisfactory were in favor of social support. Similarly, this study revealed, using the Student’s t-test, that there was no significant difference in the means between the subgroups in terms of age, sex, marital status, and duration of HD treatment, while it revealed a significant correlation, using the Pearson’s test, between kidney disease component and the two physical health and mental health components.

Conclusions:

This study revealed that the QOL of chronic HD patients is impaired. It highlighted that an action on the effects of kidney disease could improve the physical and mental health and, consequently, the QOL of HD patients.

INTRODUCTION

The term chronic kidney disease (CKD) refers to anomalies in the kidneys’ structure or function that have been present for longer than 3 months and are affecting the condition of the patient.[1] Its morbidity, mortality, and socioeconomic effects make it a major threat to health all over the world.[2] Similarly, This disease is now a real public health problem due to the increase in its incidence and prevalence.[3] The prevalence of patients with CKD worldwide is estimated at around 8%–16%.[4]

The end-stage renal disease (ESRD) requires a primary treatment, which is renal replacement therapy, of which hemodialysis (HD) is the most commonly used approach.[5] Worldwide, there are around 2 million people on HD, with only 4000 patients on HD in sub-Saharan Africa, representing <1% of cases worldwide. These gaps in treatment are due to the poor availability and high cost of treatment.[6]

Despite considerable improvements in HD treatment over the last few decades, the management of comorbidities and risk factors in HD patients remains difficult, and is still associated with high mortality rates.[7] Likewise, chronic HD patients are particularly vulnerable to emotional issues because of long-term stress related to the disease burden, dietary restrictions, functional limitations, related chronic diseases, negative drug side effects, altered self-perception, and fear of dying.[8,9]

Quality of life (QOL) is recognized worldwide as a major aspect of healthcare provision for patients with chronic diseases such as CKD.[10] In developed countries, several studies have shown that QOL is an independent predictor of morbidity and mortality.[11] In the same vein, other studies have examined how variables such as comorbidities, treatment modalities, and sociodemographic factors affect patients’ QOL.[12,13] In contrast, studies carried out in African countries on this subject are still rare.[14]

This study aimed to evaluate the QOL of patients with ESRD undergoing HD at the public HD center in Meknes prefecture of Morocco, using the Kidney disease quality of life short form (KDQOL-SF). It also aimed to explore the determinants of QOL in these patients.

SUBJECTS AND METHODS

Study design and participants

This is a cross-sectional, descriptive, and analytical study carried out at the only public sector HD center in the Meknes prefecture of Morocco from June 1, 2024 to December 1, 2024. All consenting patients over 18 years old and undergoing HD for more than 3 months, who were attending the dialysis center during the study period, were invited to take part in the study. Indeed, the study included 80 patients considered eligible. However, patients suffering from cognitive impairment, cerebrovascular accidents, and prisoners were excluded, as these factors could potentially affect their QOL.

Data collection

Data collection was based on individual interviews, guided by a questionnaire, and recorded as the interviews progressed. This questionnaire was structured in two parts. The first part was reserved for the sociodemographic and clinical characteristics of the patient. The second part was reserved for the standardized KDQOL-SF version 1.3 from the Research and Development Corporation.[15]

The KDQOL-SF data collection instrument is considered the main instrument for measuring QOL in HD patients.[16] This questionnaire includes both generic and disease-specific items, making it a valuable assessment method. It can be used to specifically explore the impact of kidney disease on QOL and even to test the effect of therapeutic interventions in people living with this disease.[17] Furthermore, KDQOL-SF 1.3 has been translated into several languages.[18] In this study, the version used is the version translated into Moroccan dialect Arabic.[19]

Data management

Data entry and analysis were performed using IBM SPSS Statistics, version 25.0 (IBM Corp., Armonk, NY, USA). The KDQOL-SF scoring tool (V2.0), which is offered as a program in an Excel spreadsheet used to generate scores and provide descriptive statistics for KDQOL-SF measures, was used. Consequently, a total score and each domain score were computed for each patient, and an average score was determined for each group.

Good QOL was defined as total scores over 50 (maximum 100), whereas bad QOL was defined as total scores below 50. Means and standard deviations (SDs) are used to display continuous variables, whereas frequencies are used to display categorical data. Comparisons of group means were made using the Student’s t-test, after verification of the normal distribution using the Kolmogorov–Smirnov test and the homogeneity of variances using the Levene’s test. P < 0.05 at a 95% confidence interval was regarded as statistically significant.

Ethical considerations

Ethical approval was obtained from the Ethical Committee for Biomedical Research in Oujda (CERBO/ref. 09/24). The study also received administrative authorization (ref. 1637/24) from the regional directorate of the Ministry of Health and Social Protection of Fez-Meknes region in Morocco. Patients were seen either prior to or during their dialysis session on the day of their HD. The information sheet was clearly explained in the language best familiar to the participant, and informed consent was received in accordance with standardized procedures recommended by the ethics committee. In addition, by employing codes in place of names in the questionnaires, participant confidentiality was protected.

RESULTS

In terms of sociodemographic characteristics, the total number of patients who took part in this study was 80. Males accounted for 53.8% of the total, with a sex ratio of 1.16. The mean age of participants was 53.05 years (SD 13.98), and 51.2% were under 60. 54.5% of participants were married. 92.5% of patients were affiliated with Mandatory health cover for citizens who are economically disadvantaged (TADAMON), and 98.8% were unemployed. 81.3% were from urban areas. 51.2% were illiterate and only 31.3%, 13.8 and 3.8% had primary, secondary, and university education, respectively.

In terms of clinical characteristics, the mean duration of treatment by the HD of the participants was 4 years (SD 3.5). Concerning the number of sessions per week, 76.3% of these patients had 2 sessions per week, whereas 23.8% had three sessions per week. For comorbidity, 39.4% of this population suffered from a comorbidity, with diabetes and hypertension being the main comorbidities raised.

As regards the scores for the domains of the KDQOL-SF questionnaire, the minimum score was 2.5 for the “professional status” domain and the maximum score was 84.06 for the “encouragement of dialysis staff” domain. The overall mean of the KDQOL-SF was 39.31 (SD 7.56). The kidney disease component score (KDCS), mental component score (MCS), and physical component score (PCS) were 47.84 (SD 11), 33.91 (SD 10.22), and 36.19 (SD 8.30), respectively [Table 1].

Table 1.

Mean scores for each domain of the kidney disease quality of life questionnaire - short-form questionnaire for hemodialysis patients

	Mean (SD)
PCS
Physical functioning	47.44 (24.68)
Role physical	17.19 (34.58)
Pain	65.66 (30.42)
General health	18.81 (16.15)
MCS
Energy/fatigue	26.63 (20.98)
Social function	52.50 (26.64)
Role emotional	26.25 (37.39)
Emotional well-being	43.10 (22.54)
KDCS
Symptoms/problems list	60.44 (16.22)
Effect of kidney disease on daily life	41.21 (15.03)
Burden of kidney disease	18.67 (15.83)
Cognitive function	48.83 (22.77)
Work status	2.50 (13.55)
Sexual function*	44.44 (30.05)
Quality of social interaction	55.67 (23.55)
Sleep	52.84 (23.42)
Social support	65.21 (27.96)
Dialysis staff encouragement	84.06 (18.01)
Patient satisfaction	49.38 (13.11)
Score global	39.31 (7.56)

*9 participants who responded to the sexual function domain. KDCS=Kidney disease component score, MCS=Mental component score, PCS=Physical component score, SD=Standard deviation

The Student’s t-test revealed that the means of the different domains of the KDQOL-SF questionnaire were significantly indifferent between the subsamples. As a result, sex, age, marital status, comorbidity, level of education, and duration of dialysis had no significant effect on the scores after the Student’s t-test (P > 0.05) [Table 2].

Table 2.

Impact of various patient characteristics on scores in the three domains of the kidney disease quality of life questionnaire - short-form questionnaire in the hemodialysis patients studied

Characteristics	n	PCS		MCS		KDCS
		Score (SD)	P	Score (SD)	P	Score (SD)	P
Gender
Male	43	36.52 (8.27)	0.70	32.72 (11.15)	0.26	47.12 (12.59)	0.53
Female	37	35.80 (8.43)		35.30 (8.97)		47.11 (8.59)
Age (years old)
<60	41	36.59 (8.59)	0.65	33.72 (10.68)	0.86	49.00 (11.59)	0.33
≥60	39	35.76 (8.07)		34.11 (9.83)		46.62 (10.34)
Marital status
Married	42	35.21 (8.86)	0.27	33.41 (10.34)	0.65	46.63 (9.89)	0.27
Unmarried	38	37.27 (7.60)		35.46 (10.18)		49.17 (12.09)
Comorbidity
With comorbidity	37	35.92 (8.86)	0.79	33.80 (10.11)	0.92	49.13 (9.15)	0.33
Without comorbidity	43	36.41 (7.88)		34.00 (10.43)		46.72 (12.36)
Duration on dialysis (years)
<4	46	35.82 (8.89)	0.65	34.81 (9.65)	0.63	48.42 (9.99)	0.58
≥4	34	36.67 (7.53)		32.69 (10.96)		47.05 (12.33)

KDCS=Kidney disease component score, MCS=Mental component score, PCS=Physical component score, SD=Standard deviation

In the past, the Pearson correlation test showed a significant correlation between the kidney disease component and the two components, physical and mental (P < 0.05).

DISCUSSION

Studies conducted in Morocco on the QOL of patients treated with maintenance HD are rare. The results of these studies have revealed mediocre QOL scores on different dimensions of QOL. Therefore, this study was designed to explore QOL in another population in another part of Morocco. Indeed, the scores of the domains of the KDQOL-SF questionnaire recorded ranged from 3.03 to 83.90. The total KDQOL-SF score was below average.

The generic part of KDQOL-SF

The physical component had a poor score equal to 37.06 (SD 8.73). In previous studies, the physical health component was revealed as a variable significantly associated with hospitalization and death.[20] This study revealed a significant correlation between the physical health component and the effect of kidney disease component [Figure 1]. Indeed, CKD and dialysis in particular are associated with a reduction in physical capacity due to the burden of disease, the specific symptoms of the disease, dependence on dialysis, and restriction of food and drink intake.[21] Similarly, fatigue is widely reported by HD patients, although it is not well recognized.[22] It manifests itself as weariness, weakness, and lack of energy.[23] It is common in HD patients and has a negative effect on their physical well-being and QOL.[24]

Figure 1.

Scatter plot showing a positive correlation between KDCS and PCS (r = 0.203, P = 0.0001)

The mental component had a poor score equal to 32.95 (SD 10.39). In our study, a significant correlation was observed between the mental component and the effect of kidney disease [Figure 2]. In fact, these patients are confronted with the following stress factors: time restrictions, diets, functional limitations, changes in sexual life, effects of medication, awareness of imminent death, and difficulties related to employment and social and family relationships.[25] Similarly, HD can have serious psychological repercussions on patients suffering from CKD.[26] Previous studies have highlighted the fact that serenity, comfort, and the prevention of depression and anxiety are among the essential needs of these patients.[27] Social support is linked to improved life satisfaction and chronic illness recovery, which enhances one’s capacity to manage stressors and mental health symptoms.[9] Similarly, spiritual health and mental health are also closely linked. Patients with high spiritual health suffer less stress, anxiety, and depression.[27] A religious/spiritual coping method is more associated with better QOL and less depression than another coping method, so it would be beneficial for CKD patients to discuss religious/spiritual issues during HD sessions.[28]

Figure 2.

Scatter plot showing a positive correlation between KDCS and MCS (r = 0.363, P = 0.0001)

The specific part of KDQOL-SF

For the section on the effect of kidney disease, the mean total score was 39.31 (SD 7.56). Our results revealed a significant correlation with this component and the two components of physical health and mental health. The domains with the lowest scores were “Work Status,” “burden of kidney disease,” “Sexual Function,” and “cognitive function.”

For “work status,” it had the lowest mean score, 3.03 (SD 14.88), which corroborates the result published by AL-Jumaih et al.[29] In fact, HD can lead to fatigue, weakness, muscle cramps, social isolation, and ultimately, disruption of employment and social status.[30] Similarly, there is a serious issue with our HD patients’ professional reintegration because the majority of them do not engage in any professional activity. Therefore, efforts must be made to create special structures responsible for the professional reinsertion of patients as soon as they are put on dialysis.[31]

In terms of “The burden of kidney disease,” this domain obtained a low score of 18.75 (SD 16.19). This finding corroborates a number of studies carried out in Africa, where the score for this domain was among the lowest.[18] In reality, patients with ESRD must be dialyzed three times a week according to medical recommendations, and the HD session lasts between 3 and 5 h, which influences their efficiency in daily activities and, consequently, their QOL.[32] In the same vein, the lack of resources in developing countries, including those in Africa, makes treatment difficult, which places a real burden on HD patients.[33] These results contrast with those of similar studies carried out in countries outside Africa.[34,35]

For “sexual function,” only 9 participants had a sexual act during the month preceding their interview. The score identified for this domain was 37.5. This sexual dysfunction, which is common in ESRD patients and affects their QOL, could be attributed to the weakening of body image and self-esteem and to the care required by CKD and HD.[36] Likewise, the poor male sexual performance associated with CKD is also attributed to erectile dysfunction, which is often the cause of great anxiety and is suffered in silence by the majority.[37] However, this subject is not mentioned by these patients, particularly Muslim women, when they need support.[38] In fact, a high level of sexual dysfunction also affects a person’s perception of health, as sexual health is considered to be an important indicator of physical and mental health.[39]

Regarding “cognitive function,” the score obtained for this domain was 48.83 (SD 22.77). In fact, cognitive disorders are common in CKD and in patients treated with HD.[40] These cognitive disorders are often manifested by alterations in processing speed and executive functions – capacities required for complex attention, switching from one mental act to another.[41] However, there is a need to develop approaches to the impairment of cognitive functions that target the specific risk factors for HD, namely modified HD parameters that stabilize cerebral saturation and blood flow.[40]

In return, this study highlighted the scores relating to social support considered satisfactory. Social support encompasses emotional assistance and the relationships provided by family, friends, and healthcare professionals.[42] Several studies have shown that social support is essential to help HD patients cope with their disease and is associated with a better QOL. In this respect, several studies have shown that social support is essential to help HD patients cope with their disease and is associated with a better QOL.[43,44,45] Indeed, basic healthcare professional training and continuing training for practicing nurses and doctors should emphasize the importance of considering social support as a means of improving outcomes for dialysis patients, given the formal and informal resources available to these patients.[6]

CONCLUSIONS

The present study provides an assessment of the QOL of a group of Moroccan HD patients using the KDQOL-SF questionnaire. No significant differences were found between the means of the subgroups, while a significant correlation was found between the effect of the kidney disease component and the two physical and mental components. Low scores were observed in the domains “professional status,” “cognitive function,” “physical role,” and “emotional role,” while high scores were observed in the domains “patient satisfaction,” “encouragement of dialysis staff,” and “quality of social interaction.” Considering the correlations raised by this study, it appeared that addressing the impacts of ESRD could enhance both the mental and physical health of HD patients and hence their QOL. As a proposal, a holistic biopsychosocial approach seems to be the best way to improve the QOL of these patients.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.