Patients Should Be Informed About Different Dialysis Treatments

Study Measures Quality of Life of Patients with Chronic Kidney Disease

Kidney dialysis patients should be educated about the different health benefits of both hemodialysis and peritoneal dialysis and then given a choice as to which they would like to undergo, according to a study conducted by researchers from the Johns Hopkins Bloomberg School of Public Health. It is one of the most comprehensive studies of the quality of life of patients with chronic kidney disease. The researchers expected to find that peritoneal dialysis allowed patients to function better, but, in fact, hemodialysis patients did better in some areas while peritoneal dialysis patients did better in others. The study, “Changes in Quality of Life during Hemodialysis and Peritoneal Dialysis Treatment: Generic and Disease Specific Measures,” is published in the March 2004 issue of the Journal of the American Society of Nephrology.

End stage renal disease (ESRD) patients, who now number over 400,000 annually in the United States and cost the federal government more than $15 billion per year, require life-saving therapy to replace the normal function of the kidney, according to the researchers. Peritoneal dialysis involves infusing fluid into the patient’s abdomen through a catheter and uses the patient’s tissues to filter toxins and excess fluid from the blood. The procedure can be done at the convenience of the patient four times each day for 30 minutes. Hemodialysis, in which the blood is circulated through an artificial kidney machine, requires lengthy visits to dialysis clinics three times each week for hours at a time.

Albert Wu, MD, MPH, associate professor in the School’s Department of Health Policy and Management, said, “These findings have important implications for physicians who evaluate and treat patients with chronic kidney disease. This study also provides a good public health lesson. When it comes to kidney dialysis treatment, physicians should be discussing the ways that the treatment will affect each patient. There is no simple answer as to which treatment is better. What patients value about their quality of life should be a factor in the choice of different treatments. Physicians should be doing what is best for each individual patient’s quality of life.”

Over 900 patients (698 hemodialysis; 230 peritoneal) in 19 states were enrolled in the Choices for Health Outcomes in Caring for ESRD study (CHOICE), a national, prospective cohort study from 1995-1998. Dr. Wu and his colleagues developed the CHOICE Health Experience Questionnaire (CHEQ) to comprehensively measure quality of life of patients on dialysis using patients’ reports of the importance they attach to different aspects of their life. Using the CHEQ they assessed self-reported health-related quality of life at the onset of dialysis therapy and one year later. The researchers looked at general domains, or the aspects of life anyone might be concerned about, such as physical and social functioning, and ESRD specific domains, which are problems specific to dialysis patients, such as diet restrictions, body image and problems with dialysis catheters.

The researchers found that both hemodialysis and peritoneal dialysis patients had improvement in nearly all aspects of general functioning and well-being. However, peritoneal dialysis patients did better in some areas of quality of life while hemodialysis patients did better in others. Peritoneal dialysis patients had improvement in their finances. Hemodialysis patients had improvements in physical functioning and general health perceptions, and better sleep. 

A report by some of the same Johns Hopkins researchers was recently published in the Feb. 11 issue of the Journal of the American Medical Association. They found that when compared to the more common hemodialysis, peritoneal dialysis patients were 1.5 times more likely to rate their overall care as excellent. Dr. Wu explained that this latest study looked at the quality of life patients experienced at the start of dialysis and one year later, whereas the previous study looked at satisfaction with care. Satisfaction with care and quality of life are both important to evaluate. Patients could be satisfied with their initial choice, even if their health outcomes are impaired later.

Dr. Wu said, “Health-related quality of life is a multidimensional concept that includes physical functioning, social and role functioning, mental health and general health perceptions. It is an important outcome of health care and one on which patients, if given the opportunity, will base treatment decisions.”

The study was supported by grants from the Agency for Health Care Research and Quality and the National Institute of Diabetes and Digestive and Kidney Diseases.

Co-authors from the Johns Hopkins Bloomberg School of Public Health included Nancy E. Fink, Jane V.R. Marsh-Manzi and Neil R. Powe. Klemens B. Meyer and Michelle M. Chapman, with Tufts-New England Medical Center, and Frederic O. Finkelstein with New Haven CAPD, also collaborated on this study.