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ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 63-66

Impact of vascular access type on health-related quality of life in patients undergoing hemodialysis: A cross-sectional observational study


Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Date of Submission10-Aug-2019
Date of Decision13-Oct-2019
Date of Acceptance21-Oct-2019
Date of Web Publication16-Mar-2020

Correspondence Address:
Dr. Parag Sonawane
Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_47_19

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  Abstract 


Objective: Patients undergoing hemodialysis (HD) have a poor health-related quality of life (HRQoL). HRQoL may differ across geography and ethnicity. This study aimed to compare HRQoL in patients undergoing HD by arteriovenous fistula (AVF) and central venous catheter (CVC) in a cohort of Indian population. Methods: This was a cross-sectional observational study conducted between March 2016 and June 2016. All patients undergoing HD (more than 2 months) who had vascular access using AVF or CVC were eligible to participate in the study. Sociodemographic characteristics were noted, and HRQoL was assessed using the Short Form 36 questionnaire. Results: A total of 58 patients were included in this study, 31 in CVC group and 27 in AVF group, without any crossover. The mean (standard deviation) age was 47.4 (18.1), and the median (range) duration of HD was 14 months (2 months–120 months).Overall, patients who underwent AVF for vascular access had significantly (P < 0.05) higher HRQoL score than those who underwent CVC. There was no significant difference of HRQoL score for majority of the parameters for sex and age, for all the parameters for duration of HD. Conclusions: Overall, results showed that patients who had vascular access using AVF showed better HRQoL as compared to CVC in patients with HD.

Keywords: Arteriovenous fistula, central venous catheter, health-related quality of life, hemodialysis, vascular access


How to cite this article:
Sonawane P, Maheshwari R, Singh A, Ganpule A, Sabnis R, Desai M. Impact of vascular access type on health-related quality of life in patients undergoing hemodialysis: A cross-sectional observational study. Indian J Vasc Endovasc Surg 2020;7:63-6

How to cite this URL:
Sonawane P, Maheshwari R, Singh A, Ganpule A, Sabnis R, Desai M. Impact of vascular access type on health-related quality of life in patients undergoing hemodialysis: A cross-sectional observational study. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Jul 5];7:63-6. Available from: http://www.indjvascsurg.org/text.asp?2020/7/1/63/280673




  Introduction Top


Hemodialysis (HD) is the treatment of choice in the majority of patients with end-stage renal disease (ESRD), considering the lower availability of donors for transplant. In India, more than 100,000 patients were undergoing HD in 2016, and significantly growing at 31%, compared to 6% in the United States and 8% in the rest of the world.[1] With the recent developments in HD techniques and improved management of comorbidities, the life expectancy of patients undergoing HD has increased significantly. Adequate vascular access contributes to the efficiency of HD and may reduce mortality and morbidity in patients with ESRD.[2] Arteriovenous fistula (AVF), central venous catheter (CVC), and arteriovenous graft (AVG) are three main types of vascular access.[3] Of these, AVF is the most preferred type of vascular access owing to its lower rates of complications and longevity.[4]

Several studies have demonstrated that AVF is associated with reduced morbidity and mortality than CVC or AVG.[5] It is also known that patients undergoing HD have a poor health-related quality of life (HRQoL) as compared to the normal population. In addition, HRQoL is also associated with the mortality in patients with ESRD; however, there are very few studies that assessed the association of HRQoL with types of vascular access in patients with ESRD. Moreover, the reported HRQoL may differ from population to population and across ethnic groups. The aim of our study was to compare HRQoL in patients undergoing HD by AVF or CVC in a cohort of Indian population.


  Methods Top


This was a cross-sectional observational study conducted between March 2016 and June 2016. The study participants were all ESRD patients undergoing maintenance intermittent HD, each session lasting for 4 h duration on thrice per week schedule (more than 2 months) using standard dialysate at the same dialysis unit (Muljibhai Patel Urological Hospital's dialysis unit). All the study patients were under regular nephrological care and had a consultation with the nephrologist at least every 15 days, with required laboratory investigations and change of medication accordingly. The vascular access was achieved using one of the two options (AVF or CVC). All the dialysis was supervised by a 3rd-year nephrology resident. All the patients with AVF were being dialyzed from a matured AVF for at least 2 months. Patients who had prior limb amputation, known history of malignancy, active liver disease, and left ventricular ejection fraction <15% were excluded from the study. Patients with catheter-related bloodstream infection in the past 1 month were excluded, as there was a possibility of reinfection and reporting poor quality of life in these patients. However, patients with a history of multiple access failures were not excluded from the study.

The study protocol was reviewed and approved by the institutional ethics committee. The study was conducted in accordance with the principles that have their origin in the Declaration of Helsinki, the good clinical practice, and the approved protocol. Each study participant provided written informed consent before participation in the study.

Sociodemographic characteristics were noted including age, sex, whether living alone or with a partner, history of smoking, educational details, marital status, monthly income, history of any sleep disturbance, previous renal transplant, alcohol abuse, coronary artery disease, and cerebrovascular disease (CVD). Body mass index was calculated using postdialysis dry weight. Laboratory parameters including blood glucose level, hemoglobin, serum creatinine, electrolytes, and C-reactive protein were assessed before and after the HD.

The HRQoL was assessed using the Short Form 36 (SF-36) questionnaire.[6] The SF-36 questionnaire is divided into two subscales, i.e., physical component summary (PCS) score and mental component summary (MCS) score, which are further divided into four components each. The PCS includes physical functioning, physical role, pain, and general health; however, MCS includes emotional role, energy fatigue, emotional well-being, and social functioning. This questionnaire includes 36 questions which are scored between 0 and 100. Higher the score better is QoL. For the present study, the SF-36 questionnaire was translated into Hindi and Gujarati languages and was validated by a pilot study.

The data was analyzed using the Microsoft Excel 2010, Statistical Package for the Social Sciences (SPSS®)V25.0 (SPSS Inc., Chicago, IL, USA). Descriptive characteristics were reported using means (standard deviations [SDs]) or as number (percentages). Kruskal–Wallis test was used for comparison of two or more groups.


  Results Top


A total of 58 patients, 31 in CVC group and 27 in AVF group, were included in this study. The mean (SD) age was 47.4 (18.1), and 39 (67.2%) patients were male [Table 1]. The duration of HD ranged from 2 to 120 months, with a median duration of 14 months. Forty-eight (82.8%) patients were married, but only 37 (77.1%) were living with their partners. A total of 47 (81.0%) patients had a history of hypertension, 24 patients (41.4%) had diabetes mellitus, and six patients had a history of previous renal transplantation. Sleep disturbance was reported by 13 (22.4%) patients, whereas 43.1% of the patients had unsatisfactory or low income [Table 1].
Table 1: Demographics and baseline characteristics

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Overall, results showed that patients who underwent AVF for vascular access had significantly (P < 0.05) higher HRQoL score than those who underwent CVC. Each HRQoL domain and both the summary scores (PCS and MCS scores) were significantly higher for patients who underwent AVF for vascular access [Table 2].
Table 2: Relation of health-related quality-of-life with sex, age group, duration of hemodialysis, and type of vascular access

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Overall, there was no statistically significant difference in the HRQoL between male and female patients in the majority of components (P > 0.05), except for the energy and fatigue domain (60.1 vs. 49.7, respectively; P < 0.05). The scores for social functioning were slightly higher for males (71.2 vs. 67.5); however, the difference was not significant. Overall, both the summary scores (PCS and MCS scores) showed no difference between males and females [Table 2].

Similarly, age and duration of HD had no statistical significance in any domains (P > 0.05), except for emotional well-being which showed a significant difference between age groups (P = 0.01). Overall, both the summary scores (PCS and MCS scores) showed no difference between age groups and duration of HD [Table 2].


  Discussion Top


In patients with ESRD, since HD is the only treatment available for the majority of patients, the QoL is important to reduce morbidity. Some of the patients may withdraw from HD because of lower HRQoL. It is possible that vascular access-related morbidity that is experienced by patients with an AVG or a CVC contributes to a poorer perception of health status and QoL among these patients.[7] If a vascular access with better HRQoL is available, this could improve patient's health status and improve the benefit from treatment. In the present study, patients who have had AVF showed a better perception of HRQoL as compared to patients who had CVC.

The AVF is considered a gold standard vascular access type for HD because of its less infectious complications, longer patency, and low mortality and morbidity, which translates into better HRQoL perceived by AVF patients.[4],[5] Several studies have demonstrated the better perception of HRQoL of AVF compared to CVC or AVG.[7],[8],[9],[10] However, a recent meta-analysis, which included 318 studies with more than 62,000 vascular accesses, showed that AVF was at high risk of maturation failure and abandonment. This study showed that by 6 months, only 26% of AVFs were mature and 21% were abandoned.[11]

In our study, patients with AVF have better PCS as compared to CVC reflecting greater exercise capacity and fewer limitations in physical activity. In patients undergoing HD, factors contributing to reduced physical activity include anemia of chronic disease and uremic myopathy.[12] Since AVF has better dialysis adequacy, there are reduced chances of anemia and uremia.[13] In CVC patients, there is a reduced PCS probably due to reduced blood flow, recirculation, catheter thrombosis, anemia, and erythropoietin resistance.[13],[14],[15] Similar findings were observed in a study by Dhingra et al. who reported that patients with AVF in ESRD were more ambulatory than patients with CVC.[16]

Patients with CVC use have a greater burden of kidney disease due to the amount of time spent in managing kidney disease, frustration level, and burden on the family. Patients with CVC have more vascular access morbidity and have daily challenges such as care of CVC site, its cosmetic effects, and imposition of the catheter, and they require more Erythropoietin for every CVC insertion.[17],[18],[19]

Not only physical aspects but also mental aspects of QoL were found higher among patients with AVF than CVC. It could probably be due to the burden on the family, lesser cosmetic effect as in CVC, pain, and discomfort caused due to cannulation and lesser morbidity. It was suggested that increased catheter use in CVC patients may cause an increase in cardiovascular and CVDs, which is further known as a common cause of cognitive impairment. However, in our study, we did not find any difference in cardiovascular and CVDs, probably because the number of enrolled patients with these diseases was low.

In the present study, age and sex of the patients did not show any significant difference in the HRQoL; however, females showed slightly poor QoL as compared to male patients. The reason for better QoL in males in India could probably be due to better social relationships and support from family and friends as compared to females. A similar observation was made by Santos et al.[17] In the present study, patients between the age groups of ≥30 and <60 years showed slightly better HRQoL. Patients ≥60 years may usually have other comorbidities, slower recovery, financial dependence, and lack of care and support from family, whereas patients <30 years showed poor HRQoL probably due to dependence on family, higher expectations from the standard of care, and disappointment.

Education level may not affect HRQoL directly, but literate patients might have a better acceptance about the treatment options, which might indirectly improve the HRQoL. Financial status has an impact on the HRQoL, as patients with higher income have a lesser financial burden in taking dialysis and managing medical emergencies and can have opportunities for recreation, which does improve the HRQoL as compared to patients with lower income. Similar results were found in another study by Seica et al.[18]

The authors acknowledge the following limitations of this study. First, the sample size of this study was comparatively small. Second, the study was a cross-sectional, observational study and has chances of being confounded by severity of illness. Third, this was a cross-sectional study and may not reflect future assessment of QoL, as patients adapt to dialysis and may also develop complications such as stenosis of vessels and aneurysms. Longitudinal studies are needed to address this question further.


  Conclusions Top


Overall, results showed that patients who had vascular access using AVF had better HRQoL as compared to CVC in patients on HD. This could help clinicians' better council patients requiring access for HD.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jha V. Dialysis in India – Today and Tomorrow. Available from: https://health.economictimes.indiatimes.com/health-files/dialysis-in-india-today-and-tomorrow/1233. [Last accessed on 2018 March 17].  Back to cited text no. 1
    
2.
Karkar A, Chaballout A, Ibrahim MH, Abdelrahman M, Al Shubaili M. Improving arteriovenous fistula rate: Effect on hemodialysis quality. Hemodial Int 2014;18:516-21.  Back to cited text no. 2
    
3.
NKF-K/DOQI clinical practice guidelines for vascular access: Update 2000. Am J Kidney Dis 2001;37:S137-81.  Back to cited text no. 3
    
4.
Polkinghorne KR, McDonald SP, Atkins RC, Kerr PG. Vascular access and all-cause mortality: A propensity score analysis. J Am Soc Nephrol 2004;15:477-86.  Back to cited text no. 4
    
5.
Lok CE, Foley R. Vascular access morbidity and mortality: Trends of the last decade. Clin J Am Soc Nephrol 2013;8:1213-9.  Back to cited text no. 5
    
6.
Kosinski M, Keller SD, Hatoum HT, Kong SX, Ware JE Jr. The SF-36 health survey as a generic outcome measure in clinical trials of patients with osteoarthritis and rheumatoid arthritis: Tests of data quality, scaling assumptions and score reliability. Med Care 1999;37:MS10-22.  Back to cited text no. 6
    
7.
Wasse H, Kutner N, Zhang R, Huang Y. Association of initial hemodialysis vascular access with patient-reported health status and quality of life. Clin J Am Soc Nephrol 2007;2:708-14.  Back to cited text no. 7
    
8.
Afsar B, Elsurer R, Covic A, Kanbay M. Vascular access type, health-related quality of life, and depression in hemodialysis patients: A preliminary report. J Vasc Access 2012;13:215-20.  Back to cited text no. 8
    
9.
Domenick Sridharan N, Fish L, Yu L, Weisbord S, Jhamb M, Makaroun MS, et al. The associations of hemodialysis access type and access satisfaction with health-related quality of life. J Vasc Surg 2018;67:229-35.  Back to cited text no. 9
    
10.
Moura A, Madureira J, Alija P, Fernandes JC, Oliveira JG, Lopez M, et al. Type of vascular access and location in online hemodiafiltration and its association with patient's perception of health-related quality of life. J Vasc Access 2014;15:175-82.  Back to cited text no. 10
    
11.
Bylsma LC, Gage SM, Reichert H, Dahl SL, Lawson JH. Arteriovenous fistulae for haemodialysis: A systematic review and meta-analysis of efficacy and safety outcomes. Eur J Vasc Endovasc Surg 2017;54:513-22.  Back to cited text no. 11
    
12.
Johansen KL. Physical functioning and exercise capacity in patients on dialysis. Adv Ren Replace Ther 1999;6:141-8.  Back to cited text no. 12
    
13.
Sehgal AR, Snow RJ, Singer ME, Amini SB, DeOreo PB, Silver MR, et al. Barriers to adequate delivery of hemodialysis. Am J Kidney Dis 1998;31:593-601.  Back to cited text no. 13
    
14.
Chand DH, Brier M, Strife CF. Comparison of vascular access type in pediatric hemodialysis patients with respect to urea clearance, anemia management, and serum albumin concentration. Am J Kidney Dis 2005;45:303-8.  Back to cited text no. 14
    
15.
Greenwood RN, Ronco C, Gastaldon F, Brendolan A, Homel P, Usvyat L, et al. Erythropoeitin dose variation in different facilities in different countries and its relationship to drug resistance. Kidney Int Suppl 2003;64:S78-86.  Back to cited text no. 15
    
16.
Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK. Type of vascular access and mortality in U.S. Hemodialysis patients. Kidney Int 2001;60:1443-51.  Back to cited text no. 16
    
17.
Santos PR, Daher EF, Silva GB Jr., Libório AB, Kerr LR. Quality of life assessment among haemodialysis patients in a single centre: A 2-year follow-up. Qual Life Res 2009;18:541-6.  Back to cited text no. 17
    
18.
Seica A, Segall L, Verzan C, Văduva N, Madincea M, Rusoiu S, et al. Factors affecting the quality of life of haemodialysis patients from Romania: A multicentric study. Nephrol Dial Transplant 2009;24:626-9.  Back to cited text no. 18
    
19.
Roberts TL, Obrador GT, St. Peter WL, Pereira BJ, Collins AJ. Relationship among catheter insertions, vascular access infections, and anemia management in hemodialysis patients. Kidney Int 2004;66:2429-36.  Back to cited text no. 19
    



 
 
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