1

EFFECT OF RECOMBINANT HUMAN ERYTHROPOIETIN (rHuEPO)

ON THE QUALITY OF LIFE OF HEMODIALYSIS PATIENTS

A STUDY PRESENTED TO
THE DEPARTMENT OF INTERNAL MEDICINE
ILOILO DOCTORS HOSPITAL AND MEDICAL CENTER
ILOILO CITY

IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE COMPLETION OF
RESIDENCY TRAINING IN INTERNAL MEDICINE

BY:
MARIE GABRIELLE A. LAGUNA M.D.
OCTOBER 2009
 2

ABSTRACT

This is a prospective, correlational, descriptive study on the effect of

Recombinant Human Erythropoietin on the Quality of life (QOL) of hemodialysis
patients in Iloilo Doctors Hospital Renal Care Unit, Iloilo City. The study is about the
socio-demographic, clinical and laboratory profile and QOL assessment using two
measures—Karnofsky Performance Status Scale (KPSS) and Medical Outcomes Short
Form Health Survey (SF- 36). Baseline values were initially taken, after which, patients
were given their recombinant human erythropoietin dose for four weeks, based on their
baseline hemoglobin levels, the duration of their treatment with recombinant human
erythropoietin and their weight. There were a total of 36 patients who came in at the
Iloilo Doctors Hospital Renal Care Unit who were enrolled in the study. The data were
drawn using the Karnofsky Performance Status Scale (KPSS) and the Medical Outcomes
Short Form Health Survey (SF 36), a multipurpose, short form health survey with 36
questions which was created by the International Quality of Life Assessment (IQOLA)
Project and was documented by nearly 4,000 studies in terms of reliability and validity.
The results showed that there is an improvement in hemoglobin, creatinine clearance
and serum albumin kevels after 4 weeks of recombinant human erythropoietin treatment.
There is also an improvement in physical functioning, bodily pain handling,
vitality, social functioning and role emotional; however there is no effect on the physical,
general health and mental health after RHuEPO. There is also an improvement in
Karnofsky scores after RHuEPO. Hemoglobin is an independent factor in physical
functioning. The KPSS and the SF 36 survey has a positive correlation thus the former
can be a good choice in patents who are not fully conscious and who cannot answer
questions of the SF-36. Bodily pain and physical functioning also affects Karnofsky
scoring.
Thus this study recommends that further studies should be done regarding the
factor which greatly affects physical functioning. Compliance to recombinant human
erythropoietin is needed. Every hemodialysis unit should be provided with counselors,
psychiatrists or psychologists. Quality of life should be routinely done in every
hemodialysis at intervals of 3, 6 or 9 months to see whether the patient improves or
deteriorates so that solutions can be done. The Karnofsky Performance Status Scale
should take the place of SF-36 in patients who cannot converse or are not fully
conscious. Physical Functioning and Bodily pain scores should be elevated in order to
maintain a high KPSS score for QOL.
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TABLE OF CONTENTS

Page
Title Page 1
Abstract 2
Table of Contents 3
List of Tables
List of Figures
CHAPTER I INTRODUCTION 1
Background and significance of the Study 1
Review of Related Literature 3
Statement of the Problem 10
Objectives of the Study 10
Scope and Limitation 11
Definition of Terms 11
Conceptual Framework 13
CHAPTER II METHODOLOGY 14
Research Design 14
Participants 14
Research Setting 15
Sampling Design 17
Research Instrument 17
Data Gathering Procedure 19
Data Analysis 20
CHAPTER III PRESENTATION OF RESULTS, ANALYSIS
AND INTERPRETATION
21
CHAPTER IV DISCUSSION 30

CHAPTER V CONCLUSION AND RECOMMENDATION 38

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LIST OF TABLES

Page

1.
 5

LIST OF FIGURES

Page

1.
 6

CHAPTER I

INTRODUCTION

Background of the Study

Chronic kidney disease affects many Filipinos each year and is one of the top ten

causes of death among Filipinos wherein 7, 000 die annually due to kidney malfunction.

Because of the increasing number of Filipinos with kidney disease, it is now considered

among the top seven health problems in the country. Worldwide, there is also an alarming

level of kidney disease with more than 500 million persons suffering from some form of

kidney damage. In 2006, the Philippine Renal Disease Registry showed that the Province

of Iloilo had the most number of patients in Region 6 with end-stage renal disease with

248 patients undergoing hemodialysis in 7 dialysis centers.

Anemia is a characteristic feature of chronic kidney disease, which is due to

inadequate secretion of erythropoietin. This complication often results to significant

cardiovascular morbidity, hospitalization and mortality. Erythropoiesis stimulating

agents, since their discovery nearly two decades ago have significantly improved care of

patients with renal anemia. However, although several reports have demonstrated the

benefits of anemia correction in patients with chronic kidney disease, little reports have

been published with regards to the relationship of erythropoiesis stimulating agents to the

quality of life among Filipinos. Thus this study aims to asses the quality of life in chronic

hemodialysis patients with anemia (hemoglobin level of 13. 5 g/ dL in adult males and

<12.0 g/dL in adult females), using the SF-36 questionnaire and the Karnofsky

performance scale, and to correlate the results with clinical and laboratory parameters

after 4 weeks of recombinant human erythropoietin (RHuEPO) therapy.

 7

Review of Related Literature

The importance of quality of life as a dimension of health is disclosed in the

constitution of the World Health Organization, “Health is a state of complete physical,

mental and social well-being and not merely the absence of disease or infirmity”. 1

Since quality of life is a very important aspect of health, there are a number of

survey tools which have been developed to investigate the components of quality of life.

Our study utilized the Karnofsky scale and the Medical Outcomes study Short-Form

Health Survey (SF-36)

The disturbed metabolism caused by the chronic kidney failure has negative

effects in the body’s organs and systems. One of the systems being affected is the

erythropoietic system, which in turn, gives rise to anemia. Anemia is a state of deficient

mass of red blood cells and hemoglobin resulting in insufficient oxygen delivery to the

body’s tissues ad organs. The National Kidney Foundation’s clinical practice guidelines

define anemia as a hemoglobin level less than 13.5 g/ dl for adult men and less than 12.0

g/ dl for adult women.

Chronic kidney disease has been associated with circulating inhibitors of

2,3,4
erthropoiesis. , but great evidence demonstrates the primary role of erythropoietin
5,6,7
deficiency as the major cause of anemia in CKD. Because anemia results to

symptoms such as fatigue, dyspnea and reduced mental acuity that degrade the

individual’s overall experience and quality of life, we must treat this by all means, with

the use of recombinant human erythropoietin.

 8

Previous studies have shown that normalization of hemoglobin improves the

quality of life of patients on hemodialysis. In cardiac patients enrolled in the

normalization of hematocrit study 7, quality of life was assessed using the Medical

Outcomes Study short form Health survey 8 ; as the hematocrit increased, quality of life

improved, although few details of the analysis are provided. A prospective randomized

double blind crossover study in 14 hemodialysis patients assessed the benefits of full
9
reversal of anemia in stable hemodialysis patients. The total score and psychosocial

dimension score were significantly better when the hemoglobin was normalized. Similar

findings were reported by Paintu and colleagues, who found an improvement in exercise
10
capacity when normalization of hematocrit was combined with exercise testing. The

latter, however remained below normal, thus suggesting that the poor exercise capacity in

dialysis patients cannot be fully explained by anemia. These results confirm earlier
11, 12, 13
findings by other investigators and implicate a role for anemia per se or local

abnormalities in electrolyte metabolism related to anemia in this clinical abnormality.

Several forms of recombinant human erythropoietin are available for the

treatment of patients with anemia related to chronic renal failure and ESRD by either the
14
intravenous or subcutaneous route. Epoietin alpha and beta (165 amino acids) are

glycoproteins produced through recombination of the human erythropoietin gene of the

chimeric hamster ovary cell. These recombinant human erythropoietin molecules differ

modestly in that the beta form contains quantitatively more basic sialic acid residues. The

half time (t ½) of epoietin alpha is between 4-12 hours when administered continuously

and is prolonged to approximately 28 hours by subcutaneous injection. Evidence based

guidelines differ in their ideal initial dosage of recombinant human erythropoietin; for
 9

K/DOQI it should be given 80-120/ kg/ week subcutaneously or 120-180 u/kg/ week IV.

In European guidelines, it is given 50-150 U/ kg/week SC and IV. In Canadian

guidelines, it is given 100-200 U/ kg/ week delivered in doses divided twice or 3 x a

week.

There are a variety of serious potential complications of therapy, including

worsening hypertension, seizures, impaired solute clearance (particularly proteins) and an

increased frequency of thrombotic events at but not confined to vascular access in situ.

Current medical practice regarding target hemoglobin levels in patients with CKD

is derived from the National Kidney Foundation K/DOQI clinical practice guidelines.

The target hemoglobin concentration should be more than 11.0 with lower levels

associated with adverse outcomes.

Statement of the Problem:

What is the Quality of Life of hemodialysis patients on recombinant human

erythropoietin therapy at Iloilo Doctors Hospital, Iloilo City?

General Objective:

To know the effect of recombinant human erythropoietin on quality of life of

hemodialysis patients at Iloilo Doctors Hospital, Iloilo City.

Specific Objectives:

1. To assess the Quality of Life of hemodialysis patients at Iloilo Doctors Hospital Renal

Care unit, Iloilo City by determining the following parameters after 4 weeks of treatment

with recombinant human erythropoietin:

 10

a. Karnofsky Performance Status Score

b. Physical Functioning

c. Role limitations due to physical health problems

d. Bodily pain

e. General health

f. Vitality (energy/ fatigue)

g. Social functioning

h. Role limitations due to emotional problems

i. Mental Health

2. To know the socio demographic profile of these patients

3. To know the clinical and laboratory parameters of their hemodialysis patients before

and after treatment with recombinant human erythropoietin for 4 weeks.

Scope and Limitation

This study focused on determining the quality of life of hemodialysis patients

before and after treatment with recombinant human erythropoietin for 4 weeks. The

respondents of this study are limited to those patients who avail of dialysis treatment at

Iloilo Doctors Hospital Renal Care unit who were coherent to undergo interview. The

tools that were used in the study are the Karnofsky Performance Status Scale and the

Short Form Health Survey (SF 36), and the laboratory parameters such as serum

creatinine, blood urea nitrogen, hemoglobin and serum albumin.

 11

Definition of Terms:

1. Physical Functioning— The person performs all types of physical activities

including the most vigorous without limitations due to health.

2. Role limitations due to Physical Health problems—The person has no problems

with work or other daily activities.

3. Bodily Pain— The person has no pain or limitations due to pain.

4. General Health— The person evaluates personal health as excellent.

5. Vitality-- The person feels full of pep and energy all of the time

6. Social Functioning-- The person performs normal social activities without

interference due to physical or emotional problems

7. Role limitations due to emotional problems—The person has no problems with

work or other daily activities

8. Mental Health—The person feels peaceful, happy, and calm all of the time

9. Quality of Life (QOL)-. Patients perception of their Physical wellness, emotional

well- being, social status, cognitive ability and self-care/functional or the level of

functioning and capacity to care for oneself.

 12

Conceptual Framework

The conceptual framework depicts that the quality of life is modified and affected

by sociodemographic factors, hemodialysis treatment, recombinant human erythropoietin

treatment, and clinical and laboratory parameters. These factors have reciprocal

relationships and are interrelated in predicting the outcome of QOL. There is a one-way

arrow between hemodialysis treatment and socio-demographic factors and another arrow

between recombinant human erythropoietin treatment and socio demographic factors

because their ease of access to treatment depends on socioeconomic status. Thus these

four interrelated factors point to and mirror the QOL of the patients. On the other hand,

their quality of life will affect treatment compliance as well as their functional recovery

for the disease which in turn has a bearing on a patient’s treatment outcomes.

Sociodemographic Factors

Clinical and
Hemodialysis QOL Erythropoietin laboratory
treatment Parameters

Adherence/ Compliance to
treatment and functional recovery

Treatment Outcome
 13

CHAPTER II

Methodology

Research Design

This study used a prospective, correlational, descriptive study design. There are

two parts in this paper. First quality of Life was assessed using Karnofsky Performance

Status Scale and Short Form Health Survey (SF-36). Sociodemographic, clinical and

laboratory profiles were also obtained. Then the patients had recombinant human

erythropoietin treatment for 4 weeks. In the second part, the Quality of Life , using KPSS

and SF-36 were again obtained from these patients and the results compared.

Participants

Inclusion Criteria:

1. Male or female, aged 19 years or older.

2. On hemodialysis, either as outpatient or as inpatient, at Iloilo Doctors Hospital

Renal Care Unit from June 1, 2009 to August 31, 2009.

3. Anemia (hemoglobin levels of 13. 5 g/ dL in adult males and <12.0 g/dL in

adult females)

Exclusion Criteria:

1. Daily prednisone dose of at least 10 mg

2. Medical conditions likely to reduce epoietin responsiveness, including

concurrent malignancy, therapy with cytotoxic agents, seizure in the

preceding year, hypersensitivity to intravenous iron and current pregnancy or

breastfeeding.
 14

3. Patients being prepared for renal transplantation

4. Patients who will not consent

Research Setting

The study was conducted at Iloilo Doctors Hospital and Medical Center Renal

Care Unit, Iloilo City. Iloilo Doctors Hospital is a tertiary hospital with a 300-bed

capacity and ISO certification. The Iloilo Doctors Hospital Renal Care unit caters to

patients from Iloilo City, Capiz, Akjlan and Antique. There were 44 patients for a 3-

month period of June – August 2009. They are in either 2 sets of sessions in a day which

starts at 7:30 AM and ends at 5PM; the IDH Renal Care unit is open 24 hours a day for

emergency hemodialysis. The unit is well equipped with amenities and facilities needed

by the patient in accordance to the ruled and regulations of Department of Health Region

6. They have 6 functional hemodialysis machines and the unit id adjacent to the Medical

and Surgical Intensive Care units where patient can have access to critical care equipment

and staff. The staff is headed by a nephrologist who is a Fellow of the Philippine College

of Physicians and the Philippine Society of Nephrology; 2 active consultant staff

nephrologists, visiting nephrologists and 2 resident physicians rotating in Nephrology; a

hemodialysis nursing manager, 3 hemodialysis nurses, volunteer nurses and 2 technicians

who maintain the machines and facilities. The unit also has access to surgeons who

perform hemodialysis access procedures on patients anytime once called.

 15

Sampling Design:

All patients undergoing hemodialysis at Iloilo Doctors Hospital Renal Care Unit

from June to August 2009 were enrolled in the study. The researcher visited the unit

everyday to include all the patients within the three-month period. The researcher was

able to administer the questions to 36 out of 44 patients at the hemodialysis unit.

Research Instruments:

There were 2 measures of QOL used in the study: the Karnofsky Performance

Status Scale and the Short Form Health Survey (SF-36).

The Karnofsky Performance Status Scale numerically describes in an easily

administered, single global score, “the patient’s ability to carry on his normal activity and

work, or his need for a certain amount of custodial care, or his dependence on constant

medical care.” The description of each 10-point increment is in Table 1. The KPSS was

originally developed to evaluate a patient’s response to a chemotherapeutic agent.

Nevertheless, the validity and reliability of the KPSS has been well documented. 15, 16, 17

Table I: Karnofsky Performance Status scale

Normal no complaints; no evidence

100
Able to carry on normal activity and to work;
no special care needed.
Unable to work; able to live at home and care
for most personal needs; varying amount of
assistance needed.
of disease.
Able to carry on normal activity;
90
minor signs or symptoms of disease.
Normal activity with effort; some
80
signs or symptoms of disease.
Cares for self; unable to carry on
70
normal activity or to do active work.
60 Requires occasional assistance, but
is able to care for most of his
personal needs.
 16

Requires considerable assistance and

50
frequent medical care.
Disabled; requires special care and
40
assistance.
Severely disabled; hospital
30 admission is indicated although
Unable to care for self; requires equivalent of death not imminent.
institutional or hospital care; disease may be Very sick; hospital admission
progressing rapidly. 20 necessary; active supportive
treatment necessary.
Moribund; fatal processes
10
progressing rapidly.
0 Dead

The SF 36 questionnaire is a measure which is sensitive to the effect of co

morbidity. In it, the data from 36 questions are combined to provide a measure of health

related quality of life in eight dimensions. These are: physical functioning, role

limitations attributable to physical problems, bodily pain, perception of general health,

vitality, social functioning, role limitations attributable to emotional problems and mental

health. A score from 0 (lowest health related quality of life) to 100 (highest) is derived

for each.

The experience to date on SF 36 has been described in nearly 4,000 studies. Its
18,19
reliability and validity has been well assessed, , and narrative data exists for the

general English population. It has also been shown to be valid and acceptable to patients
20,21
< 65 years old. . Although it is increasingly being used as an outcome measure for

patients with end stage renal failure, it has not been formally assessed in this population.

A summary of information about SF 36 scales and physical and mental

component interpretations is shown in Table II.

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Table II: Summary of Information about SF-36® Scales and Physical and Mental
Component Summary Measures
Correlations Number of Definition (% observed)
Lowest Possible Highest Possible
Scales PCS MCS Items Levels Mean SD Reliability Cla
Score (Floor)c Score (Ceiling)c
Very limited in Performs all types of
performing all physical physical activities including
Physical
.85 .12 10 21 84.2 23.3 .93 12.3 activities, including the most vigorous without
Functioning
bathing or dressing limitations due to health
(0.8%) (38.8%)
Problems with work or
Role-Physical other daily activities as No problems with work or
.81 .27 4 5 80.9 34.0 .89 22.6
(RP) a result of physical other daily activities (70.9%)
health (10.3%)
Very severe and
No pain or limitations due to
Bodily Pain .76 .28 2 11 75.2 23.7 .90 15.0 extremely limiting pain
pain (31.9%)
(0.6%)
Evaluates personal
General health as poor and Evaluates personal health as
.69 .37 5 21 71.9 20.3 .81 17.6
Health (GH) believes it is likely to excellent (7.4%)
get worse (0.0%)
Feels tired and worn out Feels full of pep and energy
Vitality .47 .65 4 21 60.9 20.9 .86 15.6
all of the time (0.5%) all of the time (1.5%)
Extreme and frequent Performs normal social
interference with normal activities without
Social
.42 .67 2 9 83.3 22.7 .68 25.7 social activities due to interference due to physical
Functioning
physical and emotional or emotional problems
problems (0.6%) (52.3%)
Problems with work or
Role-
other daily activities as No problems with work or
Emotional .16 .78 3 4 81.3 33.0 .82 28.0
a result of emotional other daily activities (71.0%)
(RE)
problems (9.6%)
Feelings of nervousness
Mental Health Feels peaceful, happy, and
.17 .87 5 26 74.7 18.1 .84 14.0 and depression all of the
(MH) calm all of the time (0.2%)
time (0.0%)
Limitations in self-care,
No physical limitations,
physical, social, and role
Physical disabilities, or decrements in
activities, severe bodily
Component 35 567b 50.0 10.0 .92 5.7 well-being, high energy
pain, frequent tiredness,
Summary level, health rated
health rated "poor"
"excellent" (0.0%)
(0.0%)
Frequent positive affect,
Frequent psychological
absence of psychological
distress, social and role
Mental distress and limitations in
disability due to
Component 35 493b 50.0 10.0 .88 6.3 usual social/role activities
emotional problems,
Summary due to emotional problems,
health rated "poor"
health rated "excellent"
(0.0%)
(0.0%)

Note. From Ware, Kosinski, and Keller (1994).

a
CI=95% confidence interval
b
Numberof levels observed at baseline; scores rounded to the first decimal place
(n=2,474).
d
Scores for eight scales are the percentage of the total possible score achieved for each of
these scales. Scores for PCS and MCS are

Data Gathering
 18

The researcher visited the IDH Renal Care Unit everyday within the months of

June- August 2009. The researcher first obtained sociodemographic data from the

patients. She introduced herself to them and asked permission to each of them to become

a part of the study. After being given consent, the researcher administered the 2 QOL

instruments to the participants during the dialysis sessions. Clinical and laboratory data

were obtained from the patients’ records at the IDH renal care unit.

The patients were then given their weekly 2-3x dosages of recombinant human

erythropoietin injections for 4 weeks. The dosage was based on their initial and

maintenance doses as prescribed by their attending nephrologists and based on their

weight and hemoglobin levels. After 4 weeks, laboratory parameters such as serum

creatinine, BUN, hemoglobin and albumin were again obtained. Creatinine Clearance

was solved using the Cockroft-Gault equation. The 2 QOL measures were again

administered and adverse effects to the treatment were noted, as well as the mean systolic

blood pressure at the end of the 4 week treatment.

Afterwards, the data collected in the questions such as the demographic, clinical

and laboratory profiles were tallied. The 2 QOL measures were translated in the

Hiligaynon dialect which most of them could speak and understand as well. The results

of the SF-36 survey were then encoded in COES software.

The data obtained were transcribed by the researcher the soonest possible time to

minimize errors.

Data Gathering

Descriptive statistics were used to analyze the data. The mean scores were

obtained for each domain among all the participants.

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CHAPTER III

Presentation of Results, Analysis and Interpretation

I. Demographic and Laboratory profile

Table III. Basic Socio-Demographic Data of patients at Iloilo Doctors Hospital Renal
Care Unit.
Category F Mean SD Percentage
(%)
A. Sex
Male 21 58%
Female 15 42%
Total 36 100%

B. Age
0-10 0 0 0 0
11-20 0 0 0 0
21-30 4 27.75 2.872 11
31-40 1 0 0 3
41-50 9 47.43 2.878 25
51-60 12 56.50 2.844 33
61-70 4 64 3.742 11
71-80 6 73.43 2.637 17
81-90 0 0 0 0
91-100 0 0 0 0
Total 36 100

C.Marital
Status
Single 5 14
Married 27 75
Separated 1 3
Widowed 3 8
Total 36 100

D.Occupation
Unemployed 1 3
Semiskilled 33 92
Senior
Employee 2 5
Total 36 100
 20

E.Level of
Education 0 0
Nil 0 0
Primary 3 8
Secondary
Higher 33 92
Education 36 100
Total

The respondents of this study were 36 patients who underwent hemodialysis at

Iloilo Doctors Hospital Renal Care Unit during the months of June to August 2009 (3-

month period). When classified as to sex, 21 (or 58%) were males and 15 (42%) were

females.

When classified as to age, patients within the age range of 51-60 years old were

recorded to compose the majority who underwent hemodialysis during the months of

June to August 2009 (33%) with a standard deviation of 2.844. Meanwhile, patients

belonging to ages 0-12, 10-20, 81-90 and 91-100 years old brackets were recorded as the

lowest rates to undergo hemodialysis with a result of 0.

When classified as to marital status, 5 or 14 % were single while 27 or 75% are

married. 3 or 8% are widowed.

When classified as to occupation, 1 or 3% were unemployed. 33 or 92% are

semis-0killed and 2 or 5% are senior employees.

When classified as to education, 33 or 92% attained higher education (college

degree)

Note: All entries that got 1 were constant.

 21

Table IV. Duration of hemodialysis of patients (in months) at Iloilo Dcotors Hospital
Renal Care Unit at the time of data collection (June to August 2009)
Category F Percentage (%)
Months
0-15 29 80
16-30 3 8
31-45 0 0
46-60 0 0
61-75 0 0
76-90 1 3
91-105 0 0
106-120 1 3
121-135 1 3
136-150 1 3
Total 36 100%

Table IV shows the patient’s duration of hemodialysis at the time of data

collection, with a mean of 15.65 months and a standard deviation of 32. 88. Majority of

the patients (29 or 80%) have been undergoing hemodialysis for 0-15 months, while 3 or

8% have been undergoing hemodialysis for 16-30 months.

Laboratory Parameters observed in patients

Table V: Mean Baseline Laboratory Parameters observed in patients

Parameters HD Patients (N=36)
Serum creatinine (umol/L) 817.16 +/- 370.19
Blood urea nitrogen (mmol/L) 22.64 +/- 21.57
Creatinine clearance (ml/min) 8.66 +/- 4.49
Hemoglobin concentration (g/dl) 96 +/- 8.77
Serum albumin (g/L) 36.17 +/- 11.2

Table V shows the baseline serum creatinine levels of patients (in umol/l) at Iloilo

Doctors Hospital Renal care Unit at the time of data collection, with a mean of 817.16

umol/L and a standard deviation of 370.19. The mean blood urea nitrogen observed in

these patients is 22.64mmol/L, with a standard deviation of 21.57. The baseline creatinine
 22

clearance is 8.66 ml/min, with a standard deviation of 4.49. The baseline hemoglobin

level is 96 g/dl, with standard deviation of 8.77. The Baseline serum albumin level is

36.17 g/L, with a standard deviation of 11.2.

Table VI. Laboratory Parameters observed in patients after 4 weeks of

recombinant human erythropoietin therapy and the percent change from the baseline.

Parameters Hemodialysis patients

Baseline Post RHuEPO % change
from
baseline

Serum Creatinine (mmol/L) 817. 16 +/- 370. 19 804.16 +/- 393.21 1.50 %

Blood Urea Nitrogen 22.64 +/- 21.57 24.36 +/- 8.52 7.59%
(mmol/L)

Creatinine Clearance 8.66 +/- 4.49 8.66 +/- 4.49 0

(ml/min)

Hemoglobin concentration 96+/- 8.77 96.13 +/- 8.77 0.13%

(g/dl)\

Serum albumin (g/L) 36.17 +/- 11.2 37.2 +/- 11.2 2.84%

Table VI shows the laboratory parameters observed in patients after 4 weeks of

recombinant human erythropoietin therapy and the percent change from the baseline.

There is a slight drop in serum creatinine levels (1.5%) after 4 weeks of treatment with

RHuEPO. However, there is a noted increase in BUN levels. There is no change in

creatinine clearance observed. There was slight improvement in hemoglobin

concentration observed in treatment with RHuEPO for 4 weeks, as well as an

improvement in serum albumin levels.

 23

The mean systolic BP taken before the start of erythropoietin therapy was 140 +/-

22. The mean systolic blood pressure after 4 weeks of treatment with erythropoietin was

140 +/- 32. There were no adverse reactions noted by patients after the 4 week period.

II. Quality of Life Assessment

Table VII. QOL parameters, baseline values, scores after 4 weeks of recombinant
erythropoietin therapy and their percent change.

Parameters Baseline values After 4 weeks of % change

RhuEPO

Physical functioning 58.19 +/- 47.20 68.88 +/- 47 18.37%

Role physical 31.25 +/- 62.26 22.22 +/- 62 28.89%

Bodily Pain 46.33 +/- 16.14 50.77 +/- 16 9.58%

General Health 71.08 +/- 15.25 64.41 +/- 15.25 9.38%

Vitality 62.5 +/- 12. 67 63.05 +/- 12 0.88%

Social Functioning 63.33 +/- 19.67 70.58 +/- 19.5 11.44%

Role emotional 92.61% +/- 0 100 +/- 0 7.97%

Mental Health 64.55 +/- 10.18 60.44 +/- 10 6.36%

Karnofsky score 64.16 +/- 20 66.11 +/- 20 3.03%

Table VII shows the various QOL parameters of SF-36, the Karnofsky

Performance Status score, their baseline values, their values after 4 weeks of

erythropoietin therapy and their percent change. Note that there is an improvement in
 24

physical functioning, bodily pain handling, vitality, social functioning, role emotional and

Karnofsky score. However there is decrease in role physical, general health and mental

health areas.

Figure I. Correlation between SF-36 and Karnofsky Scores prior to

erythropoietin therapy.
100

80

60
SF-36Item
Scores
40

20

50 60 70 80 90

KarnofskyScores

RoleEm otional Fit linefor RoleEmotional

karnofsky karnofsky
RSqLinear =0.005
Physical Functioning Fit linefor Physical
RSqLinear =0.009 karnofsky Functioning
karnofsky
Social Functioning
RSqLinear =0.046 karnofsky Fit linefor Social Functioning
karnofsky

r = -0.07, p = 0.70 : r = 0.09, p = 0.59 : r = 0.22, p = 0.21

Figure II. Correlation between SF-36 and Karnofsky Scores after erythropoietin
therapy.
 25

140

120

100

80
SF-36 Item
Score
60

40

20

50 60 70 80 90

Karnofsky Scores

Role Emotional Fit line for Role Emotional

karnofsky karnofsky
R Sq Linear = 0.161
Physical Functioning Fit line for Physical
karnofsky Functioning R Sq Linear = 0.286
Social Functioning karnofsky
karnofsky Fit line for Social R Sq Linear = 0.142
Functioning
karnofsky

r = 0.401*, p = 0.015 : r = 0.535**, p = 0.001 : r = -0.377*, p = 0.023

Figures I and II shows the correlation of Karnofsky score with 3 SF 36 items. The
results showed positive correlation regardless of the erythropoietin treatment.

Figure III. Correlation between hemoglobin and physical functioning score in patients
after 4 weeks of ESA Therapy
115

110

105
Hemoglobin

100

95

90

85

0 20 40 60 80 100

Physical Functioning
R Sq Linear = 0.025

r = -0.159, p = 0.543
 26

Figure III is aboot the correlation of hemoglobin levels with ohysical function.
The graph shows a negative correlation betweem hemoglobin levels and physical
functioning.

Figure IV: Correlation of Karnofsky scores with the different SF 36 items

r = 0.28, p = 0.09 : r = 0.38*, p = 0.02 : r = -0.22, p = 0.19 ; r = 0.53** , p = 0.001 ; r = -0.37*, p = 0.03

Table 1. Multiple Regression Analysis - Forward

Coefficientsa

Unstandardized Standardized
Coefficients Coefficients
Model B Std. Error Beta t Sig.
1 (Constant) 59.480 5.039 11.804 .000
Physical Functioning .235 .064 .531 3.651 .001
2 (Constant) 71.624 6.758 10.599 .000
Physical Functioning .319 .069 .722 4.642 .000
Bodily Pain -.365 .146 -.388 -2.496 .018
a. Dependent Variable: karnofsky
 27

Two variables were found to be affecting Karnofsky scores namely Physical

Functioning and Bodily Pain.
The equation is Ykarnofsky score = 71.624+0.319 xPhysical Functioning – 0.365 xBodily Pain + ε

CHAPTER IV

DISCUSSION

The effect of recombinant human erythropoietin treatment may be attributed by

some studies to be due to its reversing effect on the diminution of erythrocyte survival in

CKD. In this study, we have found out that there is some improvement in hemoglobin

levels, although minimal, after recombinant human erythropoietin treatment for 4 weeks.
23
This may be the reason for such. Schwartz et al have shown that erythrocytes in CKD

have a significantly reduced survival with a half life of as low as 22 days. Polenakovich

and Sikole studied 40 chronic hemodialysis patients. Prior to initiation of RHuEPO

treatment, the mean erythrocyte half life was 23.3 +/- 2.6 days. After 12 days of

treatment, the mean erythrocyte half life increased slightly to 27.2 +/- 4.1 days and after

discontinuing RHuEPO for 12 months, the erythrocyte half life decreased again to 22.1

+/- 3.6 days. Increased erythrocyte antioxidant level after RHuEPO treatment may

contribute to improved red cell survival.

There is also a significant improvement I creatinine clearance. This agrees with

the findings of various investigators regarding the relationship of hemoglobin with

creatinine clearance. A study by Radtke HW et al showed that serum erythropoietin

levels in patients with kidney disease were generally higher than in normal subjects. With
 28

decreasing levels of creatinine clearance in the range of 20-90 ml/min, mean serum

erythropoietin concentration increases as mean hematocrit decreases. With severe renal

insufficiency (creatinine clearance < 209 ml./ min), serum erythropoietin levels were

markedly decreased for the degree of anemia present. 22

Serum albumin was also said to improve after RHuEPO treatment. In reference to

this is a study done by Thomas and associates which dealt with the contribution of

proteinuria to anemia in diabetes among Australian patients with Type II diabetes. The

prevalence of anemia was found to increase greatly in patients with macroalbuminuria as

25
compared to microalbuminuria or no albuminuria . Thus further studies are needed

regarding this matter.

Our findings also revealed an improvement in physical functioning, bodily pain,

vitality, social functioning and role emotional. Physical functioning means that the

patient is able to perform all types of physical activities without limitations due to health.

Increased performance may be due to the correction of anemia, which results to an

increased delivery of oxygen to body tissues. Bodily pain means that the patient has no

pain or no limitations due to pain. Vitality means that the patient is full of pep and energy

all the time. Social functioning means the person performs social activities without

interference.

However, our study also found out that recombinant human erythropoietin does

not lead to any improvement to role physical, mental health and general health. A low

score in role physical means that there are problems in work and in daily activities as a

result of physical health. A low score in general health means that the person evaluates
 29

his or her own health as poor and believes it is likely to get worse. A low score in mental

health means that there is feeling of nervousness and depression all the time.

There was also an improvement in Karnofsky scores after RHuEPO therapy, and

this means that the patient’s ability to carry out his normal work and activity improves

after therapy. The mean score of 60 means that the patient requires occasional assistance,

but can perform his or her activities well.

This study has also shown a positive correlation between KPSS and SF-36

through physical functioning, social functioning and mental health. Thus it agrees to the

findings of other investigators that although KPSS is physician dependent with little or no

input from the patient in contrast to SF 36, it may replace SF-36 in patients who are not

conscious enough or are ill and not able to converse well to respond to questions and may

serve its purpose well.

There is a negative correlation between hemoglobin concentration and physical

26
activity scores. This agrees with the study of Mingardi et al which said that there is not

association between HRQOL and hemoglobin. Perhaps there is a factor, not anemia or a

low hemoglobin, which greatly affects physical functioning in patients with end stage

renal disease, and this call for further studies to prove this fact.

Another interesting finding in our study is the fact that among the 8 domains of

the SF-36 survey, the two factors which greatly affect Karnofsky Scores are Physical

Functioning and bodily pain. Thus we should address these two factors well, so that a

person’s performance can be maximized to his full potential. Addressing these two

problem factors are maybe the keys in raising our Karnofsky scores.
 30

CHAPTER V

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

In summary, the study examined the quality of life of hemodialysis patients in

Iloilo Doctors Hospital renal Care Unit before and after 4 weeks of treatment with

recombinant Human erythropoietin (RHuEPO), under a prospective, correlational,

prospective design. The results showed that there is an improvement in hemoglobin,

creatinine clearance and serum albumin kevels after 4 weeks of recombinant human

erythropoietin treatment.

There is also an improvement in physical functioning, bodily pain handling,

vitality, social functioning and role emotional; however there is not effect on the

physical, general health and mental health after RHuEPO. There is also an improvement

in Karnofsky scores after RHuEPO.

Hemoglobin is an independent factor in physical functioning. The KPSS and the

SF 36 survey have a positive correlation thus the former can be a good choice in patents

who are both fully conscious and who cannot answer questions of the SF-36. Bodily pain

and physical functioning also affects Karnofsky scoring.

Thus study therefore recommends the following:

1. Further studies should be done regarding the factor which greatly affects

physical functioning, since hemoglobin is ruled out as a factor, as shown

in our study.
 31

2. Compliance to recombinant human erythropoietin is needed so that the

patient can function well everyday with minimal assistance, can tolerate

body pain well, can increase vitality and can make one function well.

3. Every hemodialysis unit should be provided with counselors, psychiatrists

or psychologists so that quality of life can be maintained in our patients.

4. Quality of life should be routinely done in every hemodialysis at intervals

of 3, 6 or 0=9 months to see whether the patient improves or deteriorates

so that solutions can be done.

5. The Karnofsky Performance Straus Scale should take the place of SF-36

in patients who cannot converse or are not fully conscious.

6. Physical Functioning and Bodily pain scores should be elevated in order to

maintain a high KPSS score for QOL.

 32

REFERENCES

1. El-Achkan TM, Ohmit SE, Mc Cullogh PA et al. Higher prevalence of anemia of

diabetes mellitus in moderate kidney insufficiency. The Kidney Early Evaluation

Program Kidney Int 67: 1483-1488, 2005

2. RadtkeHW, Rege AB, Lamaeche B et al. Identification of spermine as an

inhibitor of erthropoiesis in chronic renal failure.

3. Massry SG: Is Parathyroid hormone a uremic toxin? Nephron 19:125-139, 1977

4. Fisher JW, Hatch FE, Roh BL et al. Erythropoietin inhibitor in kidney extracts for

anemic uremic subjects. Blood 31 (4) 440-452, 1968

5. Erslev AJ: Berbard A: The rate and control of baseline red cell production in

hematologically wise stable patients with uremia. J Lab Clin Med 126: 283-286,

1997

6. Eschbach, JW. The anemia of chronic renal failure: Pathophysiology and the

effects of recombinant human erythropoietin. Kidney Int 18(6): 732-745, 1989.

7. Bernard A, Bolton WK, Bromme JK et al: The effects of normal as compared

with low hematocrit values in patients with cardiac disease whoa re receiving

hemodialysis and epoietin. N Eng J Med 339: 584-590, 1998.

8. McHarvey CA. Ware JE, Raczec AE. The MOS 36-1 short form Health survey

(SF-36) II: Psychometric and clinical tests of validity in managing physical and

mental health. Med Lane 31:247, 263, 1993.

 33

9. McMahon LP, Mason k, Skinnes SL et al. Effects of hemoglobin normalization

on quality of life and cardiovascular parameters in end sate renal failure. Nephrol

Dial Yanoplat 15: 1475-1430, 2000.

10. Pointer P, Moore g, Carlson L et al. Effect of exercise testing plus normalization

of hematocrit on exercise capacity and health related quality of life. Am J Kidney

Dis 39: 257-265, 2002.

11. Mc Horney CA, Ware JE, Raczec AE: The MOS 36-item short form health

survey (SF-36) II. Psychometric and clinical tests of validity in meaning physical

and mental health constructs. Med Lane 31: 247-263, 1993.

12. Suzuki, M, Tsutsui M, Yokohama A, Hirasan Y. Normalization of hematocrit

with recombinant human erythropoietin in chronic hemodialysis patients dies not

improve their exercise tolerance abilities. Artif Organ 19: 1258-1261, 1995

13. Mc Mahon LP, MKenn MJ, et al: Physical Performance and associated electrolyte

changes for hemoglobin normalization: a comparative study is hemodialysis

patients. Nephrol Dial Transplant 14: 1182-1187, 1999.

14. Egrie J: The cloning and production of recombinant human erythropoietin.

Pharmacotherapy 101 Suppl 2: 3-8, 1990.

15. Yates JW, Chaler B, McKegney FP. Evaluation of patients with advanced cancer

using the Karnofsky Performance Status. Cancer 1980; 45: 2220-4.

16. Mot V, Caliberte L. The Karnofsky Performance Status scale, an examination of

its reliability and validity in a research setting. Connect 1984; 53: 2002-7

17. Schag, CC Heinricvh RL et al. Karnofsky Performance Status Scale: reliability,

validity, guidelines. J. Clinical Oncol 1984: 2: 1987-93.

 34

18. Outcomes Briefing Issue 4. UK Clearinghouse for health Outcome, Notfield

Institute of Health, 1994.

19. Brazier, JE, Harper R et al. Validating the SF 36 health survey questionnaire—

new outcome measure for primary care. BMJ 1993: 305, 160-4.

20. Lynns RA, Pery HM. Evidence for the validity of the short form 36 questionnaire

(SF 36) in an elderly population. Age, Aging 1994: 23:182-4

21. Singleton N, Tuner A. SF 36 is suitable for elderly patients. BMJ 1993: 307: 126-

22. Radtke, HW. Serum erythrocyte concentration in chronic renal failure>

Relationship to excretory renal function. Blood 54(4): 877-884, 1979.

23. Schwarts, AB, Kelch B et al. One year of RHuEPO therapy prolongs RBC

survival and may stabilize RBC membranes despite natural progression of chronic

renal failure to anemia and trend for dialysis. ASA 10 Trans 36 (3) M691-M696,

1990

24. Palenakp, VM, Sikole A: Is erythropoietin treatment a crucial factor for red blood

cells. J A J. Nephro 7 (8): 1178-1188, 1996

25. Thomas MC, Mac Isaac RJ et al, Anemia in patients with type I diabetes. J

Clinical Endocrine Metabolism 89 (9) 4359-4363, 2004.

 35

APPENDIX A
Quality of life Questionnaire

PAGPAHANUGOT KA PASYENTE (CONSENT FORM)

Pangalan : ____________________________________ Edad : ___________

Ginahatag ko ang pahanugot kay Dr. ______________________ nga amo ang duktor nga

nagatuon nahanungod sa epekto sang erythropoietin sa kalidad sang kabuhi sa mga

pasyente nga nagadialysis diri sa Iloilo Doctors Hospital Renal Care Unit.

Ginapamatud-an ko subong nga:

1. Lubos ko nga naintiendihan ang ginahimo nga pagtulon-an nahanungod sini.

2. Ginpaintiende sa akon ang kaayuhan sang sini nga pag-tulun-an kag ang mayo

nga igadulot sini sa pareho ko nga nagadialysis.

3. Ginhatagan ako sang tiyempo para makapamangkot nahanungod sa ini nga

pagtuon.

4. Nakaintiende ako na wede ko bawion ang akon pagpahanugot sa maski ano oras

kung gusto ko kag kung nabatyagan ko nga malain ini para sa akon.

________________________

Ngalan kag Pirma ka Pasyente/Tagapag-alaga

 36

Survey nahanungod sa Ikaayong-lawas sang mga pasyente nga naga

Dialysis (SF36)

Today’s Date:_________
Name: Last:_______________________ First: _______________ Date of Birth: __________
Ang ini nga survey nagapangayu sang imu opinion bahin sa imo panglawason. Palihug sabat sang
ini nga mga pamangkot.
1- Anu ang masiling mo parte sa imu panglawason?:
1. Excellente gid 2. Tama gid ka mayo 3. Maayu 4. medyo mayo man 5.
Pigado gid
2- Ikumpara sang nagligad nga tuig, kumusta ang panglawasun mo?
1. Mas mayo kesa nagligad nga tuig
2. Maayu-ayo na lang kesa nagligad nga tuig
3. Daw pareho man lang
4. Mas malala kesa nagligad nga tuig.
5. Grabe gid kalala kesa nagligad nga tuig

3- Ang ini nga mga pamangkot parte sa mga ginaobra mo sa pang-adlaw-adlaw. May limitasyon
bala ng imo pag obra sa mga pang adlaw-adlaw nga buluhaton?
Mga bulohaton 1. Huo, 2. Huo, 3. Indi gid
Limitado Medyo limitado,
katama limitado masulhay gid
a) Makapoy na mga bulohaton, pareho sang pagdalagan, 1. 2. Huo, 3. Indi
pagpanghakwat sing mabug-at, isports? Huo, medyo gid limitado,
limitado limitado masulhay gid
katama
b) Medyo makapoy na buluhaton, pareho sang pagtulod sang 1. 2. Huo, 3. Indi
lamesa, panilihig o paghampang sang golf? Huo, medyo gid limitado,
limitado limitado masulhay gid
katama
c) Pagpanghakwat o bitbit mga grocery? 1. 2. Huo, 3. Indi
Huo, medyo gid limitado,
limitado limitado masulhay gid
katama
d) Kung magsaka ikaw sa madamu nga hagdanan? 1. 2. Huo, 3. Indi
Huo, medyo gid limitado,
limitado limitado masulhay gid
katama
e) Kung magsaka ikaw sa isa lang ka hagdanan? 1. 2. Huo, 3. Indi
Huo, medyo gid limitado,
limitado limitado masulhay gid
katama
 37

f) Pagduko, pagluhod? 1. 2. Huo, 3. Indi

Huo, medyo gid limitado,
limitado limitado masulhay gid
katama
g) Paglakat sang sobra isa ka milya? 1. 2. Huo, 3. Indi
Huo, medyo gid limitado,
limitado limitado masulhay gid
katama
h) Maglakat sa mga balay sang imo kaingod? 1. 2. Huo, 3. Indi
Huo, medyo gid limitado,
limitado limitado masulhay gid
katama
i) Maglakat sa isa lang ka balay nga imo kaingod? 1. 2. Huo, 3. Indi
Huo, medyo gid limitado,
limitado limitado masulhay gid
katama
j) Ang pagpaligo mo o pag-ilis? 1. 2. Huo, 3. Indi
Huo, medyo gid limitado,
limitado limitado masulhay gid
katama

4- Sa sulod sang nagligad nga apat ka semana, may ara ka bala mga problema sa imo nga
ikaayong-lawas?
Yes No
a) Limitado na bala ang tyempo sang pag-obra mo? 1. huo 2. Indi
b) Limitado na bala ang mga buluhaton nga maobra mo? 1. huo 2. Indi
c)Limitado ka man bala sa iban mo nga gina pang-obra? 1. huo 2. Indi
d) Nabudlayan ka gid bala sa pag-obra? 1. huo 2. Indi
5. Sa nagligad nga apat ka semana, may mga problema ka bala nga nagadulot sa imo sang pag-
ugtas o pagkasubo o pagka emosyonal?
Yes No
a) Gamay na lang bala ang tiempo sang pag-obra mo tungod 1. huo 2. Indi
sang imo pagkaemosyonal?
b) Gamay na lang bala ang buluhaton nga maobra mo tungod sa 1. huo 2. Indi
imu pagka-emosyonal?
c) Indi na bala mayo ang imo pang-obra tungod sa imo 1. huo 2. Indi
pagkaemosyonal?

6. Sa sulod sang nagligad nga apat ka semana, grabe gid bala ang epekto sang imo ginabatyag sa
imo relasyon sa imo mga abyan, kapamilya kag mga kakailala?
1. Daw wala man epekto 2. Gamay man lang 3. Tama-tama lang 4. Medyo may
epekto 5. Grabe gid ang epekto

7. Ano gid kadaku ang sakit sa imo kalawasan sa sulod sang nagligad nga 4 ka semana?
1. Wala 2. Tuman ka diyutay 3. Gamay lang 4. Medyo lang 5.
Masyado kasakit 6. Grabe gid nga kasakit
 38

8. Sa sulod sang nagligad nga 4 ka semana, naestorbo bala ang imo pang-adlaw adlaw nga
buluhaton?
1. Wala gid 2. Gamay lang 3. Medyo lang 4. Daw naestorbo 5. Grabe
gid

9. Ang ini nga mga pamangkot parte sa imo na ginabatyag sa nagligad nga apat ka semana. Sa
nagligad nga apat ka semana, pirme ka lang bala…
1. Sa 2.Kalaba 3. Pirme 4. Kung 5. Daw 6. Wala gid
tanan na nan nga lang kis-a lang wala man
tiyempo tiyempo
a) Puno sang kalipay kag 1. Sa 2. 3. 4. 5. Daw 6. Wala
kaanyag? tanan Kalaban Pirme lang Kung wala man gid
nga an nga kis-a lang
tiyempo tiyempo
b) May pagkanerbyos? 1. Sa 2. 3. 4. 5. Daw 6. Wala
tanan Kalaban Pirme lang Kung wala man gid
nga an nga kis-a lang
tiyempo tiyempo
c) Nagabatyag sang grabe nga 1. Sa 2. 3. 4. 5. Daw 6. Wala
kasubo? tanan Kalaban Pirme lang Kung wala man gid
nga an nga kis-a lang
tiyempo tiyempo
d) Nagabatyag sang 1. Sa 2. 3. 4. 5. Daw 6. Wala
pagkasulhay kag katawhay? tanan Kalaban Pirme lang Kung wala man gid
nga an nga kis-a lang
tiyempo tiyempo
e) Puno sang enerhiya? 1. Sa 2. 3. 4. 5. Daw 6. Wala
tanan Kalaban Pirme lang Kung wala man gid
nga an nga kis-a lang
tiyempo tiyempo
f) Nagabatyag sang depression? 1. Sa 2. 3. 4. 5. Daw 6. Wala
tanan Kalaban Pirme lang Kung wala man gid
nga an nga kis-a lang
tiyempo tiyempo
g) Grabe na pagpalamuypoy? 1. Sa 2. 3. 4. 5. Daw 6. Wala
tanan Kalaban Pirme lang Kung wala man gid
nga an nga kis-a lang
tiyempo tiyempo
h) Malipayon bala ikaw na 1. Sa 2. 3. 4. 5. Daw 6. Wala
klase sang tawu? tanan Kalaban Pirme lang Kung wala man gid
nga an nga kis-a lang
tiyempo tiyempo
i) Pirme bala ikaw ginakapoy? 1. Sa 2. 3. 4. 5. Daw 6. Wala
tanan Kalaban Pirme lang Kung wala man gid
nga an nga kis-a lang
tiyempo tiyempo
 39

10. Sa sulod sang nagligad nga 4 ka bulan, ano kadaku ang tiyempo nga naistorbo ang imo
pangabuhi sang mga problema mo sa ikayong-lawas kag mga problema emosyonal?
1. Sa tanan nga tiyempo
2. Kalabanan nga tiyempo
3. Kung kis-a
4. Gamay lang na tiyempo
5. Wala man

11. Ano kamatuod ang ini nga mga butang para sa imo?
1. Huo, 2. Malapit 3. Wala 4. Daw 5. Indi gid
matuod sa ako indi man
gid ini kamatuoran kabalu
a) May madasig ako magmasakit 1. 2. 3. 4. 5.
kesa sa iban nga tawu? Huo, Malapit sa Wala ako Daw indi Indi gid
matuod kamatuoran kabalu man
gid ini
b) Maayo ang akon ikayong-lawas 1. 2. 3. 4. 5.
pareho sang iban? Huo, Malapit sa Wala ako Daw indi Indi gid
matuod kamatuoran kabalu man
gid ini
c) Naga expectar ako na maglala 1. 2. 3. 4. 5.
ang akon ginabatyag? Huo, Malapit sa Wala ako Daw indi Indi gid
matuod kamatuoran kabalu man
gid ini
d) Maayo ang akon ikaayong lawas? 1. 2. 3. 4. 5.
Huo, Malapit sa Wala ako Daw indi Indi gid
matuod kamatuoran kabalu man
gid ini
Madamu gid nga salamat! 
 40

Patient Data Form

A. Demographic profile:
Name:______________________________________ Age:_____________
Sex:________
Hosiptal:___________________________________Date:____________________
Marital Status: Single:_____ Married:_______ Divorced:________ Widowed______
Occupation: Unemployed:_________ Semiskilled:_________ Senior Employee:_______
Level of Education: Nil: _____ Primary:_____ Secondary:______ Higher education:____
Duration of hemodialysis in years:______________

B. Laboratory profile:
First Testing:
Date:_________________
Serum creatinine (umol/L):____________________
Blood urea nitrogen (mmol/L):_______________________
Hemoglobin concentration:__________________________

C. HRQOL:
Karnofsky performance score:_______________
SF-36:__________

Second Testing: (after 4 weeks from the first testing)

Date:_________________
Compliance with erythropoietin: Good:____ Fair:_________ Poor:______
Serum creatinine (umol/L):____________________
Blood urea nitrogen (mmol/L):_______________________
Hemoglobin concentration:__________________________

C. HRQOL:
Karnofsky performance score:__________________
SF-36:_______________
41