Nephrol Dial Transplant (2009) 24: 626–629

doi: 10.1093/ndt/gfn506
Advance Access publication 15 September 2008

Original Article

Factors affecting the quality of life of haemodialysis patients

from Romania: a multicentric study

Anca Seica1 , Liviu Segall1 , Constantin Verzan2 , Nina Văduva2 , Maria Madincea3 , Simona Rusoiu4 ,
Sorina Cristea5 , Maria Ştefan6 , Daniela Şerbănescu7 , Petronela Moroşanu8 , Luminita Grăjdeanu9 ,
Roxana Andronache10 , Maria Nechita11 , Dorina Dragoş12 , Anca Dronca13 , Paul Gusbeth-Tatomir1 ,
Gabriel Mircescu2 and Adrian Covic1

1
Nephrocare Dialysis Center, Iaşi, 2 Nephrocare Dialysis Center Carol Davila, Bucureşti, 3 Timişoara Dialysis Center, 4 Craiova

Downloaded from http://ndt.oxfordjournals.org/ by Gabriela Elena Voicu on March 27, 2012

Dialysis Center, 5 Floreasca Bucureşti Dialysis Center, 6 Tı̂rgu-Mureş Dialysis Center, 7 Nephrocare Dialysis Center, Constanţa,
8
Piatra Neamţ Dialysis Center, 9 Focşani Dialysis Center, 10 Petroşani Dialysis Center, 11 Baia-Mare Dialysis Center, 12 N.C. Paulescu
Institute Dialysis Center, Bucureşti, Romania and 13 Deva Dialysis Center

Abstract
Background. The quality of life (QoL) is an important
predictor of outcome in end-stage renal disease (ESRD)
patients. Therefore, QoL needs to be regularly assessed
in this setting. Our study describes QoL, as well as de-
mographic and clinical variables associated with QoL in
chronic haemodialysis (HD) patients in Romania.
Methods. All prevalent chronic HD patients (N = 709;
mean age 51.7 ± 12.6 years) in 12 dialysis centres from the
three main regions of Romania were included in the study.
Six hundred and six of these completed the Short-Form
Health Survey (SF-36) and the Kidney Disease Quality of
Life Questionnaire—Short Form (KDQOL-SF).
Results. The mean physical component summary (PCS)
score was 46.3 ± 19.2, and the mean mental component
summary (MCS) score was 55.1 ± 19.3. These figures were
lower than those previously described in non-dialysis age-
matched Romanian individuals. The mean kidney disease
summary component (KDSC) score was 68.3 ± 11.3, simi-
lar to other studies. The worst dimension of QoL was work,
whereas the best ones were cognitive function and quality
of social interaction. We found older age, female gender,
lower socio-economic status and higher educational level
to be associated with lower QoL scores.
Conclusions. The QoL of HD patients in Romania is lower
than that in the general population. Our results suggest that
at least one-third of these patients might be considered for
rehabilitation therapy, in order to try and prevent complica-
tions and mortality.
Keywords: end-stage renal disease; haemodialysis;
quality of life
Correspondence and offprint requests to: Anca Seica, Nephrocare
Dialysis Center, University Hospital, ‘C.I. Parhon’, 50 Carol 1st Blvd,
700503 Iasi, Romania. Tel: +40-727-889089; Fax: +40-232-211752;
E-mail: ancagusbeth@yahoo.com


C The Author [2008]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
For Permissions, please e-mail: journals.permissions@oxfordjournals.org
Introduction
‘Adding life to years and not just years to life’ is as true
for ESRD patients as for any other individuals. In mainte-
nance HD population, health-related QoL is usually poorer
than that in the age-matched general population, because
of the typically high burden of comorbidity and complica-
tions of ESRD [1–3]. Therefore, attaining a good QoL in
these patients is a difficult task, requiring significant ef-
forts from nephrologists and support from social workers
and psychologists.
Several large studies have demonstrated QoL, as assessed
with the SF-36, to be a consistent and powerful predictor of
death and hospitalization in HD patients [3–5]. The Dialysis
Outcomes and Practice Patterns Study (DOPPS) [4] found
the PCS score of SF-36 to predict mortality better than
serum albumin. Lowrie et al. [3] showed that a PCS score
<43 and a MCS score <51 significantly increase the risk
of death and hospitalization; a one-point increase in PCS
is associated with a 2% reduction in mortality, indepen-
dently of demographic and comorbid variables. Moreover,
a MCS score under 43 is highly specific and sensitive for
depression [2].
In Romania, as well as in other Central and Eastern
European countries, dialysis centres have dramatically de-
veloped and expanded during the past 20 years. The current
policy of employment of psychology specialists in dialysis
care teams is aimed at improving QoL in ESRD patients
in our country. Romanian specialists have recently settled
regular psychonephrology national summits, validated two
QoL evaluation instruments in HD subjects and created a
set of guidelines for rehabilitation and psychology practice
in chronic kidney disease and ESRD patients.
The present study is in line with these efforts. For the
first time in the Romanian dialysis population, we inves-
tigated QoL in a wide survey, analysed demographic and
clinical factors influencing QoL and compared our results
with those from similar Western European research.
QoL in Romania 627

Subjects and methods Table 1. Demographic and clinical data

Patients N = 606

All prevalent HD patients (N = 709) in 12 dialysis centres Age (years) 51.7 (12.6)
from the three main geographic regions of Romania (Mol- Men (%) 54.7
davia, Walachia and Transylvania) were included in the Dialysis vintage (months) 63.2 (51.4)
Educational level
study. The 12 centres represent ∼17% of all dialysis cen- Low (%) 45.5
tres, comprising roughly 10% of the total chronic HD pop- Medium (%) 45.2
ulation in our country. We selected only those centres em- High (%) 9.3
ploying full-time psychologists who are the only qualified Socio-economic level/family unit
Low (%) 45.9
professionals in performing QoL assessment in Romania. High (%) 54.1
Thirty-eight patients were excluded from the study be- Living alone (%) 6.2
cause of concomitant acute illnesses (that may have acutely Hb (g/dL) 10.8 (1.9)
influenced their QoL). Of the remaining patients, 65 did Kt/V 1.4 (0.3)
not complete the QoL questionnaires either because they Diabetes (%) 8.2
Heart failure (%) 5.9
did not understand the questions or because they refused to
answer.

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We analysed the following socio-demographic and clin-
ical factors: (1) age; (2) gender; (3) dialysis vintage; (4) ysis vintage, Kt/V, and Hb). Comparisons were made using
educational level (low level was defined as secondary Student’s t-test for independent variables. All demographic,
school graduate or less; medium level—as high-school socio-economic and clinical variables were included in a
undergraduate or graduate; high level—as college grad- multivariate analysis. A P-value of 0.05 or less was consid-
uate); (5) socio-economic level (i.e. net family income: low ered to indicate statistical significance.
level—was defined as ≤400 euros/month; high level—as
>400 euros/month); (6) living status (i.e. living within fam-
ily versus living alone); (7) serum haemoglobin (Hb); (8) Results
Kt/V; (9) diabetes and (10) heart failure.
Demographic, socio-economic and clinical characteristics
Instruments are shown in Table 1. We found no significant differences
between geographic regions for any of these variables.
QoL was assessed by SF-36 [1], a generic QoL instrument
QoL results are presented in Table 2. A PCS score of
adapted for the Romanian population [6]. SF-36 evalu-
<43 was found in 44.9% of patients, and a MCS score
ates QoL on eight dimensions: physical functioning, social
of <52 was found in 43% of patients, while 35.5% of
functioning, role-functioning emotional, role-functioning
patients had both PCS and MCS below these critical scores.
physical, vitality, pain, mental health and general health
Depression (i.e. MCS < 43 [2]) was found in 27.7% of
perceptions. Two summary scores were calculated: (1) the
patients. The analysis of the ESRD-targeted areas showed
physical component summary score (PCS), as the mean
of physical functioning, role-functioning physical, vitality,
pain and general health perceptions scores and (2) the men-
Table 2. SF-36 and KDQOL scores
tal component summary score (MCS), as the mean of social
functioning, role-functioning emotional, mental health, vi- SF-36 scores (N = 606) Mean (SD)
tality and general health perceptions scores. Scores range
from 0 to 100; the higher the score, the better the QoL. Physical functioning 55.5 (25.1)
A total of 117 patients completed the 11 kidney disease- Role-physical 33.8 (36.3)
specific scales of the Kidney Disease Quality of Life Ques- Pain 51 (26.5)
General health 39.5 (18.8)
tionnaire (KDQOL-SF), also validated in the Romanian Role-emotional 56.1 (35.7)
population [7]: symptoms/problems list, effects of kidney Social function 64.9 (29.1)
disease on daily life, burden of kidney disease, work sta- Vitality 52.5 (31.2)
tus, cognitive function, quality of social interaction, sexual Emotional well-being 62.6 (20.7)
function, sleep, social support, dialysis staff encouragement Physical component summary (PCS) score 46.3 (19.2)
Mental component summary (MCS) score 55.1 (19.3)
and patient satisfaction. Scores range again from 0 to 100; ESRD-targeted areas (N = 117)
the higher the score, the better the QoL. To exclude poten- Symptom/problem list 66.8 (21.1)
tial bias in the assessment of QoL, both instruments were Effects of kidney disease 44.4 (28.1)
self-administered [8]. Burden of kidney disease 60.1 (21.1)
Work status 20.0 (35.3)
Cognitive function 78.8 (18.5)
Data analysis Quality of social interaction 76.3 (18.3)
Sexual function 66.1 (26.5)
Statistical analysis was performed with SPSS 12.0 for Win- Sleep 88.1 (62.0)
dows. Based on other studies, we used in our analysis the Social support 69.9 (23.6)
cut-off scores of 43 for PCS [3], and 51 [3] and 43 [2] Dialysis staff encouragement 79.3 (22.9)
Patient satisfaction 67.7 (25.2)
for MCS. Pearson correlation was used to assess the rela- Kidney Disease Component Summary (KDCS) score 68.3 (11.3)
tionship between QoL and continuous variables (age, dial-
628 A. Seica et al.
Table 3. Comparisons of SF-36 scores by demographic variables

Age P Gender P

<65 years mean (SD) ≥65 years mean (SD) Male mean (SD) Female mean (SD)

Physical functioning 56.8 (24.6) 45.2 (26.3) 0.000 58.3 (24.3) 52.2 (25.7) 0.004
Vitality 53.9 (30.4) 44.5 (30.8) 0.01 55.1 (31.3) 49.5 (30.1) 0.03
Role-physical 35.2 (34.2) 25.0 (23.9) 0.02 32.8 (15.7) 35.1 (36.9) ns
Physical component summary score (PCS) 47.2 (18.8) 39.5 (19.2) 0.001 47.3 (18.5) 45.2 (19.6) ns

Table 4. Comparison of SF-36 scores based on socio-economic and educational levels

Educational level P Socio-economical level P

Low mean (SD) High mean (SD) Low mean (SD) Medium-high mean (SD)

Role-physical 37.2 (37.6) 28.5 (34.5) 0.05 36.5 (37.4) 29.1 (34.7) ns
Vitality 57.0 (36.4) 46.2 (37.7) 0.02 56.7 (34.6) 45.7 (40.7) ns
Role-emotional 59.8 (31.5) 54.9 (28.4) Ns 50.9 (22.8) 61.8 (33.4) 0.005

Downloaded from http://ndt.oxfordjournals.org/ by Gabriela Elena Voicu on March 27, 2012

Physical component summary score (PCS) 48.3 (18.6) 43.5 (16.5) 0.03 45.7 (40.7) 56.7 (34.6) 0.01

that the most affected dimension of QoL in our patients was
work, whereas the best results were observed for cognitive
function and quality of social interaction. Only 42.7% of
patients answered the questions about sexual function.
Differences between SF-36 scale scores by demographic,
socio-economic and clinical factors are illustrated in Tables
3 and 4. Women scored lower in all QoL dimensions, but
significantly so only for physical functioning and vitality
(P = 0.004 and P = 0.03, respectively). Patients aged 65 or
more had poorer QoL scores, but significantly so for PCS
(P = 0.001), social support (P = 0.03) and patient satis-
faction (P = 0.01). Patients’ educational level and socio-
economical status had a significant influence on PCS, but
not on MCS; better PCS scores were associated with lower
educational (P = 0.03) and with higher income levels (P =
0.01). The presence of diabetes was a significant factor for
worse physical functioning (P = 0.05). There were no sig-
nificant differences in QoL scores by geographic regions.
PCS and MCS correlated positively with Hb (P < 0.001
and P < 0.05, respectively) and negatively with age
100
90 HD Age-matched general
80
70 64,4 63,8
60 54,2
46,5
50
40
30
20
10
0 chronic illness [12,13]. The prevalence of depression (MH
PCS M CS
Fig. 1. SF-36 composite summary scores of the study group and the
general population from Romania (Mihaila et al., QoL Newsletter, 2000
[6]).
Table 5. QoL scores in various HD populations
Seica et al. Fukuhara et al. [23] Vasilieva [18]
N 606 2406 1047
Mean age 51.7 59.9 43.5
PCS 46.3 35.5 36.9
MCS 55.1 43.2 44.2
PCS = physical component summary score; MCS = mental component
summary score.
(P < 0.001). In multivariate analysis, PCS was predicted
only by age (R2 = 0.03; P = 0.001; 95% CI = −12.82 to
−3.22), whereas no significant predictors were found for
MCS.
Discussion
Little data is available concerning the QoL of Eastern Eu-
ropean HD patients in general. We used both a generic
(SF-36) and a specific tool (KDQOL-SF) for QoL assess-
ment, as recommended by Rettig et al. [9] and Cagney
et al. [10]. Our study showed that QoL scores of HD patients
in Romania are lower than those in the general population
(Figure 1). About 35% of HD patients in our study have
both PCS and MCS scores lower than the critical scores, as
established by Lowrie et al. [3].
MCS scores were higher than PCS scores in our patients,
similar to other studies in HD patients [11]. The difference
between MCS and PCS was larger (+7.7) than that reported
by Mihaila et al. [7] in a Romanian non-dialysis popula-
tion (−6.6). In other words, despite the worsening of the
physical health status, the mental health of dialysis patients
is relatively preserved. This was previously explained by
dynamic adaptation of patients’ expectations to their
≤ 42) was 21.5%, similar to the findings of DeOreo et al.
[2], which reported a prevalence of depression of 25%.
Among demographic factors, we found older age, female
gender, low socio-economic status and high educational
QoL in Romania
level to be associated with lower QoL scores. Patients <65
years old had significantly higher PCS scores, but similar
MCS scores, compared with those ≥65 [2,14–16]. In multi-
ple regression analysis, age had a significant impact on PCS
(R2 = 0.03; P = 0.001), which is in agreement with other
studies [5,17,18], but not on MCS. However, when looking
at the R2 value, age explains <3% of the variation of QoL.
This means that QoL is influenced by a lot of other unrec-
ognized factors. Therefore, a close psycho-social follow-up
of dialysis patients becomes even more crucial, as they all
should receive personalized attention.
Women had lower QoL scores than men, as already re-
ported by others [19,20]; this may be explained by women’s
multiple domestic tasks and responsibilities that, unlike
men, they cannot circumvent [21].
Similar to other studies [22], we showed a low socio-
economical level to be associated with lower QoL in our HD
patients. In contrast, we found that a lower educational level
was associated with better PCS scores. Possibly, the expla-
nation is that less educated patients rely completely on phys-
ical labour for a living even after starting on dialysis, which
may help them maintain a better physical functioning com-
pared to their more sedentary highly educated counterparts.
Another particular finding in our patients was a lower
burden of kidney disease than that reported by the DOPPS
[4]. This may be due to specific aspects of Romanian policy
of compensation for disability, resulting in a paradoxical
switch from lowly paid and harsh work to a better living
standard for a large number of patients and their families.
A parallel between QoL scores of our population and
those from other studies is presented in Table 5. In compar-
ison with Western European HD patients [23], our subjects
had a similar kidney disease summary composite (KDSC)
score, but better PCS and MCS scores; this is probably be-
cause our population was younger (51.7 versus 59.9 years
old, on average), and had a lower prevalence of diabetes
(8.2% versus 13.8%) and heart failure (5.9% versus 24.1%).
When compared with other Eastern European HD popula-
tions, our patients also did better; for example, Romanians
had higher QoL than Russian patients [18], in spite of older
age (51.7 versus 43.5).
We believe that patients with lowest PCS and MCS scores
might benefit from rehabilitation programmes, in order to
try and reduce their morbidity and mortality risks. We sug-
gest that future studies in Romanian ESRD patients should
focus on the impact of comorbidity burden on QoL, compar-
isons between various renal replacement modalities (HD,
peritoneal dialysis and renal transplantation) and interven-
tions to improve QoL.
Conflict of interest statement. None declared.
References
1. Ware JE, Sherbourne CD. The MOS 36-item short-form health survey
(SF-36). Med Care 1992; 30: 473–483
2. DeOreo PB. Haemodialysis patient-assessed functional health status
predicts continued survival, hospitalization and dialysis-attendance
compliance. Am J Kidney Dis 1997; 30: 204–212
629
3. Lowrie EG, Zhang H, LePain N et al. The association of SF-36 quality
of life scales with patient mortality. CQI Memorandum, Fresenius
Medical Care, 1997
4. Mapes DL, Lopes AA, Satayathum S et al. Health-related quality
of life as a predictor of mortality and hospitalization: the Dialysis
Outcomes and Practice Patterns Study (DOPPS). Kidney Int 2003;
64: 339–349
5. Knight EL, Ofsthun N, Lazarus M et al. The association between
mental health, physical function and haemodialysis mortality. Kidney
Int 2003; 63: 1843–1851
6. Mihaila V, Enachescu D, Badulescu M. General population
norms for Romania using the Short Form 36 Health Survey
(SF-36). QoL Newsletter 26, 2000 (http://www.mapi-research-
inst.com/pdf/art/qol26_12.pdf)
7. Verzan C, Mircescu G, Vaduva N et al. Reliability and validity of the
Romanian version of Kidney Disease Quality of Life Questionnaire
(KDQOL-SF). Nefrologia 2007; 30: A94
8. Unruh M, Yan G, Radeva M et al. HEMO Study Group. Bias in
assessment of health-related quality of life in a hemodialysis popula-
tion: a comparison of self-administered and interviewer-administered
Downloaded from http://ndt.oxfordjournals.org/ by Gabriela Elena Voicu on March 27, 2012
surveys in the HEMO study. J Am Soc Nephrol 2003; 14: 2132–2141
9. Rettig RA, Sadler JH, Meyer KB et al. Assessing health and quality
of life outcomes in dialysis: a report on an Institute of Medicine
workshop. Am J Kidney Dis 1997; 30: 140–155
10. Cagney KA, Wu AW, Fink NE et al. Formal literature review of quality
of life instruments used in end-stage renal disease. Am J Kidney Dis
2000; 36: 327–336
11. Kutner NG. Assessing end-stage renal disease patients’ functioning
and well-being: measurement approaches and implications for clinical
practice. Am J Kidney Dis 1994; 24: 321–333
12. Dolan P. Modelling valuations for health states: the effect of duration.
Health Policy 1996; 38: 189–203
13. Singer MA, Hopman WM, MacKenzie TA. Physical functioning and
mental health in patients with chronic medical conditions. Qual Life
Res 1999; 8: 687–691
14. Mingardi G, Cornalba L, Cortinovis E et al. Health-related quality of
life in dialysis patients. A report from an Italian study using the SF-36
Health Survey. DIA-QOL Group. Nephrol Dial Transplant 1999; 14:
1503–1510
15. Blake C, Codd MB, Cassidy A et al. Physical function, employment
and quality of life in end-stage renal disease. J Nephrol 2000; 13:
142–149
16. Carmichael P, Popoola J, John I et al. Assessment of quality of life in a
single centre dialysis population using the KDQOL-SF questionnaire.
Qual Life Res 2000; 9: 195–205
17. Stojanovic M, Stefanovic V. Assessment of health-related quality
of life in patients treated with hemodialysis in Serbia: influence of
comorbidity, age, and income. Artif Organs 2007; 31: 53–60
18. Vasilieva IA. Quality of life in chronic hemodialysis patients in Russia.
Hemodial Int 2006; 10: 274–278
19. Harris LE, Luft FC, Rudy DW et al. Clinical correlates of functional
status in patients with chronic renal insufficiency. Am J Kidney Dis
1993; 21: 161–166
20. Rebollo P, Ortega F, Baltar JM et al. Health-related quality of life
(HRQOL) in end stage renal disease (ESRD) patients over 65 years.
Geriatr Nephrol Urol 1998; 8: 85–94
21. Turner-Musa J, Leidner D, Simmens S et al. Family structure and
patient survival in an African-American end-stage renal disease pop-
ulation: a preliminary investigation. Soc Sci Med 1999; 48: 1333–1340
22. Blake C, Plant WD. Measures to improve quality of life in end-stage
renal disease patients. In: Brady HD and Wilcox CS (eds). Therapy
in Nephrology and Hypertension. Saunders, Philadelphia, 2003, 747–
751
23. Fukuhara S, Lopes AA, Bragg-Gresham JL et al. Worldwide Dialysis
Outcomes and Practice Patterns Study.Health-related quality of life
among dialysis patients on three continents: the Dialysis Outcomes
and Practice Patterns Study. Kidney Int 2003; 64: 1903–1910
Received for publication: 12.6.08
Accepted in revised form: 18.8.08