Quality of life of chronic kidney patients on hemodialysis and related factors

Objective: to verify the association between the health-related quality of life of chronic renal patients on hemodialysis with sociodemographic, clinical, depression and medication adherence characteristics. Method: a cross-sectional study with 183 chronic renal patients undergoing hemodialysis in the state of Rio Grande do Sul, Brazil. A sociodemographic and clinical questionnaire, Kidney Disease and Quality of Life Short-Form, Beck Depression Inventory and Morisky Medication Adherence Scale - eight items were used. Among the variables, comorbidities, complications of kidney disease and intercurrences during and after hemodialysis were evaluated. The analysis was performed with descriptive and analytical statistics. Results: 55.2% of the patients were 60 years old or older, 35.0% were hypertensive, with regular quality of life, average of 62.61. Scores below average in the dimensions of quality of life were mainly associated with repetitive infections and edema as complications of the disease, pain during hemodialysis and weakness afterwards. Low drug adherence resulted in a worse quality of life, impacting ten of the 20 dimensions evaluated and depression in all, except for patient satisfaction. Conclusion: reduced quality of life in this population is associated with depressive symptoms, complications such as repetitive infections, pain and anemia, weakness after the dialysis session and low medication adherence. Actions aimed at changing these factors can promote well-being.


Introduction
The number of deaths caused by Chronic Kidney Disease (CKD) is increasing worldwide and, in 2017, 1,230.2 million people died (1) . In Brazil, in the same year, the number of deaths of patients on dialysis was estimated at 25,187 deaths, which represented a gross mortality rate of 19.9%. In the country, to ensure survival and treatment of patients, the number of active dialysis centers has increased and, among the modalities of renal replacement therapies offered, hemodialysis is predominant. In 2017, 93.1% of the patients were on this therapy (2) . CKD is characterized by decreased renal function, explained by a glomerular filtration rate of less than 60 ml/min/1.73 m² and/or markers of renal damage lasting three months or more (3) . Progressively, it becomes a metabolic and endocrine problem that triggers inflammation and compromises immune capacity.
Patients affected by this disease have low socioeconomic conditions, a high risk of morbidity, mortality and lower Health-Related Quality of Life -HRQoL (3)(4)(5) .
HRQoL is the subject's perception in relation to his position in life, cultural environment and values in which he is inserted, objectives, expectations, standards and concerns. It is related to physical health, mental state, independence, social relationships, beliefs and peculiarities of the environment (6) . So, it comprises effects of the disease and/or treatment in the diverse life dimensions.
Psychosocial and biological changes related to dialysis treatment increase the risk of developing depression in patients with CKD. It is estimated that this population has rates of this disorder being three to four times higher than the general population and two to three times higher than in individuals with other chronic diseases. Depression also increases the risk of progression of kidney disease, worse clinical outcomes and mortality (7) .
Although the relationship between depression and HRQoL in CKD is well established (8)(9) , it can be deepened with respect to the commitment of each domain that integrates it. Studies with chronic renal patients undergoing hemodialysis have also shown an association between quality of life, sociodemographic characteristics (10)(11)(12) and comorbidities (13) . Regarding the relationship with complications of kidney disease, few studies have attempted to identify it (14) or assess association with specific complications, such as pain (15) and anemia (16) .
With regard to intercurrences during hemodialysis, investigations show, however, that they do not stop to explore their connection with HRQoL (17)(18) . No specific studies on intercurrences were found after the end of the hemodialysis session and few were identified with general approaches on the symptoms (19)(20) . Regarding adherence to drug therapy, there are few publications on the subject in this population that analyze the relationship with quality of life (21) .  (23) . Each item is scored from zero to three: less than ten means no depression; ten to 18, indicative of mild depression; 19 to 29, moderate; 30 to 63, severe depression.
The Morisky Medication Adherence Scale -eight items was validated and adapted to Brazil and assesses the patient's behavior regarding the usual drug use.
It consists of seven questions with closed answers of a dichotomous yes/no character and the last question answered based on the options "never", "almost never", "sometimes", "often" and "always". Low adherence is considered to be those who answer affirmatively to more items from the test (24) .
The application of data collection instruments during the hemodialysis, although extensive, was not perceived by patients as uncomfortable, as the interview, as a form of interpersonal relationship, favored the perception that time in the dialysis unit passed more quickly. Absolute and relative frequencies were also used.
Joint frequency distributions were also performed and two study variables were simultaneously observed in order to identify a relationship between them using the chi-square test. A significance level of 0.05 was considered.  Table 1.
Rev. Latino-Am. Enfermagem 2020;28:e3327.         (25) . These data reveal that the well-being of patients on hemodialysis is compromised due to the physical, psycho-emotional state and the difficulties in maintaining a job and that support is an important tool to face this condition.
Regarding the indications of depression, more than half of the patients had symptoms, which is in line with the results of a study in India (26) . Depressive disorders in this population can be related to the worst clinical outcomes, comorbidities, complications of the disease and treatment, hospitalizations, increased length of hospital stay, abandonment of dialysis, mortality and reduced quality of life (9,27) .

In this investigation, indications of depression
were associated with reduced scores in all dimensions of HRQoL, except patient's satisfaction. A study in Egypt showed a similar result, except for the domain Limitations due to physical problems (28) . Despite the link between depression and unfavorable outcomes, a minority of the patients is adequately diagnosed and this situation may be due to the overlap of symptoms associated with uremia (7) . are considered negative predictors of the physical and mental components (14) .
Infections increase the risk of hospitalization and are common in renal patients. A study in the United States found a crude infection incidence rate of 23.6 per thousand person/year, a higher number associated with lower glomerular filtration rates or a high urinary albumin/creatinine ratio, also related to the increased risk of mortality (29) . Both hospitalizations and infections decrease HRQoL and their management can be done with health-promoting, preventive and curative interventions.
As for edema, research in the United Kingdom has shown an association between chronic edema and quality of life, which is particularly reduced in terms of physical and emotional capacity and health in general (30) . It is considered that educational activities that favor self-care can positively impact the reduction of edema and improve HRQoL.
Pain is a common symptom among hemodialysis patients. In this research, a higher frequency of headache type was evidenced. In this sense, research in Western Pennsylvania found a painful sensation in 79% of patients, inversely linked to the Physical, mental components and global quality of life score (15) .
During the dialysis session, the submitted data show Among the results, anemia also appeared as a common complication of CKD Iranian research found prevalence of anemia in 28.3% of the patients, 3% with hemoglobin levels below 8 g/dl (32) . Multicentric research, in Brazil, France, Japan and Germany, showed a worsening in the quality of life according to the severity of the anemia and indicated an association of this complication with the progression of kidney disease and mortality (16) . Data suggest that the adequate treatment of anemia, together with interventions that improve gastrointestinal symptoms and encourage compliance with the diet, and the provision of nursing care to prevent blood loss in hemodialysis may decrease the risk of this complication and its consequences.
Cramps, both as a complication of CKD and as a complication during hemodialysis, were reported as frequent by patients, with involvement of the lower limbs, hands and abdomen hypovolemia, hypomagnesemia, carnitine deficiency and elevated serum leptin levels appear to be involved in the event (17) .
In this sense, research in Greece demonstrated an association between cramps and limitations due to physical problems, pain, general health and interpersonal relationships (31) . It is considered that the proper identification and management of this complication is a patient's right and must integrate nursing care.
During the dialysis session, another prevalent complication was hypotension. Research in the Netherlands found a link between hypotension, increased cardiovascular morbidity and mortality and presence in more than half of dialysis sessions. The authors also revealed that patients with hypotension had lower pre-dialysis heart rates, low body weight and no residual renal function (18) .
After dialysis, the weakness was associated with the greater number of dimensions of HRQoL and may be linked to the waste of protein energy and low physical activity (33) . A study in England and Ireland evaluated the presence of symptoms and identified that just 3% of the patients did not have symptoms.
There was a predominance of weakness in 78.0% of the patients, difficulty in movement in 66.0% and pain in 64%, all independently associated with a worse quality of life (19) . It is assessed that the weakness interferes with the recovery time after dialysis, the return to daily activities and, in this context, the Rev. Latino-Am. Enfermagem 2020;28:e3327.
his condition and the importance of adherence to treatment (35) . It is inferred that not using the medication properly increases the perception of the symptoms of the disease and the occurrence of damage to physical, psycho-emotional and social well-being.
As for the presence of comorbidities, a higher percentage of patients with arterial hypertension and diabetes was identified, concomitantly or with only one.
The first was related to lower scores in the dimensions Work status and Pain; the second was associated with Vitality, Health in general, Functional capacity, Sexual function and Physical component. These diseases are considered the main causes of CKD (3) and, regarding HRQoL, both negatively affect it (13) . It appears that having one or more diseases simultaneously increases the burden of physical, psycho-emotional symptoms and necessary care, which results in greater limitations, with a consequent worsening in the quality of life and evolution of the disease.
In the investigated patients, the sociodemographic profile is similar to that of research in São Paulo, except for age (36) . Regarding the association between HRQoL and sociodemographic characteristics, the age of less than 60 years had a lower score in the aspects Limitations A Brazilian study also showed less satisfaction in sexual function in individuals with a fixed partner (37) in disagreement with another investigation, also Brazilian, which showed the partner as a synonym for greater social support (38) (12) . Thus, it is understood that individuals with low education have little access to information and the ability to properly understand traumatic events, which can translate into greater concern, anxiety, insomnia and decrease their energy for other activities.
Income from retirement in CKD patients was linked to reduced quality of sleep and social interaction. On the other hand, research in Nepal showed that higher income was related to high scores in the Psychological, Environmental and Health domains in general (39) . It is suggested that people with less financial resources experience difficulties in coping with the costs of the disease, limiting their spending, including on leisure, which can interfere with sleep patterns and social interaction.
Assessing the HRQoL in patients with CKD undergoing hemodialysis is a complex task in view of the multiple factors involved in its perception and the difficulty to fully address it. However, the assessment of HRQoL favors the identification of the subjects' needs for planning aimed at coping with the disease.
In this sense, Nursing as a profession that requires direct contact with the patient must be able to identify factors that affect the quality of life of these patients, as well as to develop activities capable of reducing symptoms, improving physical and mental capacity, promoting self-care, that assist patients in adapting and coping with problems.
The results presented and discussed in this especially from Nursing, at the same time that they can become the focus of attention and care in order to promote health and well-being.
As a limitation of this research one highlights the methodology of the cross-sectional study, which allows only a specific perception of the patient's conditions, although it is useful to identify needs and encourage the implementation of improvement interventions.

Conclusion
The