Dyadic Relationship and Quality of Life Patients with Chronic Kidney Disease

Introduction: Chronic Renal insufficiency (CRI) and dialysis treatment lead to a succession of situations for kidney chronic patient, which compromises his aspect, not only physically, and psychologically, with personal, family and social repercussions. Objective: (1) to verify the existence of differences of dyadic adjustment (DA) according to renal replacement treatment (RRT) and (2) verify the existence of differences quality of life (QOL) in accordance with the RRT. Methods: This is a cross-sectional study of a descriptive nature through surveys, exploratory and correlational. The sample consisted of 125 participants. Of these, 31 were to be made RRT by automated peritoneal dialysis (APD) and 94 hemodialysis (HD). Participants were selected from three renal centers: (1) Centro Renal da Prelada (Porto, Portugal), (2) Centrodial (S. João da Madeira, Portugal) and Centro Renal da Misericórdia de Paredes (Paredes, Portugal). The study was carried out for 6 months. The following instruments were applied: Socio-demographic and clinical questionnaire (SDCQ), Dyadic Adjustment Scale (DAS), World Health Organization Quality of Life (WHOQOL-Bref). Results: The results demonstrate the existence of statistically significant differences between the type of RRT and most areas of QOL, as well as the existence of statistically significant differences between the subscales of the DAS evaluated and the type of RRT. Conclusion: The present study demonstrates a greater commitment in terms of QOL of individuals undergoing treatment for HD when compared with those subjected to APD. It turns out, also, that DA is most strongly perceived by patients in APD than with HD. absTRacT


Resumo
Palavras-chave: ajustamento social; qualidade de vida; terapia de substituição renal.DOI: 10.5935/0101-2800.20150051inTRoducTion Chronic kidney disease (CKD) and dialysis treatment lead to a succession of situations for chronic kidney patient, which compromises his aspect, not only physically, and psychologically, with personal, family and social repercussions.For Riella, 1 chronic renal patient experiences a sudden change in life, live with limitations, with the painful treatment that is hemodialysis, spend time thinking about death, but coexists with the possibility to undergo a kidney transplant and the expectation of improving their quality of life.Consequently, Lima & Gualda 2 report that chronic renal patients end up getting discouraged, desperate and often, for these reasons or for lack of guidance, eventually abandoning the treatment or do not give importance to the constant care that should have.It is therefore necessary to stimulate their abilities to adapt positively to new lifestyle and take control of their treatment.
All aspects of life are affected by kidney disease and its treatment, and the effects extend to all people who have a closer involvement with the patient. 3A better understanding of the anxieties and concerns of patients on a daily basis allows professionals who work in Nephrology units responding with appropriate support. 4It has to start as early as possible to avoid problems, both practical and material (for example related with employment or financial situation) or emotionally (as is the case of the problems in personal relations and unnecessary fears prognosis and treatment). 3o, faced with a crisis or illness, the subject tends to make use of all its resources available, struggling to promote his self-balance, which was supposed to possess and how he feels being threatened.Therefore, it seems more or less clear that the social network of support is one of the important variables that can intervene in a beneficial or malevolent way in a crisis or illness. 5It is therefore very important to assess the level of marital relationship and dyadic adjustment (DA) perceived by patients with CRI, providing relevant information for the knowledge of variations in terms of psychological well-being related to health and disease, and also with the quality of life from variables such as depression, self-esteem preserved and acceptance of renal substitutive treatment.Given this, it seems clear that the supportive family and friends acts as a lever for the maintenance of the balance of the patient, taking into account changes of individual habits and the continued promotion of behaviors that improve overall health, involving people who also give assistance to the patient. 6ne can consider, that social support (SS) is the result of positive or negative action of the relationships perceived by individuals, which meets definitions of Sarason et al. 7 Roughly speaking, it seems apparent that the in SS, the dyadic adjustment may function as precursor of a better adaptability of individuals suffering from CRI, likely to increase optimism and positivity, as well as the quality of life of these same individuals have strong relationship between everyone, since the renal treatment strongly influence the physical and mental level. 8s noted earlier, it seems appropriate to systemize the psychosocial implications inherent in this health problem, since people who face CRI suffer a devastating impact on the social and psychological state, either as a direct consequence of the effects of the disease and treatments, and either indirectly by the implications of these same effects on personal performance.Recently, the attention of health professionals began to turn to a therapy aimed at improving chronic renal patient QOL as a relevant factor in the setting of renal therapy, and not only the extension of his life.
In relation to chronic renal patient to achieve a better QOL, this goal is always present in your everyday life, and its indicator of QOL or wellbeing is extremely different from an individual considered healthy, because their health goals focus on achieving a level of life/health compatible with a life with dignity and independence. 9It is obvious that in recent decades, due to the onset of renal replacement treatment (RRT) and adjuvant therapy, 9 there have been technological advances and considerable therapeutic allowing a better well-being of these patients, particularly in racing to his longevity and permanence of some of its capabilities (even if it is not possible to enjoy a full quality).
The problem of CKD and its influence on QOL of individuals can be better understood if Complete with brief patho-physiological considerations of CKD framework, therefore, reach a certain level of health and QOL depends a lot of uncertainties and fears about the future; family concerns; sleep disturbance; occupational limitations due to dialysis; lack of vitality; too much time spent on treatments; dietary restrictions; medicated schemes; technical problems with equipment; and fear of complications during dialysis.[12]

meThod
In the present study, there will be an analysis of the relationship between the DA and the QOL of people with CKD.It is thus a transversal study of descriptive nature, exploratory and correlational with the sense of contributing to a greater understanding of the importance of the DA in the QOL of people with CKD and the alleged predictive values of DA.
The objective of this study are to (1) verify the existence of differences of dyadic adjustment (DA) according to renal replacement treatment (RRT) and ( 2) verify the existence of differences quality of life (QOL) in accordance with the RRT.matErial Social-demographic and clinical questionnaire: For collection and evaluation of socio-demographic and clinical data was constructed a questionnaire taking into account the preferential items of this investigation.In order to characterize the sample, we proceeded to the elaboration of a social-demographic and clinical questionnaire (SDCQ).It consists of 24 items: 3 items are of a general nature, 8 items are socio-demographic in nature, 11 items are clinical in nature and last items 2 that allow the interviewee to talk about the study and on the SDCQ.
Dyadic Adjustment Scale: to evaluate the DA appealed to the Dyadic Adjustment Scale (DAS) Spanier. 13,14This scale pioneered by integrating all cohabiting couples, whether married or not.The DAS is composed of 32 items, which seek to assess marital adjustment, using Likert-type scales: scales are used five, six and seven points.Generally speaking, the extreme points of the scales mean «never» and «all time», respectively.The items 29 and 30 have only two options, "yes" or "no".So, to increase the reliability of the scale, some items are positive affirmations and other are negative remarks.The total scale can vary from 0 to 151 and is obtained by summing the values obtained in the four scales.Individuals who obtain 101 points or less must be classified as in the experience of a relationship of suffering or misfit and people who reach 102 points or more would be experiencing a relationship without suffering or well adjusted.][17] Quality of life questionnaire: quality of life was evaluated through the Whoqol-Bref (Whoqol-Group, 1998). 18  (16, 17, 18, 19, 20, 21, 22 and  23).The abridged version such as the Whoqol-100 (long version) presents a Lickert scale type response, in which the total values oscillate between 0 and 100, with higher values of QOL synonyms. 19,20ocEdurE The investigation began with the request and subsequent authorization for the use of instruments used.Then it was settled a protocol establishing the principles and procedures inherent in the present investigation; the research project was initiated with the (a) presentation to the Clinical centers, to be granted authorization to start the study; (b) the investigation followed the fundamental principles such as the right to dignity, security and well-being of the respondent, as well as the respect for him; (c) in addition, the participants were informed about the purpose and procedures of investigation involving, if they so wish, in the absence of any pressure or coercion on its participation; (d) the interview is confidential and the participant does not had the obligation to respond, and could end the same when find timely; (e) all questionnaires were filled in by the investigator due to postural difficulties of the participants throughout the treatment for renal dialysis substitutionary technique.Therefore, we decided to do the same for the participants, who have renal substitutive treatment for automated peritoneal dialysis, thus giving a certain consistency to this research; (f) when a subject did not understand some of the issues raised by the investigator, it was given the right to explain as many times as necessary until the complete understanding and reasoning; (g) for the optimization of best results in the responses given by participants, account has been taken of the physical and mental suffering throughout the interview, being that, in some situations we decided to evaluate the same subject for two days; (h) all participants have been selected in accordance with the consent of the same in collaborating, as well as according to their physical and mental capabilities.The collection of data, in present study, was carried out between September 2008 and May 2009.Data were related with the last six months and the interviews were conducted in the last month of investigation.
Patients undergoing treatment for HD were interviewed during the renal substitutive treatment and patients undergoing treatment for APD were interviewed after a pre schedulling of time and place.Furthermore, all patients had to answer questions from SDCQ, DAS, Whoqol-Bref and HADS.The interview took, on average, 40 minutes (23-79 minutes) (41 minutes for individuals in RRT for HD and 36 minutes for individuals in RRT by DPA), being that, given the specificity and duration of treatment of patients in HD, the interviews tended to be longer given that, sometimes, the rhythm of the same would have to be slowed down depending on the patient's conditions and generally, corresponded to cases in which individuals asked for help to clarify some issues about their problems.
To assure that responses were feasible, the investigator was always the same throughout the interview and the fact that it is completed by the investigator himself may possibly have diminished some limitations inherent in the fills of the questionnaires, such as: (I) the retrospective bias (tendency to minimize or exaggerate the symptomatic subject perception at the time of inventory administration); (II) the social desirability bias (tendency to respond to the inventory according to what's socially correct and expected); (III) the random responses bias (when the responder is not motivated or when it is not able to respond.In this case, the subject select the reply in an almost randomized way, without any criteria).We also shall state that the fact that the investigator administer and quote the instruments items, can possibly have diminished the impact of issues related to fidelity.

ResulTs samplE
The sample consists of 125 participants with CKD.Of these, 31 were using RRT by CAPD and 94 are effecting RRT for HD.participants were selected from three kidney centers: (1) Renal Center of Prelada (Porto); (2) Centrodial (São João da Madeira); and (3) Kidney Center of Misericórdia da Paredes (Paredes).The study took place during six months (24 weeks).It should be noted at the outset that the sample is not probabilistic, being the type of sampling by rational selection.
All participants obeyed the following inclusion criteria: 1. Have CKD diagnosis; 2. Have more than 18 years of age; 3. Live in cohabitation in whole or in part; 4. Have full knowledge and be well informed about your diagnosis; 5. Do not present a disturbance state of consciousness; 6. Do not submit most significant disease than CKD, except those resulting from the CKD itself; 7. Have given consent to participate in the study (informed consent).
A total of 125 individuals were evaluated, who fulfilled the inclusion criteria of the study.Sociodemographic characteristics of 125 individuals are expressed in Table 1.It turns out that there is a balanced distribution between the two sexes in the sample studied, and there is a huge variability in terms of age and schooling.
The vast majority is in a situation of no activity, i.e. can be retired (in advance or not) or unemployed.It should be noted, also, that the majority of the sample resides or carries out treatments in the Porto district.
An analysis to the clinical variables we can mention that 75 of the patients interviewed have a pathology, diabetes mellitus, in co-morbidity, representing 60% sample.Note, also, that diseases which may have caused the CKD most representative in this population were arterial hypertension in 40 patients and diabetes mellitus in 35 patients.Reading the table indicates that 94 of the individuals participating in the study are on Hemodialysis and 31 individuals in APD.Of the total of 125 individuals that make up the sample more than half (52.8%) presents the clinical parameters changed (Table 2).

diffErEncEs bEtwEEn qol and thE rrt typE
There was no missing data in the Whoqol-Bref.In Table 3 are expressed the mean values, standard deviations, as well as the significance value obtained from the differences between the subjects on Automated Peritoneal Dialysis and Hemodialysis.It should be noted, that the scales of the Whoqol-Bref are coded so that higher values correspond to better QOL.There are statistically significant differences in the various Domains of the Whoqol-Bref, being that the subjects who underwent treatment by APD always obtain higher values than the subjects who underwent treatment for HD.
Differences between the perceived dyadic adjustment and dialysis modality that patient with CKD are submitted.
The results show an analysis of dichotomized DA an important relationship between the DA and the kind of RRT (Table 4).Therefore, the results allow us to highlight the dependence of both variables, being that one is always predictive of another.In this  sense, and so that we can have more concrete results we decided to analyze the subscales of the DAS (not dichotomized) in relation to the type of RRT, and the results achieved through the t Student test suggests the existence of statistically significant differences, revealing the existence of a relationship between the variables evaluated (Table 5).

discussion
2][23][24] The variability in terms of education reflects well the heterogeneity of users of Kidney Centers.However, the average schooling of the sample seems to mirror some of the usual difficulties that users of the Renal Centers have in filling of self-report instruments, by which, we opted for assisted administration of instruments used in this study.The present study demonstrates a greater commitment in terms of QOL of individuals undergoing treatment for HD when compared with those subjected to APD.2][23] Therefore, there is a greater commitment in the fields of QOL 23 with significant losses in terms of physical dimensions and is also patent the commitment of some physical, social and emotional aspects.5][26] All the CKD experience may suffer major changes, especially in the patient in HD, since changes are present in everyday bodily activities as well as recreational. 27t turns out, also, that DA is most strongly perceived by patients in APD than with HD, once that the treatment could be not as negative for the subsystem of the couple adopting an affective protection and where the healthy spouse offers support and help and increase self-confidence and the ability to implement adjusted behavior.Consequently, and in accordance with the present study, a smaller dyadic adjustment, present in HD patients, may be synonymous of less protection factor against stress and vulnerability that these individuals are exposed.It also noted the existence of severe loss, and this is usually huge and lasting for the patient with kidney disease in HD, renal function, sense of well-being, of its role both in the family and at work, loss of time, financial resources, sources of sexual function, among others 24 with highly painful reflections on dyadic relationship of these patients.Given the changes highlighted, there is in many cases a desperate resignation that influences negatively in overcoming traumatic situation.
This research is limited, because the results obtained should not be regarded as representative of the Portuguese population with CKD, since the process of selection of the participants for the study was restricted to only three kidney centers, which may have caused a bias in the results obtained. 28nother limitation concerns the transverse nature of study what inhibits from making any statement with respect to directionality and causality.It would be essential to draw longitudinal character studies, which make it possible to infer causality relationships between the variables studied.Thus, it will be important to follow individuals with CRI and evaluate them for a certain period of time.Therefore, we will try to obtain a temporal relationship between the factors of exposure and the characteristic being studied.

conclusion
It is concluded with the present study, that (1) the type of RRT affects the perception of QOL of individuals with CKD; (2) a better understanding of DA implies a better understanding of QOL, and (3) better understanding of DA in CKD subjected to RRT by APD.

Table 2
dEscription of thE samplE in clinical tErms

Table 4
rElationship bEtwEEn da (dichotomizEd) and rrt typE

Table 3
valuEs obtainEd in thE whoqol-brEf instrumEnt according to thE rrt typE * significance; a p <. 01; ** significance a p <. 05.

Table 5
valuEs obtainEd in thE das instrumEnt according to thE rrt typE DAS Cons.: Consensus Dyadic adjustment scale; DAS Sat.: Dyadic adjustment scale Satisfaction; DAS Cohes.: Cohesion, Dyadic adjustment scale; DAS Exp.: Dyadic adjustment scale Expression of affection; DAS Tot.: Total Dyadic adjustment scale; * significance a p < .01;** significance a p < 0.05.