Determining Quality of Life and Sleep in

Hemodialysis Patients
Havva Tel, MD
The author is with Erciyes University, Ataturk School for Health Sciences, Kayseri, Turkey.

BACKGROUND: Hemodialysis causes major changes in patients lifestyles that affect their quality of life (QoL) and
sleep quality. The purpose of this study was to determine the quality of life and sleep of hemodialysis patients.
METHODS AND MATERIALS: The study sample was 138 patients receiving dialysis in a university hospital dialysis
unit. Data were collected with a personal information form (PIF), Medical Outcomes Study 36-item Short Form (SF36) questionnaire, and the Pittsburg Sleep Quality Index (PSQI).
RESULTS: All of the hemodialysis patients had low quality of life. There was a significant correlation between QoL
and sleep quality (p < .001); as QoL decreased sleep quality also decreased. As patients age increased their QoL
and sleep decreased. Women, housewives, those with no formal education, and patients living in extended families
had lower QoL. Patients aged 51 years and older had low QoL and sleep. No significant difference was found in
QoL and sleep according to the patients duration of hemodialysis (p > .05).
CONCLUSION: Hemodialysis patients have a low QoL and there is a close correlation between QoL and sleep quality. Interventions to help dialysis patients maintain their QoL and sleep are as important as extending their lives.

ince dialysis and kidney transplantation began to be used for

treatment of end-stage renal
disease (ESRD) the numbers
of patients with ESRD has continued
to climb. By 2001, more than 1 million patients worldwide were reported to
receive dialysis treatment alone, with the
numbers growing at an annual global average rate of 7%.1,2 The incidence and prevalence of ESRD is increasing in Turkey,
as it has throughout the world. According
to Turkish Health Ministry statistics from
2006, there were 39,026 patients receiving hemodialysis in Turkey.3 The majority of these patients need conventional
hemodialysis 3 times a week to remain
alive. Distressing complications such as
cramping, vomiting, and hypotension frequently occur during cumbersome and
time-consuming hemodialysis. Fatigue,
lethargy, disability, loss of appetite, and
even major depression may decrease the
patients well-being.4-8

Although there have been improvements in ESRD treatment, patients continue to have significant problems with their
health-related quality of life (HRQoL). The
clinical manifestations of the disease itself
and the adverse effects of its treatment
have a negative effect on ESRD patients
HRQoL. Some studies have shown that
hemodialysis patients receive significantly
lower scores on QoL than the general population.8,9 Dialysis patients often have a feeling of uncertainty about the future and this
concern and lack of energy can also have a
significant effect on decreasing the QoL.10
Sleep complaints in the general population
also have a negative impact on HRQoL.11
Sleep complaints are also very common
in hemodialysis patients.12 It has been
reported that more than 85% of hemodialysis patients have sleep problems serious
enough to affect their QoL.13-15 This study
was conducted for the purpose of determining the relationship between QoL and quality of sleep in hemodialysis patients.

Methods and Materials

This study was conducted with 138 patients
who were undergoing hemodialysis in a
university hospitals hemodialysis unit.
Permission to conduct the study was
received from the hospital administration.
After patients were given information about
the study their verbal consent to participate
was received. Adult patients (20 years and
older) who had no formal education, were
being dialyzed 3 days a week, who had
no communication problems or emotional
problems, and who agreed to participate in
the study were included.

Measurement
Data were collected with a Personal
Information Form (PIF), the Pittsburgh
Sleep Quality Index (PSQI), and the Medical
Outcomes Study 36-item Short Form (SF-36)
questionnaire. The PIF was developed by
the researchers and included questions about
June 2009 Dialysis & Transplantation 1

Characteristics

Gender
Female
Male
Age
2035 years
3650 years
51 years and older
Marital status
Single
Married

n (%)

71 (51.4)
67 (48.6)
24 (17.4)
39 (28.3)
75 (54.3)
24 (18.1)
113 (81.9)

Education
No formal education
Primary school
High school

50 (36.2)
61 (44.2)
27 (19.6)

Occupation
Housewife
Civil servant
Retired

71 (51.4)
17 (12.3)
50 (36.2)

Family type
Nuclear
Extended

102 (73.9)
36 (26.1)

Hemodialysis duration
Less than 1 year
12 years
3 years or more

29 (21.0)
35 (25.4)
74 (53.6)

the patients age, gender, marital status, educational level, occupation, family type, and
duration of hemodialysis treatment.
Sleep quality was measured with the
PSQI. This instrument was developed in
1989 by Buysse and colleagues. It is a
self-report survey that measures quality of
sleep.16 The validity and reliability study
for the Turkish version of the instrument
was conducted in 1996 by Agargn. The
total score for PSQI can be between 0 and
21 points. A high PSQI total score indicates
poor sleep quality. A total score over 5 indicates that the quality of sleep is poor.16,17
Health-related quality of life was evaluated using the Medical Outcomes Study
36-item Short Form (SF-36) questionnaire.
This instrument has been used extensively
in populations of patients with renal disease.18 The validity and reliability study for
the Turkish version of the instrument was
conducted in 1995 by Pinar.19 The SF-36 is
a 36-item self-administered questionnaire
that yields scores for 8 domains of HRQoL
2 Dialysis & Transplantation June 2009

(physical functioning, role limitationsphysical, bodily pain, general health perceptions, vitality, social functioning, role
limitations-emotional, and mental health)
as well as a summary, a physical component summary score (PCS), and mental
component summary score (MCS). The
SF-36 is divided into 2 domains: PCS and
MCS. The PCS and MCS scores are standardized to a mean (SD) of 50, with scores
above and below 50 indicating above and
below average functioning, respectively.
Global SF, PCS and MCS scores can all
vary between 0 and 100. A high score indicates a better QoL.18-20
The Statistical Package for the Social
Sciences (SPSS) version 15.0 was used for
data analysis in the study. Pearson correlation analysis was used to determine relationships between QoL and sleep quality,
QoL and age, QoL and duration of hemodialysis, sleep quality and age, and sleep
quality and duration of hemodialysis. The
t test and analysis of variance were used

in the evaluation of QoL and sleep quality

according to sociodemographic characteristics.

Results
A total of 138 patients were included in
this study. Their age range was 20 to 70
years with a mean age of 50.51
14.23
years. The patients PSQI scores were 221
(mean 13.28
7.33). Their global SF-36
scores were 3659 (mean 47.05
6.36)
PCS scores were 4062 (mean 47.73

5.95), and MCS scores were 3159 (mean
45.78
8.50).
The patients personal characteristics
are shown in Table I. The majority of
patients were female (51.4%), 51 years or
older (54.3%), married (81.9%), housewives (51.4%), had a primary school education (44.2%), lived in nuclear families
(73.9%), and had been on hemodialysis for
3 or more years (53.6%).
The patients QoL and sleep quality
scores according to their personal characteristics are shown in Table II. No significant differences were found between
QoL scores according to patients gender, education, occupation, or family type
(p < .05). Patients who were female, had
no formal education, were housewives, and
lived in extended families had lower global
SF scores. There were significant differences determined in QoL and sleep quality scores according to patients age (p <
.05); patients in the 51 and older age group
had lower QoL and poor sleep quality. No
significant relationship was found between
duration of hemodialysis and QoL or sleep
quality (p > .05).
The relationships between patients
age, QoL, and sleep quality are shown in
Table III. There was a negative relationship
determined between patients age and PCS
(r  0.318, p  .000) and global SF-36
(r  0.227, p  .008); as age increased
PCS and global SF-36 decreased. There
was also a significant relationship between
patients age and PSQI (r  0.186,
p  .029); as age increased, the PSQI
increased and sleep quality worsened. The
positive relationship between patients
sleep quality and PCS scores (r  0.396,
p  .000), and negative relationships
between MCS (r  0.559; p  .000) and
global SF-36 (r  0.568; p  .000)

TABLE I. Patients personal characteristics (n  138).

Quality of Life and Sleep Quality

TABLE II. Patients quality of life and sleep quality scores according to personal characteristics (n 138).
Global SF-36

Global PSQI

Mean SD

Mean SD

44.53
9.03
47.11
7.74
t  1.798
p  .074

45.94
6.40
48.23
6.14
t  2.145
p  .034

14.30
7.23
12.21
7.33
t  1.683
p  .095

51.16
7.13
48.61
5.57
46.18
5.22
F  7.606
p  .001

47.54
5.50
47.23
8.16
44.48
9.30
F  1.986
p  .141

49.50
5.70
48.23
5.49
45.66
6.68
F  4.432
p  .014

12.00
7.42
10.95
7.99
14.91
6.59
F  4.392
p  .014

45.62
5.33
49.32
5.34
48.07
7.26
F  5.745
p  .004

45.26
8.78
46.85
8.21
44.37
8.63
F  .948
p  .390

45.60
6.05
48.47
5.98
46.55
7.25
F  2.993
p  .053

14.64
7.32
12.90
7.10
11.63
7.68
F  1.641
p  .198

Occupation
Housewife
Civil servant
Retired

46.38
5.59
49.52
6.26
49.06
6.01
F  4.011
p  .020

44.30
8.93
48.82
5.95
46.86
8.31
F  2.612
p  .077

45.74
6.53
49.29
4.72
48.16
6.27
F  3.423
p  .035

14.62
7.14
11.88
6.83
11.86
7.52
F  2.486
p  .087

Family type
Nuclear
Extended

48.37
5.90
45.94
5.81
t  2.129
p  .035

46.50
8.36
43.77
8.68
t  1.662
p  .099

47.76
6.34
45.05
6.07
t  2.227
p  .028

12.65
7.20
15.08
7.48
t  1.727
p  .086

Hemodialysis duration
Less than 1 year
12 years
3 years

47.24
5.92
47.40
6.08
48.09
5.97
F  .287
p  .751

47.17
8.48
46.82
7.96
44.75
8.73
F  1.193
p  .306

47.41
6.48
47.48
6.25
46.71
6.43
F  .228
p  .796

12.03
7.87
12.94
7.54
13.93
7.03
F  .746
p  .476

Age group
2035 years
3650 years
51 years

Education
No formal education
Primary school
High school

Mental Component
Score

Mean SD

Mean SD

46.69
5.67
48.85
6.08
t  2.157
p  .033

show that as sleep quality worsened, QoL

decreased.

Discussion
The perception of QoL by patients with
end-stage renal disease is an important
measure of patient outcome. Patients on
hemodialysis have a significant level of
disturbance in their QoL.5,21,22 In this study
the QoL scores for hemodialysis patients
were determined to be low. This finding
is consistent with findings from previous
research.20-23

The female patients in this study were

found to have low PCS and global SF QoL
scores. Differences are seen between genders
for QoL results in hemodialysis patients. In
the study by Niechzial et al gender was
found to have an effect on hemodialysis
patients QoL24; in Harris et al, physical
QoL was higher in male patients.25 However,
in Acaray and Pinar there was no difference
found in QoL according to gender,20 and
Suet-Ching determined that female patients
QoL was worse than male patients.26 The
results of this study are consistent with those
of the study by Suet-Ching.

In this study as patients age increased

their PCS, global SF quality, and sleep quality decreased. Patients who were 51 years or
older had worse QoL than the other age group
patients (Tables II and III). In this study differences were seen and patients PCS scores
decreased according to some individual characteristics. Cleary and Drennan determined
that physical health QoL was lower in hemodialysis patients than in the general population.27 In this study, patients were found
to have a low physical health QoL. As the
patients age increased, their QoL and sleep
decreased. Physical inadequacies come

Gender
Female
Male

Physical Component
Score

June 2009 Dialysis & Transplantation 3

Quality of Life and Sleep Quality

with aging, but patients on hemodialysis also

have a loss of activity.28 The results obtained
from this study suggest that hemodialysis
caused limitations in patients daily living
activities in addition to inadequacies that
occur with aging. Williams et al reported
that there is a relationship between dialysis
patients sleep disorders and their physical
and emotional wellness and that sleep quality has a direct effect on individuals QoL12;
Gutman et al reported that dialysis patients
level of physical activity decreases with
aging and that patients 60 years or older are
only independent in 40% of their activities of
daily living29; and Levendoglu et al reported
that elderly dialysis patients have low functional status and well-being.30 The results of
this study are consistent with those reported
in the literature.
In this study it was determined that
patients had a low sleep quality and QoL;
that there was a negative relationship
between sleep quality and PCS and global
QoL; and that as patients sleep quality
fell their QoL also decreased. Sleep and
sleep-related disturbances are very common in hemodialysis patients. Sleep disorders are also known to have a negative
effect on individuals QoL and their physical and emotional wellness.5,6,31,32 Parker
et al determined that 85% of hemodialysis
patients have major sleep disorders affecting their QoL.33 Novak et al also reported
that sleep disorders significantly disturb
individuals QoL.34 In this study, patients
with poor sleep quality also had lower
QoL scores in all areas. This result can be
explained as sleep quality has a direct effect
on decreasing patients QoL.
Patients who had no formal education in this study were found to have low
physical and global QoL scores. In other
studies, differences have been shown in
hemodialysis patients QoL according to
their level of education. Parker et al did not
find a significant relationship between QoL
and education,33 but Niechzial et al did find
that educational level had an influence on
hemodialysis patients QoL,24 and SuetChing reported that as educational level
increased in hemodialysis patients their
global QoL also increased.26
Patients in this study who lived in
extended families and were housewives
were found to have low physical and
global QoL scores. Being attached to
a dialysis machine for certain days of
4 Dialysis & Transplantation June 2009

TABLE III. Relationships between patient age, sleep quality, and

quality of life.
Quality of Life
(PCS)

Quality of Life
(MCS)

Quality of Life
Global SF-36

Age

r  .318**
p  .000

r  .116
p  .175

r  .227**
p  .008

Sleep quality

r  .396**
p  .000

r  .559**
p .000

r  .568**
p  .000

Global SF-36

r  .788**
p  .000

r  896**
p  .000

Sleep Quality
Global PSQI

r  .186*
p  .029

r  .568**
p  .000

*Correlation is significant at the .05 level (2-tailed). **Correlation is significant at the .01 level (2-tailed).

every week generally decreases patients

physical activities and work productivity
which can cause patients to feel as if they
are not functional.35,36 Because patients
who live in extended families and housewives have more domestic roles and
responsibilities, the limitations that occur
with hemodialysis may have had an effect
on this result.
No statistically significant differences
in patients QoL and sleep quality scores
were found according to their duration of
hemodialysis (p > .05). This result is different from previous studies. In studies
conducted with hemodialysis patients it has
been determined that as duration of hemodialysis increased their QoL decreased.20,24
Merkus et al reported that physical QoL
decreased in patients 18 months after they
had begun hemodialysis, but that mental
QoL remained stable37; Unruha and Hessb
reported that patients hemodialysis duration had a negative effect on QoL because
they were not able to take an active role in
the home or community38; Yoshioka et al
reported that sleep disturbances experienced
by hemodialysis patients and long-term
hemodialysis treatment caused a decrease
in patients QoL39; and Tel et al reported
that as hemodialysis patients duration of
hemodialysis increased their sleep quality
decreased.40 Although there are differences
in study results sleep disorders experienced
by hemodialysis patients and duration of
hemodialysis have an effect on QoL.
Improving the QoL of hemodialysis
patients is as important as increasing the
length of their lives. For this reason patients
need to be considered together with their

families in a family-centered approach, and

regular individual or group education needs
to be given to them about maintaining
QoL and sleep quality, which has such a
significant effect on QoL. Counseling also
needs to be provided to patients about how
to organize their daily lives. D&T

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