The Relationship of Clinical Laboratory Parameters and Patient Attributes

Japan Journal of Nursing Science (2009) 6, 920
doi:10.1111/j.1742-7924.2009.00116.x
ORIGINAL ARTICLE
The relationship of clinical laboratory parameters and patient

attributes to the quality of life of patients on hemodialysis
jjns_116
9..20
Eiko YAMANA
Faculty of Nursing, Fukuoka Prefectural University, Fukuoka, Japan
Abstract
Aim: With advances in medicine, the subjective assessment of patients on hemodialysis regarding their
quality of life (QOL) is gaining importance. Clinicians cannot rely solely on objective markers, such as the
rates of complications and mortality, when evaluating responses to dialysis. In clinical settings, laboratory
values are used as measures of patients health. However, the relationship between clinical laboratory values
and QOL has not been elucidated yet. Therefore, the present study aimed to define the relationship of
laboratory values and patient attributes to the QOL of outpatients on hemodialysis in order to obtain basic
data for reevaluating nursing support for patients on hemodialysis in the future.
Methods: The participants were 44 outpatients receiving hemodialysis at Hospital B. The QOL was
surveyed using a self-administered questionnaire, the Kidney Disease Quality of Life Short Form. The
following patient attributes and laboratory values were taken from the medical records: age; sex; primary
disease; number of years on hemodialysis; complications; number of hours of hemodialysis per session;
percentage weight gain; cardiothoracic ratio; blood pressure; hematocrit; and the serum levels of albumin,
potassium, phosphorus, and calcium.
Results: The serum potassium level significantly affected mental health, social functioning, symptoms, and
the effect of kidney disease, with the 3.55.0 mEq/L target range group scoring higher than the 5.1 mEq/L
group.
Conclusions: The serum potassium level significantly affected not only physical health, but also QOL, a
measure of psychosocial health. This suggests that providing nursing support to patients, guided by the
serum potassium target range of 3.55.0 mEq/L, might improve and maintain QOL.
Key words: laboratory parameters, patients on hemodialysis in Japan, quality of life.
INTRODUCTION
The number of patients receiving hemodialysis due to
end-stage renal disease is increasing with the rapid aging
of society and advances in medicine (Statistics and
Research Committee, Japanese Society for Dialysis
Therapy, 2008). In Japan, the number reached 264 000
in 2006; some people had been on dialysis for as long as
39 years. In this environment, growing importance has
Correspondence: Eiko Yamana, Faculty of Nursing, Fukuoka
Prefectural University, 4395 Ita Tagawa, Fukuoka 825-8585,
Japan. Email: yamana@fukuoka-pu.ac.jp
Received 10 October 2008; accepted 14 January 2009.
2009 The Author

Journal compilation 2009 Japan Academy of Nursing Science
been attached to the patients own subjective evaluation

of their quality of life (QOL) when evaluating the lifeprolonging effects of hemodialysis (Bakewell, Higgins &
Edmunds, 2001; Carmichael, Popoola, John, Stevens &
Carmichael, 2000; Fukuhara et al., 2003; Lopes et al.,
2003; Mapers et al., 2003; Tsuji-Hayashi et al., 2001).
This contrasts with concentrating solely on objective
measures of treatment as assessed by the caregiver, such
as complication rates and mortality rates.
Kuroda (1992) showed that QOL data are useful
for determining patients treatment preferences. In the
actual clinical setting, however, nephrology nurses use
laboratory values as measures and rely on information,
such as complication rates and mortality rates, to
E. Yamana
educate patients in daily health management. They do

not provide patients with QOL measurements and QOL
information for educational purposes. Laboratory
values and information, such as complication and mortality rates, alone do not readily motivate or inspire
patients to pursue their daily health management regimes
(Sehgal et al., 2002; Sagawa, Oka, Chaboyer, Satoh &
Yamaguchi, 2001). To the patients on hemodialysis,
laboratory values related to health management are
important measures that tell them if their daily therapy
and management are working. Patients can lead a
healthy life without untoward incidents when they use
laboratory values as an assessment tool for combining
proper diet and weight control with 5 h of therapy three
times per week. Thus, to the patients on hemodialysis
and nephrology nurses, laboratory values are important
indicators for recognizing the early precursors of an
abnormal condition and to avert fatal complications.
Nonetheless, the only published research elucidating the
relationship between the QOL and laboratory values of
patients on hemodialysis is a study reporting the benefits
of low dialysis efficiency and long hemodialysis times
to maintain the QOL of patients with a low muscle
mass and poor nutritional state (Nakai, Takai, Shinzato,
Fukuhara & Maeda, 2000). In addition, although
one study addressed how QOL is related to aging,
the prolongation of hemodialysis, and its complications
(Yoshiya, Hasunuma, Oka, Ohmae & Kamidono,
2001), a more detailed QOL measurement scale for
patients on hemodialysis has not been used to examine
the relationship of QOL to patient clinicodemographic
attributes and laboratory values and how this relationship might influence the course of the disease.
An important part of a nephrology nurses job is to
educate patients on hemodialysis regarding health management. In light of the above, health management education by nephrology nurses based on clinical laboratory
test values might lead to improvements in the QOL of
patients on hemodialysis. Thus, the present study aimed
to define the relationship that laboratory values and
patient attributes have with the QOL of outpatients on
hemodialysis in order to obtain basic data for reevaluating nursing support for patients on hemodialysis in the
future.
METHODS
Participants and survey method
The participants were 44 outpatients receiving hemodialysis at Hospital B in City A. The duration of the
10
survey period was 3 months, starting on 10 August

2002. The initial conditions for participant inclusion
were: (i) the ability to complete the questionnaire by
oneself or, if the patient had impaired vision, the ability
to respond when the questions were read aloud; and
(ii) that the patient travelled to the hospital for hemodialysis. The nursing manager (chief nurse) referred
potential participants. Whether or not the patients
fulfilled these criteria was established at an interview
for consent and from the medical records. As various
physical, psychological, and social problems occur
during the 3 month initiation phase after starting
hemodialysis therapy, the following inclusion criteria
were selected on the basis of Yamazakis (1999a)
guideline for transition from the initiation phase to the
maintenance dialysis: hemodialysis experience of at
least 4 months, excluding the initiation phase; systemically stable physical condition; side-effects of hemodialysis, such as dialysis disequilibrium syndrome, are
controlled well; weight gain is stabilized and a target
weight is established; vascular access is functioning reliably; and mental and emotional stability. The survey
method consisted of: (i) reading medical records to
collect the attributes and laboratory values related to
the health management of patients on hemodialysis;
and (ii) using a questionnaire to survey the participants.
The laboratory values that were obtained at the time
that the QOL survey was administered were collected.
It was confirmed that these values did not change
markedly after the survey. The Kidney Disease Quality
of Life Short Form (KDQOL-SF) (Miura, Green &
Fukuhara, 2001) was used in the survey after registering with the Rand Corporation (Santa Monica, CA,
USA) and obtaining authorization to use the form. The
questionnaire was given to the participants when they
provided consent and all the participants completed the
questionnaire on non-dialysis days. Any questions or
comments regarding the questionnaire were addressed
on collection.
Survey items and data collection

Participants attributes and laboratory data
The patients attributes were modeled on those used
in Current state of chronic dialysis treatment in Japan
by the Statistics and Research Committee, Japanese
Society for Dialysis Therapy (2008). They consisted of
age, sex, primary disease, number of years on dialysis,
presence of complications, and number of hours on
dialysis per session. The clinical laboratory values
studied were those generally used to evaluate and
2009 The Author

educate patients regarding health management; namely,

percentage weight gain, cardiothoracic ratio, blood
pressure, hematocrit, and the serum levels of albumin,
potassium, phosphorus, and calcium. To examine
whether the QOL differed according to the participants attributes and laboratory values, the laboratory
values were categorized as falling into a target group or
non-target group for health management, modeled on
the target clinical laboratory values proposed by
Sanaka (1999). The attributes were divided into two or
three groups, based on Current state of chronic dialysis
treatment in Japan by the Statistics and Research Committee, Japanese Society for Dialysis Therapy (2008).
Age was divided into two groups (<60 years and
60 years), as was the number of years on dialysis
(<5 years and 5 years). Primary disease was divided
into three groups of chronic glomerulonephritis,
diabetic nephropathy, and other. The following
attributes were dichotomized: complications, present
and absent; hemodialysis time, <5.5 h and 5.5 h; percentage weight gain, 3.0% and 3.1%; cardiothoracic ratio, 50% and 50.1%; and systolic blood
pressure, 160 mm Hg and 161 mm Hg. The laboratory values were categorized as follows: hematocrit, 2535% and 35.1%; serum albumin level,
<4.0 g/dL and 4.0 g/dL; serum potassium level, 3.5
5.0 mEq/L and 5.1 mEq/L; serum phosphorus level,
5.0 mg/dL and 5.1 mg/dL; and serum calcium level,
8.510.5 mg/dL, <8.5 mg/dL, and 10.6 mg/dL.
The percentage weight gain was defined as the percentage of weight gain on alternate days, calculated by
subtracting the weight after the previous hemodialysis
session from the weight immediately before hemodialysis and dividing the remainder by the target weight. The
following equation was used:
Percentage weight gain (%) =

Weight immediately before hemodialysis (kg )
Weight after previous hemodialysis (kg )
100
Target weight (kg )
Hemodialysis parameters and quality of life
health-related scales and kidney disease-targeted scales.

The results of the Short Form-36 (Fukuhara, Suzukamo,
Bito & Kurokawa, 2001), the general health-related
scales, can be compared to national norms. The general
health-related scales consist of eight subscales divided
according to the factors that are generally common to
healthy people: physical functioning, role functioning
(physical), bodily pain, general health perceptions,
mental health, role functioning (emotional), social functioning, and vitality. The kidney disease-targeted scales
consist of 11 subscales for the detailed measurement of
symptoms particular to the disease and their effects:
symptoms, effect of kidney disease, burden of kidney
disease, work status, cognitive function, quality of social
interaction, sexual function, sleep, social support,
encouragement by dialysis staff, and patient satisfaction.
There are 79 items on the KDQOL-SF, with the scoring
reversed on some items (high to low). With one exception, the response options are structured in the form of
a five-point or six-point Likert scale. The score for each
subscale ranges from 0100, with higher scores indicating a higher QOL in most cases.
Statistical analysis
The score for each subscale was calculated from the data
obtained using the KDQOL-SF scoring method and categorized into two or three groups for each patient
attribute and clinical laboratory value. The scores were
not normally distributed, so non-parametric tests were
used. The Wilcoxons Rank Sum test was used for comparison between the two groups, while the KruskalWallis test was used for comparison among the three
groups. P-values that were <0.05 were considered to
be statistically significant and medians were used for
comparison between the groups. The SPSS 11.5J for
Windows statistical analysis package (SPSS Japan Inc.,
Tokyo, Japan) was used.
Ethical considerations
Kidney Disease Quality of Life Short Form
The QOL measurement instrument used was the
KDQOL-SF, a kidney disease-targeted measure of QOL.
The reliability of the Japanese version of the KDQOL-SF
was validated by Green et al. (2001) and the manual
was prepared by Miura, Green & Fukuhara, (2001). It is
a multivariate scale that provides multidimensional
measurements and yields an abundance of clinical information. Structurally, the KDQOL-SF consists of general
2009 The Author

The following was explained to the participants

regarding ethics: that the results would undergo statistical analysis, but the individuals would not be identified; that the information obtained was confidential
and confidentiality would be strictly protected; that the
data obtained would not be used for any purposes
other than research; and that participation in the study
was voluntary and consent could be retracted at any
time. It also was explained that, although the questionnaire was anonymous, an encoding system using the
11
E. Yamana
participants date of birth would be used to match the

questionnaire results with the clinical laboratory
values. The questionnaires were collected directly from
the participants on the dialysis day to ensure that there
were no omissions. Two participants consented to participate in the questionnaire survey but did not consent
to having the questionnaire results matched with the
clinical laboratory values; therefore, they were
excluded from the study. The study complied with the
Declaration of Helsinki (World Medical Association,
2008).
and the serum calcium level was 9.5 0.8 mg/dL

(Table 2).
Distribution of the Kidney Disease Quality of

Life Short Form scores
The distribution of the participants scores (median,
minimummaximum) in the 19 subscales of the
KDQOL-SF is presented in Table 3.
Table 2 Participants investigation results and laboratory

values (n = 44)
RESULTS
Investigation
Overview of the participants

Participants attributes and laboratory values
There were 32 male and 12 female participants, aged
57.0 13.8 years (mean standard deviation), with
5.7 3.4 years on dialysis. The primary disease was
chronic glomerulonephritis in 14 participants, diabetic
nephropathy in 10 participants, and other in 20 participants. Twenty-eight participants had complications
(cardiovascular disease, n = 13; bone and joint disease,
n = 7; and other disease, n = 15) and 16 did not
(Table 1). The hemodialysis time was <5.5 h for 38
participants and 5.5 h for six participants. The percentage weight gain was 3.2 1.6% and the cardiothoracic ratio was 47.9 5.4%. The hematocrit was
33.4 3.7% and the albumin level was 4.1 0.3 g/
dL. The serum potassium level was 4.7 0.6 mEq/L,
the serum phosphorus level was 5.1 1.2 mg/dL,
Table 1 Clinicodemographic attributes of the participants

(n = 44)
Attribute
Age (years)
Dialysis (years)
Sex
Men
Women
Primary disease
Chronic glomerulonephritis
Diabetic nephropathy
Other
Complications
Present
Absent
12
Mean standard
deviation
N (%)
57.0 13.8
5.7 3.4
32 (72.7)
12 (27.3)
14 (31.8)
10 (22.7)
20 (45.5)
28 (63.6)
16 (36.4)
Percentage weight gain (%)

CTR (%)
SBP/DBP (mm Hg)
Ht (%)
Alb (g/dL)
K (mEq/L)
P (mg/dL)
Ca (mg/dL)
Mean standard deviation

3.2 1.6
47.9 5.4
151.7 20.6/82.1 11.1
33.4 3.7
4.1 0.3
4.7 0.6
5.1 1.2
9.5 0.8
Alb, serum albumin; Ca, serum calcium; CTR, cardiothoracic ratio;

DBP, diastolic blood pressure; Ht, hematocrit; K, serum potassium; P,
serum phosphorus; SBP, systolic blood pressure.
Table 3 Participants Kidney Disease Quality of Life Short

Form score distributions (n = 44)
Subscale (range: 0100)
General health-related scale
Physical functioning
Role functioning (physical)
Bodily pain
General health perceptions
Mental health
Role functioning (emotional)
Social functioning
Vitality
Kidney disease-targeted scale
Symptoms
Effect of kidney disease
Burden of kidney disease
Work status
Cognitive function
Quality of social interaction
Sexual function
Sleep
Social support
Encouragement by dialysis staff
Median
(Minimum
maximum)
80.0
100.0
77.5
45.0
72.0
100.0
87.5
60.0
(0.0100.0)
(0.0100.0)
(0.0100.0)
(5.075.0)
(20.0100.0)
(0.0100.0)
(25.0100.0)
(0.090.0)
85.2
76.6
31.3
50.0
93.3
100.0
81.3
62.5
66.7
75.0
83.3
(27.397.7)
(28.196.9)
(0.087.5)
(0.0100.0)
(33.3100.0)
(0.0100.0)
(0.0100.0)
(25.0100.0)
(33.3100.0)
(0.0100.0)
(16.7100.0)
2009 The Author

Comparison of the Kidney Disease

Quality of Life Short Form scores by
group classification
Comparison of the Kidney Disease Quality of
Life Short Form scores by the patients attributes
significant difference in the scores according to the dialysis time, with the <5.5 h group scoring higher than the
5.5 h group (Table 6).

Life Short Form scores by laboratory values
In Tables 46, the KDQOL-SF scores are compared

by patient attributes, which are divided into two or
three groups. The subscales showing a significant agerelated difference in the scores were the quality of
social interaction, social support, and encouragement by
dialysis staff, with the participants aged 60 years
scoring higher than those aged <60 years. No significant
sex-related difference in the scores was observed
(Table 4).
The primary disease had no significant effect on the
scores. The subscales that showed a significant difference in the scores according to the number of years on
dialysis were role functioning (physical), role functioning (emotional), social functioning, and cognitive function, with the 5 year group scoring higher than the
<5 year group. The difference in role functioning (physical) was particularly remarkable (Table 5).
The complications did not have a significant effect
on the scores. Only the symptoms subscale showed a
In Tables 79, the KDQOL-SF scores are compared by

dichotomized clinical laboratory values. The work
status was the only subscale to show a significant difference in the scores according to the percentage weight
increase, with the 3.1% group scoring higher than the
target value 3.0% group. The cardiothoracic ratio did
not significantly affect the KDQOL-SF scores (Table 7).
The burden of kidney disease was the only subscale to
be significantly affected by the hematocrit, with the
2535% target value group showing higher scores than
the 35.1% group. Neither the albumin level nor the
systolic blood pressure significantly affected the
KDQOL-SF scores (Table 8).
Mental health, social functioning, symptoms, and the
effect of kidney disease were significantly affected by the
serum potassium level, with the 3.55.0 mEq/L target
value group scoring higher than the 5.1 mEq/L group
on all four subscales. Neither the serum phosphorus
Table 4 Comparison of the Kidney Disease Quality of Life Short Form scores (medians) by age and sex
Age
Subscale
Bodily pain
Mental health
Social functioning
Vitality
Symptoms
Work status
Cognitive function
Sexual function
Sleep
Social support
Patient satisfaction
Sex
<60 years
(n = 22)
60 years
(n = 22)
Male
(n = 31)
Female
(n = 13)
85.0
100.0
73.8
45.0
72.0
100.0
87.5
60.0
85.2
76.6
28.1
100.0
86.7
80.0
87.5
62.5
66.7
75.0
83.3
80.0
75.0
77.5
50.0
74.0
100.0
93.8
62.5
57.5
76.6
31.3
50.0
93.3
100.0**
62.5
63.8
83.3**
75.0*
83.3
80.0
100.0
77.5
45.0
72.0
100.0
87.5
60.0
84.1
78.1
25.0
50.0
93.3
100.0
81.3
62.5
66.7
75.0
83.3
80.0
50.0
75.0
45.0
70.0
83.3
75.0
55.0
90.9
71.9
31.3
50.0
86.7
100.0
75.0
67.5
83.3
75.0
83.3
*P < 0.05 and **P < 0.01 using Wilcoxons Rank sum test.
2009 The Author

13
E. Yamana
Table 5 Comparison of the Kidney Disease Quality of Life Short Form scores (medians) by primary disease and the number of years
on dialysis
Primary disease
Subscale
Number of years on dialysis
Chronic
glomerulonephritis
(n = 14)
Diabetic
nephropathy
(n = 10)
Other
(n = 20)
<5 years
(n = 17)
5 years
(n = 27)
80.0
50.0
81.3
45.0
72.0
66.7
87.5
57.5
89.8
83.3
34.4
75.0
90.0
100.0
100.0
70.0
75.0
56.3
75.0
75.0
50.0
77.5
50.0
62.0
100.0
87.5
55.0
75.0
75.0
18.8
25.0
86.7
90.0
75.0
58.8
66.7
75.0
83.3
82.5
100.0
68.8
47.5
76.0
100.0
100.0
60.0
87.5
73.4
31.3
50.0
93.3
95.0
50.0
61.3
66.7
75.0
83.3
80.0
50.0
77.5
40.0
66.0
66.7
87.5
50.0
88.6
75.0
25.0
50.0
86.7
90.0
87.5
60.0
66.7
68.8
83.3
80.0
100.0**
75.0
50.0
76.0
100.0*
100.0*
60.0
84.1
78.1
31.3
50.0
93.3*
100.0
75.0
65.0
66.7
75.0
83.3
Bodily pain
Mental health
Social functioning
Vitality
Symptoms
Work status
Cognitive function
Sexual function
Sleep
Social support
*P < 0.05 and **P < 0.01 using the Kruskal-Wallis test and Wilcoxons Rank Sum test.
Table 6 Comparison of the Kidney Disease Quality of Life Short Form scores (medians) by the presence of complications and the
number of hours on dialysis per session
Complications
Subscale
Bodily pain
Mental health
Social functioning
Vitality
Symptoms
Work status
Cognitive function
Sexual function
Sleep
Social support
Number of hours on dialysis per session
Present
(n = 28)
Absent
(n = 16)
<5.5 h
(n = 38)
5.5 h
(n = 6)
80.0
100.0
75.0
47.5
76.0
100.0
87.5
60.0
85.2
76.6
31.3
50.0
93.3
100.0
75.0
58.8
66.7
75.0
83.3
50.0
50.0
82.5
45.0
64.0
100.0
87.5
50.0
84.1
76.6
25.0
50.0
86.7
90.0
87.5
70.0
66.7
62.5
83.3
80.0
75.0
77.5
50.0
72.0
100.0
87.5
60.0
88.6
78.1
31.3
50.0
93.3
100.0
81.3
63.8
66.7
75.0
83.3
55.0
100.0
62.5
37.5
68.0
100.0
87.5
57.5
71.6*
58.9
31.3
100.0
80.0
85.0
50.0
60.0
66.7
56.3
66.7
*P < 0.05 using Wilcoxons Rank Sum test.
14
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Table 7 Comparison of the Kidney Disease Quality of Life Short Form scores (medians) by the percentage weight gain and
cardiothoracic ratio
Percentage weight gain
Subscale
Bodily pain
Mental health
Social functioning
Vitality
Symptoms
Work status
Cognitive function
Sexual function
Sleep
Social support
Cardiothoracic ratio
3.0
(n = 23)
3.1
(n = 21)
50.0
(n = 32)
50.1
(n = 12)
80.0
100.0
70.0
45.0
72.0
100.0
87.5
60.0
84.1
71.9
31.3
50.0
86.7
80.0
50.0
62.5
66.7
75.0
83.3
85.0
75.0
85.0
45.0
72.0
100.0
87.5
57.5
88.6
78.6
31.3
100.0*
93.3
100.0
87.5
70.0
66.7
75.0
83.3
82.5
87.5
77.5
47.5
72.0
100.0
87.5
60.0
87.5
78.1
31.3
50.0
90.0
90.0
81.3
62.5
66.7
75.0
83.3
75.0
100.0
71.3
42.5
70.0
100.0
100.0
55.0
78.8
70.9
31.3
50.0
93.3
100.0
75.0
62.5
75.0
75.0
66.7
Table 8 Comparison of the Kidney Disease Quality of Life Short Form scores (medians) by the hematocrit, serum albumin level,
and systolic blood pressure
Hematocrit (%)
Subscale
Albumin (g/dL)
Systolic blood pressure (mm Hg)
2535
(n = 32)
35.1
(n = 11)
<4.0
(n = 11)
4.0
(n = 33)
160
(n = 6)
161
(n = 18)
80.0
100.0
73.8
50.0
72.0
100.0
87.5
57.5
88.6
78.4
34.4
50.0
93.3
95.0
87.5
66.3
66.7
75.0
83.3
80.0
50.0
76.3
45.0
64.0
100.0
87.5
57.5
77.3
59.4
18.8*
50.0
86.7
100.0
37.5
60.0
66.7
75.0
83.3
80.0
100.0
78.8
35.0
72.0
100.0
75.0
55.0
86.4
78.6
37.5
50.0
93.3
100.0
75.0
60.0
66.7
75.0
83.3
80.0
87.5
77.5
50.0
72.0
100.0
100.0
60.0
84.1
75.0
31.3
50.0
86.7
90.0
81.3
62.5
66.7
75.0
83.3
85.0
100.0
82.5
45.0
76.0
100.0
87.5
60.0
88.6
78.1
28.1
100.0
93.3
100.0
87.5
66.3
66.7
75.0
83.3
72.5
50.0
75.0
50.0
68.0
100.0
100.0
55.0
79.8
73.4
31.3
50.0
90.0
95.0
50.0
60.0
66.7
75.0
83.3
Bodily pain
Mental health
Social functioning
Vitality
Symptoms
Work status
Cognitive function
Sexual function
Sleep
Social support
2009 The Author

15
E. Yamana
Table 9 Comparison of the Kidney Disease Quality of Life Short Form scores (medians) by the serum levels of potassium,
phosphorus, and calcium
Potassium
Subscale
Bodily pain
Mental health
Social functioning
Vitality
Symptoms
Work status
Cognitive function
Sexual function
Sleep
Social support
Phosphorus
Calcium
3.55.0
(n = 33)
5.1
(n = 10)
5.0
(n = 20)
5.1
(n = 24)
8.510.5
(n = 34)
8.4, 10.6
(n = 10)
80.0
100.0
76.3
50.0
76.0
100.0
100.0
60.0
88.6
78.6
31.3
50.0
93.3
100.0
87.5
60.0
66.7
75.0
83.3
82.5
37.5
72.5
40.0
56.0*
100.0
62.5*
45.0
73.8*
64.1*
31.3
50.0
90.0
85.0
62.5
67.5
66.7
75.0
83.3
80.0
75.0
77.5
45.0
72.0
100.0
100.0
50.0
84.1
81.7
34.4
50.0
93.3
100.0
93.8
65.0
66.7
75.0
83.3
82.5
100.0
70.0
47.5
70.0
100.0
87.5
60.0
88.6
70.9
25.0
50.0
90.0
90.0
75.0
61.3
66.7
75.0
83.3
80.0
87.0
77.5
45.0
72.0
100.0
87.5
57.5
87.5
75.0
31.3
50.0
86.7
90.0
75.0
65.0
66.7
75.0
83.3
77.5
100.0
67.5
50.0
74.0
100.0
87.5
60.0
75.0
83.0
34.4
50.0
93.3
100.0
100.0
58.8
66.7
75.0
66.7
level nor the serum calcium level significantly affected

the subscale scores (Table 9).
DISCUSSION
Overview of the participants
According to the Statistics and Research Committee,
Japanese Society for Dialysis Therapy (2008)), the mean
age of the entire Japanese dialysis population is
61.6 years. That survey also found that the primary
disease requiring hemodialysis is glomerulonephritis in
49.6% of dialysis patients and diabetic nephropathy in
27.2%. In the present study, the primary disease was
glomerulonephritis in 31.8% of the participants and
diabetic nephropathy in 22.7% of the participants, with
the proportion of participants with diabetic nephropathy being virtually the same as in the Overview of
Regular Dialysis Treatment in Japan. The clinical laboratory values in the present study included: potassium,
4.7 0.6 (mean standard deviation); hematocrit,
33.4 3.7%; albumin, 4.1 0.3 g/dL; and calcium,
9.5 0.8 mg/dL.
An earlier Current state of chronic dialysis treatment
in Japan (Statistics and Research Committee, Japanese
16
Society for Dialysis Therapy, 1999) reported a serum

calcium level of 9.4 1.0 mg/dL for the overall dialysis
population, which is virtually the same as that found in
the present study.
The participants in the present study scored 30.5 on
average for the burden of kidney disease on the
KDQOL-SF. Green et al. (2001) showed a similarly low
mean score of 35.2.

Life Short Form scores by group classification
Life Short Form scores by patient attributes
The QOL scores differed significantly according to the
age, number of years on dialysis, and the number of
hours of dialysis per session. Conversely, they were not
significantly affected by the sex, primary disease, or
presence of complications.
The subscales that showed a significant age-related
difference were the quality of social interaction, social
support, and encouragement by dialysis staff, with those
aged 60 years scoring higher. For the quality of social
interaction, the questions included items, such as Do
you act in an irritable manner toward those around
2009 The Author

you? Carmichael et al. (2000) reported that the relationship between age and QOL reveals that patients can
adapt to the disease as they age. This suggests that older
patients scored higher in the present study because they
had adapted better to the disease and were therefore
irritable less often. To confirm this, it would be necessary to conduct a multivariate analysis, with the subscale showing a significant difference as the dependent
variable and age as the independent variable, and to
include relationships with variables other than age. In
addition, the participants aged 60 years in the present
study went out three times per week for therapy and
therefore gained opportunities for personal interaction,
which might explain the higher score in this group.
The subscales that were significantly affected by the
number of years on dialysis were role functioning
(physical), role functioning (emotional), social functioning, and cognitive function, with the 5 year group
scoring higher. The questions in these subscales ask
whether physical, emotional, or cognitive problems
interfere with work, normal activities, or interaction
with family and friends. Sakai et al. (2000) classified the
problems arising as a result of having renal disease: the
effects of renal disease on daily life, interference with
daily life, and symptoms. In their nursing model for the
management of chronic illness, Corbin and Strauss
thought of the patients condition as going through eight
phases (Oka, Kajihara, Yamamoto, Satou & Hyoudou,
2001). These include an asymptomatic phase, a phase
during which the patient is examined and diagnosed, a
phase during which hospitalization is necessary due to
the symptoms and complications, and a phase during
which the patients health is stabilized.
The participants on dialysis for at least 5 years had
coped with symptoms and complications throughout
this period and had performed activities of daily living
while traveling to the hospital for treatment. Accordingly, the higher scores in the 5 year group, compared
with the <5 year group, can be attributed to the former
groups greater experience of coping with the health
condition and complications and to the greater ability
to self-manage while dealing successfully with these
challenges.
The only subscale showing a significant difference in
the scores according to the number of hours on dialysis
per session was symptoms, with the <5.5 h group
scoring higher. Nakai et al. (2000) reported that the
length of the dialysis session does not affect the QOL.
Similarly, the present study found no significant differences on the general health-related scales but a significant difference in the symptoms on the kidney disease-
2009 The Author

targeted scales. This means that the <5.5 h group had

fewer symptoms, such as chest symptoms and muscle
cramps, than did the 5.5 h group. The participants
who required at least 5.5 h of dialysis did so because of
problems with vascular access, reduced blood pressure,
muscle cramps during dialysis, and cardiovascular
disease (longer dialysis times reduce the strain on the
heart). The significant difference in symptoms according
to the length of the dialysis session can be attributed to
the fact that various symptoms arise from these conditions that require longer dialysis times of 5.5 h.

Life Short Form scores by laboratory values
The QOL scores were significantly affected by the percentage weight gain, hematocrit, and serum potassium
level, but not by the cardiothoracic ratio and systolic
blood pressure or by the serum albumin, phosphorus, or
calcium levels.
The work status was the only score significantly
affected by the percentage weight gain, with the 3.1%
group scoring higher. When nurses provide weight
control education to patients who exceed 3.0% weight
gain in the actual clinical setting, they assess the cardiothoracic ratio, the presence of prodromal symptoms of
pulmonary edema, and the systemic condition (e.g.
nutrition). However, in their social roles, patients might
be called on to consume excess fluids (e.g. when having
tea or going out to eat with others) and it might be
difficult to manage their weight effectively. Oka et al.
(2001) reported that employed dialysis patients who
travel to the clinic are more frequently unable to adhere
to self-care regimens, such as weight management, compared with dialysis patients who are not employed. In
the present study, the questions on work status were
Do you work at a paying job? and Does your health
keep you from working at a paying job? The present
finding, that those with a 3.1% weight gain had a
higher work status score, therefore agrees with the clinical findings of Oka et al. The benchmark of 3.0%
weight gain was selected because it is approximately
equivalent to the amount of water removed in a single
dialysis session and is the weight gain cut-off recommended to avoid reductions in blood pressure due to
strain on the heart during hemodialysis. However, a
3.0% weight gain is hardly suitable for maintaining a
good work status. Yamazaki (1999b) studied the relationship between failed work rehabilitation and factors,
such as the weight gain rate, dialysis time, and cardiothoracic ratio, in the Current state of chronic dialysis
treatment in Japan. They found that such parameters
17
E. Yamana
confer high relative risk with respect to work rehabilitation and survival. In other words, there is a high risk
of failed work rehabilitation when there is a high rate of
weight gain. Studies on the relationship between work
and the weight gain rate in dialysis patients have dealt
with employment and household income (Oka et al.,
2001), but none have dealt in detail with the relationship between the percentage weight gain and work rehabilitation. To do that, first it would be necessary to
perform detailed studies to learn the employment status
of patients returning to work, such as the number of
hours worked and the amount of physical labor, and
other work status factors, such as whether or not
patients returning to work are on daytime or night-time
dialysis.
The only KDQOL-SF score that showed a significant
difference according to the hematocrit was the burden
of kidney disease, with the 2535% target value group
scoring higher. Previous studies using the same KDQOL
considered the relationship between renal anemia and
QOL (Akizawa et al., 2002) and evaluated medical
interventions, such as the administration of recombinant erythropoietin (Fukuhara, Takai & Miura, 1997).
Akizawa et al. divided their population into patients
with hematocrit values 27% and 33% and compared their QOL, but they reported no significant difference in the scores. Fukuhara et al. reported that
erythropoietin treatment for renal anemia leads to an
improved QOL, but they stated that they did not know
if the improvement in anemia explains the improved
QOL and that it is unclear how important target hematocrit values are in the treatment of renal anemia. Using
the SF-36 health-related scales, Yoshiya et al. (2001)
reported that the hematocrit value and QOL are not
related. It is hard to compare the results of the present
study with those of Akizawa et al. because the hematocrit values were divided differently, but if we consider
that the QOL generally increases as anemia improves, it
would be possible to predict that patients with hematocrit values of at least 35.1% will show higher vitality
and symptoms scores. In contrast, however, our results
showed higher scores in the 2535% group. This could
be because a hematocrit value of 35.1% carries the
risks of shunt occlusion, symptoms related to hypertension or blood pressure elevation, and the side-effects of
erythropoietin. This seems to suggest that patients with
a hematocrit of 35.1% would not necessarily have a
high QOL. One of the responses to the burden of
kidney disease questions is Too much time is spent
dealing with my kidney disease. If we take this to
reflect the dialysis time, the burden score was probably
18
affected by the fact that 45.5% of the participants in the

hematocrit 35.1% group had dialysis times of 5.5 h.
The score for My kidney disease interferes too much
with my life was probably affected by the fact that
81.8% of the participants in the hematocrit 35.1%
group had complications. It also would be necessary to
study the effect of other variables, such as the serum
iron and serum ferritin, the markers of renal anemia, in
order to explain the relationship between the hematocrit and QOL.
The scores that were significantly affected by the
serum potassium level were mental health, social functioning, symptoms, and the effect of kidney disease, with
the serum potassium 3.55.0 mEq/L target value group
showing higher scores in all of these subscales. The diet
is the cause of excess potassium intake in almost all
cases, suggesting that the serum potassium level can be
managed by the diet. As dialysis patients can selfmanage potassium levels by aiming for target values,
they should be able to relax and enjoy life without
worrying about fluid and dietary restrictions or becoming nervous or depressed. It is unlikely that patients
would be bothered by hallmark symptoms of potassium
imbalance, such as chest pain, muscle cramps, and
shortness of breath. Therefore, patients with target
serum potassium levels would not experience much
interference with social interaction for physical or psychological reasons.
Laboratory values have been considered to be important markers for ascertaining the state of therapy and
management and avoiding fatal complications in
patients on hemodialysis. The present study of the relationship between clinical laboratory test values and
QOL found that the participants with optimal serum
potassium levels scored significantly higher, not only for
the physical symptoms characteristic of renal disease but
also for general mental health and social functioning.
This suggests that managing the serum potassium level
as part of the renal disease management regimen will
have psychosocial benefits for the patient.
Limitations of the study

It is difficult to generalize the results of this study
because it was limited to 44 participants traveling to a
single facility for hemodialysis. Future studies should
recruit more participants from multiple facilities and
include survey questions on the activities of daily living
related to QOL and work rehabilitation status in order
to examine whether or not nursing support that is
guided by target laboratory values improves QOL.
2009 The Author

CONCLUSION
The relationship that laboratory values and patient
attributes have with the QOL of patients on hemodialysis was elucidated. In particular, the serum potassium
level significantly affected not only physical health, but
also QOL, which reflects psychosocial health. This suggests that providing nursing support to patients that is
guided by the serum potassium target value of 3.5
5.0 mEq/L might improve and maintain QOL.
ACKNOWLEDGMENTS
I would like to express my sincere gratitude for the
cooperation of the patients and staff of Hospital B in
performing this study. I also would like to thank Professor Midori Furuse and Professor Sumako Yoshitani for
their unfailing guidance and for reading the manuscript
while it was in preparation.
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2009 The Author


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Japan Journal of Nursing Science (2009) 6, 920