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INTRODUCTION
Haemodialysis causes major changes in patients’ daily lives due to many physical and psychological symptoms such as dietary and liquid limitations and compulsory visits at the haemodialysiscentres.(1-3)The most commonly reported symptoms experienced by haemodialysis patients are fatigue, pain, muscle cramps, nausea, vomiting, constipation, diarrhoea, itchiness, dry skin, sleep disorders, emotional, and sexual dysfunctions.(2,4-5)The frequency and severity of these symptoms exhibit individual differences.(3-4,6-9)As the frequency and the severity of the symptoms increase, patients start to feel hopelessness and unstably toward future and experience disruptions in their quality of life.(1,2,4,9)
It is reported that 35-50% of haemodialysis patients experience four to ten symptoms, and 25-35% of them experience more than ten symptoms.(4) Another study found that the 11 symptoms seen in end stage kidney failure were as common as those experienced by patients with four chronic diseases: chronic obstructive lung disease, heart disease, AIDS and late stage cancer patients.(5) Although, they show similarities with symptoms experienced by cancer patients, symptoms in haemodialysis patients are not recognized as early as in cancer patients.(3,5,9)This might delay the treatment and care of the symptoms. Thus, symptom management is also crucial in haemodialysis patients. Symptom management requires a multi-disciplinary approach. Major role falls on nurses for reducing the severity of the symptoms and resolving them. It is of utmost importance for the nurses to be aware of the existence and severity of haemodialysis patients’ symptoms in order to enable symptom management. Symptom management in haemodialysis patients should consider individuals’ socio-demographic features, disease characteristics, haemodialysis adequacy and personality traits as well as psychologicalfactors.(2)
Evaluation of haemodialysis adequacy has a critical role in clinical practices. Hence, a series of haemodialysis adequacy indices are used in studies and clinical settings.(2,10-11) One of the most frequently used dialysis adequacy measurement method is the urea kinetic model (Kt/V) developed by Daugirdas and it can be personalized for all patients as a scale of haemodialysis adequacy. The K in Kt/V is the dialyzer clearance, t is the dialysis duration, V is the urea distribution volume.(12)Studies have shown that high (>1.2) Kt/Vvalue is associated with longer life span, less complication and better quality of life.(10-11,13) The Big Five personality traits (neuroticism,extraversion, openness to experience, agreeableness, conscientiousness) define individual permanent and inter-culturally valid characteristics that are known to influence unlimited number of health results such as disease load and health behaviour.(14-15)Generally, agreeableness, openness to experience and conscientiousness is associated with good health perception, and neuroticism is associated with bad health perception.(14,16-19)Previous studies conducted with haemodialysis patients showed that patients with high agreeableness, openness to experience and conscientiousness traits can better maintain their self-discipline and more easily adapt to dialytic treatment.(19-20)On the other hand, patients with neuroticism trait have difficulty in sustaining motivation, usually give up before completing jobs, expect to be encouraged to achieve goals and thus, have lower adaptation rate to the treatment.(17,19-20)Neuroticism was also found to be the sole predictor of depression symptoms in dialysis patients.(16,18)Studies conducted on the factors affecting symptoms of haemodialysis patients are mostly limited to demographic and clinical features. No study was found in the literature focusing on the relation between the physical and psychological symptoms experienced by haemodialysis patients and their personality traits.Investigation of the impact of other relevant factors on symptoms on haemodialysis patients will contribute to better understanding of symptom burdens and effective symptom management.This study is significant owing to the fact that it is one of the first studies to investigate the relation between personality traits, haemodialysis adequacy and symptoms of haemodialysis patients.
METHOD
Aim
This study was conducted in order to investigate the relation between symptoms seen in haemodialysis patients with haemodialysis adequacy and personality traits.
Design
This descriptive cross-sectional study was conducted at two dialysis centres in Turkey between January and June 2019.
Sample/participants
Without any sampling, all patients who volunteered to participate in the duration of the study who are 18 and above; have been receiving haemodialysis treatment for minimum six months; are using arteriovenous fistula; and do not have any communication problems. Patients who use central venous catheter and arteriovenous graft were not included in the study. Thus, a total of 103 patients participated in the study.
Datacollection
The data for the study were collected through Demographic Information Form, the Dialysis Symptom Index, The Big Five Inventory as well as calculation of Kt/V and URR (Urea Reduction Rate) values for dialysis adequacy.Researchers collected data face-to-face while patients were receiving haemodialysis after informing them about the study. The data collection for each participant lasted for about 25-30 minutes including filling in the forms, getting laboratory values from patients’ records and weight measurements.
DemographicInformation Form
This form was developed by the researchers based on the review of relevant literature.(6-8,10,12)The Demographic Information Form consisted of ten questions about descriptive features of haemodialysis patients; 11 questions on their background and parameters regarding pre- and post-dialysis BUN values, patients’ weights, and duration of dialysis.
The Dialysis Symptom Index
The Dialysis Symptom Index was developed by Weisbord et al.(2004) in order to evaluate the physical and emotional symptoms and their severity. DSIconsists of 30 symptoms each of which targets either a physical or emotional indicator. The symptoms experienced in the last seven days are indicated as yes-no; if yes, to what extent it bothered was rated in 5-point Likert-type: 1=not at all, 2=a little bit, 3=somewhat, 4=quite a bit, 5=very much. The Turkish adaptation of DSI along with its validity and reliability was conducted by Önsöz, Usta Yeşilbalkan (2013) who found the Cronbach Alpha Coefficient as 0.83.(21)The Cronbach Alpha Coefficient in this study was calculated as 0.86.
The Big Five Inventory
The Big Five Inventory (BFI), developed by John, Donahue and Kentle (1991), is a short scalemeasuring the prototypical components of five major dimensions. It is a 5-point Likert-type scale consisting of five major dimensions: extraversion (8 items);agreeableness(9 items), conscientiousness (9 items), neuroticism(8 items) and openness to experience (10 items). Items 2, 6, 8, 9, 12, 18, 21, 23, 24, 27, 31, 34, 37, 41and 43 are reversely coded (John and Srivastava, 1999). The Turkish validity of the scale was done by Sümer, Lajunen and Özkan (2005). The Cronbach Alpha Coefficients of the sub-dimensions in the Turkish validity ranged between 0.66 and 0.77.(22)For this study, it was found that the Cronbach Alpha Coefficients ranged between 0.70 and 0.76.
Dialysis adequacy
Kt/Vand URRvalues were used for dialysis adequacy. Kt/Vvalues was calculated by using Daugirdas formula:12
Kt/V= -log(Upost/Upre-0,008t) + (4-3,5Upost/Upre) x (Wpre-Wpost)/Wpost
Upost= Post-haemodialysisBUN
Upre= Pre-haemodialysisBUN
Wpost= Post-haemodialysisweight
Wpre= Pre-haemodialysisweight
t= HD duration
URR= (Upre-Upost/Upre) x 100
Ethical consideration
Prior to the study, approval was received from Akdeniz University Clinical Studies Ethics Board (protocol n°2012/KAEK/20-599 -29.08.2018) and written permission was collected from the institutions where the study will be conducted Individuals who accepted to participate in the study also provided their written informed consent.
Data analysis
The statistical analysis of the data was done through SPSS 21.0 statistical package software. Descriptive statistical methods (frequency, percentile, and standard deviation, mean) were used to analyse the collected. Binary logistics regression analysis was used to evaluate the BIF dimensions, Kt/V URR values and some descriptive variables (age, gender, dialysis year) that might influence haemodialysis symptoms. The findings were assessed within 95% confidence interval and at p<05 significance level.
FINDINGS
Demographicfeatures
The findings showed that the mean age of haemodialysis patients was60.07±12.50; 68.0% were male, 68.9% were graduates of primary education, 81.6% were married, 92.2% were unemployed, 69.9% were living in the town, and 88.3% had social security. It was also found that 38.8% of the patients whostartedhaemodialysishaddiagnosis of diabetic nephropathy, 67.0% have a minimum of one additional disease, 95.1% receive dialysis 3 times a week and 30.1% were receiving haemodialysis for 5-10 years (5,78±5,07). (Table 1)
It was calculated that the mean of patients’ Kt/V values was 1.51 ± .32 and URR value mean was 71.60±7.66. Out of all participants, 70.9% had Kt/V value above 1.4, and 87% had URR value of above 65%.(Table 1)
Distribution of patients’ Big Five Inventory (BIF) score means with existence of symptom and severity of the symptom
The BIF score means for extraversion, agreeableness, conscientiousness, neuroticism, openness to experience sub-dimensions are 25.61±3.58, 27.63±4.34, 27.44±4.24, 25.35±3.65, 31.97±5.54, respectively.(Table 2)
The least common symptom vomiting (10.7%) and the most common symptom was feeling tired or lack of energy (70.7%). A cut point was determined between the least common percentage and the most common percentage of symptoms through a simple mathematical formula (10.7+70.7)/2).As a result of the calculation, symptoms with more than 44.2% commonality were acknowledged as the most common symptoms. It was determined that the most commonly experienced symptoms by patients were feeling tired, lack of energy, (77.7%; 2.97±.77), decreased interest in sex (55.3%; 2.94±.74), difficulty becoming sexually aroused (54.4%, 2.78±.84), muscle cramps (54.0%, 2,79±,71), feeling nervous (51.5%, 2.64±.76), feeling sad (47.6%, 2.69±.68), feeling anxious (47.6%; 2.67±.79), and difficulty falling asleep (47.6%, 2.83±.62) (Table 2).It was determined that 77.6% of the patients experiencedsix or more symptoms.
Evaluation of the relation between dialysis symptoms with dialysis adequacy and personality traits via logistic regression analysis
The predictors for the most common symptoms in haemodialysis patients were found via logistic regression analysis by means of Wald method, URR and Kt/V values as predictors of age, gender, year of dialysis, dialysis adequacy and by including BIF sub-dimensions, the best model for falling asleep and feeling sad symptoms were found in the first model and for other symptoms, it was found in the 2nd model. URR and Kt/V values were not found in any of the models.(Table 3)
The model estimates that on average the odds of the feeling tired and without energy increases 4.83 times more in neuroticism than in those that are not (CI: .056-.826). It was determined that patients with extroversion experience 86,5% less tiredness and lack of energy symptom (Nagelkerke R2:0.233. Model: x2=17.035,p=0.001).
The model estimates that on average the odds of the decreased interest in sex symptom are experienced 4,603 times more by men than women (CI: 1.805-11.735). This model estimates that on average the odds of lower sexual interest increase 12% per year of hemodialysis (Nagelkerke R2:0.119. Model: x2=15.850, p=0.000).
The model estimated that on average the odds of the difficulty becoming sexually aroused symptom is experienced 5,425 times more by men than women (CI: 2.074-14.186). This model estimated that on average the odds of lower difficulty becoming sexually aroused increase 12.6% per year of hemodialysis (Nagelkerke R2:0.216. Model: x2=18.163, p=0.000).
The model estimated that on average the odds of the muscle cramps symptom,is experienced 1.046 times with each unit of increase in age (CI: 1.009-1.085). Men experienced this symptom 62.3% more than women (Nagelkerke R2:0.112. Model: x2= 9.065, p=0.011).
The model estimated that on average the odds of the feeling nervous symptomwas experienced 4.836 times with each unit of increase in neuroticism (CI: 3.010-23.951) and 1.122 times with each unit of haemodialysis year (CI: 1.018-1.236). It was found that extroverted patients experienced 68.35% less nervousness (Nagelkerke R2:0.254. Model: x2=21.769, p=0.000).
The model estimated that on average the odds of the symptom of feeling sad symptom is experienced 4.429 times by an increase of one unit in neuroticism (CI:1.534-8.995). Extraverted patients were found to experience 63.6% less sadness (Nagelkerke R2:0.123. Model: x2=10.000, p=0.007).
The model estimated that on average the odds of the symptom of difficulty falling asleep were experienced by 1.158 times with one unit is rise in extraversion trait (Nagelkerke R2:0.080. Model: x2=6400, p=0.011, CI: 1.028-1.304).
The model estimated that on average the odds of the symptom of feeling anxiety is experienced 4.679 times with every unit of increase in neuroticism (CI: 1.873-11.692). Extraverted patients were found to experience 75.6% less sadness (Nagelkerke R2:0.160. Model: x2=12.913, p=0.002).
DISCUSSION
It is important to examine the physical and emotional symptoms experienced by haemodialysis patients and the factors influencing them in order to maintain effective symptom management. This study examined the relation between haemodialysis adequacy and personality traits with symptoms experienced by haemodialysis patients.
The most common experienced symptoms by haemodialysis patients are feeling tired/lack of energy, decreased interest in sex, difficulty becoming sexually aroused, muscle cramps, feeling nervous, feeling sad, and feeling anxiety, difficulty falling asleep, respectively. Feeling tired is indicated as the most common symptom in haemodialysis patients(1,3,16) yet, other symptoms’ existence and severity show differences.(7,9,23)The frequency and severity of symptoms might show differences but the fact is that both in this study and the previous studiesit was found that patients suffer from a high number of symptoms.(1,3,9) Nurses being aware of the symptoms that might be seen in haemodialysis patients and their severity would increase patients’ quality of life by enabling effective symptom management and arrangement of nursing practices accordingly.
The predictors of the most common symptoms in the study were examined via logistic regression analysis; and the results determined male gender, age, haemodialysis years, extraversionness, and neuroticism. URR and Kt/V values were not located in any of the models.
It was found that male haemodialysis patients experience tiredness and muscle cramps less compared to female patients. The majority of the studies also reported that male patients experience lower symptom load and severity as compared to female patients.(6-8,24)Yet, some studies found no relation among tiredness, muscle cramps and gender.(1,4,25)It is noted in this study that male patients experience decreased sexual interest and difficulty becoming sexually aroused symptoms more severely. The sexual problems showed differences according to gender in studies investigating sexuality in haemodialysis patients.(7,24)While dissatisfaction and nonsensuality is high in women, avoidance is high in men. The reasons benign avoidance is suggested to be related to the gynaecomastia in 30% of women and erectile dysfunction in 72% of men.(24)
It was reported that muscle cramps increase with age in haemodialysis patients. However, some studies, different from this study, found no difference due to age and symptoms experienced.(6-8) However, it is believed that an objective assessment is hindered as the symptom studies on haemodialysis patients use the total symptom index score to compare socio-demographic data.
The decreased interest in sex, difficulty becoming sexually aroused and feeling nervous symptoms increase as the years of haemodialysis increases. The relation between haemodialysis duration and the experienced symptoms show differences.(4,6-7,24) Similarly, another study reported that patients dissatisfaction and avoidance in sexual interest symptoms increase with longer haemodialysis durations.(24) Yet, certain studies found no relation between haemodialysis duration and experienced symptoms.(4,6-7,26)
The findings showed that patients with high neuroticism experience increased tiredness, feeling nervous, feeling sad, and feeling anxious symptoms. No study was found investigating the relation between tiredness in haemodialysis patients and their personality traits. In the 6-month follow-up study conducted with women with breast cancer and benign breast problems (n=304), neuroticism was found to be in a stronger relation with tiredness than demographic features, cancer diagnosis period, and cancer treatment method.(17)Studies have reported that people with high neuroticism have worse health results(19)worse health perception(14-15)and lower quality of life.(20)Other studies on haemodialysis patients also found neuroticism as associated with low mental life quality and a significant predictor of depression symptoms.(16,18,20,27)Individuals with high neuroticism are potentially more sensitive toward negative stimuli. Thus, it is not surprising to find that patients with high neuroticism experience nervousness, sadness, anxiety, and tiredness more severely. Nurses need to be aware that patients with high neuroticism require more support for symptom management and plan their nursing initiatives accordingly.
The study found that patients with high extraversionness experienced decreased symptoms of tiredness, feeling nervous, feeling sad, and feeling anxiety. In parallel to our findings, studies conducted with various chronic patients, also reported that high extraversionness is in a negative relation with tiredness.(7,19)Studies have conveyed that high extraversionness is related with better health results.(14,19,27-28)Studies conducted with chronic kidney failure patients showed that high extraversionness is related with better mental quality of life.(27-28)It is possible that patients with high extraversion express themselves more clearly, cooperate with healthcare professionals regarding their disease management and use management techniques more efficiently; thus, decrease the severity of tiredness, nervousness, sadness and anxiety symptoms.
Previous studies have mostly focused on the relation of dialysis adequacy with biochemical parameters and studies focusing on quality of life, physical and psychological symptoms remained quite limited.(29-30)Some studies have found a relation between Kt/V value and quality of life and depression.(10-11,13)This study did not identify any relation between Kt/V value and other symptoms. Although almost all the patients had desired levels of Kt/V values, more than half of them experienced over six symptoms. These findings prove that dialysis adequacy evaluation should not only consider biochemical parameters but also the symptoms experienced by the patients.
Limitations of the study
The study group consists of a heterogeneous sample based on first disease diagnosis, existence of additional diseases, time to start haemodialysis.Also, participants’ depression and anxiety levels have not been measured and these variables were not assessed as controlling variables. These issues can be listed as the limitations of this study. In addition to this, it has strength as it is one of the first studies to investigate the relation between the Big Five personality traits and symptoms experienced in regard to haemodialysis.
CONCLUSION
It was found in the study that although almost all the patients have desired Kt/V and URR values, most of the haemodialysis patients experience six or more symptoms. While a relation was found among the symptoms experienced by haemodialysis patients and age, gender, haemodialysis period and personality traits, no relation was found with haemodialysis adequacy. It was also observed that haemodialysis patients with high neuroticism trait exhibit more symptoms, whereas patients with high extraversion trait experience fewer symptoms.
Nurses are health professional who play a key role in symptom management during haemodialysis and it is important for them to use their nursing roles effectively and accurately. Personality traits need to be considered as a significant psychological parameter contributing to the development of effective nursing initiative strategies. Nurses and other health professionals should be aware that patients with high neuroticism are inclined to exaggerate and catastrophize disease and treatment symptoms, can get angry more easily, have more difficulty in implementing management strategies, experience more anxiety and sadness regarding the treatment and disease.
Since the studies investigating the relation between personality traits of haemodialysis patients and symptoms, it is suggested to replicate this study with larger sample groups. Similar to this study’s finding, majority of the studies in the literature also identified tiredness as the most commonly seen symptom in haemodialysis patients. In the study, tiredness dramatically increased in patients with high neuroticism. Additionally, it is suggested to examined the relation between tiredness and neuroticism by including new variables, as it can provide insights into the reasons underlying tiredness and not only physiological causes.
Conflict of interest: Authors declare no conflict of interest.
