Quality of Life in Patients Undergoing

Hemodialysis and Renal

Transplantation A Meta-Analytic
Review
Kandace Landreneau
Kathryn Lee
Michael D. Landreneau

here has been a long trajectory

of concern regarding quality of
life issues in patients with renal
failure. Renal replacement therapies have moved from experimental
medicine to accepted treatment
modalities. In the early years, medical
centers had committees that evaluated patients quality of life and their
potential for achieving bio-psychosocial well being. Over the last five
decades, renal replacement therapies
have greatly expanded, and many
hundreds of studies have been done
to evaluate the quality of life for adults
with chronic kidney disease (CKD).
Transplantation seems to be the renal
replacement therapy that gives the
best quality of life as seen in integrated reviews of literature. With a metaanalysis, specific domains of quality
of life can be quantitatively synthesized, and findings can be statistically
reported. This meta-analysis was
capable of finding effects that have

Kandace Landreneau, PhD, RN, CCTC, is an

Associate Professor in Nursing, University of Texas
Tyler, Tyler, TX. She may be reached via email at
Kandace_Landreneau@uttyler.edu
Kathryn Lee, PhD, RN, FAAN, is a Professor,
University of California San Francisco, School of
Nursing, San Francisco, CA. She may be reached via
email at kathryn.lee@nursing.ucsf.edu
Michael D. Landreneau, MD, is a Transplant
Surgeon, Eunice, LA.

Copyright 2010 American Nephrology Nurses Association

Landreneau, K., Lee, K., & Landreneau, M.D. (2010). Quality of life in patients undergoing hemodialysis and renal transplantation A meta-analytic review. Nephrology
Nursing Journal, 37(1), 37- 45 .
The purpose of this review was to determine the magnitude of effect of renal transplant
on quality of life measures when compared with hemodialysis. Sixteen studies were ana lyzed, and the summary effect sizes were as follows: general quality of life was 0.98,
physical functioning was 0.77, and psychosocial functioning was 0.39. Compared to
hemodialysis, renal transplantation was significantly more effective in improving all
three domains, particularly general overall quality of life and physical functioning.

Goal
To provide an overview of the effectiveness of renal transplantation in improving general overall quality of life and physical functioning via a meta-analysis review.
Objectives
1. Describe how renal transplantation improved general quality of life, physical
functioning, and psychosocial functioning as indicated in the literature review
presented in this article.
2. Explain how this meta-analysis review provides valuable data on quality of life for
patients who have had renal transplantation.

been obscured in other approaches of

summarizing research through qualitative and narrative summaries of
findings.
The construct of quality of life is
widely valued in health care. The
multidimensional aspects of quality of
life have been reported in the healthrelated literature and include not only

an overall perception of ones general

quality of life, but also specific aspects
of physical functioning, psychological
functioning, and social functioning. In
the past 20 years, there has been a
growing interest in the inclusion of
quality of life measures to assess the
efficacy of particular interventions.
Quality of life measures have mostly

This offering for 1.3 contact hours is being provided by the American Nephrology Nurses
Association (ANNA).

Acknowledgments: Support is acknowledged from

the University of California San Francisco, School
of Nursing, and a Post-Doctoral Research Fellowship
f rom the National Institute of Nursing Research, NIH
2 T32 NR007088 (Dr. Kathryn Lee, PI) .

ANNA is accredited as a provider of continuing nursing education (CNE) by the American Nurses
Credentialing Centers Commission on Accreditation.

Statement of Disclosure: The authors reported no

actual or potential conflict of interest in relation to
this continuing nursing education article.

Accreditation status does not imply endorsement by ANNA or ANCC of any commercial product.

NEPHROLOGY NURSING JOURNAL

ANNA is a provider approved by the California Board of Registered Nursing, provider number
CEP 00910.
This CNE article meets the Nephrology Nursing Certification Commissions (NNCCs) continuing
nursing education requirements for certification and recertification.

January-February 2010

Vol. 37, No. 1

37

Quality of Life in Patients Undergoing Hemodialysis and Renal Transplantation A Meta-Analytic Review

evolved from participants personal

perceptions and key factors that are
perceived as important in defining
quality of life by the individual.
Simmons and Abress (1990)
defined important dimensions of
quality of life, which included measures of physical, emotional, and social
well-being; vocational rehabilitation;
sexual adjustment; and marital/family adjustment. Parfrey, Vavasour, and
Gault (1988) reported the importance
of the measures used to assess quality
of life. Renal transplantation (RT)
showed a significant decrease in quality of life on a measure by Parfrey et
al. (1988) and a significant improvement in a measure by Campbell and
Converse (1976). The measure by
Parfrey et al. (1988) was a newer
measure that used two indexes, one
for physical symptoms and one for
emotional symptoms, in his sample of
67 patients undergoing dialysis and
67 patients who had a RT. In comparison, the measure by Campbell and
Converse (1976) showed a large, significant improvement in quality of
life. A large number of quality of life
measures have been developed over
the past several decades and used in
studies of patients with CKD. These
include life satisfaction scales, the
Karnofsky performance index, the
S i ckness Impact Profile, and the
Medical Outcomes Study Short Form
36-Item Health Survey.
Regardless of how quality of life is
measured in research studies, there
are mathematical techniques to determine a common metric for synthesis
of the findings using a meta-analytic
approach. For this systematic review
and meta-analysis, quality of life was
defined as overall general quality of
life, as well as dimensions of physical
functioning and a combination of psychosocial functioning as assessed with
any type of instrument validated for
estimating one of these aspects of
quality of life. The rationale for using
these domains seemed appropriate
because these three specific outcomes
were mentioned most often and
seemed to better define quality of life
as an outcome in this meta-analysis
rather than provide studies that listed

38

numerous and finite quality of life

indicators.
In 1999, Keogh and Feehally stated there were no patient studies comparing quality of life between dialysis
and RT. However, the literature
search in this meta-analysis included
16 studies comparing hemodialysis
(HD) to RT in regard to quality of life
outcomes. Cameron, Whiteside,
Katz, and Devins (2000) published
the first meta-analysis on differences
in emotional distress and psychological well being for various renal
replacement therapies, and included
11 studies in their analysis. They
included all renal replacement therapies (HD, RT, and peritoneal dialysis
[PD]) and found that differences in
quality of life may be attributable to
either valid differences in physiological effectiveness of their renal replacement, reduced medical complications, the effect of the type of renal
replacement therapy on their lifestyle,
or unknown selection bias in samples
of patients for research comparisons.
The UCSF Symptom Management
Model (Dodd et al., 20 01) provides a
useful approach to addressing outcomes from any patient care intervention. In addition to improvement in a
patients primary symptoms, adherence to any type of therapy is influenced by the efficacy of the intervention and by patients and family members who see an improved quality of
life as a result of the intervention. The
model guides researchers and clinicians to consider the person and his
or her environment in relation to
symptom experience. The model
itself is not specific to any particular
symptom; however, it is very useful
for understanding quality of life issues
and outcomes in persons living with
chronic conditions.
Dew and colleagues (1997) performed an analysis of the published
literature on quality of life in patients
undergoing renal, renal-pancreas,
heart, lung, heart-lung, liver, and
bone marrow transplants. They
included only patients who had transplants in their sample of studies for
review. The 66 studies they included
showed that RT resulted in a signifi-

cant improvement in both physical

and psychosocial aspects of quality of
life, as well as overall health perception.

Purpose
RT and HD are the two most frequently used renal replacement therapies. The purpose of this meta-analysis is to provide a current synthesis of
all controlled and uncontrolled studies examining the effectiveness of RT
on specific domains of quality of life
compared to the most frequently used
renal replacement therapy, which is
HD. PD is used in a small percentage
of patients with CKD and is seldom
included in these research studies of
this population. The research question for this meta-analysis was, Does
RT improve quality of life to a greater
extent than HD?

Methods
Search Strategy
Several search strategies were
employed to find published studies
on the quality of life domains of general quality of life, physical functioning, and psychosocial functioning
with RT and HD treatment comparisons. The first search strategy used
computerized database searches using
MEDL INE, PubMed, PsychINFO,
CINA HL, and Cochran Database for
all studies prior to November 20 07.
The authors attempted to retrieve all
available research studies that provide the most extensive amount of
research literature on this topic from
these databases. Key words and
phrases used included choice in renal
replacement therapies, hemodialysis,
renal transplant, renal replacement
therapies, and quality of life in renal
replacement therapies. The next strategy was reviewing articles cited in
previous reviews and research articles
on renal replacement therapies.
Finally, content experts were contacted to find any studies missed by the
electronic searches.
By combining these three strategies, a total of 1123 articles were locat-

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Table 1
Characteristics of Studies Included in Meta-Analysis

C o u n t ry

Sample
Size
H D / RT

Mean Age
HD/RT
(Ye a rs )

Instruments

Quality of
Life Domain

Year

Author

1984

Simmons,
Anderson, &
Kamstra

USA

70/55

37/37

Questionnaire

Psychosocial Function

1985

Evans et al.

USA

287/144

52/37

K a rnofsky
Index of Psychological Affect
Index of Overall Life
Satisfaction
Index of Well-Being

Psychosocial Function

1988

Morris & Jones

USA

24/69

57/49

General Health Questionnaire

General QOL
Psychosocial Function

1988

Parfrey, Vavasour,
& Gault

Canada

63/67

34/54

Questionnaire

General QOL

1989

Bremer, McCauley,
Wrona, & Johnson

USA

41/166

55/38

The Comorbid Index

Positive and Negative Affect
Scales Psychosocial Function
Affect Balance Scale
Index of General Affect
Index of Well-Being

General QOL
Psychosocial Function

1990

White, Ketefian,
Starr, & VoepelLewis

USA

55/55

40/40

Kidney Transplant Questionnaire

General QOL

1990

Koch & Muthny

Germany

290/761

50/44

Semi-Structured Questionnaire

General QOL
Physical Function
Psychosocial Function

1990

Simmons & Abress

USA

83/91

37/37

S u rvey Questionnaire

General QOL
Physical Function
Psychosocial Function

1990

Shih et al.

Ta i wan

50/50

38/38

Visual Analog Scales

General QOL
Psychosocial Function

1990

Devins et al.

Canada

39/34

43/36

S e l f - R e p o rtScales
Physical Function
Intrusiveness Ratings Scale
Psychosocial Function
Psychosocial Function
Fat igu e-I nertia Subscale (of
Profile of Mood States)
Life Satisfaction Rating
Bradbu rn Affect Balance Scale
Beck Depression Inventory
Rosenberg Self-Esteem Inve n t o ry
Hopelessness Scale
Minnesota Mutiphasic Personality
Inve n t o ry

1990

Sayag, Kaplan
De-Nour, Shapira,
Kahan, & Bonet

Israel

31/31

44/43

Psychosocial Adjustment to
Illness Scale
Brief Symptom Inve n t o ry

Psychosocial Function

1995

Gudex

England

188/313

55/47

Health Measurement
Questionnaire

Physical Function
Psychosocial Function

Notes: HD = hemodialysis; RT = renal transplant; QOL = quality of life.

continued on page 40

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39

Quality of Life in Patients Undergoing Hemodialysis and Renal Transplantation A Meta-Analytic Review

Table 1 (continued)
Characteristics of Studies Included in Meta-Analysis

Year

Author

Country

Sample
S i ze
HD/RT

Mean Age
HD/RT
(Years)

Korea

27/30

none

Psychosocial Adjustment to
Illness Scale
State Trait Anxiety Inve n t o ry
Beck Depression Inve n t o ry
Sickness Impact Profile
Symptom Checklist 90

Psychosocial Function

Quality of
Life Domain

Instruments

1996

Pa rk et al.

1996

Laupacis et al.

Canada

168/134

49/42

Kidney Disease Questionnaire

Kidney Transplant Questionnaire
Sickness Impact Profile
Time Trade Off

Psychosocial Function

1999

Keogh & Feehally

England

50/91

60/48

Acceptance of Illness Scale

General QOL

2000

Starzomski &
Hilton

Canada

20/20

52/52

Sense of Coherence Scale

Uncertainty Stress scale
Sickness Impact Profile

Physical Function
Psychosocial Function

Notes: HD = hemodialysis; RT = renal transplant; QOL = quality of life.

ed, with most being in English and a

few being Italian. Data from these
articles were collected over a 12month period in 20 05 to 20 06. The
first author reviewed each of the 1123
abstracts and/or full texts, and 1098
were omitted due to being review
articles or lacking statistical data
analysis. Both authors reviewed the
remaining 25 studies that reported
quality of life outcomes in RT and
HD for inclusion in the meta-analysis.
These 25 studies met initial screening
criteria and were extracted for further
evaluation. Only 25 studies were
found to compare quality of life
between one or more types of dialysis
with a living or cadaveric renal transplant recipient. Sixteen studies, the
final number in this meta-analysis,
were used because they included data
comparing HD with RT and used any
type of quality of life scale. Nine of
the 25 studies were excluded because
they did not compare HD to RT, did
not quantitatively measure quality of
life as an outcome, did not report the
statistical data needed to compute the
analysis, and/or patients were dialyzed using both types of dialysis (HD
or PD) without differentiating the specific type of dialysis. Of the 25 studies,
16 provided the statistical analysis

40

information needed to complete a

meta-analysis. There were no randomized studies, and most studies
were either cross-sectional or pre/
post-test designs (see Table 1).
The 16 studies were each coded
for author, publication year, country,
quality of life domain, investigator,
investigators institution, sample size,
gender, ethnicity, and quality of life
measures, with means plus standard
deviations (SD) to compute the effect
size in SD units for RT compared to
HD. Quality of life was defined by
three domains: general quality of life,
physical functioning, and psychosocial functioning. The domains were
selected because they were most commonly reported quality of life domains in the literature. The co-authors
abstracted data from the 16 studies and
assessed agreement between the outcome variables (general quality of life
and/or physical functioning, and/or
psychosocial functioning).
The inclusion criteria consisted of
studies which (a) compared HD with
transplantation, (b) reported that one
or more of the specific domains of
quality of life were measured, (c)
reported statistical data, and (d)
included men and women. Studies
were omitted if they did not meet the

inclusion criteria. Quality of life measures for each study were examined by
the authors to categorize quality of life
data by whether it measured one or
more of the following domains: general quality of life, physical functioning, or psychosocial functioning. The
general quality of life domain was
defined by inclusion of assessment of
functional impairment, acceptance of
illness, usual activity, general well
being, life satisfaction, and overall
quality of life. The physical functioning domain was defined by inclusion
of assessment of mobility, physical
performance, percent of time feeling
tired, and work capacity. The last
quality of life domain assessed was
defined by the inclusion of assessment of psychosocial functioning,
which included social-personal relations, emotional state, employment,
and psychosocial adjustment. The coauthors coded the studies according
to the previously specified criteria
and calculated the effect sizes. Any
discrepancies between the co-authors
during coding were resolved by discussion.

Statistical Analysis
DSTAT software ( Johnson, 1989 )
was used, and the g was used for the

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Figure 1
Effect Sizes and 95% Confidence Interval (CI)
for General Quality of Life

calculation of effect size for RT versus

HD in each individual study. The
effect size was calculated using the difference between the group means
divided by the pooled SD (Lipsey &
Wilson, 2001). Because of the direction of the effect size mean differences, a positive effect size favors the
RT group in general quality of life,
and a negative effect size favors RT in
physical functioning and psychosocial
functioning. The 95% confidence
intervals (CI) were determined for
each study effect size, and an overall
mean effect size was calculated for
each of the three dimensions of quality of life.
Some of the uncontrolled studies
included data analysis, and others
only included means or stated a difference to be non-significant. Where
means and SD were available, effect
sizes were calculated, and these studies were included.

NEPHROLOGY NURSING JOURNAL

Findings
Study Characteristics
Of the 16 studies included in the
meta-analysis, four included all three
quality of life domains (see Table 1).
There was also considerable variability
in age, comorbidity, and socio-economics of the participants included in
these studies.

Analyses
General quality of life. The result
indicates that the RT intervention
across 9 studies was effective in
improving quality of life at 0 to 24
months post-RT compared to HD. The
summary effect size was 0.98 SD units
(see Figure 1). Since higher scores on
general quality of life scales indicate
better general quality of life, a positive
effect size favors RT.
Overall, patients who had RTs had
better general quality of life than
patients who were treated with HD, as

January-February 2010

Vol. 37, No. 1

seen by effect sizes greater than 0.58.

With a summary effect size of 0.98, the
two groups differ by almost one SD
unit, indicating that the average person
after RT has a better quality of life than
72% of those on HD.
Physical functioning. The RT
intervention across 7 studies was effective in improving quality of life (see
Figure 2). The summary effect size was
0.769. Since higher scores indicate
worse physical functioning, a negative
effect size favors.
Patients who had RT also had consistently improved physical functioning
as seen by effect sizes for four studies
greater than 0.77. The two groups differed by three-quarter SD units, indicating that the average patient who had
RT had better physical functioning
than 78% of the patients who were
treated with HD.
Psychosocial functioning. Psychosocial functioning data were less consistent than physical functioning and general quality of life. The summary effect
size was 0.388, indicating that RT
across 16 studies was effectively
improved but less so than other dimensions of quality of life
There was little consistency in the
effect sizes for psychosocial functioning
when patients who had a RT were
compared to patients who were undergoing HD. Seven studies had effect
sizes less than 0.37. One study had a
moderate effect size of 0.45. Five studies had large effects, with effect sizes
greater than 0.86. With an overall effect
size of 0.388 SD units, the average person after RT had better psychosocial
functioning than 64% of those who
were continuing with HD.
Ten of the 16 studies were conducted outside the United States, where the
renal replacement therapies may be
slightly different. There was no notable
difference in quality of life between
studies in the U.S. and outside the U.S.

Conclusions
In considering using a meta-analysis, the authors were able to summarize
and analyze a body of research studies
rather than use conventional research
reviewing techniques. This labor-inten-

41

Quality of Life in Patients Undergoing Hemodialysis and Renal Transplantation A Meta-Analytic Review

Figure 2
Effect Sizes and 95% Confidence Interval (CI)
for Physical Functioning

Figure 3
Effect Sizes and 95% Confidence Interval (CI)
for Psychosocial Functioning

42

sive approach provided a quantitative

synthesis of quality of life among a
large group of patients who have CKD .
Through this detailed scrutiny of this
meta-analysis, the differences between
studies and associated differences were
analyzed. A limitation of this study was
the bias toward use of only published
articles, since published reports are often
published because of significant findings. Several studies had to be omitted
due to the lack of data in which to perform a meta-analysis. Attempts were
made to contact the authors for their
raw data, and the response was poor.
The poor data quality in some studies
led to the inability to include those
studies in the meta-analysis. This
revealed an important need of better
reporting of the data in future studies.
Investigators defined quality of life
with multiple domains, and it is
important to synthesize the definition
of quality of life as it applies to patients
with CKD who use the different renal
replacement therapies. Throughout
the end stage renal disease (ESRD) literature, quality of life is a complex
construct with no agreed-upon operational definition ( Jofre, Lopez-Gomez,
& Valderrabano, 2000). Some may be
critical of the selection of these three
domains in this studys definition of
the construct of quality of life. As stated, these three specific outcomes were
mentioned most often and seemed to
better define quality of life as the outcome.
The number of patients currently
requiring renal replacement therapies
greatly exceeds the original projections
from the congressional entitlement
program that began in 1973. More than
$ 49 billion is spent annually by the
U.S. federal government for the treatment of CKD (U.S. Renal Data System
[USRDS], 20 08). As financial healthcare concerns become more of an issue
and the large contrast of quality of life
in the different renal replacement therapies is better known, RT should
become increasingly attractive to
patients, healthcare providers, and the
U.S. government. Currently, approximately 65% of patients with CKD
undergo HD (USRDS, 2008 ).
Reduced quality of life, increased cost

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of health care, and increased

risks/complications for the HD population should be addressed. RT affords
the patient the opportunity to receive
the most highly successful renal
replacement, return to living without
renal failure, cessation of the ravages of
renal failure on all body systems, and a
quality of life similar to that of the general healthy population (Sutton &
Pelletier-Murphy, 1989 ) .
Future studies, which compare
quality of life of those affected by CKD
using different renal replacement therapies, should include statistical control
of at least sex, age, race, education, diabetes mellitus, comorbidity, the effect
of time in renal replacement therapy
or failed transplants, and pre-renal
replacement therapy psychiatric morbidity.
Another problem that has affected
quality of life research is the use of
many different instruments. There continues to be disagreement about what
to measure and how and when it
should be measured. The studies with
the largest effect sizes used all different
measures, and none of the studies used
the same measures. This meta-analysis
serves as an important synthesis in
renal replacement therapy research
findings regarding quality of life.
However, a key finding in the study is
the lack of adequate clinical trials using
dialysis therapy with that of RT, even
when methodologies other than randomized clinical trials were considered.
More trials comparing dialysis with RT
are needed.
It has been predicted that ESRD
will be increasing at a much higher rate
since diabetes mellitus is now the primary cause. Given the improved quality of life included in both types of dialysis, the enormous success rate of RT,
the increased possibility and availability of living donors (related and nonrelated), and the increased healthcare
dollar burden of this disease on the
Medicare system, the lack of promotion of RT is surprising, since approximately 65% of patients with CKD
remain on HD (USRDS, 2008).
Controlled trials are urgently needed
and should include the scientific rigor
necessary to provide the data quality to

NEPHROLOGY NURSING JOURNAL

integrate findings in which to report the

true state of this science RT in this
21st century.
RT is the preferred treatment for
renal failure since the success rate is
high, the patient no longer has renal
failure, and the treatment provides the
patient with a functional kidney.
Medications or side effects may
decrease quality of life if the RT fails,
since a small number have organ rejection. HD requires dependence on technology at least three days per week and
has increased morbidity and mortality
rates. The impact of renal failure on
quality of life as perceived by the
patient is considerable. HD, as a renal
replacement therapy, only partially
corrects the symptoms experienced by
the patient and mandates additional
changes in their daily activities that can
diminish quality of life.
The gaps in knowledge are clearly
seen in this area due to the different
designs, the many different measures,
the differences in sample size, and the
way they grouped the comparison
groups. However, by using meta-analysis, valuable data on quality of life were
integrated into useable findings.
Although general quality of life and
physical functioning with RT show
effects of improved quality of life, psychosocial functioning does not show
sufficient data to recommend RT, overall. What remains unknown is when
does the psychosocial functioning
improve after the renal transplant.
These studies were not consistent in the
time frames used after RT. The time
frame was anywhere from 1 day to 10
years post-renal transplant.

Summary
Patients should know that RT may
not be the solution to all their problems, but it remains the optimal treatment for ESRD. With RT, the patient
no longer has renal failure or the ravages of renal failure on all major bodily systems; there are fewer risks than
with other renal replacement therapies;
and there are many more benefits than
the other renal replacement therapies.
Patients who remain on either type of
dialysis continue to have increased

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risks as time progresses due to the renal

failure that remains. Although RT may
not provide quality of life equal to what
the patient had prior to renal failure,
convergent evidence suggests that quality of life benefits are distinctly better
over that of HD after the immediate
reduction in immunosuppression.
Lastly, general quality of life and physical functioning are better with RT as
the method of renal replacement therapy as seen in the last several decades of
ESRD research.
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