Among diverse profound impacts on patients’ quality of life (QoL), end-stage renal disease (ESRD) frequently results in increased levels of depression, anxiety, and stress. Renal replacement therapies such as hemodialysis (HD) and transplantation (TX) are intended to enhance QoL, although their ability to alleviate psychological distress remains uncertain. This research posits the existence of a significant correlation between negative emotional states and QoL among ESRD patients, with varying effects observed in HD and TX patients.

To examine the relationship between QoL and negative emotional states (depression, anxiety, and stress) and predicted QoL in various end-stage renal replacement therapy patients with ESRD.

This cross-sectional study included HD or TX patients in the Eastern Region of Saudi Arabia. The 36-item Short Form Survey and Depression Anxiety Stress Scale (DASS) was used for data collection, and correlation and regression analyses were performed.

The HD and TX transplantation groups showed statistically significant inverse relationships between QoL and DASS scores. HD patients with high anxiety levels and less education scored low on the physical component summary (PCS). In addition, the results of the mental component summary (MCS) were associated with reduced depression. Compared with older transplant patients, TX patients’ PCS scores were lower, and depression, stress, and negative working conditions were highly correlated with MCS scores.

The findings of this study revealed notable connections between well-being and mental turmoil experienced by individuals undergoing HD and TX. The PCS of HD patients is affected by heightened levels of anxiety and lower educational attainment, while the MCS of transplant patients is influenced by advancing age and elevated stress levels. These insights will contribute to a more comprehensive understanding of patient support.

There has been a recent increase in interest among patients undergoing rehabilitative interventions, such as kidney replacement therapy and transplantation, with the goal of improving their quality of life (QoL) and addressing associated mental stress. Recent data from the Global Burden of Disease Study reveals a growing prevalence of end-stage renal disease (ESRD). In 2019, approximately 17.3 million individuals worldwide were affected by chronic kidney disease (CKD) caused by glomerulonephritis, and projections suggest that this number will rise to 18.6 million by 2030[1]. Numerous studies have been conducted to assess the impact of these treatments on patients' psychological well-being and emotional health. Lyrakos et al[2] emphasized the significance of psychological support, noting that patients who received such support exhibited lower levels of anxiety, depression, and suicidal ideation. Similarly, Ratti et al[3] emphasized the role of social support in reducing psychological distress and depressive symptoms in ESRD patients.

Patients with ESRD experience substantial benefits from renal replacement therapy, which is considered a fundamental medical solution for improving their overall well-being. Nevertheless, the QoL for many individuals with advanced-stage or terminal kidney conditions is noticeably lower compared to the general population or those with other chronic disabilities. This decline in QoL can be attributed to several factors, such as inadequate fluid intake, dietary restrictions, and the daily adherence to prescribed medications[4].

Patients receiving renal replacement therapy, whether through hemodialysis (HD) or TX, often experience psychological distress due to factors such as physical pain, limited treatment options, and concerns about long-term health outcomes. Previous studies have shown that renal TX generally leads to a better QoL compared to HD[5]. However, a significant number of patients undergoing both treatments continue to report feelings of sadness and anxiety[6,7]. It has been recognized that providing psychological support is crucial in reducing anxiety levels among these patients. Both in-person and online counseling sessions have been shown to significantly decrease both trait and state anxiety levels[7,8]. Furthermore, psychosocial factors like somatization and mood disorders have been found to be associated with higher healthcare costs and poorer outcomes in kidney TX recipients. This highlights the importance of addressing the psychological well-being of this patient population[9].

Patients with ESRD have concerns about their overall physical and psychological well-being, as well as the particular effects of dialysis and TX. This research explores the link between ESRD patients’ QoL and psychological health disorders (i.e. depression, anxiety, and stress [DAS]), using the Depression, Anxiety, and Stress Scale (DASS). The goal is to fill the knowledge gap regarding the intricate mechanisms that impact the health of ESRD patients receiving different renal replacement treatments.

This cross-sectional study was conducted in the Eastern Region of Saudi Arabia. The study participants consisted of patients diagnosed with ESRD undergoing renal treatment through either HD or TX. The data were collected using convenience sampling. This study was part of the “Quality of Life, Depression and Anxiety in Patients Undergoing Renal Replacement Therapies” research project[10]. A sample size calculation was conducted using a bivariate normal model with an exact distribution to examine a correlation coefficient of 0.2 in a one-tailed test, with an α error probability of 0.05 and a power of 0.80. The null hypothesis presumed no correlation (ρ = 0). The investigation concluded that 153 participants were necessary to attain adequate statistical power to meet the research objectives. The effect size for the correlation was computed and categorized following the guidelines outlined by[11]. A small effect size is represented by R² = 0.01, a medium effect size by R² = 0.09, and a large effect size by R² = 0.25.

The 36-item Short Form Survey is a widely used questionnaire established as a standard measure for various purposes. It is considered one of the most widely used assessments of health-related QoL and has a validated and reliable Arabic-language version[12]. This comprehensive measure evaluates eight dimensions pertaining to health: physical functionality, limitations caused by physical health issues, physical pain experienced, social capability, overall mental well-being, limitations arising from emotional problems, energy levels and fatigue (vitality), and the general perception of personal health[13].

The adapted Arabic version of the DASS was developed to measure the intensity of negative emotional states including DAS. This self-report questionnaire consists of 42 items and assesses the severity of depression, anxiety, and related symptoms over the past week. Respondents indicated the occurrence of symptoms, with each item rated from 0 (no stress or depression in the last week) to 3 (severe depression and stress in the last week)[14].

This study included 105 HD patients and 92 TX patients. Figure 1 summarizes key demographic data for both groups. There was a notably higher proportional of males among HD patients (76.2%) compared to TX patients (63.0%). Both groups had a fairly even distribution of married and unmarried participants. Patients with HD had higher rates of illiteracy (19.0% vs 4.3%) and lower rates of higher education (14.3% vs 26.1%) compared to TX patients. Rates for G1-8 and G9-12 education were similar between the groups, while diploma attainment rates were nearly identical. Non-employment rates were 58.1% for HD patients and 42.4% for TX patients. The majority of TX patients were of Saudi nationality (96.7%).

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Figure 1 Demographic characteristics. HD: Hemodialysis; TX: Transplantation.

Table 1 shows the correlations between the QoL and DASS domains. In HD patients, there were noteworthy negative associations observed between scores reflecting QoL and indicators of DAS. Specifically, for the PCS, the correlations were found to be -0.404¹ (R� = 0.163), -0.314¹ (R� = 0.099), and -0.412¹ (R� = 0.170), respectively, denoting medium to large effect sizes. The MCS also exhibited notable correlations: -0.332¹ (R� = 0.110) for depression, -0.368¹ (R� = 0.135) for anxiety, and -0.240² (R� = 0.058) for stress. Conversely, in TX patients, significant associations were established for MCS: -0.544¹ (R� = 0.295) for depression, -0.388¹ (R� = 0.151) for anxiety, and -0.508 (R� = 0.258) for stress, all of which indicated large effect sizes. The correlations pertaining to PCS were comparatively smaller in magnitude, with only anxiety demonstrating significance at -0.248² (R� = 0.062).

By analyzing the QoL in different patient groups, the foremost influencers of QoL could be identified. In HD patients, increased anxiety and lower education levels have been found to negatively impact PCS and QoL. The comprehensive model showed statistical significance (F = 6.07, P < 0.05), and explained 47% of the variance in the PCS scores. In a broader patient cohort, depression was found to be a significant factor that negatively affected MCS. The overall model explained 25% of the variance in QoL (R² = 0.25, F = 2.38, P < 0.05). In TX patients, older age was associated with a lower PCS score, with the model explaining 25% of the QoL variance (R² = 0.25, F = 2.24, P < 0.05). Ultimately, the mental wellbeing of TX recipients is adversely affected by heightened levels of depression, stress, and negative employment circumstances. MCS is specifically affected by psychological aspects of QoL. Through a comprehensive analysis, it was determined that the developed model could explain 66% of QoL outcomes’ variance (Table 2).

This study investigated the complex relationship between psychological well-being and QoL in patients receiving end-stage renal replacement therapy for ESRD. Poor emotional status revealed a significant negative association between QoL and DAS in HD and TX patients. According to the regression analysis, greater anxiety and lower educational attainment were associated with lower PCS scores in HD patients, whereas depression influenced MCS scores. Older TX patients had lower PCS scores, with sadness, stress, and an unfavorable employment situation all having a substantial impact on MCS scores.

Comparative analysis of existing literature consistently highlights the detrimental impact of psychological distress on QoL in both HD and TX populations. Previous research consistently identifies high prevalence rates of anxiety (20%-45%) and depression (25%-50%) among HD patients, underscoring their vulnerability to mental health challenges[15-18]. Regression analysis further highlighted the negative association between higher anxiety[17,19-21].

The regression findings provide additional evidence of the distinct effects of anxiety, depression, and stress on PCS and MCS scores, underscoring the importance of implementing targeted interventions to enhance psychological well-being among patients undergoing renal replacement therapy[17,21-24]. Effectively addressing these mental health issues is essential for improving QoL and patient outcomes (and also healthcare system efficiency).

Moreover, the comparison between cohorts undergoing HD and TX highlights significant disparities in challenges and outcomes. TX, in contrast to dialysis, presents enhanced health status and potential employment advantages. However, it is crucial to prioritize ongoing care and management to maintain these improvements[25-27]. On the other hand, individuals undergoing HD often face enduring procedural difficulties, financial limitations, and social isolation, all of which contribute to inferior psychological well-being and diminished QoL[28]. Dialysis leads to social loneliness due to loss of independence, financial challenges, and limited daily activities. This persists even though TX improves health status and ongoing care is a priority[29].

This study’s limitations include its lack of a relatively large sample size, which inherently inhibits generalizing the outcomes. Furthermore, the cross-sectional design and reliance on self-reported measures may introduce various forms of bias. It is also important to consider the cultural and regional specificity of the studied context, which further limits the generalizability of the findings. Additionally, there may be unmeasured confounding variables, such as socioeconomic status and comorbidities, that could have an impact on pertinent variables, and thus the results. In future research, it would be beneficial to address these limitations and investigate the longitudinal effects of the variables in question.

These results provide important insights into the QoL of patients with ESRD. By examining the impact of dialysis on QoL, this study contributes to the knowledge base for healthcare managers and policymakers, enabling them to identify patient needs and vulnerable populations. The findings also suggest potential improvements that can be undertaken in hospital settings in order to enhance QoL. Additionally, by predicting QoL factors using psychological and demographic variables, this study increases awareness of relevant risk factors and assists administrators in implementing effective interventions. This research enhances our understanding of the QoL of ESRD patients, and emphasizes the need for further longitudinal studies, to comprehensively explore its complexity and changes over time.