CKD is a degenerative illness that affects more than 10% of the global population, or more than 800 million people.It is a disorder where the kidneys are damaged and unable to filter blood as effectively as they should. As a result, the body retains extra fluid and blood waste, which can lead to various health issues like heart disease and stroke.End- stage renal disease (ESRD) is the term used to describe kidney failure managed with dialysis or kidney transplantation¹.As risk factors including obesity and diabetes mellitus have increased, CKD patients have also increased in number² In 2017, 843.6 million people were expected to be afflicted globally. The Global Burden of Disease (GBD) investigations have revealed that chronic kidney disease (CKD) has become a major cause of death globally, despite a drop in mortality among individuals with end-stage kidney disease (ESKD)^3-5 CKD patients not only suffer from biochemical abnormalities but also suffer from psychiatric problems. A.De Sousa discovered that depression was the most frequent psychological complication arising from renal failure. Observational studies have shown over and again that dialysis patients commit suicide at greater rates than the general healthy community. In situations of renal failure, there may be extreme worry and anxiety somatic symptoms as palpitations, sweating, chest discomfort, and dread of death^6-8. Employment, eating habits, holiday activities, sense of security, self-esteem, social interactions, and the capacity to enjoy life are among the main spheres of life impacted by ESRD and its treatment. These factors have a detrimental impact on life's physical, psychological, financial, and environmental facets, which lowers QoL. Impaired quality of life is predicted by comorbid conditions such as diabetes, heart failure, hypertension, etc. Dialysis patients' quality of life declines as treatment time rises⁹.

To study the relationship between socio demographic and clinical variables with psychiatric morbidity

In this cross-sectional observational hospital-based study, conducted in the Department of General Medicine and the Department of Nephrology at Mahatma Gandhi Medical College & Hospital in Jaipur, the objective was to evaluate the quality of life and psychiatric morbidity among patients with end-stage renal disease (ESRD) undergoing maintenance hemodialysis. The study spanned 18 months following Institutional Ethics Committee (IEC) approval.The study targeted patients over the age of 18 who had been diagnosed with ESRD and had been on hemodialysis for a minimum of three months. Participants were selected based on their willingness to participate and their ability to complete the required assessments. Those unwilling to provide consent or unable to complete the study instruments were excluded.Ethical considerations included obtaining IEC approval prior to the study's initiation and securing written informed consent from all participants. Data collection involved administering a range of tools: a socio-demographic questionnaire, the WHOQOL-BREF format, the General Health Questionnaire, the Hamilton Anxiety Scale, and the Hamilton Depression Scale. Additionally, laboratory investigations were conducted, and the results were recorded for each participant. This comprehensive approach aimed to capture a holistic view of the patients' quality of life and psychiatric health.

Study Procedure

After obtaining consent, detailed histories of study participants were recorded, including socio-demographic data, duration of chronic kidney disease (CKD), and co-morbid conditions such as diabetes, hypertension, and heart disease. Blood pressure was measured before and after dialysis, and comprehensive laboratory tests were conducted to assess various biomarkers. Participants completed the WHOQOL-BREF, Hamilton Anxiety Rating Scale (HAM-A), and Hamilton Depression Rating Scale (HDRS), either independently or with assistance, to evaluate their quality of life and psychiatric symptoms. The WHOQOL-BREF¹⁰ assesses quality of life across physical, psychological, social, and environmental domains on a 0-100 scale. The General Health Questionnaire (GHQ-12)¹¹ measures psychological distress with a maximum score of 36. The HAM-A¹² evaluates anxiety severity with a score range of 0-56, and the HDRS 14 assesses depression severity with scores indicating normal to severe levels of depression.

Data Analysıs

Entire data was compiled in MS Excel Sheet and then entered in Statistical Package for Social Sciences (SPSS) 16.0 for Windows (SPSS, Inc, Chicago, IL, USA). Various coding given to variable and then data recorded for analysis.Continuous variables were described by mean and standard deviations (SD) and categorical variables were described according to median and inter quartile range (IQR). Various parameters were compared with WHOQOL, HAM-A and HAM-D scales and suitable analysis done by cross tabulations, correlation analysis etc via SPSS software. Results were described using Chi square test and considered significant if p value found to be less than 0.05.

Table: 1. Distribution according to Socio-demographic Factors 1

As shown in the table out of total 100 subjects there are 65 (65%) males and 35 (35%) females with male to female ratio 1.86 (figure). In this study 83 (83%), 8 (8%), 4(4%) and 5(%) subjects are married, unmarried, divorcee and widower respectively. 66 (66%) subjects have their residence in rural area and rest 34(34%) have their residence in urban area.

Table 2: Distribution according to Type and Number Of Co-morbidity

The study reveals that among the participants, 35% suffer from two co-morbidities (diabetes and hypertension), while 31% have three co-morbidities (diabetes, hypertension, and anemia). Additionally, 21% have a single co-morbidity (anemia) and 6% face four co-morbidities (diabetes, hypertension, CAD, and strokes). Notably, 7% of patients have no co-morbidities. The average duration of dialysis is 5.28 years (SD 3.08), with a range from 1 to 14 years. In terms of dialysis frequency, 31% undergo one session per week, 47% have two sessions per week, and 22% receive three sessions per week.

Table 3: Distribution of score of QOL Scale and Psychological Score Scale

The study reports an overall mean WHO QOL BREF score of 48.6 (SD 4.55), with scores ranging from 40 to 58. The scores for the different domains are as follows: physical domain—39.54 (SD 3.3), psychological domain—52.37 (SD 7.2), social domain—48.77 (SD 6.01), and environmental domain—53.72 (SD 7.82). The mean General Health Questionnaire (GHQ) score is 20.40 (SD 3.69), with a range from 14 to 26. The Hamilton Depression Rating Scale (HAM-D) mean score is 14.10 (SD 6.69), ranging from 5 to 28, while the Hamilton Anxiety Rating Scale (HAM-A) mean score is 21.11 (SD 12.73), with scores ranging from 0 to 42.

Table 4: Distribution of study population according HAM-D and HAM-A Score

As shown in the table according to HAM-D Scale 24(24%), 30(30%), 13(13%), 21(21%) and 12(12%) study subjects are not suffering from depression, suffering from mild, moderate , severe and very severe depression respectively (figure). Similarly according to HAM-A scale 45(45%), 16(16%), 11(11%) and 28(28%) of the study subjects are suffering from mild , mild to moderate, moderate to severe and severe to very severe anxiety respectively.

Table 5: Relationship between CKD duration, Number Of Co-morbidity Vs QOL, GHQ, HAM-D and HAM-A Scale (p value) (ANOVA)

On comparing number of co-morbidity of the study subject with physical domain score, psychological domain score, social domain score environmental domain score, WHO QOL overall score, GHQ score, HAM-D score and HAM-A score , P value came out to be 0.000, 0.000, 0.001, 0.000, 0.000, 0.000, 0.000 and 0.000 respectively i.e all the relation statistically significant. Similarly on comparing duration of CKD with above scales the p value come out to be 0.000, 0.341, 0.331, 0.000, 0.000, 0.000, 0.000 and 0.000 respectively i.e except with psychological or social domain all relationship is statistically significant.

Table 6: Correlation Between WHO QOL Scale score and GHQ Scale, HAM-D Scale and HAM-A Scale (p value)

The above table shows that co-relational analysis of WHO QOL scale score with GHQ scale, HAM-D scale and HAM-A scale it was found out that they are negatively correlated Pearson correlation coefficient be -0.988, -0.966 and -0.977 respectively and p values 0.000, 0.000 and 0.000 respectively i.e they are statistically significant.

This study included total 100 CKD patients on hemodialysis. The mean age of the study subject is 50.05 yrs (SD 10.32) with minimum age 23 and maximum age 69 yrs out of which 65 (65%) are males and 35 (35%) are females with male to female ratio 1.86. In this study 83 (83%), 8 (8%), 4(4%) and 5(%) subjects are married, unmarried, divorcee and widower respectively. 66 (66%) subjects have their residence in rural area and rest 34(34%) have their residence in urban area In this study most of the study subject i.e 35(35%) are suffering from diabetes and hypertension and rest 7 have no co-morbidity; 21(21%) are suffering from anemia; 31(31%) are suffering from diabetes, hypertension and anemia ; and 6(6%) are suffering from diabetes, hypertension, CAD and strokes. So in this study 7(7%), 21(21%), 35(35%) 31 (31%) and 6 (6%) are suffering from no co-morbidity, one co-morbidity, two co-morbidity, three co-morbidity and four co-morbidity respectively.The overall mean WHO QOL BREF score of the subject is 48.6 (SD 4.55) . In WHO QOL BREF score the physical domain mean score is 39.54(SD 3.3), psychological domain score is 52.37(SD 7.2), social domain mean score is 48.77 (SD 6.01) and environmental domain score is 53.72 (SD 7.82). The GHQ scale mean score of the study subject is 20.40(SD 3.69) . The HAM-D scale mean score in this study is 14.10(SD 6.69). Similarly the HAM-A mean score is 21.11 (SD 12.73).According to HAM-D Scale 24(24%), 30(30%), 13(13%), 21(21%) and 12(12%) study subjects are not suffering from depression, suffering from mild, moderate, severe and very severe depression respectively. Similarly according to HAM-A scale 45(45%), 16(16%), 11(11%) and 28(28%) of the study subjects are suffering from mild , mild to moderate, moderate to severe and severe to very severe anxiety respectively.On comparing number of co-morbidity of the study subject with physical domain score, psychological domain score, social domain score environmental domain score, WHO QOL overall score, GHQ score, HAM-D score and HAM-A score , P value came out to be 0.000, 0.000, 0.001, 0.000, 0.000, 0.000, 0.000 and 0.000 respectively i.e all the relation statistically significant. Similarly on comparing duration of CKD with above scales the p value come out to be 0.000, 0.341, 0.331, 0.000, 0.000, 0.000, 0.000 and 0.000 respectively i.e except with psychological or social domain all relationship is statistically significant. Again on comparing number of dialysis per week with above scales the p value come out to be 0.000, 0.402, 0.429, 0.000, 0.000, 0.000, 0.002 and 0.002 respectively i.e except with psychological or social domain all relationship is statistically significant.Co-relational analysis of WHO QOL scale score with GHQ scale, HAM-D scale and HAM-A scale it was found out that they are negatively correlated Pearson correlation coefficient be -0.988, -0.966 and -0.977 respectively and p values 0.000,0.000 and 0.000 respectively i.e they are statistically significant. It means as the Psycological scale values are increasing the WHO QOL values are decreasing.Various studies were done in the past to compare the QOL and psychological health status of CKD patients.

In a study by Alshelleh et al¹⁴ in 2023 on CKD patients mean duration of CKD was 10.4 years and in this study mean duration is 5.28 yrs (SD 3.08). They reported 61(92.4%) patients found to have depression with female has significant higher depression compared to males (p<0.05). In this study depression is prevalent in 76% (76) of CKD patient of varying degree but there is no significant difference of prevalence of depression among male and female. (p>0.05). Single patient has significant higher anxiety score compared to married (p<0.05) whereas in our study no relation of marriage and HAM-A or HAM-D score was found (p>0.05). Mean score of physical domain was 71.74 (SD 3.5), psychological domain 75.32(SD 17), social domain 75.83 (SD 18.53) and environmental domain 76.55(SD 13.72) which in our study were 39.54(SD 3.3), 52.37(SD 7.2), 48.77 (SD 6.01) and 53.72 (SD

7.82) respectively.

There is an indirect correlation between QOL domains and GAD¹⁵ and PHQ¹⁶  score which is similar to in our study in which the QOL domain score and overall QOL score is significantly correlated with HAM-A, HAM-D and GHQ score (p<0.05). There was no significant relation of QOL to marital status which is similar to our study (p>0.05). Those who studied in university had higher physical functioning score compared to mean (p<0.05) but in our study education status has no relation to QOL (p>0.05).

In a cross-sectional study done by Abdullah et al¹⁷ in 2021 on CKD patients it was found that diabetes mellitus was present in 101 (56.1 %) of patients and hypertension was present in 23 (12.8 %) of the patients. In our study diabetes and hypertension was present in 72% (72) of the CKD patients. Among the patients, 2 (1.1 %), 112 (62.25 %) and 66 (36.7 %) on once weekly, twice weekly and thrice weekly dialysis. in our study the corresponding values were 31(31%) , 47 (47%) and 22 (22%) respectively. Mean duration of dialysis was 9.01 years (SD 5.63 yrs) which in our study was 5.28 yrs (SD 3.08). About 27 patients (15.0 %) had depressive illness which in ou.r study was present in 76% ranging from mild to very severe.

A multi-centric cross-sectional study done by Josi et al¹⁸ in 2017 on CKD patients found that QOL scores recorded as environmental domain 53.17±15.59, psychological domain 51.23±18.61, social domain 49.86±21.64, and physical domain 45.93±16.90. In our study the similar domain values are 53.72 (SD 7.82), 52.37(SD 7.2), 48.77 (SD 6.01) and 39.54(SD 3.3) respectively and those are nearly the same. Employed patients scored better in the environmental domain (p=0.019). Unemployed patients and those of the Terai/Madhesi ethnic group had significantly low scores in overall perception of health (p<0.05) as compared to other groups. Low income status and increased duration on hemodialysis were found to be the only independent negative predictors of QOL in patients with hemodialysis (p<0.05). In our study, too low family income is significant predictor of low QOL and high psychological scale values (HAM-A, HAM-D, GHQ scale) with p <0.05. In our study, increased duration of dialysis is associated with significant decrease in physical domain, environmental domain, overall QOl score, HAM-A, HAM-D and GHQ scale.

This study underscores the significant impact of chronic kidney disease (CKD) on both the physical and mental health of patients undergoing hemodialysis. It highlights that poor quality of life, including diminished physical, psychological, social, and environmental well-being, is closely linked to factors such as low family income, living in nuclear families, the number of co-morbidities, CKD duration, and dialysis frequency. The findings emphasize the critical need for comprehensive care approaches that integrate mental health services with routine medical treatment and address socio-economic support. By improving awareness and developing targeted interventions, healthcare systems can enhance the overall well-being of CKD patients, ensuring better quality of life and mental health outcomes.

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