Elsevier

Applied Nursing Research

Volume 28, Issue 4, November 2015, Pages e13-e19
Applied Nursing Research

Online Article
Relationship between symptom clusters and quality of life in patients at stages 2 to 4 chronic kidney disease in Korea

https://doi.org/10.1016/j.apnr.2015.03.004Get rights and content

Abstract

Purpose

This study was conducted to identify the relationship between symptom clusters and quality of life (QOL) in patients with stages 2 to 4 chronic kidney disease (CKD) in Korea.

Methods

Using self-reported questionnaires, data were collected from 143 patients who underwent treatment for CKD at one hospital in Korea. The 17-item Patient Outcome Scale was used to measure symptoms, and the 36-item Short Form Health Survey Instrument Version 2 (SF-36v2) was used to measure the QOL. Data were analyzed using factor analysis to draw symptom clusters.

Results

Among five symptom clusters, the energy insufficiency and pain cluster was found to have the highest prevalence and greatest severity. The severity of symptom clusters showed negative correlations with both physical and mental component summary (PCS and MCS) scores. Elderly patients scored low on PCS, whereas younger patients in their 30s and 40s scored low on MCS. Negative correlations were found between symptom clusters and PCS as well as MCS. The severity of symptoms and QOL had stronger relationships with subjective perception of symptoms and psychological factors than with objective clinical indicators.

Conclusion

As the effects of physical and psychological symptoms on the QOL in patients with stages 2 to 4 CKD were identified in this study, nurses should develop strategic nursing plans focused on symptom clusters and patients' subjective perception of symptoms rather than objective clinical indicators in order to improve the QOL in patients with CKD.

Introduction

The morbidity and mortality rates of chronic kidney disease (CKD) have increased worldwide, and the number of patients who undergo dialysis treatment for CKD in Korea has doubled in the past 10 years (Jin et al., 2012). Patients with CKD suffer from a wide range of physical and psychological symptoms (Thong et al., 2009), such as fatigue, lack of energy, drowsiness, pain, and pruritus (Almutary et al., 2013, Murtagh et al., 2007a), all of which emerge at different stages during the course of the disease. In patients with CKD, multiple symptoms occur simultaneously as a cluster rather than in isolation (Lee, Lin, Chaboyer, Chiang, & Hung, 2007). For example, fatigue occurs in association with the co-existing symptoms of pruritus, sleep disturbance, and depression (Jablonski, 2007, Thong et al., 2009). Furthermore, a symptom constellation is affected by the complexity of the severity of isolated single symptoms (Gift, Jablonski, Stommel, & William Given, 2004). As a result, patients who have multiple symptoms bear an aggravated symptom burden from the complexity of isolated single symptoms, which, in turn, leads to the deterioration of their quality of life (QOL) (Murtagh, Addington-Hall, & Higginson, 2007).

If nursing plans for patients with CKD are instituted based on a disease-oriented approach to change the clinical indicators of a characteristic set of signs, it will not be effective in decreasing the severity of symptoms that are perceived by patients (Kimmel et al., 2008, Murtagh et al., 2007a). Therefore, it is important for nurses to provide nursing care for patients with CKD based on a patient-oriented approach customized to patients' symptom clusters perceived by the patients.

A symptom cluster is referred to as a group of symptoms of a disease, which co-occurs with more than three symptoms in the form of a pathophysiological and psychological constellation (Dodd et al., 2001a, Miaskowski et al., 2007). Symptom clusters have an adverse effect on patient outcomes and morbidity (Dodd, Miaskowski, & Paul, 2001). Therefore, it is important for nurses to understand not only isolated single symptoms of CKD, but also symptom clusters that occur simultaneously with various symptoms.

Although numerous studies have been conducted with patients at end stage renal disease (ESRD) to derive symptom clusters from a wide range of characteristic symptoms of CKD (Jablonski, 2007, Thong et al., 2009, Yong et al., 2009, Yu et al., 2012), little research has been done to identify the symptom clusters of patients with CKD, who are neither at ESRD nor on dialysis (Murtagh, Addington-Hall, Edmondset al., 2007). Patients with stages 2 to 4 CKD who are not yet on dialysis also experience multiple symptoms or co-morbid conditions such as anemia, hypertension, depression, and symptom burden, all of which affect their QOL. Therefore, it is critical to identify symptom clusters and their effect on QOL before beginning dialysis treatment.

An instrument was recently developed to measure the symptom clusters of CKD (Agarwal, 2010). However, Agarwal's (2010) instrument is tailored to Western, mostly male patients, and contains too many questions to be easily utilized in a clinical setting. In light of addressing the issue of the lack of applicable and replicable measuring instruments for Korean patients who have different physical and psychological make-ups from their Western counterparts, there needs to be a study to identify which symptom clusters are related to the QOL for Korean patients.

Therefore, the purpose of this study was to derive symptom clusters from multiple symptoms experienced by patients with stages 2 to 4 CKD in Korea through factor analysis, assess the prevalence and severity of symptoms and symptom clusters, compare the differences in cluster scores by demographic and clinical characteristics, and identify the relationship between the severity of symptom clusters and QOL.

Section snippets

Study design

This study utilized a cross-sectional survey design that has descriptive and correlational characteristics in analysis.

Sample and setting

Among those who agreed to participate in this study, 143 patients who underwent treatment for stages 2 to 4 CKD at a hospital in Korea were selected as study participants. Power analysis with version 3.1.2 of the G*power program indicated that a sample of 143 patients would provide a power of .84 for detecting group differences using independent t-test at an alpha level of .05

Demographic and clinical characteristics, and quality of life

A total of 54 patients (37.8%) were female, and the mean age of the participants was 66.3 years (SD = 14.29). Those who had occupations accounted for 36.6% (52 participants). Almost two-thirds of the participants had hypertension, 43.3% had diabetes mellitus, and 2.1%, cardiovascular disease. As many as 22 patients (15.4%) had eGFR over 60 mL/min/1.73 m2, and 38 (26.6%) had eGFR between 15.1 and 29.9 mL/min/1.73 m2 (see Table 1). Among those with stage 4 CKD, nine participants were in their 30s and

Discussion

This study was conducted to derive symptom clusters from 17 symptoms in patients with stages 2 to 4 CKD in Korea, and to identify the relationship between the severity of symptom clusters and the QOL in those patients. As a result, the information obtained from this study can be used to develop a more effective nursing intervention by taking patients' subjective symptoms into consideration in order to improve their QOL.

In this study, the severity of symptoms for stage 2 to 4 CKD was measured

Conclusion

This study was conducted to derive symptom clusters from multiple symptoms of CKD in patients with stages 2 to 4 CKD in Korea. As a result, five symptom clusters were derived from 17 symptoms. Among them, the symptom cluster that showed the highest prevalence and severity was ‘energy insufficiency and pain’ and the cluster showed negative correlations with PCS and MCS. More specifically, those who were relatively young, in their 30s and 40s, were more likely to score low on the MCS, while those

Acknowledgment

This research was supported by Basic Research Program through the National Research Foundation of Korea (NRF) from the Ministry of Education, Research, Science and Technology (no. NRF-2013 R1A1A3 008750).

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    Conflict of interest: No conflict of Interest has been declared by the authors.

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