Improving quality of life in older dialysis patients: the case for broader functional assessment

The incidence of end-stage kidney disease (ESKD) is rising, particularly among adults aged 65 and older, who account for over half of new cases in Europe. While older adults consistently prioritize quality of life (QoL), it is rarely a primary endpoint in clinical trials and remains underemphasized in clinical decision making. Health-related QoL (HRQoL) captures only part of the broader QoL concept, which may contribute to inconsistencies across studies. We examined determinants of overall QoL and its relationship to HRQoL using comprehensive assessments.

We conducted a cross-sectional study of adults ≥65 receiving in-center hemodialysis at four hospitals in Flanders, Belgium. Data included sociodemographic and treatment-specific information, a comprehensive geriatric assessment, Groningen Frailty Indicator, Brussels Integrated Activities of Daily Living Inventory, and HRQoL measures [EuroQol 5-Dimension 3-Level Questionnaire (EQ-5D-3L), Quality of Life Questionnaire-Core 30 (QLQ-C30), and Quality of Life Questionnaire-Myeloma Module]. Overall QoL was assessed with the Anamnestic Comparative Self-Assessment (ACSA). We conducted descriptive, univariate, multivariate, and cluster analyses.

We included 111 patients (64.9% male; mean age 78.1 ± 7.4 years; median dialysis vintage 36.0 months [interquartile range 11.0-65.8]). Overall QoL was moderately positive (ACSA mean 1.97 ± 2.05; range -5 to 5). The EQ-5D utility index was not correlated with the ACSA (ρ = -0.052, P = .591). Multivariate analysis identified "cognitive functioning" (QLQ-C30), "usual activities" (EQ-5D-3L), hospital admissions, "subjective health status" (EQ-5D-3L), and "social functioning" (QLQ-C30) as independent predictors, explaining 31% of the variance in the ACSA. Cluster analysis identified three subgroups: a relatively resilient subgroup (n = 59), a functioning-impaired subgroup (n = 36), and a psychologically frail subgroup (n = 12).

Focusing on cognition, usual activities, and social functioning may improve outcome relevance, identify vulnerable subgroups, and support more effective resource allocation for older adults with ESKD.