REVIEW OF RELATED LITERATURE

This research study is to understand of the experience of people

living on dialysis. Some books, journals, and articles are reviewed

having connection in the present study. These are classified into

foreign and local in origin. Discussion of this group of papers

suggests that the renal client experience can be comprehensively

interpreted as a response to renal illness and therapy within the

specialized health care context of renal replacement therapy. From

a better understanding of the experience of people living on

dialysis, health professionals can more adequately support them

so they can live as fully as possible.

Hemodialysis

Hemodialysis is a treatment to filter wastes and water from

your blood, as the kidneys did when they were healthy. Hemodialysis

helps control blood pressure and balance important minerals, such

as potassium, sodium, and calcium, in your blood. Hemodialysis can

help you feel better and live longer, but it’s not a cure for kidney

failure. (https://www.niddk.nih.gov)

During hemodialysis, the blood goes through a filter, called

a dialyzer, outside your body. A dialyzer is sometimes called an

“artificial kidney.” At the start of a hemodialysis treatment, a

 dialysis nurse or technician places two needles into your

arm. Patient may prefer to put in the own needles after you’re

trained by your health care team. A numbing cream or spray can be

used if placing the needles bothers the patient. Each needle is

attached to a soft tube connected to the dialysis machine. The

dialysis machine pumps blood through the filter and returns the

blood to your body. During the process, the dialysis machine checks

the blood pressure and controls how quickly Blood enters at one

end of the filter and is forced into many, very thin, hollow fibers.

As the blood passes through the hollow fibers, dialysis solution

passes in the opposite direction on the outside of the fibers. Waste

products from your blood move into the dialysis solution. Filtered

blood remains in the hollow fibers and returns to the body. The

nephrologist—a doctor who specializes in kidney problems—will

prescribe a dialysis solution to meet the needs. The dialysis

solution contains water and chemicals that are added to safely

remove wastes, extra salt, and fluid from your blood.

(https://www.niddk.nih.gov). Most patients tolerate hemodialysis

well. However, side effects of hemodialysis can occur. Low blood

pressure is the most common complication and can be accompanied

by lightheadedness, shortness of breath, abdominal cramps, muscle

cramps, nausea, or vomiting (Ellam & Wilkie, 2015).

Lifestyle Consideration

Aside from the clinical challenges that dialysis treatment

poses, individuals diagnosed with ESRD are also faced with numerous

lifestyle alterations including diet and fluid intake limitations;

school, work, and travel modifications; sleep and energy level

variations; burdens placed on loved ones; inability to control

changes in physical appearance, body image, sexuality, and

fertility; and lastly, overall prognosis (Schatell, 2015). Based

on Schatell’s (2015) patient interactions and 18 years of

experience, lifestyle is the most important factor considered by

individuals with ESRD who are faced with choosing a long-term

treatment option. Maintaining quality of life, adjusting to

haemodialysis, coping with chronic depression and hopelessness are

common concerns of individuals with CKD. The treatment regimen

demands may be overwhelming for a debilitated patient and further

reduce the role functioning within the family. Also severe fluid

and dietary restrictions further increase discomfort and

frustration with the disease.

Patients on hemodialysis not only face treatment-related

stressors, but also have to deal with changes in their concept of

self and self-confidence, reversal in family roles, an loss of

dignity (Ibrahim, Taboonpong, & Nilnamat,2009). These changes

affect the whole person and may also affect how patients on

hemodialysis go through their lives and take meaning to their

lives. Nurses and other health professionals need to understand

the lived experiences of patients on hemodialysis to properly

respond to these physical, psychological, emotional, and spiritual

changes. By gaining these insights, health professionals can

develop appropriate nursing responses and improve quality of care

(Polaschek, 2003). Feeling Mental and Emotional Distress Patients

on hemodialysis experience not only physical problems, but also

psychological problems, including mental and emotional distress.

All studies reviewed revealed mental and emotional distress.

Mental fatigue, as a kind of mental and emotional

dis-tress, was one of the most frequent problems

identified in those studies. Heike et al. (2003) used the

theme “mental fatigue” to express patients ‘experiences of mental

distress. The feeling of fatigue was described as different from

a normal feeling of fatigue an unpleasant, sickly, and heavy

feeling, which patients experienced as something they really had

to fight to overcome. As one said, “You feel like you’re

poisoned…the feeling of fatigue is something like that” (Heiweet

al., 2003, p. 172). It is evident from the literature that

depression, uncertainty, changes in personality, anger,

denial, worth-lessens, fear, anxiety, and hopeless-ness

are expressions of mental and emotional distress

experienced by patients on hemodialysis. These are negative

emotional responses to their condition. Physical problems and

mental emotional distress resulting from ESRD and

hemodialysis therapy may affect patients’ mental and

emotional statuses. Mental and emotional distress also affects

their social lives. The theme of “disrupted marital, family, and

social life” (Hagren et al.,2001, p. 200) reveals how

physical and altered mental emotional status affects

patients’ relationships and social life. Physical and mental

emotional problems that emerge due to hemodialysis therapy

influence views, perceptions, and responses of significant others

to patients on hemodialysis-sis. Significant others, such as

spouses, children, neighbors, colleagues, and friends, may have

positive or negative responses to the patients. If a significant

other expresses a negative view, perception, or response, it may

cause negative effects in their relationship with the

patients, and disruptions in some relationships occur.

Patients ‘mental and emotional statuses could become worse.

However, patients on hemodialysis need family and social support

to reduce negative effects of mental and emotional distress.

Non-pharmacological interventions

Psychotherapy has been used for a wide range of chronic

illnesses, including patients with HD (Hedayati & Finkelstein,

2009). Of these approaches, cognitive behavioral therapy (CBT),

a well-documented evidence-based therapy for depression, has been

shown to be effective (Chen et al., 2011; Duarte et al., 2009).

CBT is based on the assumption that one’s dysfunctional “automatic

thoughts” in response to a situation can result in strong negative

feelings/emotions, and thus lead to depression. Correction of

those faulty dysfunctional constructs can lead to clinical

improvement. Duarte et al. (2009) demonstrated that CBT performed

during 3-month-long group therapy is effective for improving

depression and many dimensions of QoL in chronic HD patients. Chen

et al. (2011) conducted a randomized controlled interventional

study of 72 sleep-disturbed HD patients. Compared with the control

group (who received sleep health education), patients who received

CBT had significant improvements in sleep quality, fatigue,

depression, and anxiety. Interestingly, CRP, IL-18, and oxidized

low-density lipoprotein levels also significantly declined among

those receiving CBT in comparison to those in the control group

(Chen et al., 2011). The Psychological Impact of Hemodialysis on

Patients with Chronic Renal Failure 229 these studies suggest that

CBT might be effective for improving mental health, and for

reducing inflammation and oxidative stress in HD patients.

Exercise programs may have a beneficial effect on depressive

symptoms in patients with ESRD. Ouzouni et al. (2009) reported that

10-month intradialytic exercise training improved QoL in both

physical functioning and psychological status in HD patients, and

decreased in self-reported depression. In another study, a 1-year

exercise training program reduced emotional distress and

concomitantly improved cardiac autonomic modulation measured by

heart rate variability (HRV) indices (Kouidi et al., 2010). For

alternative therapy, Kim et al. (2011) reported that 24 HD patients

who received individualized acupuncture treatments over 6

consecutive weeks showed significant improvements in some QoL

subscales. Social support has been shown to help improve emotional

disturbances in a variety of chronic illnesses. Support and

education, either individually to patients or including their

caregivers and family members, may be helpful (Symister & Friend,

2003). A patient’s depression could be influenced by the

psychosocial status of his or her spouse, and the spouse might be

amenable to interventions that could improve patient outcome

(Daneker et al., 2001). Social support has been shown to decrease

depression by improving the selfesteem of patients with ESRD, which

led to increased optimism (Symister & Friend, 2003). Treatment

programs that address problems with social interactions of

patients need to be comprehensive, and should explore use of family

and marital counseling, and involvement of the community, along

with consideration of the patient’s social life (Cohen et al.,

2014).
Interventions for the people undergoing haemodialysis

As the CKD population grows, it becomes highly significant to

reduce costs of care. Patients are very happy with cost saving

associated with reduced hospital admissions. Increased adherence

to prescribed therapeutic regimen brings down. number and duration

of hospitalizations. While patients must decide their own level

of adherence, nurses must strive to help them achieve better health

outcome. This can be done by providing patients with knowledge and

encouragement so that they can make better choices. Earlier studies

have proved that dialysis patients and their care givers lack

knowledge on illness management and that their knowledge could be

improved by educating them. Researches also gave evidences that

improvement in the knowledge alone did not bring positive change

in their compliance to the therapeutic regimen. Education,

reinforcement interventions, shared decision making and follow-up

responsibility can empower people to become responsible with their

treatment regimen management. (Cohen et al., 2014)

Psychological and social factors for depression

Depression is the most common psychological problem in the

dialysis population. The diagnosis of depression in dialysis

patients is confounded by the fact that several symptoms of uraemia

mimic the somatic components of depression. It affects the

physical, psychological and social well being of the dialysis

population in several ways. A number of studies have focused upon

the effects of HD patients, including feelings of hopelessness,

perceptions of loss and lack of control, job loss, and altered

family and social relationships (Kimmel, 2001). Because ESRD is

a lifelong disease, feelings of lack of control and perceptions

of overwhelming illness might be inevitable. The intrusiveness of

these thoughts is related to depression (Christensen & Ehlers,

2002; Devins et al., 1997). More recent work has focused upon the

possible effects of underlying illness upon depressive symptoms

among ESRD patients (Guzman & Nicassio, 2003). Perception of loss

has been regarded as a strong predictor of depression (Chan et al.,

2009), which in turn predicts mortality (Chilcot et al., 2011).

In terms of the risk by demographic characteristics results have

been inconsistent (Taskapan et al., 2005). It was reported that

depression among dialysis patients increased with increasing age

and lower educational levels (Keskin & Engin, 2011). In some

studies, depressive symptoms were more common among women,

and increased with unemployment and also rose among patients with

higher co morbidity of physical diseases (Araujo et al., 2011; Chen

et al., 2010; Ibrahim & El Salamony, 2008). Thus, negative

cognition and lack of social support might exacerbate patients’

negative feelings, and thus further contribute to depression.

Decreased Quality of Life (QoL)

Health-related QoL is an important measure of how a disease

affects the lives of patients. The QoL domains include physical,

psychological, and social functioning and general satisfaction

with life (Tsay & Healstead, 2002). Once patients with ESRD start

to receive HD, they must face the chronic stress related to

restrictions on their time, the economical and vocational costs

related to treatment, functional limitations, dietary

constraints, and possible adverse effects of medications (Son et

al., 2009). Numerous studies have demonstrated that these patients

have a lower QoL than that of healthy populations (Kao et al., 2009;

Perlman et al., 2005; Wolcott et al., 1988). Depression is strongly

correlated with decreased healthrelated QoL, especially in mental

dimensions (Chen et al., 2010; Kao et al., 2009). Furthermore,

several studies have shown that patients with poorer QoL had a

higher incidence of anxiety and fatigue (Kring & Crane, 2009), and
longitudinal follow-up showed increased mortality (Drayer et al.,

2006; Wolcott et al., 1988). Biological function, mental

illnesses, general health perception, and characteristics of the

individual and environment may contribute to the variability in

patients’ QoL (Kring & Crane, 2009). Biological factors that have

been associated with QoL include altered hemoglobin, albumin,

ferritin, CRP, IL-6, IL-8, and TNF-α levels (Farag et al., 2011;

Kalender et al., 2007a; Montinaro et al., 2010; Perlman et al.,

2005). Poor exercise tolerance and muscle weakness may limit daily

activity, again causing poor QoL (Hsieh et al., 2007; Sakkas et

al., 2003). However, Barros et al. (2011) suggested there was no

association of nutritional status with malnutrition-inflammation,

QoL, or depressive symptoms. There is still debate about whether

patients’ QoL can be directly correlated to

malnutrition-inflammation markers. Among psychological issues,

uncertainty about the future and lack of energy emerged as the major

contributors to poor QoL (Tsay & Healstead, 2002). A patient’s

dependency on treatment may negatively impact his or her QoL and

exacerbate feelings of a loss of control (Chilcot et al., 2008).

Improved QoL is correlated with higher self-esteem and lower levels

of mood disturbances (Wolcott et al., 1988). Furthermore, time of

diagnosis of chronic renal failure may be an important factor

related to the QoL of patients receiving dialysis. Late diagnosis

of renal failure and the consequent lack of predialysis care

adversely affect QoL among these patients (Sesso & Yoshihiro,

1997). Therefore, early detection of renal failure and

identification of underlying mental illnesses might be important

issues for establishing better QoL in HD patients.

Prevalence of hemodialysis patient

Kidney diseases, especially End Stage Renal Disease (ESRD), are

already the 7th leading cause of death among the Filipinos. One

Filipino develops chronic renal failure every hour or about 120

Filipinos per million population per year. More than 5,000 Filipino

patients are presently undergoing dialysis and approximately 1.1

million people worldwide are on renal replacement therapy.

Reliable estimates reveal that the number of these patients will

double in 2010.

In the past, chronic glomerulonephritis was the most common cause

of chronic renal failure. Today, diabetes mellitus and

hypertension have taken center stage in the causation of ESRD which

together account for almost 60% of dialysis patients.

(http://www.nkti.gov.ph).

In the last year, 20 percent of Filipinos were diagnosed with

chronic kidney disease, based on the glomerular filtration rate

(GFR) which measures kidney function. Presently, there are 70,000

patients on dialysis and even with thousands on the waiting list

for a kidney transplant, only 400 are able to undergo

transplantation annually. (Magtubo,2017)

 Dr. Luis Limchiu, head of the Adult Nephrology Department at

the National Kidney and Transplant Institute (NKTI), presented the

latest numbers as the Philippines kicked off its celebration of

World Kidney Month. While not the top cause of mortality in the

Philippines, chronic kidney disease (CKD) is among the top 10, he

told the crowd gathered at the NKTI Atrium. The kidney specialist

said that chronic kidney disease (CKD) is a burden worldwide, with

costs more than breast, colon and lung cancers combined. CKDs

include conditions which diminish the kidneys’ ability to function

properly and optimally. Waste that is not filtered will build up

and cause the organs to deteriorate. (Magtubo,2017)

The number of incident (newly reported) ESRD cases in 2014 was

120,688; the unadjusted (crude) incidence rate was 370 per

million/year. Since 2011, both the number of incident cases and

the unadjusted incidence rate have begun rising again.

The age-gender-race-ethnicity adjusted incidence rate of ESRD in

the United States rose sharply in the 1990s, leveled off in the

early 2000s, and has declined slightly since its peak in 2006.

In 2014, the adjusted ESRD incidence rate ratios for

Blacks/African Americans, Native Americans, and Asians/Pacific

Islanders, compared with Whites, were 3.1, 1.2, and 1.2,

respectively; the rate ratio for Hispanics versus non-Hispanics

was 1.3. (https://www.ajkd.org/article/pdf)

 Haemodialysis is the therapy used most commonly. Among patients

with CKD, 66 percent in the United States and 46 to 98 percent in

Europe receive haemodialysis. 38,39 When haemodialysis

effectively contributes to long-term survival, morbidity and

mortality of dialysis patients remains high, especially morbidity

and mortality due to cardiovascular diseases. 40 Only 32 to 33

percent of patients on haemodialysis survive till the fifth year

of treatment, whereas 70 percent of patients who have kidney

transplants live even after five years. On December 31, 2014, there

were 678,383 prevalent cases of ESRD; the unadjusted prevalence

(crude proportion) was 2,067 per million in the U.S. population.

While the number of ESRD incident cases plateaued in 2010, the

number of ESRD prevalent cases continues to rise by about 21,000

cases per year. Compared to Whites, ESRD prevalence in 2014 was

about 3.7 times greater in Blacks, 1.4 times greater in Native

Americans, and 1.5 times greater in Asians.

(https://www.ajkd.org/article/pdf)
Synthesis of the Review

Hemodialysis is a valuable therapy with advantages and

disadvantages, requiring individualized decision-making between

patients, families, and caregivers (Ellam &

Wilkie, 2015; Tregaskis et al., 2015). Dialysis is time-consuming

and life-altering, and requires numerous life-style changes

(Schatell, 2015). Previously conducted research regarding the

lived experiences of individuals diagnosed with ESRD and

undergoing hemodialysis treatment in the Caraga Reginal Hospital.

Therefore, this study will explore the impact of treatment choices

on the home environment, daily routines, and techniques at home

for hemodialysis patients in the Surigao Cit. The purpose of this

study is to gain insight into the lived experiences of people

undergoing hemodialysis in Caraga Regional Hospital. The cited

literature are related to the present study as materials are

dealing mainly on the importance of the lived experiences of the

patients in the hemodialysis. Theses materials are quite similar

to what the present study would wish to undertake in relation to

assessing the lived experiences of the hemodialysis patients in

the Caraga hospital.