Investigation of Perception of Quality of Life and Psychological Burden of Patients Undergoing Hemodialysis—Quality of Life of Hemodialysis Patients
, Anna Kassotaki 2, Chara Frantzeskaki 2, Maria Fragiadaki 2, Andreas Mpalaskas 2, Georgios Vasilopoulos 3 and Manolis Linardakis 4
Round 1
Reviewer 1 Report
The article “Investigation of Perception of Quality of Life and Psychological Burden of Patients Undergoing Hemodialysis” analyzes aspects of quality of life and the psychological impact of hemodialysis use and dependence on a cohort of 63 patients with end-stage renal disease at a hemodialysis center. The subject of the study has potential, but the manuscript requires revision as there are parts that are unclear. Comments for authors are described below.
Major review:
Abstract – The abstract provides little context regarding the subject of the study, why it is important, and the main conclusions drawn from this study. In the first sentence, it is written that the study aims to "investigate this relationship", but this is confusing and could be written better.
At the end of the introduction, it is reported that differences are found in relation to “physical functioning”, “vitality-energy”, “mental health” and “general health”. Could you better explain these differences for the patient with CKD and on dialysis therapy?
The study was conducted during the second year of the Covid-19 pandemic, after several lockdown measures. Due to the negative impact of the Covid-19 pandemic from a psychosocial and mental health point of view, the authors did not assess this variable during the research and did not address it during the discussion of the study findings. How do the authors assess the impact of the Covid-19 pandemic on the study findings?
About the discussion, the second paragraph summarizes all the findings of the study and only in the following paragraphs are presented studies to discuss. However, the reading was heavy to follow. I suggest presenting a certain result and then comparing it with data from the literature, then presenting another finding and other studies to discuss. Also, the third paragraph of the discussion could be joined with the first.
In the discussion, the authors report that the changes over time in quality of life addressed in this study compared to others may be due to changes in living conditions, study samples, hemodialysis or comorbidity, and stage of disease. How can this be measured by addressing the stage of the disease?
At the end of the introduction, the authors propose to identify factors that affect the health of patients on hemodialysis. However, these factors are not clearly presented in the discussion or conclusion.
Minor review:
I strongly recommend an English revision.
Standardize acronyms throughout the manuscript. For example, the term "quality of life" was used inconsistently as QoL or as its full name.
Participants – Were there exclusion criteria for study participants?
Research tools – The second and third paragraph could be joined together to form a paragraph.
Statistical Analysis – Add the normality test used in the study.
Results – Table 1 is misaligned in the review manuscript. The age part shown in the table 1 is confusing and seems incorrect. Also, it would be interesting to present how long the study participants have been on hemodialysis in the Table 1.
In the topic of results, table 4 is not cited in the text.
In table 5, the information was confusing, especially the data regarding normal, mild, moderate, and severe.
I strongly recommend an English revision. Several parts were difficult to understand and an improvement in writing will make the study better.
Author Response
September 2023
Manuscript ID: nursrep-2524427 R2
Title: Investigation of Perception of Quality of Life and Psychological Burden of Patients Undergoing Hemodialysis
RESPONSE TO REVIEWERS’ COMMENTS
The authors would like to thank the Editors for their comments. We believe that all points raised have now been clarified. Suggested additions and changes to the manuscript and current response to reviewers’ document have been marked with red text (highlighted).
Major review:
Abstract – The abstract provides little context regarding the subject of the study, why it is important, and the main conclusions drawn from this study. In the first sentence, it is written that the study aims to "investigate this relationship", but this is confusing and could be written better.
Abstract modified according to the reviewer’s suggestions.
At the end of the introduction, it is reported that differences are found in relation to “physical functioning”, “vitality-energy”, “mental health” and “general health”. Could you better explain these differences for the patient with CKD and on dialysis therapy?
Additional clarification has been made according to the reviewer’s suggestions.
The study was conducted during the second year of the Covid-19 pandemic, after several lockdown measures. Due to the negative impact of the Covid-19 pandemic from a psychosocial and mental health point of view, the authors did not assess this variable during the research and did not address it during the discussion of the study findings. How do the authors assess the impact of the Covid-19 pandemic on the study findings?
With all due respect to the reviewer’s comment, the authors did not aim to examine the impact of the pandemic on Quality of Life or disease management as no relevant data were presented. The authors' reference, in the title as well as the text, concerns the long duration of the pandemic during which the relevant data were collected. Nevertheless, additional clarification has been added according to the reviewer’s comment.
About the discussion, the second paragraph summarizes all the findings of the study and only in the following paragraphs are presented studies to discuss. However, the reading was heavy to follow. I suggest presenting a certain result and then comparing it with data from the literature, then presenting another finding and other studies to discuss. Also, the third paragraph of the discussion could be joined with the first.
The section has been modified according to the reviewer’s suggestions.
In the discussion, the authors report that the changes over time in quality of life addressed in this study compared to others may be due to changes in living conditions, study samples, hemodialysis or comorbidity, and stage of disease. How can this be measured by addressing the stage of the disease?
Clarifications have been made according to the reviewer’s suggestions.
At the end of the introduction, the authors propose to identify factors that affect the health of patients on hemodialysis. However, these factors are not clearly presented in the discussion or conclusion.
The manuscript has been modified and clarifications have been made according to the reviewer’s suggestions.
Minor review:
I strongly recommend an English revision.
The paper has been reviewed by a native English speaker and professional translator.
Standardize acronyms throughout the manuscript. For example, the term "quality of life" was used inconsistently as QoL or as its full name.
The authors have standardized acronyms throughout the manuscript as (Qol) according to the reviewer’s suggestions.
Participants – Were there exclusion criteria for study participants?
No exclusion criteria were set due to the specificity of the study population and the specific inclusion criteria.
Research tools – The second and third paragraph could be joined together to form a paragraph.
The section has been modified according to the reviewer’s suggestions.
Statistical Analysis – Add the normality test used in the study.
The authors refer to Blom’s method (Q-Q plot).
Results – Table 1 is misaligned in the review manuscript. The age part shown in the table 1 is confusing and seems incorrect. Also, it would be interesting to present how long the study participants have been on hemodialysis in the Table 1.
The authors apologize for this error. The value in parenthesis was the standard deviation of age and has been corrected, while the years of hemodialysis have been added.
In the topic of results, table 4 is not cited in the text.
Table 4 is included in the text, lines 228-234.
In table 5, the information was confusing, especially the data regarding normal, mild, moderate, and severe.
The comment “Higher score (→100) determines higher QoL” was an error and the authors apologize for this confusion. The Anxiety and Depression scale have their own classification as presented in table 2 (4 categories: normal or <8, mild or 8-10, moderate or 11-14, and severe or 15-21). A clarification has been added to the table.
Reviewer 2 Report
The study conducted a cross-sectional analysis with 63 patients to investigate relationships between various factors, utilizing the HADS and KDQOL-SF™ tools. The research revealed moderate to mild levels of Anxiety and Depression and their significant correlation with lower QoL. The study also found that higher education levels were associated with lower Depression and higher QoL and that a higher number of years of hemodialysis correlated with reduced Anxiety and better sleep quality. Accessibility to the HDU significantly correlated with lower levels of social support. Urban living, higher education, and higher income correlated with higher mental composite scores. The findings emphasized the importance of the medical, nursing, and social environment in influencing well-being and improving patients' health.
Strengths:
Using standardized research tools (HADS and KDQOL-SF™) ensures a certain level of validity in the data collection. Especially they used the Greek version of both tools.
The study identifies several key factors correlated with mental and physical well-being, which can be useful for healthcare practitioners.
Weaknesses:
With only 63 patients, the sample size is relatively small, and the findings may not be widely generalizable. Please justify the small sample size.
The study's cross-sectional nature does not allow for the determination of causality between the variables; it only identifies associations. Which has already been highlighted by the authors.
The abstract does not mention the specific demographic characteristics of the patients, such as age or gender, which could impact the study's conclusions.
[Optional] Iron overload is prevalent in patients with ESRD and rarely discussed by the literature, especially its impact on Qol (Despite its prevalence, the issue remains under-explored, leaving a gap in the understanding of how it may influence patients' well-being); the authors could benefit from the following recent systematic review and meta-analysis to highlight this issue https://onlinelibrary.wiley.com/doi/full/10.1111/hdi.13054
Author Response
September 2023
Manuscript ID: nursrep-2524427 R2
Title: Investigation of Perception of Quality of Life and Psychological Burden of Patients Undergoing Hemodialysis
RESPONSE TO REVIEWERS’ COMMENTS
The authors would like to thank the Editors for their comments. We believe that all points raised have now been clarified. Suggested additions and changes to the manuscript and current response to reviewers’ document have been marked with red text (highlighted).
The study conducted a cross-sectional analysis with 63 patients to investigate relationships between various factors, utilizing the HADS and KDQOL-SF™ tools. The research revealed moderate to mild levels of Anxiety and Depression and their significant correlation with lower QoL. The study also found that higher education levels were associated with lower Depression and higher QoL and that a higher number of years of hemodialysis correlated with reduced Anxiety and better sleep quality. Accessibility to the HDU significantly correlated with lower levels of social support. Urban living, higher education, and higher income correlated with higher mental composite scores. The findings emphasized the importance of the medical, nursing, and social environment in influencing well-being and improving patients' health.
Strengths:
Using standardized research tools (HADS and KDQOL-SF™) ensures a certain level of validity in the data collection. Especially they used the Greek version of both tools.
The study identifies several key factors correlated with mental and physical well-being, which can be useful for healthcare practitioners.
We would like to thank the reviewer for these comments.
Weaknesses:
With only 63 patients, the sample size is relatively small, and the findings may not be widely generalizable. Please justify the small sample size.
The main weakness was the small sample of selected patients, which was determined by the influx into the Hemodialysis Unit of the hospital, while no other unit could be used due to the pandemic and the lockdown measures.
The study's cross-sectional nature does not allow for the determination of causality between the variables; it only identifies associations. Which has already been highlighted by the authors.
Τhe authors strongly agree with the reviewer's observation.
The abstract does not mention the specific demographic characteristics of the patients, such as age or gender, which could impact the study's conclusions.
The Abstract has been modified according to the reviewer’s suggestions.
[Optional] Iron overload is prevalent in patients with ESRD and rarely discussed by the literature, especially its impact on Qol (Despite its prevalence, the issue remains under-explored, leaving a gap in the understanding of how it may influence patients' well-being); the authors could benefit from the following recent systematic review and meta-analysis to highlight this issue https://onlinelibrary.wiley.com/doi/full/10.1111/hdi.13054.
We would like to thank the reviewer for this suggestion.
Reviewer 3 Report
Please find attached.
Comments for author File: 
Comments.pdf
OK.
Author Response
September 2023
Manuscript ID: nursrep-2524427 R2
Title: Investigation of Perception of Quality of Life and Psychological Burden of Patients Undergoing Hemodialysis
RESPONSE TO REVIEWERS’ COMMENTS
The authors would like to thank the Editors for their comments. We believe that all points raised have now been clarified. Suggested additions and changes to the manuscript and current response to reviewers’ document have been marked with red text (highlighted).
Thanks for allowing me to review the manuscript.
Abstract
The abstract should provide an introducion about the current statusof the investigation as a background. Could beuseful to describe a short introducion about the Quality of life. In the end of the background could be useful toestablish the aim. To the reader, it is necessary first of all to introduce the background of the research. After that,the material and methods have to be more detailed. Sampling inclusion criteria, exclusion criteria, statistics, andthe results and conclusion. The abstract does not provide full correct informaion. Related to Keywords I suggestchecking the MESH term. The scales are not related as MESH Terms, so I suggest changing it into for example#ansiety #depression, etc.
The Abstract and Keywords have been modified according to the reviewer’s suggestions.
Introducion.
It is necessary more detailed introducion. It is not enough three paragraphs for it. Please try to provide a biggerframework.
We would like to thank the reviewer for this comment. We have revised the Introduction to provide an improvement framework.
Material and method.
It is ok. I suggest in "research tool" to change by " variables and adequacy" because the study is done with thevariables of the scales. In this section as well you can describe the scales you have used.
The phrase has been modified and additional information on the scales has been added according to the reviewer’s suggestions.
Sta. s. cal Analysis.
Is it necessary to change somethings. For example “ Lines 115-117 How it was calculated? Maybe it is beter to write:Quantitave variables are described using the mean and standard deviason or median and interquartile rangeaccording to the type of distribution…
Additional information on the measures of central tendency, position and dispersion has been added according to the reviewer’s suggestion.
Why did the author use Cronbach’s alpha? If I understand properly “The present study aimed to inves. gate the percep. on of quality of life and 64 psychological burdens of patients undergoing hemodialysis and to identify thefactors of-65 affecting their level of health.” So it is necessary to know that the KDQOL-Sused is validated in Greek population. It is not necessary to calculate reliability if you are using validated scales and your aim is to describerelationship. In fact, last study recommended using omega more than Cronbach Alpha. See DOI: 10.1080/19312458.2020.1718629
The Biostatistician of the Authors’ group would like to thank the reviewer for this accurate comment. Nevertheless, there were serious reasons for using Cronbach’s coefficient, due to the initial and validated use of the scales in the Greek population, and especially in order to be able to compare the coefficient with other similar studies (e.g. the omega coefficient would not allow this).
Results.
In table 1. Could be necessary to specify Unmarried, Divorced, and Widowed. As well the result of agecould be necessary mean ± ST
Changes have been made according to the reviewer’s suggestion.
Table 2. SD remember ± ( can be positive or negative ) Why is calculated Cronbach’s α _??
Table 3. SD remember ±
The Biostatistician has explained the rationale for using Cronbach’s coefficient above. With respect to the reviewer’s comment, the Authors prefer to retain the current format options emphasizing each of the measures of central tendency, position and dispersion.
Again some of items of the Cronbach alfa are not good fits (ONLYRANGES0.70-0.90)
ITEMS: Disease burden Work status Quality of social interaction General Health
Emotional well-being , Vitality has not a good fit…. For that, if the objective is not validated ( withconfirmatory and exploratory analysis) has no sense to specify Cronbach ( from my point of view)
The authors would like to thank the reviewer for this comment. We have explained above why we used Cronbach’s coefficient, for clear presentation and comparison with other studies (and/or patients). Nevertheless, the QoL subscales, due to the nature of the items per subscale, seem to produce similar results in the reliability analysis (https://www.mednet.gr/archives/2007-6/pdf/590.pdf, https://www.jcpsp.pk/archive/2016/Aug2016/04.pdf, https://www.journals.ac.za/ajn/article/view/4840/3306, http://dl.lib.uom.lk/bitstream/handle/123/20796/senanayake-2017%28489%29.pdf?sequence=1&isAllowed=y).
Discussion:
Discussion is not results. The first part is focused on results, the second part of the discussion is quite good. It isnecessary to compare your results with the evidence. More evidence is necessary, see 23 references and 14-23in the discussion it is not enough. In addition, Negative correlation should provide with a explication.
The “Discussion” paragraph has been modified and enriched with more references according to the reviewer’s suggestions.
Overview: The authors do a great job however it is necessary to improve from my point of view.Congratulations and keep it up!!
Please don’t hesitate to contact me if you have any doubts
The authors would like to thank the reviewer for their kind remarks.
Round 2
Reviewer 1 Report
Dear authors,
The manuscript has improved from its first version and the reviewer's concerns have been addressed. That said, I recommend publishing the study.
Best Regards,
Note: I did not find the citation from table 4 (e.g. "see in table 4") in the text of the manuscript.
Reviewer 3 Report
changes have been addressed
