臺灣血液透析病患透析中不適症狀、透析後恢復時間與健康相關生活品質之相關性研究

Abstract

研究背景： 近二十年來，血液透析病患的健康相關生活品質(Health-Related Quality of Life, HRQOL)已被國際醫療界視為重要指標。血液透析過程中的不適症狀及透析後恢復時間對病患的日常生活生理與心理健康生活品質具有顯著相關，且與生存率、住院率密切相關。醫療專業人員與病患在對照護結果的關注點不同：醫療人員主要依據檢驗報告和臨床指標來評估透析的品質，而病患則更關心他們的生活品質及透析帶來的不適。病患回饋結果測量(Patient Reported Outcome Measures, PROMs)除了可以收集健康相關生活品質也可更廣泛的獲取病患治療感受的資訊，幫助醫護人員獲得病患感觀的照護品質資訊可進而調整照護計畫。相較國外已有諸多研究進行血液透析病患在透析治療中感受到的不適症狀和透析後恢復時間與病患相關生活品質探討，國內尚未有相關研究。

研究目的： 本研究旨在探討臺灣血液透析病患透析中不適症狀、透析後恢復時間與健康相關生活品質之相關性。

研究對象及方法： 本研究採用橫斷性問卷調查法，針對血液透析病患進行問卷調查，收案期間自2023年6月至2023年8月，研究對象為願意參與本研究之10間透析中心中接受長期血液透析的病患。透過病患回饋結果收集病患透析中不適症狀及嚴重度、透析後恢復正常作息的時間，以及健康相關生活品質。本研究採用逐步線性迴歸分析(Stepwise Linear Regression)與逐步羅吉斯迴歸分析(Stepwise Logistic Regression)來瞭解病患特徵、臨床參數、不適症狀嚴重度，恢復時間與健康相關生活品質之間的相關性。

結果： 本研究共有603位血液透析病患參與，男性有325位(佔53.9%)，女性有278位(佔46.1%)，平均年齡為65.5±11.7歲。研究結果顯示，有449位血液透析病患(佔74.5%) 在前一週透析中無不適症狀，然而，有154位的病患(佔25.5%)在透析中出現1至12個症狀，而其中有113位病患(佔73.4%) 出現3個或更多症狀。不適症狀嚴重度與兩次透析間體重增加和身體質量指數(Body Mass Index, BMI)大於24 呈正相關。此外，有417位病患(佔69.2%)透析後3小時內恢復良好，但有186位病患(佔30.8%)需超過3小時。血紅蛋白濃度大於12 g/dL與較短恢復時間相關，而低血鉀則與長恢復時間顯著相關，且透析中不適症狀嚴重度與恢復時間呈正相關。病患的生理健康和心理健康生活品質平均分別為40.1和48.8，男性通常擁有較好的生理生活品質；透析年資、經年齡調整Charlson共病指數和廓清率與生活品質呈現負相關；透析中不適症狀嚴重度與生理及心理的生活品質呈負相關；較長的恢復時間亦與較低的生活品質相關。

結論： 透過603位血液透析病患回饋結果，本研究確認了透析過程中不適症狀的嚴重度與透析後恢復時間及相關生活品質間存在顯著相關。藉此研究也了解到臺灣血液透析病患較常發生的透析不適症狀多與國外相似，惟發生率相較低很多；病患透析後恢復正常的時間和健康相關生活品質分數皆與國外近似。建議未來臺灣血液透析治療可將病患的健康相關生活品質，以及病患實際感受的透析中不適症狀與透析後恢復時間一併納入常態資訊收集，以更進一步落實病患為中心的照護理念，增進病患權益；未來研究可納入死亡率和住院率。本研究調查過程亦顯示，電子化病患回饋結果測量是一可行、有效率的病患感受資料收集方式，未來研究或臨床照護可考慮採用。

Background: Over the past two decades, health-related quality of life (HRQOL) in hemodialysis patients has been recognized internationally as an important indicator of quality medical care. Intradialytic symptoms and the recovery time after dialysis significantly impact the physical and mental aspects of the patients’ daily life, and are closely related to rates of survival and hospitalization. Traditionally, clinicians and patients focus on different aspects of care outcomes: healthcare teams primarily base dialysis quality on laboratory results and clinical indicators, while patients are more concerned with their quality of life and the discomfort caused by dialysis. Patient-reported outcome measures (PROMs) collect HRQOL data and in-depth information on patients' experience of care, helping healthcare professionals to obtain patients' perceptions of care quality and to adjust care plans accordingly. While there have been many international studies on the intradialytic symptoms experienced during dialysis and the post-dialysis recovery time, as well as their correlation with patients' quality of life, similar research is lacking in Taiwan.

Objective: This study aims to explore the correlation between intradialytic symptoms, post-dialysis recovery time, and HRQOL among hemodialysis patients in Taiwan.

Methods: This study adopted a cross-sectional survey design, targeting hemodialysis patients through questionnaires from June to August 2023. The subjects were patients receiving long-term treatments at ten hemodialysis centers and consented to participation. Through PROMs, data on intradialytic symptoms and their severity during dialysis, the time to resume normal activities post-dialysis, as well as the health-related quality of life were collected. Stepwise linear regression and stepwise logistic regression analyses were employed to understand the correlations between patient characteristics, clinical parameters, intradialytic symptoms and their severity, recovery time, and HRQOL.

Results: A total of 603 hemodialysis patients participated in this study, with 53.9% male and 46.1% female, averaging 65.5±11.7 years old. The results show that most dialysis patients (n=449, 74.5%) had no intradialytic symptoms in the week before dialysis, but (n=154, 25.5%) experienced 1 to 12 symptoms during dialysis, with the majority (n=113, 73.4%) having three or more symptoms. The severity of intradialytic symptoms was positively correlated with intradialytic weight gain and BMI >24. Additionally, most patients (n=417, 69.2%) recovered well within three hours post-dialysis, but (n=186, 30.8%) took more than three hours to recover. Hemoglobin levels >12 g/dL were associated with shorter recovery times, low potassium levels were significantly related to longer recovery times, and the severity of intradialytic symptoms was positively correlated with longer recovery times. The average physical and mental HRQOL scores were 40.1 and 48.8, respectively. Males generally had better physical quality of life; dialysis vintage, age-adjusted Charlson comorbidity index, and Kt/V were negatively correlated with quality of life; the severity of intradialytic symptoms was negatively correlated with both physical and mental quality of life; longer recovery times were also associated with lower quality of life.

Conclusion: This study of PROMs of 603 hemodialysis patients showed significant positive correlations between the severity of intradialytic symptoms, post-dialysis recovery time, and HRQOL. The study also showed that the common intradialytic symptoms experienced by hemodialysis patients in Taiwan were similar to those reported internationally, albeit occurring at much lower rates; post-dialysis recovery times and HRQOL were similar. It is recommended that collection of HRQOL, intradialytic symptoms and post-dialysis recovery times as experienced by patients become routine in the delivery of hemodialysis. This is to advance patient-centered care and promote patient rights in Taiwan. Future research could include rates of mortality and hospitalization. The study also showed that electronic collection of PROMs is feasible, can be implemented efficiently, and should be considered for adoption in future research studies and in clinical practice.