Symptom burden and health-related quality of life in chronic kidney disease: A global systematic review and meta-analysis

Author summary Why was this study done? Chronic kidney disease (CKD) is a common disease globally.Patients with CKD have a reduced quality of life and a greater risk of hospitalisation, heart problems, and death.Monitoring patient symptoms and quality of life can provide important information to help optimise CKD management.There is a lack of clear evidence on differences in patient quality of life between CKD groups and which symptoms are experienced most often and/or are most severe. What did the researchers do and find? We reviewed 449 studies that included 199,147 patients from 62 countries.Patients with CKD reported a range of common and/or severe symptoms; the exact symptom burden depended on the stage of the disease and how it was being treated. Fatigue, however, was a very common and severe symptom in all patient groups.Quality of life for patients with CKD was significantly lower than for individuals without the disease, and was worst in patients receiving dialysis.In general, patients who had received a kidney transplant experienced fewer and less severe symptoms and had an improved quality of life, but this was still worse than that of people without CKD. What do these findings mean? Symptom burden and negative impact on quality of life are considerable for people with CKD, especially for those receiving dialysis treatment.The findings of this study will support healthcare professionals when discussing, measuring, and managing the potential treatment burden associated with CKD.This global review of symptoms in patients with CKD will help in the selection of symptoms for inclusion in remote monitoring to identify patients in need of intervention. BackgroundThe importance of patient-reported outcome measurement in chronic kidney disease (CKD) populations has been established. However, there remains a lack of research that has synthesised data around CKD-specific symptom and health-related quality of life (HRQOL) burden globally, to inform focused measurement of the most relevant patient-important information in a way that minimises patient burden. The aim of this review was to synthesise symptom prevalence/severity and HRQOL data across the following CKD clinical groups globally: (1) stage 1-5 and not on renal replacement therapy (RRT), (2) receiving dialysis, or (3) in receipt of a kidney transplant. Methods and findingsMEDLINE, PsycINFO, and CINAHL were searched for English-language cross-sectional/longitudinal studies reporting prevalence and/or severity of symptoms and/or HRQOL in CKD, published between January 2000 and September 2021, including adult patients with CKD, and measuring symptom prevalence/severity and/or HRQOL using a patient-reported outcome measure (PROM). Random effects meta-analyses were used to pool data, stratified by CKD group: not on RRT, receiving dialysis, or in receipt of a kidney transplant. Methodological quality of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data, and an exploration of publication bias performed. The search identified 1,529 studies, of which 449, with 199,147 participants from 62 countries, were included in the analysis. Studies used 67 different symptom and HRQOL outcome measures, which provided data on 68 reported symptoms. Random effects meta-analyses highlighted the considerable symptom and HRQOL burden associated with CKD, with fatigue particularly prevalent, both in patients not on RRT (14 studies, 4,139 participants: 70%, 95% CI 60%-79%) and those receiving dialysis (21 studies, 2,943 participants: 70%, 95% CI 64%-76%). A number of symptoms were significantly (p < 0.05 after adjustment for multiple testing) less prevalent and/or less severe within the post-transplantation population, which may suggest attribution to CKD (fatigue, depression, itching, poor mobility, poor sleep, and dry mouth). Quality of life was commonly lower in patients on dialysis (36-Item Short Form Health Survey [SF-36] Mental Component Summary [MCS] 45.7 [95% CI 45.5-45.8]; SF-36 Physical Component Summary [PCS] 35.5 [95% CI 35.3-35.6]; 91 studies, 32,105 participants for MCS and PCS) than in other CKD populations (patients not on RRT: SF-36 MCS 66.6 [95% CI 66.5-66.6], p = 0.002; PCS 66.3 [95% CI 66.2-66.4], p = 0.002; 39 studies, 24,600 participants; transplant: MCS 50.0 [95% CI 49.9-50.1], p = 0.002; PCS 48.0 [95% CI 47.9-48.1], p = 0.002; 39 studies, 9,664 participants). Limitations of the analysis are the relatively few studies contributing to symptom severity estimates and inconsistent use of PROMs (different measures and time points) across the included literature, which hindered interpretation. ConclusionsThe main findings highlight the considerable symptom and HRQOL burden associated with CKD. The synthesis provides a detailed overview of the symptom/HRQOL profile across clinical groups, which may support healthcare professionals when discussing, measuring, and managing the potential treatment burden associated with CKD. Protocol registrationPROSPERO CRD42020164737.