Prevalence of Excessive Daytime sleepiness, Depression and Quality of Life among Hemodialysis Patients

Pakistan Journal of Medical & Cardiological Review https://pakjmcr.com/index.php/1/about Online ISSN Print ISSN 3007-2387 3007-2379 Vol. 4 No. 4 (2025) Pakistan Journal of Medical & Cardiological Review Page 1129 Prevalence of Excessive Daytime sleepiness, Depression and Quality of Life among Hemodialysis Patients Muhammad Imran University College of Pharmacy, University of the Punjab Email: [email protected] Umeed Ullah Ghaznawi University College of Pharmacy, University of the Punjab Email: [email protected] Hemodialysis, while essential for managing end-stage renal disease (ESRD), is frequently associated with excessive daytime sleepiness (EDS), depression, and reduced quality of life (QoL). This cross-sectional study aimed to determine the prevalence and interrelationship of these factors among 152 hemodialysis patients across four hospitals in Punjab, Pakistan. Data were collected using validated tools: the Epworth Sleepiness Scale (ESS), the Depression subscale of DASS-21, and the Kidney Disease Quality of Life (KDQOL-36) questionnaire. Findings revealed that patients in their first year of dialysis reported significantly higher levels of depression and EDS, particularly in low-stimulus settings such as reading (p = 0.016). Quality of life varied with dialysis duration; those with 4–5 years on dialysis reported better mental health scores, while patients undergoing dialysis for over five years experienced the greatest burden of kidney disease. These results highlight the evolving psychological and functional challenges throughout the dialysis journey and underscore the need for early psychosocial support and tailored interventions to improve patient outcomes in the Pakistani context. Introduction: Hemodialysis is a method by which metabolic waste substances are removed from the body when kidneys are unable to perform their normal functions. Hemodialysis is one of the treatments of chronic kidney disease (CKD). CKD is defined as persistent abnormality in kidney structure or function. Factors that can increase the risk of CKD include: Diabetes, Hypertension, Polycystic kidney disease, Obstructive nephropathy, and Glomerulonephritis. According to studies, it is more common in Females than Males, In African Americans than White Americans, and in Elderly than young ones. Although hemodialysis prolongs life, it has major effects on patients’ physical, emotional, and social well-being, Among the most commonly reported are daytime Abstract Author Details Keywords:. Received on 05 Oct 2025 Accepted on 02 Nov 2025 Published on 12 Nov 2025 Corresponding E-mail & Author*: MUHAMMAD IMRAN University College of Pharmacy, University of the Punjab Email: [email protected] Page 1130 sleepiness and depression both of which severely impacts the quality of life (QOL). {Anjum., 2023 #15}. The prevalence of chronic kidney disease (CKD) varies across different regions of the world, with developing countries experiencing particularly high rates {Hasan, 2018 #18}. The CKD prevalence in Southeast Asia ranges from 7.0% to 34.3% {Thaminda, 2022 #19}. In Pakistan, studies have reported a prevalence of CKD ranging from 12.5% to 29.9%. {Khan, 2024 #20}. In Pakistan, dialysis is difficult and expensive, with only 40% of patients with CKD having access to dialysis, and most of these patients are under dialyzed; they are dialyzed twice, instead of the recommended thrice weekly. {Prasad, 2015 #21} A study was conducted in India that involved 47 patients undergoing maintenance hemodialysis (MHD) for over 3 months, with a mean age of 37.1 years. Poor sleep quality was reported by 68.1%, while only 10.6% showed signs of daytime sleepiness. Fatigue affected 44.7% of patients, and 72.3% had depression. Fatigue was significantly associated with less frequent dialysis sessions. (Gadia, Awasthi et al. 2020) Similarly, another study in China included 275 hemodialysis patients aged 24 to 88 years, with a mean age of 61.0 years. Over half 57.1% of the participants had poor sleep quality, indicated by a PSQI score greater than 6. (Chang and Yang 2011) In Saudi Arab, a study of 286 patients with End Stage Renal Disease (ESRD) was conducted. Among 286 patients, 58.2% of the participants were men. Of three age groups, the majority of participants were over 40 years of age. Only 32 (11.3%) participants were diagnosed with depression or anxiety before the ESRD onset, and 20 (7%) were currently taking depression or anxiety medications. Fifty-seven (21.1%) participants scored above the cutoff for probable depression, and 63 (23.3%) scored above the cutoff for probable anxiety. 57 (21.1%) patients were probable cases of anxiety and 63 (23.3%) were probable cases of depression. Only 32 (11.3%) were diagnosed with depression or anxiety before ESRD onset. (Turkistani, Nuqali et al. 2014) In Spain, a study of 186 patients with a mean age of 70 years was conducted, nearly 40% of were women. Based on HADS scores, 27.9% had or likely had depression or anxiety. Additionally, 34% were taking medication for affective disorders, primarily anxiolytics or antidepressants. (Delgado-Domínguez, Sanz-Gómez et al. 2021) In a study 107 patients in Albania hemodialysis patients, anxiety was prevalent in 85.98% and depression in 84.11%. Anxiety severity was classified as low in 14%, moderate in 30%, and potentially concerning in 56% of patients. For depression, 2.8% had no symptoms, 13% had mild, 31.8% moderate, 36.4% moderately severe, and 16% severe depression. (Elezi, Abazaj et al. 2023) A study was conducted in USA, where health and functioning (H&F), quality of life index (QLI) and multiple sleep latency test (MSLT) scores indicated that better quality of life is linked to lower daytime sleeping. Subjective sleep issues, such as difficulty falling asleep or early waking, were significantly related to lower scores across all QLI subscales.(Parker, Kutner et al. 2003) A Study was conducted in UK on 123 hemodialysis patients, where 53.7% reported to fatigue, 43.9% anxiety, 33.3% depression, and 56.9% poor sleep. Fatigue, anxiety, and poor sleep were significantly linked to being female and having family or relatives affected by COVID-19. (Al Naamani, Gormley et al. 2021) Most existing studies focus on anxiety, depression, quality of life or sleep quality independently, without assessing their interplay or cumulative burden. Despite the growing recognition of the high prevalence and adverse impact of depression, anxiety, fatigue, sleep disturbance and quality of life in hemodialysis patients globally, there remains a significant gap in integrated research that simultaneously evaluates these Page 1131 factors and their combined effect on quality of life—especially in lowand middleincome countries like Pakistan. Furthermore, while regions such as Europe, the US, and parts of Asia have developed multidisciplinary approaches to address these issues, Pakistan lacks comprehensive data and coordinated care strategies due to limited research infrastructure and absence of national registries. The high rates of hepatitis C and high cost of hemodialysis services further complicate the psychosocial health of Pakistani hemodialysis patients {Rizzolo, 2022 #17}, underscoring the need for contextualized research. Our research directly addresses a significant gap of this independent research of these factors in the current literature by examining the prevalence and interrelationships of daytime sleepiness, depression, and quality of life among hemodialysis patients in Pakistan. Unlike many previous studies that have considered these factors separately, our approach is to look at how these domains interact and influence each other within the same patient population. By integrating these aspects, we aim to provide a more complete and comprehensive understanding of the psychosocial and functional challenges faced by hemodialysis patients. This holistic approach not only bridges the existing gap in the literature but also offers practical guidance for clinicians and policymakers. Understanding these interconnections will inform targeted interventions aimed at improving overall well-being and clinical outcomes in improving patient-centered care for hemodialysis patients. METHODS Ethical Approval The Human Ethical Committee University College of Pharmacy, University of the Punjab, Lahore, approved the study, reference number HEC/PUCP/099/2025. Verbal consent was obtained from all the participants. Study Design: A descriptive cross-sectional study was conducted by sampling responses of hemodialysis patients from University of Lahore Teaching Hospital, Ittefaq Hospital Lahore, DHQ Hospital Okara and DHQ Hospital Hafizabad. The study was for a period of 6 months starting from October 2024 - April 2025. Data was collected from hemodialysis patients only. First the objective of the study was to investigate the prevalence, interrelationship and associated factors of excessive Daytime sleepiness, depression and impaired quality of life (QoL) among patients undergoing hemodialysis. This will evaluate risk factors and analyze how these conditions interact to impact on patient well-being. All the patients were briefed about the nature and objective of the research. Study Population: A total of 152 patients from University of Lahore teaching hospital, Ittefaq Hospital Lahore, DHQ Hospital Okara & DHQ Hospital Hafizabad were enrolled in the study. The sampling frame consisted of patients undergoing hemodialysis. A sample size of 152 patients was recruited for this cross-sectional study based on feasibility and availability of patients at hospital, rather than a prior statistical estimation. Inclusion criteria: All the patients undergoing hemodialysis, able to understand and respond to the questions being asked, irrespective of age, gender, ethnicity, religion, social class. Only patients willing to take part in the study were enrolled. Exclusion criteria: Patients with acute medical illness i.e. infection, surgery or those having cognitive impairment or unable to provide data were excluded. Patients on sedatives, hypnotics and other stimulant medications were also not considered for this cross-sectional case study. Page 1132 Data Collection Data collection was done by means of comprehensive instruments of measure i.e. Epworth sleepiness scale (ESS), patient health questionnaire (PHQ-9), generalized anxiety disorder (GAD-7), kidney disease quality of life 36 (KDQOL-36) designed after extensive literature review. The questionnaire was sent to subject experts for content validation to ensure clarity and reliability. The internal consistency of the study tools was assessed using Cronbach's alpha. The PHQ-9, GAD-7, and Epworth Sleepiness Scale all demonstrated acceptable reliability. Patients were asked the questions from the questionnaire during their routine clinical visits. Only fully completed questionnaires were included in the analysis. 152 completed KDQOL-36 questionnaires were analyzed for scoring and interpretation. The questionnaire was outlined into the following 4 sections. Section 1: Demographics: Age, gender, area of residence, social class, education level, Duration of hemodialysis and CKD, Number of dialysis sessions per week, Comorbidities, Causes of kidney failure. Section 2: Epworth Sleepiness Scale (ESS): Participants rate their tendency to fall asleep in 8 everyday scenarios, scored from 0 (would never doze) to 3 (high chance of dozing). Section 3: (Anxiety and Depression): Depression subscale of the DAS-7 (Depression Anxiety Stress Scales): 14 specific items related to depression symptoms Each item scored from 0 to 3. Total score interpreted as: Normal (0–9), Mild (10–13), Moderate (14–20), Severe (21–27), Extremely severe (28+) Section 4: Quality of Life (KDQOL-36) Assesses health-related quality of life specific to kidney disease: General health perception, Physical functioning limitations, Emotional well-being and mental health, Interference with social activities, kidney disease-specific burden and symptoms, Impact of kidney disease on work, travel, appearance, sexual health, and relationships with healthcare providers. Data Analysis: The data were entered into Microsoft Excel and analyzed using SPSS (IBM, version 22). Descriptive analysis was performed to estimate the percentages and frequencies. Associations of dependent variables including levels of excessive daytime sleepiness (ESS scores), depression (PHQ-9 scores), anxiety (GAD-7 scores), and quality of life (KDQOL-36 subscale scores) and independent variables such as demographic and clinical characteristics (e.g., age, gender, duration of dialysis, comorbidities) were assessed. Non-parametric Manny-Whitney test was used to compare the difference between questionnaire scores between independent groups. The normality of the data was determined by Shapiro-Wilk test, confirming that data did not represent a normal distribution pattern. Pearson’s Chi-square test was used to examine associations between categorical variables (e.g., presence/absence of depression, anxiety levels) and demographic characteristics. An alpha value of 0.05 or less was considered statistically significant. Results: Basic Demographics of Hemodialysis patients based on duration Basic demographics of hemodialysis patients based on duration, < 1 year (<1), 1 – 3 years (1-3), 4 – 5 years (4-5) and > 5 years (>5), are summarized in Table 1. Data suggested that significant differences were observed in the frequency distribution of demographic variables regarding duration of hemodialysis, such as age; mostly were between 31 – 50 years of age (<1: 33.3%, 1-3: 42.2%, 4-5: 21.1%, >5: 63.5%, p=0.003), social class; mostly were from middle class background (<1: 69.4%, 1-3: 64.4%, 4-5: 57.9%, >5: 57.7%, p=0.0001), education; mostly had primary education Page 1133 (<1: 44.4%, 1-3: 44.4%, 4-5: 31.6%, >5: 42.3%, p=0.049), number of dialysis /week; mostly had 2 in a week (<1: 80.6%, 1-3: 100%, 4-5: 89.5%, >5: 100%, p=0.0001) and causes of kidney failure; in most of the cases it was hypertension (HTN) (<1: 61.1%, 1-3: 73.3%, 4-5: 84.2%, >5: 86.5%, p=0.017) (Table 1). No significant differences were observed in the other variables, such as gender and area of residence (Table 1). Table 1. Demographics of hemodialysis patients based on its duration Duration of hemodialysis (Years) Characteristics Less than 1, n=36 (%) 1-3, n=45 (%) 4-5, n=19 (%) Greater than 5, n=52 (%) p-values Age 10 to 30 31to 50 51 to 70 Above 70 9 (25) 12 (33.3) 12 (33.3) 3 (8.3) 9 (20) 19 (42.2) 17 (37.8) 0 (0.0) 3 (15.8) 4 (21.1) 8 (42.1) 4 (21.1) 7 (13.5) 33 (63.5) 11 (21.2) 1 (1.9) 0.003* Gender Male Female 29 (80.6) 7 (19.4) 28 (62.2) 17 (37.8) 13 (68.4) 6 (31.6) 31 (59.6) 21 (40.4) 0.195 Area of residence Urban Rural 21 (58.3) 15 (41.7) 32 (71.1) 13 (28.9) 15 (78.9) 4 (21.1) 31 (59.6) 21 (40.4) 0.292 Social class Lower Middle Upper 10 (27.8) 25 (69.4) 1 (2.8) 14 (31.1) 29 (64.4) 2 (4.4) 3 (15.8) 11 (57.9) 5 (26.3) 22 (42.3) 30 (57.7) 0 (0.0) 0.001** Education Illiterate Primary Secondary College/university 12 (33.3) 16 (44.4) 4 (11.1) 4 (11.1) 9 (20.0) 20 (44.4) 6 (13.3) 10 (22.2) 1 (5.3) 6 (31.6) 9 (47.4) 3 (15.8) 10 (19.2) 22 (42.3) 13 (25.0) 7 (13.5) 0.049* Comorbidities HTN Diabetes Others 5 (13.9) 9 (25.0) 22 (61.1) 13 (28.9) 5 (11.1) 27 (60.0) 13 (68.4) 0 (0.0) 6 (31.6) 20 (38.5) 2 (3.8) 30 (57.7) 0.0001** Duration of CKD (years) Less than 1 1-3 4-5 Greater than 5 30 (83.3) 3 (8.3) 2 (5.6) 1 (2.8) 0 (0.0) 37 (82.2) 4 (8.9) 4 (8.9) 0 (0.0) 0 (0.0) 10 (52.6) 9 (47.4) 0 (0.0) 0 (0.0) 5 (9.6) 47 (90.4) 0.0001** No of dialysis /week 2 3 29 (80.6) 7 (19.4) 45 (100.0) 0 (0.0) 17 (89.5) 2 (10.5) 52 (100.0) 0 (0.0) 0.0001** Causes of kidney failure HTN D2M Glomerulonephritis Others 22 (61.1) 1 (2.8) 0 (0.0) 13 (36.1) 33 (73.3) 3 (6.7) 0 (0.0) 9 (20.0) 16 (84.2) 0 (0.0) 1 (5.3) 2 (10.5) 45 (86.5) 0 (0.0) 0 (0.0) 7 (13.5) 0.017* Page 1134 Excessive daytime sleepiness among Hemodialysis patients based on duration Excessive daytime sleepiness among hemodialysis patients based on duration, < 1 year (<1), 1 – 3 years (1-3), 4 – 5 years (4-5) and > 5 years (>5), are summarized in Table 2. Data suggested that significant differences were observed in the frequency distribution of Epworth sleepiness scales (ESS) regarding duration of hemodialysis in the domain of sitting and reading; mostly had no chance of dozing off (<1: 61.1%, 1– 3: 68.9%, 4–5: 73.7%, >5: 92.3%, p = 0.016) (Table 2). No significant differences were observed in the other variables, such as watching TV (<1: 69.4%, 1–3: 62.2%, 4–5: 84.2%, >5: 76.9%, p = 0.185), sitting inactive in a public place (<1: 75.0%, 1–3: 82.2%, 4–5: 89.5%, >5: 92.3%, p = 0.264), as a passenger in a car without a break (<1: 69.4%, 1–3: 73.3%, 4–5: 73.3%, >5: 78.8%, p = 0.652), lying down to rest in the afternoon (<1: 30.6%, 1–3: 53.3%, 4–5: 63.2%, >5: 65.4%, p = 0.063), sitting and talking to someone (<1: 88.9%, 1–3: 88.9%, 4–5: 94.7%, >5: 94.2%, p = 0.151), and being in a car stopped in traffic (<1: 86.1%, 1–3: 95.6%, 4–5: 100.0%, >5: 90.4%, p = 0.415). Table 2. Excessive daytime sleepiness among hemodialysis patients based on its duration Duration of Hemodialysis (Years) ESS Less than 1, n=36 (%) 1-3, n=45 (%) 4-5, n=19 (%) More than 5, n=52 (%) pvalue Sitting and reading Would never nod off (0) Slight chance of nodding off (1) Moderate chance of nodding off (2) High chance of nodding off (3) 22 (61.1) 7 (19.4) 5 (13.9) 2 (5.6) 31 (68.9) 10 (22.2) 3 (6.7) 1 (2.2) 14 (73.7) 5 (26.3) 0 (0.0) 0 (0.0) 48 (2.3) 4 (7.7) 0 (0.0) 0 (0.0) 0.016 * Watching TV Would never nod off (0) Slight chance of nodding off (1) Moderate chance of nodding off (2) High chance of nodding off (3) 25 (69.4) 6 (16.7) 3 (8.3) 2 (5.6) 28 (62.2) 8 (17.8) 8 (17.8) 1 (2.2) 16 (84.2) 3 (15.8) 0 (0.0) 0 (0.0) 40 (76.9) 10 (19.2) 2 (3.8) 0 (0.0) 0.185 Sitting inactive in a public place (e.g., a theater, meeting, or restaurant) Would never nod off (0) Slight chance of nodding off (1) Moderate chance of nodding off (2) High chance of nodding off (3) 27 (75) 6 (16.7) 1 (2.8) 2 (5.6) 37 (82.2) 3 (6.7) 4 (8.9) 1 (2.2) 17 (89.5) 1 (5.3) 0 (0.0) 48 (92.3) 2 (3.8) 2 (3.8) 0 (0.0) 0.264 As a passenger in a car for an hour without a break Would never nod off (0) Slight chance of nodding off (1) Moderate chance of nodding off (2) High chance of nodding off (3) 25 (69.4) 6 (16.7) 4 (11.1) 1 (2.8) 33 (73.3) 7 (15.6) 5 (11.1) 0 (0.0) 14 (73.3) 2 (10.5) 2 (10.5) 1 (5.3) 41 (78.8) 9 (17.3) 2 (3.8) 0 (0.0) 0.652 Lying down to rest in the afternoon when circumstances permit Would never nod off (0) Slight chance of nodding off (1) Moderate chance of nodding off (2) 11 (30.6) 19 (52.8) 6 (16.7) 0 (0.0) 24 (53.3) 15 (33.3) 5 (11.1) 1 (2.2) 12 (63.2) 5 (26.3) 1 (5.3) 1 (5.3) 34 (65.4) 15 (28.8) 3 (5.8) 0 (0.0) 0.063 Page 1135 High chance of nodding off (3) Sitting and talking to someone Would never nod off (0) Slight chance of nodding off (1) Moderate chance of nodding off (2) 32 (88.9) 2 (5.6) 2 (5.6) 40 (88.9) 5 (11.1) 0 (0.0) 18 (94.7) 1 (5.3) 0 (0.0) 49 (94.2) 0 (0.0) 3 (5.8) 0.151 In a car while stopped for a few minutes in traffic Would never nod off (0) Slight chance of nodding off (1) Moderate chance of nodding off (2) High chance of nodding off (3) 31 (86.1) 3 (8.3) 1 (2.8) 1 (2.8) 43 (95.6) 2 (4.4) 0 (0.0) 0 (0.0) 19 (100) 0 (0.0) 0 (0.0) 0 (0.0) 47 (90.4) 5 (9.6) 0 (0.0) 0 (0.0) 0.415 Anxiety and depression among Hemodialysis patients based on duration Anxiety and depression among hemodialysis patients based on duration, < 1 year (<1), 1 – 3 years (1-3), 4 – 5 years (4-5) and > 5 years (>5), are summarized in Table 3. Data suggested that significant differences were observed in the frequency distribution of Anxiety and Depression regarding duration of hemodialysis, such as, Patients with less than 1 year of hemodialysis most frequently reported they “couldn’t seem to experience any positive feeling at all” (61.1%) compared to 26.7%, 26.3%, and 46.2% in the 1–3 years, 3–5 years, and >5 years groups, respectively (p=0.002). Statistically significant differences were also found for those who “just couldn’t seem to get going” (<1: 36.1%, 1–3: 28.9%, 4–5: 5.3%, >5: 38.5%; p=0.043), “felt they had nothing to look forward to” (<1: 44.4%, 1–3: 20.0%, 4–5: 26.3%, >5: 34.6%; p=0.0001), “felt sad and depressed” (<1: 36.1%, 1–3: 33.3%, 4–5: 10.5%, >5: 36.5%; p=0.032), “felt un-hearted and blue” (<1: 36.1%, 1–3: 26.7%, 4–5: 36.8%, >5: 51.9%; p=0.0001), “were unable to become enthusiastic about anything” (<1: 58.3%, 1–3: 24.4%, 4–5: 15.8%, >5: 34.6%; p=0.008), “felt life was meaningless” (<1: 52.8%, 1– 3: 37.8%, 4–5: 42.1%, >5: 36.5%; p=0.025), “found it difficult to work up the initiative to do things” (<1: 38.9%, 1–3: 35.6%, 4–5: 26.3%, >5: 53.8%; p=0.027), and “could see nothing in the future to be hopeful about” (<1: 61.1%, 1–3: 44.4%, 4– 5: 36.8%, >5: 51.9%; p=0.025). However, no statistically significant differences were found in the variables “I felt I was pretty worthless” and “I felt that I had lost interest in just about everything” (Table 3). Table 3. Anxiety and depression among hemodialysis patients based on its duration Duration of Hemodialysis (Years) Anxiety and Depression Less than 1, n=36 (%) 1-3, n=45 (%) 4-5, n=19 (%) More than 5, n=52 (%) p-value I couldn’t seem to experience any positive feeling at all Does not apply (0) To some degree (1) Considerable degree (2) Most of the time (3) 22 (61.1) 10 (27.8) 1 (2.8) 2 (8.3) 12 (26.7) 15 (33.3) 12 (26.7) 6 (13.3) 5 (26.3) 7 (36.8) 4 (21.1) 3 (15.8) 24 (46.2) 24 (46.2) 3 (5.8) 1 (1.9) 0.002* I just couldn’t seem to get going Does not apply (0) To some degree (1) Considerable degree (2) Most of the time (3) 13 (36.1) 18 (44.4) 4 (11.1) 3 (8.3) 13 (28.9) 12 (26.7) 17 (37.8) 3 (6.7) 1 (5.3) 10 (52.6) 5 (26.3) 3 (15.8) 20 (38.5) 19 (36.5) 11 (21.2) 2 (3.8) 0.043* Page 1136 I felt that I had nothing to look to forward to Does not apply (0) To some degree (1) Considerable degree (2) Most of the time (3) 16 (44.4) 15 (41.7) 5 (13.9) 0 (0.0) 9 (20.0) 20 (44.4) 5 (11.1) 11 (24.4) 5 (26.3) 4 (21.1) 7 (36.8) 3 (15.8) 18 (34.6) 26 (50.0) 8 (15.4) 0 (0.0) 0.0001 ** I felt sad and depressed Does not apply (0) To some degree (1) Considerable degree (2) Most of the time (3) 13 (36.1) 14 (38.9) 8 (22.2) 1 (2.8) 15 (33.3) 8 (17.8) 18 (40.0) 4 (8.9) 2 (10.5) 11 (57.9) 3 (15.8) 3 (15.8) 19 (36.5) 19 (36.5) 10 (19.2) 4 (7.7) 0.032* I felt that I had lost interest in just about everything Does not apply (0) To some degree (1) Considerable degree (2) Most of the time (3) 17 (47.2) 11 (30.6) 8 (22.2) 0 (0.0) 13 (28.9) 13 (28.9) 14 (31.1) 5 (11.1) 6 (31.6) 8 (42.1) 2 (10.5) 3 (15.8) 29 (55.5) 9 (17.3) 11 (21.2) 3 (5.8) 0.053 I felt I wasn’t worth much as a person Does not apply (0) To some degree (1) Considerable degree (2) Most of the time (3) 16 (44.4) 16 (44.4) 4 (11.1) 0 (0.0) 18 (40.0) 8 (17.8) 12 (26.7) 7 (15.6) 6 (31.6) 7 (36.8) 3 (15.8) 3 (15.8) 15 (28.8) 30 (57.7) 4 (7.7) 3 (5.8) 0.003* I felt that life wasn’t worthwhile Does not apply (0) To some degree (1) Considerable degree (2) Most of the time (3) 22 (61.1) 11 (30.6) 2 (5.6) 1 (2.8) 17 (37.8) 9 (20.0) 14 (31.1) 5 (11.1) 6 (31.6) 3 (15.8) 6 (31.6) 4 (21.1) 17 (32.7) 29 (55.8) 3 (5.8) 3 (5.8) 0.0001 ** I couldn’t seem to get any enjoyment out of the things I did Does not apply (0) To some degree (1) Considerable degree (2) Most of the time (3) 22 (61.1) 9 (25.0) 5 (13.9) 0 (0.0) 17 (37.8) 12 (26.7) 7 (15.8) 9 (20.0) 2 (10.5) 5 (26.3) 9 (47.4) 3 (15.8) 22 (42.3) 20 (38.5) 7 (13.5) 3 (5.8) 0.001* * I felt un-hearted and blue Does not apply (0) To some degree (1) Considerable degree (2) Most of the time (3) 13 (36.1) 19 (52.8) 4 (11.1) 0 (0.00) 12 (26.7) 15 (33.3) 11 (24.4) 7 (15.6) 7 (36.8) 1 (5.3) 8 (42.1) 3 (15.8) 27 (51.9) 11 (21.2) 13 (25.0) 1 (1.9) 0.0001 ** I was unable to become enthusiastic about anything Does not apply (0) To some degree (1) Considerable degree (2) Most of the time (3) 21 (58.3) 10 (27.8) 5 (13.9) 0 (0.0) 11 (24.4) 22 (48.9) 7 (15.6) 5 (11.1) 3 (15.8) 11 (57.9) 2 (10.5) 3 (15.8) 18 (34.6) 22 (42.3) 11 (21.1) 1 (1.9) 0.008* I felt I was pretty worthless Does not apply (0) To some degree (1) Considerable degree (2) Most of the time (3) 16 (44.4) 14 (38.9) 3 (8.3) 3 (8.3) 16 (35.6) 15 (33.3) 8 (17.8) 6 (13.3) 7 (36.8) 5 (26.3) 4 (21.1) 3 (15.8) 26 (50.0) 18 (34.6) 6 (11.5) 2 (3.8) 0.581 I could see nothing in the future to be hopeful about Page 1137 Does not apply (0) To some degree (1) Considerable degree (2) Most of the time (3) 22 (61.1) 11 (30.6) 3 (8.3) 0 (0.0) 20 (44.4) 10 (22.2) 12 (26.7) 3 (6.7) 7 (36.8) 3 (15.8) 6 (31.6) 3 (15.8) 27 (51.9) 15 (28.8) 10 (19.2) 0 (0.0) 0.025* I felt that life was meaningless Does not apply (0) To some degree (1) Considerable degree (2) Most of the time (3) 19 (52.8) 12 (33.3) 4 (11.1) 1 (2.8) 17 (37.8) 10 (22.2) 15 (33.3) 3 (6.7) 8 (42.1) 5 (26.3) 3 (15.8) 3 (15.8) 19 (36.5) 25 (48.1) 5 (9.6) 3 (5.8) 0.025* I found it difficult to work up the initiative to do things Does not apply (0) To some degree (1) Considerable degree (2) Most of the time (3) 14 (38.9) 19 (52.8) 3 (8.3) 0 (0.0) 16 (35.6) 14 (31.1) 8 (17.8) 7 (15.6) 5 (26.3) 8 (42.1) 3 (15.8) 3 (15.8) 28 (53.8) 13 (25.0) 9 (17.3) 2 (3.8) 0.027* Impact of hemodialysis duration on KDQOL-36 Subdomains. KDQOL-36 scores across the four groups of hemodialysis duration (< 1 year, 1–3 years, 4–5 years, and > 5 years) are presented in Table 4. Statistically significant differences were observed in all five KDQOL subscales. The mean score for the Symptom/Problem List was highest among patients on dialysis for 1–3 (6.1 ± 13.6) and lowest in those with < 1 (3.8 ± 11.4) (p = 0.0001). For the Effects of Kidney Disease, the highest score was noted among the 4–5 group (33.7 ± 18.9), while the lowest was in the > 5 group (24.9 ± 22.1) (p = 0.0001). The Burden of Kidney Disease score was highest among patients with > 5 of dialysis (54.1 ± 19.8) and lowest in the 4–5 group (40.8 ± 22.9) (p = 0.0001). The SF-12 Physical Composite scores ranged from 37.7 ± 5.3 (< 1 year) to 39.8 ± 4.5 (> 5 years), while the SF-12 Mental Composite ranged from 39.9 ± 5.9 (1–3) to 41.4 ± 5.3 (4–5), both showing statistically significant differences across groups (p = 0.0001) (Table 4). Table 4. Impact of hemodialysis duration on KDQOL-36 Subdomains. Duration of Hemodialysis Symptom/ problem list Effects of kidney disease Burden of kidney disease SF-12 Physical composite SF-12 Mental composite p-values Less than 1, n=36 3.8 ± 11.4 30.9 ± 21.4 48.1 ± 17.2 37.7 ± 5.3 40.2 ± 5.2 0.0001** 1-3, n=45 6.1 ± 13.6 29.7 ± 21.4 47.8 ± 21.9 39.4 ± 4.6 39.9 ± 5.9 0.0001** 4-5, n=18 5.7 ± 12.3 33.7 ± 18.9 40.8 ± 22.9 37.9 ± 6.6 41.4 ± 5.3 0.0001** > 5, n=53 4.3 ± 11.2 24.9 ± 22.1 54.1 ± 19.8 39.8 ± 4.5 41.2 ± 5.7 0.0001** Discussion: Table 1 presents the demographic and clinical characteristics of hemodialysis patients across different durations of treatment, revealing several statistically significant differences. Age distribution varied notably (p=0.003), with the 31–50 years age group being the most prevalent, particularly among patients undergoing dialysis for more than five years, consistent with previous studies showing a higher prevalence of middle-aged adults among long-term dialysis populations (Ravani, Palmer et al. 2013). Social class (p=0.001) and education level (p=0.049) also differed, with most patients