Vascular Access Function and Psychological Well-Being of Haemodialysis Patients

Abstract

Background: Stress, anxiety and depression are phenomena that often accompany the onset of chronic illness. The development of psychosomatic medicine has led to the study of the influence of other emotional factors, including the presence of anxiety and depression, on a patient’s health status, in addition to quality of life. The aim of this study is to evaluate the relationship between vascular access function and the occurrence of stress, anxiety and depression in haemodialysis patients. Methods: A total of 202 haemodialysis patients were included in the analysis, and the severity of vascular access problems and levels of negative emotions (feelings of stress, anxiety, depression) were assessed using standardised questionnaires (VAQ, HADS-M, PSS-10). Results: The results show that an increase in vascular access function problems correlated with increased levels of stress (r = 0.262; p < 0.001), anxiety (r = 0.456; p < 0.001) and depression (r = 0.391; p < 0.001). Conclusions: The study confirms the significant impact of vascular access quality on patients’ emotional state, highlighting the need to monitor and optimise its functioning to improve the psychological well-being of dialysis patients.

1. Introduction

Stress, anxiety and depression are phenomena that frequently accompany the onset of chronic diseases. The advent of psychosomatic medicine has precipitated an investigation into the impact of not only quality of life, but also other emotional factors, including anxiety and depression, on the patient’s state of health. The potential impact of strong emotional experiences on the course of chronic diseases has been a subject of observation by clinicians for many years. The initial diagnosis of a chronic condition, the necessity to adapt or comply with treatment regimens, and the associated stress are frequently associated with the onset of anxiety and depression. The symptoms described above have been shown to have a detrimental effect on the quality of life of the patient, and there is a strong correlation between these symptoms and the patient’s state of health. The symptoms manifest themselves through a deterioration in nutritional status, an increase in inflammatory markers, an increase in the frequency and length of hospitalisation, or a deterioration in cooperation. These factors underscore the necessity for systematic monitoring of stress, anxiety and depression levels among patient groups, and the implementation of measures aimed at enhancing their emotional well-being [1,2,3].

The findings of other researchers indicate the presence or absence of an effect of vascular access function on the occurrence of negative emotions, particularly depression, in haemodialysis patients (Hyoung Kim Do et al., Meng-Ting Li et al.), suggesting a necessity for further research in this area [4,5,6,7]. Health-related quality of life (HRQOL) is a non-clinical factor that may determine survival in patients on renal replacement therapy. It has been demonstrated that patients with chronic kidney disease who exhibit elevated levels of stress or depressive symptoms have reduced survival time in comparison to those who demonstrate emotional positivity [4,8,9,10,11]. The present study therefore seeks to examine the relationship between vascular access and the occurrence of these symptoms.

The aim of this study is to assess the relationship between vascular access function and the incidence of stress, anxiety and depression in haemodialysis patients.

2. Materials and Methods

2.1. Study Design and Subject

The present study was conducted over the period from January 2021 to December 2022. The study group was selected from among patients undergoing renal replacement therapy by haemodialysis at a dialysis centre in Lublin, Poland (120 respondents), as well as patients of other centres located in Poland belonging to an online community of dialysis patients (112 respondents). The total size of the study group was 232, of which 202 respondents’ answers qualified for statistical analysis.

2.2. Inclusion Criteria

The inclusion criteria for the study were as follows: the provision of informed consent to participate in the study, age over 18 years, chronic kidney disease treated by haemodialysis and possession of active vascular access to haemodialysis. The study design received a favourable opinion from the Bioethics Committee at the Medical University of Lublin (resolution no. KE-0254/178/2021).

2.3. Methods, Techniques, Research Tools

The study employed a diagnostic survey method, an auditorium survey technique, a distributed survey, an online survey and a face-to-face interview technique. The following research tools were used to conduct the survey:

The survey questionnaire, which was developed by the authors, comprises questions pertaining to the subject’s sociodemographic variables, including age, gender and the type of vascular access held.

The Vascular Access Questionnaire (VAQ) is a tool designed to assess objective and subjective factors related to the functioning of the dialysis vascular access. The questionnaire contains 17 potential problems perceived by the patient. Each problem is scored on a 5-point Likert scale, where 1 signifies that the vascular access problem has not bothered the patient in the past 4 weeks, and 5 signifies that it has bothered the patient enormously. The summed score is then used to determine the severity of the vascular access function problems. The full version of the VAQ questionnaire (the original English version of the form) is presented in

Table 1. Vascular Access Questionnaire (VAQ).

How Much Have the Following Vascular Access Issues Bothered You in the Last 4 Weeks? Circle the Number That Best Describes Your Situation.	Not at All	A Little	Moderately	Quite a Bit	Extremely
Pain	0	1	2	3	4
Bleeding	0	1	2	3	4
Swelling	0	1	2	3	4
Bruising	0	1	2	3	4
Redness	0	1	2	3	4
Infection	0	1	2	3	4
Clotting	0	1	2	3	4
Appearance of your access	0	1	2	3	4
Worries about whether your access is working well to clean the blood properly	0	1	2	3	4
Having to come early to the dialysis unit because of your access	0	1	2	3	4
Having to come early to the dialysis unit because of your access	0	1	2	3	4
Problems sleeping because of your access	0	1	2	3	4
Having to be careful to protect your access	0	1	2	3	4
Your access interfering with your daily activities (e.g., work or other regular daily activities)	0	1	2	3	4
Your access interfering with your social and leisure activities	0	1	2	3	4
Worries about being hospitalised because of problems with your access	0	1	2	3	4
Worries about being hospitalised because of problems with your access	0	1	2	3	4

below [12,13].

The Hospital Anxiety and Depression Scale (HADS-M) is a modified version of the HADS scale, as developed by A. Zigmond and R. Snaith. The Polish version was developed by M. Majkowicz, K. de Walden-Gałuszko and G. Chojnacka-Szawłowska. The scale comprises 14 questions, which are divided into subscales for the assessment of anxiety and depression, as well as two additional questions on irritability. The tool assesses negative emotions occurring in patients at different stages of the disease, which can indirectly affect their quality of life. Scores are given on a 4-point Likert scale and describe the presence or absence of regularity, depending on the sum of scores obtained in each category [14,15].

The Polish adaptation of the Perceived Stress Scale (PSS-10) was developed by S. Cohen, T. Kamarck, R. Mermelstein [16] and Z. Juczyński and Nina Ogińska-Bulik. It consists of 10 questions, assessing the frequency of occurrence of events and problems on a scale of 0—never, 1—almost never, 2—sometimes, 3—quite often, 4—very often. The total score, which is indicative of the level of perceived stress, is calculated by adding together the points obtained, and is expressed on a sten scale. Scores from 1 to 4 sten are characterised as low, from 5 to 6 as average, and from 7 sten upwards as high intensity of stress [16,17].

2.4. Statistical Analysis

The results obtained were summarised in a statistical analysis, in which the R programming language version 4.2.2 and the RStudio environment version 2022.12.0 were utilised. A p-value less than 0.05 was deemed to be statistically significant. The results were presented using basic statistical measures. The normality of the distribution was verified using the Shapiro–Wilk test, and correlation analyses between subjects were presented using Pearson’s r correlation coefficient.

3. Results

3.1. Characteristics of the Study Group

A total of 202 haemodialysed patients participated in the main study, of whom 51.98% (105 patients) were female and 48.02% (97 patients) were male. The mean age of the patients in the study group was 52.78 years with a standard deviation of 16.52 years, while the median was 51 years. The age range of the patients included in the study was from 21 to 92 years. The mean duration of dialysis was 5.87 years with a standard deviation of 8.75, while the median was 2.67 years. The shortest duration of dialysis was less than one month, while the longest was over 53 years. The most prevalent types of vascular access among patients were an arteriovenous fistula from their own vessels (exceeding 50% of respondents) and a tunnelled central venous catheter. The characteristics of the patients are shown in

Table 2. Characteristics of patients.

Variable		n	%	M	SD	Me	Min	Max
Age		202	-	52.78	16.52	51	21	92
Sex	Men	105	51.98
	Female	97	48.02
Type of Vascular Access	Arteriovenous Fistula (AVF)	134	66.34
	Tunnelled Central Venous Catheter (CVC)	58	28.71
	Non-Tunnelled Central Venous Catheter (CVC)	5	2.48
	Arteriovenous Graft (AVG)	5	2.48

n—number of observations: %—percentage; M—mean; Me—median; SD—standard deviation; Min—minimum; Max—maximum.

.

3.2. Problems Related to Vascular Access

The occurrence of vascular access complications was evaluated using the VAQ questionnaire. In the study group of haemodialysis patients, the mean severity of vascular access problems was 13.79, with a standard deviation of 11.22 and a median of 11. The study group included patients with both very low and very high severity of vascular access function problems (range 0–62). The Shapiro–Wilk test revealed statistically significant disparities between the distribution of severity of vascular access problems in the study group of haemodialysis patients and a normal distribution (W = 0.892; p = 0.000). The respondents exhibited a moderately low severity of vascular access problems. The aforementioned data are presented in

Table 3. Severity of vascular access problems.

Variable	n	M	SD	Me	Min	Max	Shapiro–Wilk Test
							S-W	p
Severity of vascular access problems	202	13.79	11.22	11	0	62	0.892	0.000

n—number of observations; M—mean; Me—median; SD—standard deviation; S-W—Shapiro–Wilk test result; p—test probability.

.

3.3. Perceived Stress, Anxiety and Depression

The following section presents a statistical description of the results obtained in the study group using the PSS—10, HADS—M questionnaires. In addition, the relationships between the occurrence of negative emotions (anxiety and depression) in the study group, the occurrence of stress and the severity of vascular access problems are verified.

Table 4. Perceived Stress level.

Variable	n	M	SD	Me	Min	Max	Shapiro–Wilk Test
							S-W	p
Perceived Stress	202	23.69	4.46	24	0	32	0.85	0.000

n—number of observations; M—mean; Me—median; SD—standard deviation; S-W—Shapiro–Wilk test result; p—test probability.

presents the distribution of feelings of stress in the study group.

The study group of haemodialysis patients exhibited a mean sense of stress rating of 23.69, with a standard deviation of 4.46 and a median of 24.00. The results ranged from 0.00 to 32.00. The Shapiro–Wilk test revealed statistically significant disparities between the distribution of stress levels in the haemodialysis group and the standard distribution (W = 0.850; p = 0.000). Following conversion of the scores to a sten scale, the mean stress level of the patients studied was determined to be 7.76, with a deviation of 1.26. The respondents exhibited a relatively elevated level of stress.

Table 5. Occurrence of anxiety and depression.

Variable	n	M	SD	Me	Min	Max	Shapiro–Wilk Test
							S-W	p
Anxiety	202	8.57	4.81	8	0	20	0.979	0.004
Depression	202	6.79	5.02	7	0	20	0.944	0.000

n—number of observations; M—mean; Me—median; SD—standard deviation; S-W—Shapiro–Wilk test result; p—test probability.

provides an overview of the prevalence of anxiety and depression among the subjects.

In the group of haemodialysis patients who were the subject of the study, the mean anxiety score was 8.57, with a standard deviation of 4.81 and a median of 8.00. The results ranged from 0.00 to 20.00. The Shapiro–Wilk test revealed statistically significant disparities between the distribution of anxiety in the haemodialysis group and the standard distribution (W = 0.979; p = 0.004).

The mean level of depression ascertained using the HADS-M questionnaire was 6.79, with a standard deviation of 5.02 and a median of 7.00. The results ranged from 0.00 to 20.00. The Shapiro–Wilk test revealed statistically significant disparities between the depression distribution in the haemodialysis group and the standard distribution (W = 0.944; p = 0.000).

The anxiety levels were as follows: the largest group (approximately 40 per cent of individuals) was without disorder (44.06 per cent); a smaller group (one in three individuals) with disorder (34.16 per cent); and the smallest fraction (one in five individuals) with borderline condition (21.78 per cent). For the level of depression, the largest group (more than half of the people) was without disorders (54.95%), followed by (one in four people) borderline status (24.75%), and the smallest fraction (one in five people) was disorders (20.30%).

3.4. Correlation of Negative Emotions and Vascular Access Related Problems

Table 6. Prevalence of negative emotions, stress and severity of vascular access problems.

Variable	Severity of Vascular Access Problems
	r	p
Perceived Stress	0.262	0.000
Anxiety	0.456	0.000
Depression	0.391	0.000

r—Pearson’s correlation coefficient r; p—test probability.

presents the associations of the presence of negative emotions and stress with the severity of vascular access problems.

A strong correlation was identified between the severity of vascular access problems and anxiety (r = 0.456; p = 0.000), depression (r = 0.391; p = 0.000) and stress (r = 0.262; p = 0.000). It is evident that as the severity of vascular access problems increases, so too do the levels of anxiety, depression and stress.

4. Discussion

In the present study, a range of stress and anxiety-depressive symptoms were identified among the patient cohort. It is noteworthy that approximately 25% of patients exhibited symptoms consistent with a depressive disorder, while more than 33% demonstrated anxiety. Concurrently, the patients exhibited elevated levels of stress. These observations have been corroborated by other researchers [9,18,19]. The observed correlations suggest that the disease itself and the need for renal replacement therapy may be contributing factors to the manifestation of these adverse emotions in patients. However, our study demonstrates a correlation between these outcomes and vascular access function, underscoring the significance of vascular access care for patients’ overall well-being. The findings of this study indicate that lower satisfaction with vascular access, higher levels of problems, or incidence of complications are associated with a higher incidence of anxiety, depression and stress.

The necessity to cannulate a fistula or vascular prosthesis appears to be one of the elements linking vascular access to anxiety and depression. Typically, patients must prepare for approximately 320 punctures per year, each of which is accompanied by an element of uncertainty regarding its success and the potential for discomfort, stress, and, in the longer term, the development of depression. This supposition is in line with the results of a study by Ibrahim M.B et al., where the association of the occurrence of anxiety and depression with the need for fistula cannulation was assessed in 117 patients on haemodialysis [18]. Nevertheless, it is important to note that patients with arteriovenous fistulas are not the only individuals at risk of developing such disorders. A further study by Hao W. et al., Büberci R. et al. and Qawaqzeh D.T.A. et al., in addition to demonstrating the effect of vascular access on the incidence of anxiety and depression in haemodialysis patients, points out that a higher incidence of anxiety and depression is observed in patients using a central venous catheter. This relationship may be a result of the limitations introduced by the vascular catheter, the more frequent number of hospitalisations, or the advanced age of those in whom it is usually decided to use this type of access [20,21,22,23].

From a patient care perspective, the maintenance of vascular access function is a priority. A study by Brito D.C. et al. demonstrates an increase in the severity of anxiety symptoms in patients who had experienced the loss of a previously held vascular access within the past 12 months. Consequently, it is imperative that staff actions in vascular access care are grounded in scientific principles to minimise the risk of vascular access loss and, by extension, reduce anxiety in haemodialysis patients [24].

In addition, educational measures should be implemented for patients exhibiting depressive symptoms. The positive effect of psychoeducation and social support in reducing depressive symptoms in haemodialysis patients has been demonstrated in studies by Espahodi F. et al. and Lilympaki I. et al. [25,26]. It is imperative that this education incorporates components designed to impart self-care skills and the management of vascular access, with a focus on both the patient and their family. It is recommended that attention be paid to the aforementioned aspects in order to enhance the quality of dialysis care and reduce negative emotions (stress, anxiety, depression) in the population of patients undergoing renal replacement therapy.

The limitations of the study must be noted. The selection of the study group could be extended to include patients treated in dialysis centres in other countries, which would increase the representativeness of the study. Furthermore, the present analysis does not take into account objective factors related to vascular access function, such as arteriovenous fistula blood flow, laboratory results or the adequacy of dialysis using access as measured by the Kt/V ratio. The incorporation of these clinical variables is imperative when conducting subsequent studies in this field. Additionally, some of the data concerning the subjects’ vascular access history and comorbidities were unavailable and were therefore not included in the study, despite their potential impact. This should be taken into account in future studies.

5. Conclusions

The functionality of vascular access significantly impacts the emotional state of haemodialysis patients, with increased vascular access complications being associated with elevated levels of stress, anxiety and depression. Patients encountering greater challenges in accessing vascular facilities are more prone to adverse emotions, which can exert a detrimental effect on their quality of life and the extent to which they are able to engage with the therapeutic process. Consequently, it is imperative to closely monitor patients’ mental well-being and optimise vascular access care, as these measures have been shown to enhance mental wellbeing and improve treatment outcomes.