Journal of

Clinical Medicine

Article
Vascular Access Perception and Quality of Life of
Haemodialysis Patients
Kamil Sikora 1, * , Agnieszka Zwolak 1 , Robert Jan Łuczyk 1 , Agnieszka Wawryniuk 1 and Marta Łuczyk 2

1 Department of Internal Medicine and Internal Nursing, Chair of Preventive Nursing, Faculty of Health
Sciences, Medical University of Lublin, Ul. Chodźki 7, 20-093 Lublin, Poland
2 Department of Long-Term Care Nursing, Chair of Preventive Nursing, Faculty of Health Sciences, Medical
University of Lublin, Ul. Chodźki 7, 20-093 Lublin, Poland
* Correspondence: kamil.sikora@umlub.pl

Abstract: Background: Patient quality of life is widely used as a non-clinical determinant of care.
For patients undergoing hemodialysis, vascular access is vital to the delivery of hemodialysis and its
function may affect not only the clinical outcome of treatment but also the overall quality of life of the
patient, highlighting the need for increased efforts to improve the quality of hemodialysis vascular
access care. The objective of this study was to evaluate the correlation between vascular access
perception and quality of life in patients undergoing hemodialysis. Methods: A total of 202 patients
with active hemodialysis vascular access were included in the study. Quality of life was assessed
using the Kidney Disease Quality of Life Instrument (KDQOL™) questionnaire, while vascular
access perception was evaluated using the Vascular Access Questionnaire (VAQ). Results: The study
presented evidence on the influence of vascular access for hemodialysis patients on their quality of
life. This impact is related to factors directly associated with vascular access, such as the type of
access and the patient’s subjective evaluation of the access. Conclusions: The perception of vascular
access is one of the factors that determines the quality of life of hemodialysis patients. The quality of
life of hemodialysis patients decreases as the number of vascular access-related problems increases.

Keywords: quality of life; renal dialysis; vascular fistula; central venous catheter; functional status

Citation: Sikora, K.; Zwolak, A.;

Łuczyk, R.J.; Wawryniuk, A.; Łuczyk,
M. Vascular Access Perception and 1. Introduction
Quality of Life of Haemodialysis Patient opinions on the impact of the healthcare they receive are increasingly being
Patients. J. Clin. Med. 2024, 13, 2425. used as a measure of the effectiveness of clinical decision-making. Haemodialysis patients
https://doi.org/10.3390/jcm13082425 understand the significance of vascular access (VA) to renal replacement therapy and its
Academic Editors: Jonathan Barratt impact on health-related quality of life (HRQOL). Although commonly used tools for
and Hiroshi Tanaka assessing the quality of life of dialysis patients, such as the Kidney Disease Quality of Life
Instrument (KDQOL™), include elements related to vascular access, its impact on HRQOL
Received: 22 March 2024 has not been sufficiently assessed using current tools. This highlights the need for further
Revised: 9 April 2024
research in this area [1–4]. Examples of such assessments include patient-reported outcome
Accepted: 18 April 2024
measures (PROMs) and patient-reported experience measures (PREMs). These methods
Published: 21 April 2024
are standardized for assessing the impact of vascular access on a patient’s health status
and, consequently, their health-related quality of life [3].
Due to the complexity of hemodialysis, vascular access can have a significant impact
Copyright: © 2024 by the authors.
on the quality of life of patients. One modifiable factor that influences the HRQOL of
Licensee MDPI, Basel, Switzerland. patients undergoing dialysis is the type of vascular access used. Studies in this area have
This article is an open access article shown that the type of vascular access can affect patients’ quality of life, although the
distributed under the terms and results are not yet conclusive. The impact on quality of life extends beyond the type of
conditions of the Creative Commons vascular access used, and includes physical symptoms such as pain, bleeding, bruising,
Attribution (CC BY) license (https:// and oedema, as well as complications like thrombosis and infection. Patient satisfaction
creativecommons.org/licenses/by/ with access and social functioning are also important factors to consider [5–7]. The study
4.0/). took all of these factors into consideration. The objective of this study was to evaluate

J. Clin. Med. 2024, 13, 2425. https://doi.org/10.3390/jcm13082425 https://www.mdpi.com/journal/jcm

J. Clin. Med. 2024, 13, 2425 2 of 11

the correlation between vascular access perception and quality of life in patients treated
by hemodialysis.

2. Materials and Methods

The study was conducted from January 2021 to December 2022. The study group
consisted of 120 respondents undergoing renal replacement therapy by hemodialysis at a
dialysis center in Lublin, Poland, and 112 respondents from other centers in Poland who
were part of an online community of dialysis patients. In the main stage of the study,
232 people were included in the total size of the study group. Out of these, 202 respondents’
answers qualified for statistical analysis.
The inclusion criteria were informed consent to participate in the study, age above 18
years, chronic kidney disease treated by hemodialysis, and having active vascular access
for hemodialysis. The study protocol was approved by the Bioethics Committee of the
Medical University of Lublin, Resolution No. KE-0254/178/2021 of 24 June 2021.
For the study, we used various diagnostic survey methods, including an auditorium
survey technique, a distributed survey, an online survey, and a face-to-face interview
technique. The research tools used in the study included a self-administered survey
questionnaire that contained questions on sociodemographic variables such as age, gender,
and type of vascular access.
The Vascular Access Questionnaire (VAQ) is a tool used to assess objective and subjec-
tive factors related to the functioning of vascular access for dialysis. It contains 17 potential
problems perceived by the patient, each scored on a 5-point Likert scale. A score of 1 in-
dicates that the vascular access problem has not bothered the patient in the past 4 weeks,
while a score of 5 indicates that it has bothered the patient enormously. The summed score
helps to determine the severity of vascular access function problems [8,9].
The Kidney Disease Quality of Life Instrument—Short Form (KDQOL-SF) is a stan-
dardized survey used to evaluate the quality of life of patients with kidney disease. The
questionnaire comprises 24 questions, categorized by general perceptions of one’s health,
information about kidney disease, its impact on daily life, and satisfaction with care. The
initial section of the questionnaire utilizes the SF-36 quality of life assessment tool, which
comprises 36 statements divided into 11 categories. The second section of the KDQOL-
SF questionnaire evaluates the effect of kidney disease on the participant’s life and their
contentment with the care they receive [10,11].
Statistical analyses were conducted using the R programming language version 4.2.2
and the RStudio environment version 2022.12.0. A significance level of α < 0.05 was used.
The results for vascular access problems (VAQ), quality of life of the subjects (KDQOL-
SF), duration of disease, dialysis, and age of the subjects were described using mean,
standard deviation, median, mean rank, skewness, and kurtosis coefficients. The results for
demographic variables and medical data of the subjects were statistically described using
count and percentage distributions. To assess the relationship between the subjects’ quality
of life and variables characterizing vascular access, Kruskal–Wallis tests were employed.
Pearson’s r correlation coefficient and Gamma correlation coefficient were used to verify
the associations between vascular access problems and quality of life of the domains.

3. Results
The study included 202 hemodialysis patients, of whom 51.98% (105 patients) were
female and 48.02% (97 patients) were male. The mean age of the patients was 52.78 years
(SD = 16.52), with a median of 51 years. The youngest patient was 21 years old, and the
oldest was 92 years old. The mean duration of dialysis was 5.87 years (SD = 8.75), with a
median of 2.67 years. The duration of dialysis ranged from less than one month to over
53 years. The age of patients and duration of dialysis are presented in Table 1 below.
J. Clin. Med. 2024, 13, 2425 3 of 11

Table 1. Patient’s age and duration of dialysis (in years).

Variable n M SD Me Min Max Skew Kurt

Age 202 52.78 16.52 51 21 92 0.096 −0.975
Duration of dialysis 193 5.87 8.75 2.67 0.08 53.81 2.853 9.203
n—number of observations; M—mean; Me—median; SD—standard deviation; Skew—skewness coefficient;
Kurt—kurtosis coefficient.

The majority of patients had an arteriovenous fistula created from their own vessels
(AVF), while a tunneled central venous catheter (CVC) was also common. Table 2 displays
the characteristics of the different types of vascular access that patients had.

Table 2. Type of vascular access.

Type of Vascular Access n %

Arteriovenous Fistula (AVF) 134 66.34
Tunneled Central Venous Catheter (CVC) 58 28.71
Non-Tunneled Central Venous Catheter (CVC) 5 2.48
Arteriovenous Graft (AVG) 5 2.48
n—number of observations; %—percentage.

The study assessed vascular access problems using the VAQ questionnaire among
hemodialysis patients. The mean severity of vascular access problems in the study group
was 13.79, with a standard deviation of 11.22 and a median of 11. The study group com-
prised patients with different levels of severity of vascular access problems, from lack of
problems to highly impactful problems (range 0–62). The study group of hemodialysis pa-
tients showed statistically significant differences in the severity of vascular access problems
compared to a normal distribution. The severity of vascular access problems reported by
respondents was moderately low. Table 3 presents the aforementioned data.

Table 3. Severity of vascular access problems.

Variable n M SD Me Min Max Skew Kurt

Severity of vascular access problems 202 13.79 11.22 11 0 62 1.289 1.755
n—number of observations; M—mean; Me—median; SD—standard deviation; Skew—skewness coefficient;
Kurt—kurtosis coefficient.

The quality of life of the patients was assessed using the KDQOL-SF questionnaire,
and the relationhips between the quality of life of the patients and the severity of vascular
access problems were investigated. The higher the score on the KDQOL-SF questionnaire
scales, the better the quality of life in a specific domain. The scale names were slightly
modified to better reflect this feature.
Table 4 presents the participants’ quality of life scores, as measured by the first part of
the KDQOL-SF questionnaire.
The scores resulting from the distributions significantly deviated from the normal
distribution, with significant deviations occurring in the scales of freedom in performing
roles for emotional reasons, for health reasons, and for physical functioning.
Table 5 displays the subjects’ quality of life distribution in the area related to kidney
problems (the second part of the KDQOL-SF questionnaire).
J. Clin. Med. 2024, 13, 2425 4 of 11

Table 4. Overall quality of life of the respondents.

Quality of Life Domain n M SD Me Min Max Skew Kurt

Physical functioning 202 53.04 29.25 55.00 0 100 −0.312 −1.098
Freedom to perform roles due to
202 32.05 39.70 0.00 0 100 0.788 −1.035
physical health
Absence of pain 202 61.74 28.44 59.50 0 100 −0.279 −0.948
General health perceptions 202 38.32 19.64 40.00 0 97 0.286 −0.215
Vitality 202 45.83 20.66 48.33 0 90 −0.113 −0.350
Social function 202 55.63 27.15 50.00 0 100 −0.236 −0.701
Freedom to perform roles for
202 49.34 45.62 33.33 0 100 0.035 −1.831
emotional reasons
Emotional well-being 202 54.21 20.90 53.50 0 100 −0.239 −0.285
n—number of observations; M—mean; Me—median; SD—standard deviation; Skew—skewness coefficient;
Kurt—kurtosis coefficient.

Table 5. Respondents Quality of Life in kidney disease targeted scales.

Scale n M SD Me Min Max Skew Kurt

Symptom/problems 202 69.88 17.34 70.83 6.25 100 −0.612 0.076
Effects of kidney disease 202 49.92 24.42 50.00 0.00 100 −0.123 −0.990
Burden of kidney disease 202 33.26 25.22 25.00 0.00 100 0.558 −0.563
Work status 202 31.68 40.96 0.00 0.00 100 0.758 −1.097
Cognitive function 202 63.96 24.52 66.67 0.00 100 −0.545 −0.206
Quality of social interaction 202 60.74 22.20 60.00 0.00 100 −0.475 −0.063
Sleep 202 49.20 20.31 50.00 5.00 100 0.079 −0.591
Social support 202 66.50 24.60 66.66 0.00 100 −0.592 −0.258
Dialysis staff encouragement 202 74.07 24.37 75.00 0.00 100 −0.822 0.201
Patient satisfaction 202 60.23 23.15 66.67 0.00 100 −0.368 −0.050
n—number of observations; M—mean; Me—median; SD—standard deviation; Skew—skewness coefficient;
Kurt—kurtosis coefficient.

The scores on the analyzed scales resulted in distributions that were significantly
different from the normal distribution, with significant deviations observed in work status.
Table 6 displays the correlation between the patients’ overall quality of life and the
type of hemodialysis vascular access.
The statistical analysis revealed small but significant correlations between the type
of vascular access and the absence of pain. It is important to note that these findings are
objective and do not reflect any subjective evaluations. The highest incidence of pain-
free patients was observed in those with an arteriovenous fistula. Conversely, the lowest
incidence was observed in those with a non-tunneled central venous catheter. Patients
with a tunneled central venous catheter or an arteriovenous graft had intermediate levels
of pain.
The study showed the following relationship between overall health and type of
vascular access: those with an autologous arteriovenous fistula had the highest quality of
life in the area of overall health, those with a non-tunneled central venous catheter had the
lowest; those with a central venous catheter—tunneled—had the lowest; and those with
a vascular prosthesis had the lowest. The statistical analysis revealed that the observed
differences were both significant and small.
J. Clin. Med. 2024, 13, 2425 5 of 11

Table 6. Relationship between the overall quality of life of respondents and type of vascular access.

Quality of Life Kruskal–Wallis H Test

Type of Vascular Access n M SD Me Mr
Domain H df p η2
Non-Tunneled Central Venous Catheter 5 26.00 27.70 25.00 50.50
Tunneled Central Venous Catheter 58 48.79 28.83 50.00 93.22
Physical
functioning 6.335 3 0.096 0.017
Arteriovenous Graft 5 60.00 36.23 60.00 118.50
Arteriovenous Fistula 134 55.63 28.81 60.00 106.35
Non-Tunneled Central Venous Catheter 5 20.00 44.72 0.00 78.20
Freedom to Tunneled Central Venous Catheter 58 25.00 35.36 0.00 92.87
perform roles due 3.586 3 0.310 0.003
Arteriovenous Graft 5 45.00 51.23 25.00 117.70
to physical health
Arteriovenous Fistula 134 35.07 40.80 25.00 105.50
Non-Tunneled Central Venous Catheter 5 26.10 17.27 24.50 31.40
Tunneled Central Venous Catheter 58 59.01 28.23 58.25 96.95
Absence of pain 8.803 3 0.032 0.029
Arteriovenous Graft 5 58.40 23.57 47.00 90.00
Arteriovenous Fistula 134 64.38 28.23 69.00 106.51
Non-Tunneled Central Venous Catheter 5 37.40 15.61 35.00 97.40
Tunneled Central Venous Catheter 58 32.61 17.07 35.00 84.53
General health
perceptions 9.687 3 0.021 0.034
Arteriovenous Graft 5 28.80 24.85 22.00 67.20
Arteriovenous Fistula 134 41.18 20.15 42.00 110.28
Non-Tunneled Central Venous Catheter 5 40.00 16.96 40.00 84.10
Tunneled Central Venous Catheter 58 38.25 20.22 40.00 79.91
Vitality 12.216 3 0.007 0.046
Arteriovenous Graft 5 49.00 13.87 50.00 110.80
Arteriovenous Fistula 134 49.22 20.43 50.00 111.15
Non-Tunneled Central Venous Catheter 5 52.50 34.69 50.00 95.90
Tunneled Central Venous Catheter 58 46.12 29.91 50.00 82.98
Social function 8.611 3 0.035 0.028
Arteriovenous Graft 5 62.50 31.87 62.50 113.80
Arteriovenous Fistula 134 59.61 24.62 62.50 109.26
Non-Tunneled Central Venous Catheter 5 26.67 43.46 .33.33 76.00
Freedom to Tunneled Central Venous Catheter 58 45.40 45.33 33.33 97.23
perform roles for 3.188 3 0.364 0.001
Arteriovenous Graft 5 26.67 43.46 .66.67 76.00
emotional reasons
Arteriovenous Fistula 134 52.74 45.76 66.67 105.25
Non-Tunneled Central Venous Catheter 5 52.00 20.59 52.00 95.90
Tunneled Central Venous Catheter 58 47.64 20.61 52.00 84.69
Emotional
well-being 7.020 3 0.071 0.020
Arteriovenous Graft 5 55.20 22.16 56.00 104.20
Arteriovenous Fistula 134 57.10 20.57 56.00 108.88
n—number of observations; M—mean; SD—standard deviation; Me—median; Mr—mean rank; H—result of the
Kruskal–Wallis H-test; df—degrees of freedom; p—test probability; η2 —effect size; eta—square.

In terms of the relationship between vitality and type of vascular access, patients with
an autologous arteriovenous fistula had the highest vitality, followed by patients with a
vascular graft, lower vitality in patients with a non-tunneled central venous catheter, and
the lowest vitality in patients with a tunneled central venous catheter. It is important to
note that these findings are objective and not influenced by personal opinions or biases.
Regarding the relationship between social functioning and type of vascular access, the
best social functioning was observed in patients with a vascular graft, followed by those
with an arteriovenous fistula, then those with a non-tunneled central venous catheter, and
the least by those with a tunneled central venous catheter. The Kruskal–Wallis test revealed
statistically significant but small differences.
J. Clin. Med. 2024, 13, 2425 6 of 11

Table 7 presents the association between respondents quality of life and renal function
problems, with consideration given to the type of vascular access.

Table 7. The association between the quality of life of the respondents and problems related to kidney
function and the type of their vascular access.

Kruskal–Wallis H Test
Scale Group n M SD Me Mr
H df p η2
Non-Tunneled Central 5 60.83 16.50 56.25 67.50
Venous Catheter
Symptom/problems Tunneled Central Venous Catheter 58 69.03 18.39 70.83 98.69 2.418 3 0.490 0.003
Arteriovenous Graft 5 66.67 17.74 66.67 88.60
Arteriovenous Fistula 134 70.71 16.95 72.92 104.47
Non-Tunneled Central 5 46.25 21.23 57.14 91.30
Venous Catheter
Effects of kidney Tunneled Central Venous Catheter 58 41.29 24.10 40.62 81.71 10.268 3 0.016 0.037
disease
Arteriovenous Graft 5 47.86 20.22 40.62 93.40
Arteriovenous Fistula 134 53.86 24.04 56.25 110.75
Non-Tunneled Central 5 32.50 24.37 25.00 103.60
Venous Catheter
Burden of kidney Tunneled Central Venous Catheter 58 25.43 23.50 18.75 82.67 9.177 3 0.027 0.031
disease
Arteriovenous Graft 5 30.00 33.48 18.75 89.20
Arteriovenous Fistula 134 36.80 25.17 31.25 110.03
Non-Tunneled Central 5 20.00 27.39 0.00 91.10
Venous Catheter

Work status Tunneled Central Venous Catheter 58 31.90 40.50 0.00 102.24 0.833 3 0.841 0.011
Arteriovenous Graft 5 20.00 44.72 0.00 83.70
Arteriovenous Fistula 134 32.46 41.70 0.00 102.23
Non-Tunneled Central Venous Catheter 5 56.00 28.52 73.33 86.90
Tunneled Central Venous Catheter 58 60.23 27.53 63.33 95.32
Cognitive function 1.622 3 0.655 0.007
Arteriovenous Graft 5 60.00 27.08 60.00 91.60
Arteriovenous Fistula 134 66.02 22.89 66.67 105.09
Non-Tunneled Central Venous Catheter 5 65.33 15.92 73.33 114.70
Tunneled Central Venous Catheter 58 54.60 24.83 60.00 87.43
Quality of social 5.552 3 0.136 0.013
interaction Arteriovenous Graft 5 53.33 23.57 60.00 85.40
Arteriovenous Fistula 134 63.51 20.72 66.67 107.70
Non-Tunneled Central Venous Catheter 5 46.00 15.37 37.50 91.30
Tunneled Central Venous Catheter 58 44.76 21.61 40.00 88.38
Sleep 4.574 3 0.206 0.008
Arteriovenous Graft 5 55.50 26.60 65.00 115.60
Arteriovenous Fistula 134 51.00 19.53 51.25 107.03
Non-Tunneled Central Venous Catheter 5 73.33 9.13 66.66 110.20
Tunneled Central Venous Catheter 58 63.22 25.89 66.66 96.81
Social support 4.273 3 0.233 0.006
Arteriovenous Graft 5 49.99 20.41 49.99 54.90
Arteriovenous Fistula 134 68.28 24.34 66.66 104.94
Non-Tunneled Central 5 57.50 32.60 50.00 68.60
Venous Catheter
Dialysis staff Tunneled Central Venous Catheter 58 73.71 24.30 75.00 100.21
encouragement 4.921 3 0.178 0.010
Arteriovenous Graft 5 60.00 13.69 50.00 59.10
Arteriovenous Fistula 134 75.37 24.23 75.00 104.87
Non-Tunneled Central 5 50.00 0.00 50.00 65.00
Venous Catheter

Patient satisfaction Tunneled Central Venous Catheter 58 62.64 23.84 66.67 106.78 4.608 3 0.203 0.008
Arteriovenous Graft 5 50.00 0.00 50.00 65.00
Arteriovenous Fistula 134 59.95 23.58 66.67 101.94
n—number of observations; M—mean; SD—standard deviation; Me—median; Mr—mean rank; H—result of the
Kruskal–Wallis H-test; df—degrees of freedom; p—test probability; η2 —effect size eta—square.
J. Clin. Med. 2024, 13, 2425 7 of 11

The study analyzed the relationship between the quality of life of hemodialysis patients
with kidney disease-related problems and the type of vascular access used. The results
showed that patients with an arteriovenous fistula had the highest quality of life in relation
to the effects of the disease, followed by those with a vascular prosthesis, those with a
non-tunneled central venous catheter, and those with a tunneled central venous catheter,
who had the lowest quality of life. The Kruskal–Wallis test indicated statistically significant
and small differences.
Among hemodialysis patients, the type of vascular access is related to the quality
of life related to disease burden. Subjects with an arteriovenous fistula from their own
vessels had the highest level of quality of life in this domain, followed by those with a
non-tunneled central venous catheter, then with a vascular graft, and finally those with a
tunneled central venous catheter. The Kruskal–Wallis test indicated statistically significant
but small differences.
Table 8 presents the association between the severity of vascular access problems and
patients overall quality of life.

Table 8. Severity of vascular access problems and patients overall quality of life.

Severity of Vascular Access Problems

Quality of Life Domain
r/γ p
Physical functioning −0.139 0.049
Freedom to perform roles due to physical health −0.283 0.000
Absence of pain −0.411 0.000
General health perceptions −0.382 0.000
Vitality −0.370 0.000
Social function −0.392 0.000
Freedom to perform roles for emotional reasons −0.272 0.000
Emotional well-being −0.399 0.000
r—Pearson’s correlation coefficient r; γ—Gamma correlation coefficient; p—test probability.

The severity of vascular access problems was associated relatively strongly with the
absence of pain (r = −0.411; p = 0.000), moderately with emotional well-being (r = −0.399;
p = 0.000), and social functioning (r = −0.392; p = 0). The results indicate a negative
correlation between the participant’s general perception of health (r = −0.392; p = 0.000),
social functioning (r = −0.392; p = 0.000), vitality (r = −0.370; p = 0.000), role freedom due to
physical health (r = −0.283; p = 0.000), role freedom due to emotional reasons (γ = −0.272;
p = 0.000), and a rather small correlation with physical functioning (r = −0.139; p = 0.049).
The severity of vascular access problems negatively impacts various aspects of quality of
life, including pain, mental health, social functioning, overall health perception, vitality,
and the ability to perform physical and emotional roles.
Table 9 shows the association between the severity of vascular access problems and
the patients’ quality of life related to kidney problems.
Correlation analyses revealed a significant association between the severity of vascular
access problems and quality of life in the domains of disease effects (r = −0.515; p = 0.000),
symptoms (r = −0.468; p = 0.000), and cognitive functioning (r = −0.432; p = 0.000), as
well as moderate satisfaction with dialysis station staff care (r = −0.323; p = 0.000). The
study found statistically significant negative correlations between the severity of vascular
access problems and quality of sleep (r = −0.353; p = 0.000), quality of social relationships
(r = −0.343; p = 0.000), quality of life in the area of disease burden (r = −0.333; p = 0.000),
level of dialysis staff encouragement (r = −0.323; p = 0.000), and level of social support
(r = −0.230; p = 0.001). However, there was no statistically significant relationship between
the severity of vascular access problems and quality of life in the domain of work activity
(γ = −0.098; p = 0.167). The severity of vascular access problems negatively impacts
J. Clin. Med. 2024, 13, 2425 8 of 11

various aspects of a patient’s quality of life, including disease effects, symptoms, cognitive
functioning, satisfaction with dialysis station staff care, sleep, social relationships, disease
burden, patient support from dialysis station staff, and social support.

Table 9. Vascular access problem, severity, and patients’ kidney-related quality of life.

Severity of Vascular Access Problems

Scale
r/γ p
Symptom/problems −0.468 0.000
Effects of kidney disease −0.515 0.000
Burden of kidney disease −0.333 0.000
Work status −0.098 0.167
Cognitive function −0.432 0.000
Quality of social interaction −0.343 0.000
Sleep −0.353 0.000
Social support −0.230 0.001
Dialysis staff encouragement −0.323 0.000
Patient satisfaction −0.358 0.000
r—Pearson’s correlation coefficient r; γ—Gamma correlation coefficient; p—test probability.

4. Discussion
Quality of life (QOL) and health-related quality of life (HRQOL) are recognized as im-
portant indicators of healthcare outcomes and determinants of biopsychosocial well-being.
In hemodialysis patients, QOL is a predictor of disease progression, a valuable research tool
in assessing care effectiveness, and a prognostic factor. Systematic measurements of quality
of life and the variables that affect it can be helpful criteria in planning patient care [12–14].
The KDQOL-SF questionnaire is a commonly used tool to measure the quality of
life of patients with end stage renal disease (ESRD). Our research used this tool to obtain
results on quality of life in the study group. In the initial section of the questionnaire,
which evaluates the overall quality of life of the participants, the patients reported the
lowest quality of life in terms of physical functioning and the resulting limitations in
their daily activities, as well as a general perception of health. The Dialysis Outcome and
Practice Pattern Study (DOPPS) is a multicenter, international study based in the United
States. The study found that low scores on the physical component of health-related quality
of life (HRQOL) were associated with increased mortality and a higher risk of future
hospitalization. Therefore, it is important to prioritize educating dialysis patients on the
physical aspects of the disease [4,15,16].
In the part of the questionnaire assessing disease-related quality of life, respondents
had the lowest QoL scores in terms of the perceived burden of chronic kidney disease and
occupational activity. The above results are confirmed by the work of other researchers, who
have also shown that one of the methods of improving patients’ occupational functioning
may be a change in the type of renal replacement therapy [15,17].
The impact of vascular access functioning on the quality of life of hemodialysis patients
was a relevant element in the study. This includes the type of vascular access currently
in place, the number of previous accesses, problems with its use, the need for hospital-
ization, and the level of pain during direct care. The importance of vascular access to
the quality of life of hemodialysis patients is evident from the patients’ perspective alone.
The Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) study aimed to
determine endpoints for the overall nephrology care of hemodialysis patients. One of the
key assessment indicators affecting patients’ quality of life and function during dialysis
was identified as vascular access. However, there are few widely used, specific tools to
assess the impact of vascular access. In 2021, Richarz et al. developed the Vascular Access
J. Clin. Med. 2024, 13, 2425 9 of 11

Specific Quality of Life Measure (VASQoL), while Nordyke et al. created the Hemodialysis
Access-Related Quality of Life (HARQ) assessment tool. These tools may be useful in future
studies, including our own [18–23].
Our study demonstrated the impact of vascular access perception on patients quality
of life. The VAQ and KDQOL-SF questionnaire evaluations revealed that patients with more
vascular access-related issues experienced a lower quality of life. The relationship between
vascular access care provided by nurses and the overall well-being of the patient was noted
in every domain of quality of life outside of work activity. This was particularly evident
in the domain of symptoms and complications of the disease, physical and social aspects,
and satisfaction with the overall care of dialysis station staff. These correlations highlight
the significance of vascular access care in promoting patient well-being. Improving the
quality of nursing care, with special attention paid to hemodialysis vascular access care,
can help eliminate or reduce the incidence of problems associated with vascular access.
However, factors beyond the control of the personnel caring for the patient, such as the
type of vascular access, can also affect the patient’s quality of life and overall well-being.
Our study, along with the work of other authors, has shown that the type of vascular access
has an impact on the quality of life of hemodialysis patients. It is important to note that this
is a subjective evaluation. Therefore, it is necessary to consider other factors when making
a decision about the type of vascular access to use. Patients who preferred AVF as their
type of vascular access had the highest overall perception of health and vitality. In 2019,
Do Hyoung Kim et al. published a paper as part of a prospective cohort study conducted
by the Clinical Research Center for End Stage Renal Disease (CRC for ESRD) in Korea.
The study, which involved 1461 hemodialyzed patients across multiple centers, aimed to
confirm previous findings. Do Hyoung Kim et al. found that patients with vascular access
in the form of an arteriovenous fistula from their own vessels or a vascular prosthesis had
higher quality of life scores than patients with CVC in 10 out of 12 quality of life domains
after 3 months. After 12 months of dialysis therapy, there was an improvement in HRQOL
score, highlighting the importance of regular assessment of HRQOL and its association
with vascular access. A study conducted by Natalie Domenick Sridharan et al. on a group
of 77 hemodialyzed patients found no effect of the type of vascular access on quality
of life. The relationships observed were similar in patients with arteriovenous fistulas
(AVFs), arteriovenous grafts (AVGs), and central venous catheters (CVCs). In contrast,
patients with arteriovenous fistulas (AVFs) reported the highest satisfaction with their
access, as measured by the VAQ questionnaire. Our study also found a correlation between
vascular access perception and health-related quality of life. The duration of dialysis
therapy and the past history of patients’ vascular access could also affect HRQOL. Patients
who had previously undergone vascular access procedures, had been hospitalized due
to complications related to vascular access, or reported recent issues with its functioning
exhibited lower quality of life scores across all domains, including disease-related and
overall. M. Pole et al. also recognized the aforementioned correlations. In their evaluation
of 749 hemodialysis patients in the UK, they found a lower satisfaction rating for vascular
access, as well as an increased number of complications, hospitalizations, or the need
for intervention. Efforts to educate and implement vascular access care patterns should
be intensified, particularly in nursing practice, to ensure that vascular access is not only
effective but also contributes to the quality of life of renal replacement therapy patients.
Studies have shown that choosing AVF as the primary access results in the lowest number of
complications and the greatest impact on the overall well-being of the patient [2,7,9,24–29].
It is important to note the limitations of this study. The study group was limited to
patients treated at dialysis centers in one country, which may limit the generalizability of
the results. A minority of patients had vascular access using AVG and non-tunneled CVCs,
compared to patients with AVF and tunneled CVCs. Additionally, the analysis did not
consider objective factors related to vascular access function, such as arteriovenous fistula
blood flow, laboratory results, or the adequacy of dialysis with access as measured by the
J. Clin. Med. 2024, 13, 2425 10 of 11

Kt/V ratio. Consider adding the clinical variables mentioned above when conducting
further studies in this subject area.

5. Conclusions
This impact is determined by both objective factors, such as the type of access, and
subjective factors, such as the patient’s assessment of the access. The study demonstrated
the impact of vascular access on the quality of life of hemodialysis patients. The perception
of vascular access is a crucial element in determining the quality of life of hemodialysis
patients. The quality of life of hemodialysis patients decreases as the number of vascular
access-related problems increases.

Author Contributions: Conceptualization, K.S. and R.J.Ł.; methodology, K.S., R.J.Ł. and A.Z.; soft-
ware, A.W. and M.Ł.; validation, A.Z., K.S. and R.J.Ł.; formal analysis, A.Z.; investigation, K.S.;
resources, K.S.; data curation, R.J.Ł.; writing—original draft preparation, K.S.; writing—review and
editing, R.J.Ł. and M.Ł.; visualization, A.W.; supervision, A.Z.; project administration, K.S.; funding
acquisition, A.Z. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding. The APC was funded by the Medical University
of Lublin.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki and approved by the Institutional Ethics Committee of Medical University of Lublin
(protocol KE-0254/178/2021, date 24 June 2021).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data are contained within the article.
Conflicts of Interest: The authors declare no conflicts of interest.

References
1. Uchmanowicz, B.; Manulik, S.; Uchmanowicz, I.; Rosińczuk, J. Jakość życia zależna od stanu zdrowia u chorych na astm˛e
oskrzelowa.˛ Adv. Respir. Med. 2014, 82, 385–391. [CrossRef] [PubMed]
2. Morsch, C.M.; Gonçalves, L.F.; Barros, E. Health-related quality of life among haemodialysis patients—Relationship with clinical
indicators, morbidity and mortality. J. Clin. Nurs. 2006, 15, 498–504. [CrossRef] [PubMed]
3. Field, M.; Tullett, K.; Khawaja, A.; Jones, R.; Inston, N.G. Quality improvement in vascular access: The role of patient-reported
outcome measures. J. Vasc. Access. 2020, 21, 19–25. [CrossRef] [PubMed]
4. Mapes, D.L.; Lopes, A.A.; Satayathum, S.; McCullough, K.P.; Goodkin, D.A.; Locatelli, F.; Fukuhara, S.; Young, E.W.; Kurokawa,
K.; Saito, A.; et al. Health-related quality of life as a predictor of mortality and hospitalization: The Dialysis Outcomes and
Practice Patterns Study (DOPPS). Kidney Int. 2003, 64, 339–349. [CrossRef] [PubMed]
5. Zielińska-Wi˛eczkowska, H.; Krokowska, B. Assessment of life quality in dialysis patients. Med. Rodz. 2014, 2, 42–45.
6. Sonawane, P.; Maheshwari, R.; Singh, A.; Ganpule, A.; Sabnis, R.; Desai, M. Impact of Vascular Access Type on Health-Related
Quality of Life in Patients Undergoing Hemodialysis: A Cross-Sectional Observational Study. Indian J. Vasc. Endovasc. Surg. 2020,
7, 63. [CrossRef]
7. Kim, D.H.; Park, J.I.; Lee, J.P.; Kim, Y.L.; Kang, S.W.; Yang, C.W.; Kim, N.H.; Kim, Y.S.; Lim, C.S. The effects of vascular access
types on the survival and quality of life and depression in the incident hemodialysis patients. Ren. Fail. 2020, 42, 30–39. [CrossRef]
[PubMed]
8. Quinn, R.R.; Lamping, D.L.; Lok, C.E.; Meyer, R.A.; Hiller, J.A.; Lee, J.; Richardson, E.P.; Kiss, A.; Oliver, M.J. The Vascular Access
Questionnaire: Assessing patient-reported views of vascular access. J. Vasc. Access. 2008, 9, 122–128. [CrossRef] [PubMed]
9. Field, M.; Khawaja, A.Z.; Ellis, J.; Nieto, T.; Hodson, J.; Inston, N. The vascular access questionnaire: A single centre UK experience.
BMC Nephrol. 2019, 20, 299. [CrossRef] [PubMed]
10. Korevaar, J.C.; Merkus, M.P.; Jansen, M.A.; Dekker, F.W.; Boeschoten, E.W.; Krediet, R.T. Validation of the KDQOL-SF: A
dialysis-targeted health measure. Qual. Life Res. Int. J. Qual. Life Asp. Treat. Care Rehabil. 2002, 11, 437–447. [CrossRef] [PubMed]
11. Manju, L.; Joseph, J.; Beevi, N. Validation of Kidney Disease Quality of Life Short Form 36 (KDQOL-SFTM) in Malayalam among
Patients Undergoing Haemodialysis in South Kerala. Indian J. Nephrol. 2020, 30, 316–320. [CrossRef] [PubMed]
12. Gerasimoula, K.; Lefkothea, L.; Maria, L.; Victoria, A.; Paraskevi, T.; Maria, P. Quality of Life in Hemodialysis Patients. Mater.
Socio-Med. 2015, 27, 305–309. [CrossRef] [PubMed]
13. Theofilou, P.; Kapsalis, F.; Panagiotaki, H. Greek version of MVQOLI-15: Translation and cultural adaptation. Int. J. Caring Sci.
2012, 5, 289–295.
J. Clin. Med. 2024, 13, 2425 11 of 11

14. Bayoumi, M.; Al Harbi, A.; Al Suwaida, A.; Al Ghonaim, M.; Al Wakeel, J.; Mishkiry, A. Predictors of Quality of Life in
Hemodialysis Patients. Saudi J. Kidney Dis. Transplant. 2013, 24, 254. [CrossRef] [PubMed]
15. Alshraifeen, A.; McCreaddie, M.; Evans, J.M. Quality of life and well-being of people receiving haemodialysis treatment in
Scotland: A cross-sectional survey. Int. J. Nurs. Pract. 2014, 20, 518–523. [CrossRef] [PubMed]
16. Mandoorah, Q.M.; Shaheen, F.A.; Mandoorah, S.M.; Bawazir, S.A.; Alshohaib, S.S. Impact of Demographic and Comorbid
Conditions on Quality of Life of Hemodialysis Patients: A Cross-sectional Study. Saudi J. Kidney Dis. Transplant. 2014, 25, 432.
[CrossRef] [PubMed]
17. Tannor, E.K.; Archer, E.; Kapembwa, K.; van Schalkwyk, S.C.; Davids, M.R. Quality of life in patients on chronic dialysis in South
Africa: A comparative mixed methods study. BMC Nephrol. 2017, 18, 4. [CrossRef] [PubMed]
18. Viecelli, A.K.; Tong, A.; O’Lone, E.; Ju, A.; Hanson, C.S.; Sautenet, B.; Craig, J.C.; Manns, B.; Howell, M.; Chemla, E.; et al. Report
of the Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) Consensus Workshop on Establishing a Core Outcome
Measure for Hemodialysis Vascular Access. Am. J. Kidney Dis. Off. J. Natl. Kidney Found. 2018, 71, 690–700. [CrossRef] [PubMed]
19. Taylor, M.J.; Hanson, C.S.; Casey, J.R.; Craig, J.C.; Harris, D.; Tong, A. “You know your own fistula, it becomes a part of
you”—Patient perspectives on vascular access: A semistructured interview study. Hemodial. Int. 2016, 20, 5–14. [CrossRef]
[PubMed]
20. Verberne, W.R.; Das-Gupta, Z.; Allegretti, A.S.; Bart, H.A.; Van Biesen, W.; García-García, G.; Gibbons, E.; Parra, E.; Hemmelder,
M.H.; Jager, K.J.; et al. Development of an International Standard Set of Value-Based Outcome Measures for Patients with Chronic
Kidney Disease: A Report of the International Consortium for Health Outcomes Measurement (ICHOM) CKD Working Group.
Am. J. Kidney Dis. 2019, 73, 372–384. [CrossRef] [PubMed]
21. Richarz, S.; Greenwood, S.; Kingsmore, D.B.; Thomson, P.C.; Dunlop, M.; Bouamrane, M.M.; Meiklem, R.; Stevenson, K. Validation
of a vascular access specific quality of life measure (VASQoL). J. Vasc. Access. 2023, 24, 702–714. [CrossRef] [PubMed]
22. Nordyke, R.J.; Nicholson, G.; Gage, S.M.; Lithgow, T.; Himmelfarb, J.; Rivara, M.B.; Hays, R.D.; Woo, K.; Peipert, J.D. Vascular
access-specific health-related quality of life impacts among hemodialysis patients: Qualitative development of the hemodialysis
access-related quality of life (HARQ) instrument. BMC Nephrol. 2020, 21, 16. [CrossRef] [PubMed]
23. Nordyke, R.; Hedgeman, E.; Nicholson, G.; Dahl, S.; Gage, S.; Lithgow, T.; Hays, R.; Peipert, J. Vascular Access-Specific HRQOL
Impacts Among Hemodialysis Patients: The Hemodialysis Access-Related QOL (HARQ) Project Focus Group Results. Value
Health 2018, 21, 268. [CrossRef]
24. Lee, T. Fistula First Initiative: Historical Impact on Vascular Access Practice Patterns and Influence on Future Vascular Access
Care. Cardiovasc. Eng. Technol. 2017, 8, 244–254. [CrossRef] [PubMed]
25. Wasse, H.; Kutner, N.; Zhang, R.; Huang, Y. Association of Initial Hemodialysis Vascular Access with Patient-Reported Health
Status and Quality of Life. Clin. J. Am. Soc. Nephrol. 2007, 2, 708–714. [CrossRef] [PubMed]
26. Sridharan, N.D.; Fish, L.; Yu, L.; Weisbord, S.; Jhamb, M.; Makaroun, M.S.; Yuo, T.H. The associations of hemodialysis access type
and access satisfaction with health-related quality of life. J. Vasc. Surg. 2018, 67, 229–235. [CrossRef] [PubMed]
27. Li, M.T.; Wu, M.; Xie, Q.L.; Zhang, L.P.; Lu, W.; Pan, M.J.; Yan, X.W.; Zhang, L.; Zhang, L.; Wang, Y. The association between
vascular access satisfaction and quality of life and depression in maintained hemodialysis patients. J. Vasc. Access. 2022, 25,
439–447. [CrossRef] [PubMed]
28. Afsar, B.; Elsurer, R.; Covic, A.; Kanbay, M. Vascular Access Type, Health-Related Quality of Life, and Depression in Hemodialysis
Patients: A Preliminary Report. J. Vasc. Access. 2012, 13, 215–220. [CrossRef] [PubMed]
29. Moura, A.; Madureira, J.; Alija, P.; Fernandes, J.C.; Oliveira, J.G.; Lopez, M.; Filgueiras, M.; Amado, L.; Sameiro-Faria, M.;
Miranda, V.; et al. Type of Vascular access and Location in Online Hemodiafiltration and its Association with Patient’s Perception
of Health-Related Quality of Life. J. Vasc. Access. 2014, 15, 175–182. [CrossRef] [PubMed]

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.