Health-Related Quality of Life in Patients End-Stage Kidney Disease with Hypertension: Hemodialysis Vs Continuous Ambulatory Peritoneal Dialysis Using EQ-5D-5L at a Tertiary Center in Indonesia

Background

End-Stage Kidney Disease (ESKD) represents the terminal phase of chronic kidney disease (CKD), characterized by irreversible loss of kidney function with a Glomerular Filtration Rate (GFR) of <15 mL/min/1.73m².¹ This stage is characterized by severe physiological and metabolic disturbances, including the accumulation of toxic substances, metabolic acidosis, alterations in metabolic processes, malnutrition, insulin resistance, anemia, and vitamin D deficiency.² Kidney Replacement Therapy (KRT), either through dialysis or kidney transplantation, is required to substitute for the impaired kidney function partially. Without such interventions, ESKD is fatal and represents one of the most severe chronic diseases impacting global health.³ Globally, ESKD prevalence has increased by approximately 7%,⁴ particularly in developing countries, where it has significant consequences in terms of premature mortality, disability, reduced quality of life, psychosocial burdens, and substantial economic costs for governments, patients, and families.⁵ The World Health Organization (WHO) has recognized ESKD as a major global health issue and included it in the Global Burden of Disease (GBD) assessments.⁶

According to the Indonesia Renal Registry (IRR) 2020, ESKD accounted for the highest burden of kidney disease in the country, with a total of 61.786 cases.⁷ Hypertension, the most common comorbidity in ESKD patients (61%), plays an important role in worsening renal prognosis and increasing cardiovascular disease risk.^7,8 Effective hypertension management in ESKD patients is critical, as uncontrolled hypertension exacerbates symptoms such as fatigue, pain, and sleep disturbances, ultimately affecting patients’ physical well-being.^9,10 Additionally, it can contribute to heightened anxiety and depression, negatively impacting psychological and social dimensions, and consequently deteriorating health-related quality of life (HRQoL).¹¹ Therefore, HRQoL assessment is crucial in the management of ESKD patients with hypertension undergoing chronic therapy.

The HRQoL of ESKD patients with hypertension is strongly influenced by the choice of KRT modality, whether dialysis or kidney transplantation.¹² In Indonesia, dialysis modalities include Hemodialysis (HD) and Continuous Ambulatory Peritoneal Dialysis (CAPD). These two approaches differ in treatment method, frequency, and level of convenience, all of which influence patient outcomes and quality of life.¹³ CAPD allows patients to perform dialysis independently at home, unlike HD, which requires patients to attend healthcare facilities equipped with dialysis machines several times per week. However, CAPD requires strict hygiene maintenance to prevent peritonitis, whereas HD patients face less risk of such infections.^14,15 Although Indonesia’s national health insurance covers both modalities, HD patients often incur greater time and transportation costs compared to CAPD patients.¹⁶ Consequently, HD has been associated with reduced mobility and higher physical burden,¹⁷ while CAPD provides greater flexibility but entails significant self-management, which may increase psychological stress.¹⁸

To capture the impact of HD and CAPD on HRQoL in ESKD patients with comorbid hypertension, a valid and comprehensive instrument is required. The EQ-5D-5L is a widely used standardized tool for assessing HRQoL, recognized for its simplicity and applicability across diverse populations and health conditions. It evaluates five dimensions of health: mobility, self-care, usual daily activities, pain/discomfort, and anxiety/depression.¹⁹ The EQ-5D-5L has gained increasing global utilization in health technology assessment (HTA) and economic evaluations as an outcome measure guiding resource allocation and healthcare decision-making.²⁰

Previous studies in Indonesia investigating HRQoL among ESKD patients have generally included heterogeneous dialysis populations, reported comorbidities such as hypertension only as background characteristics, and used cross-sectional designs with a single HRQoL assessment, thereby limiting their ability to evaluate the specific impact of comorbid conditions and dialysis modality on HRQoL.^21–23 These limitations leave an important evidence gap regarding HRQoL among ESKD patients with hypertension, one of the most prevalent and clinically significant comorbidities in this setting. To address this gap, the present prospective observational cohort study focuses specifically on hypertensive ESKD patients and compares HRQoL, as measured by the EQ-5D-5L, between HD and CAPD recipients to explore potential differences in physical, psychological, and social well-being. The findings are expected to provide more nuanced, context-specific evidence to inform healthcare decision-making and policy development and to support the selection of dialysis modalities that may better promote HRQoL in hypertensive ESKD patients.

Methods

Study Design and Setting

This study employed an observational, non-experimental prospective cohort design. Patients undergoing HD or CAPD were followed prospectively, and their HRQoL was assessed at three time points over a four-week period. Data were collected from outpatients diagnosed with ESKD with comorbid hypertension who were undergoing HD or CAPD, based on the prevalence of the condition and data accessibility. Socio-demographic and clinical outcomes data were collected retrospectively from medical records, while HRQoL was assessed prospectively using the EQ-5D-5L questionnaire. The study was conducted at Dr. Hasan Sadikin General Hospital, Bandung, West Java, between September 2023 and January 2024.

Participants

The eligibility criteria for participation in this study required patients to meet the following conditions: a confirmed diagnosis of ESKD with comorbid hypertension; currently undergoing HD or CAPD for at least three consecutive months; aged ≥18 years; systolic blood pressure >140 mmHg and/or diastolic blood pressure >80 mmHg; willingness to participate documented through written informed consent; and receiving antihypertensive therapy for at least three months prior to or during dialysis treatment. Exclusion criteria included: death during the study period- and a modality switch from HD to CAPD or vice versa within ≤3 months.

Sample Size Determination

The minimum required sample size for patients undergoing hemodialysis (HD) was estimated using the Lemeshow formula,²⁴ assuming an expected HD prevalence in West Java of 25.7%, a 95% confidence level (α = 0.05), 80% power, and a precision (margin of error) of 0.10. The total HD patient population at Dr. Hasan Sadikin General Hospital in September 2023 was 260. Based on these parameters, the calculated minimum sample size was 58 participants. Patients were then recruited using consecutive sampling until the required sample size was achieved. To account for potential non-response and loss to follow-up, an additional 10% was added to the required sample size. It should be noted that this sample size calculation was based on the HD population at the study site and was not specifically powered to detect between-group differences between HD and CAPD. The number of CAPD patients (n = 33) reflects the real-world distribution of dialysis modalities at our center during the study period and consequently limits the statistical power for comparative analyses between modalities.

Instrument

The Indonesian version of the EQ-5D-5L was used in this study, as it is a widely applied instrument for measuring HRQoL and a valuable tool for health economic evaluations.²⁵ The EQ-5D-5L comprises five dimensions of health: mobility, self-care, usual daily activities, pain/discomfort, and anxiety/depression. Each dimension includes five severity levels: no problems, slight problems, moderate problems, severe problems, and extreme problems. The EQ-5D-5L index scores range from 0 to 1, where 0 represents dead and 1 represents perfect health. Calculated values cannot exceed 1; however, negative values (<0) indicate health states considered worse than death. In addition, the EQ-5D-5L includes a Visual Analog Scale (VAS) to assess patients’ overall health, presented as a scale from 0 (the worst imaginable health state) to 100 (the best imaginable health state).²⁶ Permission to use the Indonesian version of the EQ-5D-5L was obtained from the EuroQol Research Foundation under registration number 58826, using the paper self-completion method.

Data Collection Procedure and Data Source

Data collection was conducted by the research team from Universitas Padjadjaran, beginning with the provision of comprehensive information regarding the study procedures and the importance of voluntary participation. The research team emphasized that participation was entirely voluntary and free from coercion. Additional guidance was provided on how to complete the questionnaire, and participants were given opportunities to ask questions. Assistance was offered to respondents who experienced difficulties such as an inability to write, read, or hold a pen. The distribution of research instruments took place in the hemodialysis unit and the outpatient waiting area of the Hypertension-Kidney Polyclinic at Dr. Hasan Sadikin General Hospital. Data collection was performed three times at two-week intervals to assess improvements or declines in the quality of life of ESKD patients with comorbid hypertension.

Secondary data collection was also carried out to obtain socio-demographic and clinical outcomes from medical records. Socio-demographic variables included sex, age, marital status, highest level of education, occupation, domicile, number of re-hospitalizations within the past year, and type of health insurance coverage. Data on sex and age of dialysis patients had already been reported in a previous article.²⁷ Educational status in this study was classified into postgraduate education, specifically at the as master’s and doctoral levels. Employment status was categorized into the following categories: unemployed, part-time worker, private sector employee, civil servant state-owned enterprise employee, and other occupations. The unemployed group was defined as individuals without income-generating work, such as housewives and those who were not employed. Patients with flexible, non–full-time work (<8 hours per day) were categorized as part-time workers, including food couriers, online motorcycle taxi drivers, online shop operators, and boarding house attendants. Civil servants and employees of state-owned enterprises, including retirees, were grouped together as state-employed workers receiving salaries and benefits from government-controlled institutions. The private sector category included patients employed under institutions with standard 8-hour working hours, such as teachers at private schools, company staff, and sales/marketing employees.

Data Analysis

Descriptive statistics were used to summarize socio-demographic and clinical characteristics. Baseline differences between HD and CAPD were assessed using χ²-tests for categorical variables and Mann–Whitney U-tests for continuous variables. HRQoL was evaluated using EQ-5D-5L index scores, derived from the Indonesian EQ-5D-5L value set and EQ-VAS.²⁵ To account for the repeated-measures design and adjust for potential confounders, changes in EQ-5D-5L utility and EQ-VAS over time were further examined using Linear Mixed-Effects Models (LMMs) with a random intercept for each patient. In the primary models, dialysis modality (HD vs CAPD), time (baseline, week 2, week 4), and the modality × time interaction were specified as fixed effects. Baseline covariates that differed between groups and/or were considered clinically relevant—namely age and comorbidity status (presence of ≥1 comorbid condition)—were included as additional fixed-effect covariates. In exploratory models, age × comorbidity and time × comorbidity interactions terms were also evaluated to examine whether the effects of age and comorbidity on HRQoL varied over time. Model parameters were estimated using restricted maximum likelihood in R (lme4 and lmerTest packages), Type III F-tests with Satterthwaite’s approximation were used to obtain p-values, model assumptions were checked using residual diagnostics, and p-values <0.05 were considered statistically significant.

Results

A total of 260 ESKD patients were registered at Dr. Hasan Sadikin General Hospital, comprising 198 patients undergoing HD and 62 patients on CAPD. Among the HD group, 102 patients met the inclusion criteria. In comparison, 96 patients were excluded due to being <18 years of age (16 patients, 8.1%), having initiated of HD therapy for less than 3 months (14 patients, 7,1%), and having no hypertension comorbidity or antihypertensive use (66 patients, 33.3%). From the eligible HD patients, a minimum sample size of 58 was determined, with an additional 10% allowance to account for potential mortality or withdrawal. During the study, 3 patients died and 3 declined participations. In the CAPD group, 38 out of 62 patients (61.29%) met the inclusion criteria. In comparison, 24 (38.71%) were excluded due to irregular follow-up (n=10), <3 months on CAPD (n=1), transfer to other facilities (n=4), <18 years old (n=4), or absence of hypertension/antihypertensive use (n=5). Of the 38 eligible CAPD patients, 5 were subsequently excluded due to mortality (2 patients), loss to follow-up (2 patients), and conversion to HD (1 patient). The patient selection process is presented in Figure 1.

Figure 1 Research subject selection process.

Socio-Demographic and Clinical Characteristics

Descriptive statistics were used to summarise baseline characteristics, and group differences between HD and CAPD patients were examined using χ²-tests or Fisher’s exact tests for categorical variables and Mann–Whitney U-tests for continuous variables. CAPD patients were significantly younger (p = 0.007), more frequently unmarried (p = 0.028), and had notably higher educational attainment (p < 0.001). Additionally, a greater proportion of CAPD patients were supported by Badan Penyelenggara Jaminan Sosial (BPJS) non Penerima Bantuan Iuran (PBI) insurance schemes (p = 0.001), indicating more favourable socioeconomic conditions and a greater degree of independence in accessing healthcare services. From a clinical perspective, CAPD patients presented with more complex medical profiles, including a higher comorbidity burden (p < 0.001), more frequent use of multiple (>2) antihypertensive medications (p < 0.001), and increased rehospitalisation rates within the past year (p = 0.009). Despite this greater clinical complexity, CAPD therapy remained feasible and well maintained.

The socio-demographic characteristics of the study participants are summarised in Table S1. No significant differences were found in terms of sex (p = 0.661) or duration of dialysis (p = 0.264). Most participants were male and more than half were aged 40–59 years. The majority were married, nearly half were unemployed, and CAPD was more frequently chosen by younger and better-educated patients. Almost all participants were covered by the National Health Insurance, and 13.19% had been undergoing dialysis for ≥10 years. These findings indicate that age, marital status, education, employment and health insurance coverage are significantly associated with dialysis modality.

Tabel S2 summarizes the clinical characteristics of the participants. Hypertensive nephrosclerosis was identified as the most common etiology of ESKD, with no significant difference between groups (p = 0.196). Consistent with the analyses above, were observed in comorbidity burden (p < 0.001), the number of antihypertensive drug combinations (p ≤ 0.001), and re-hospitalization rates (p = 0.009) with CAPD patients generally having more comorbidities, higher hospitalization rates, and greater polypharmacy. These patterns suggest that the comorbidity burden, polypharmacy, and frequency of hospitalizations substantially shape the clinical profiles of ESKD patients receiving different modalities. Taken together, these findings suggest that CAPD is more frequently selected by younger, better-educated and socioeconomically supported individuals and remains a suitable dialysis option even among those with high disease complexity.

Health-Related Quality of Life Profile

Tables 1–3 show the distribution of EQ-5D-5L responses at baseline, week 2, and week 4. At baseline, most patients in both modalities reported no problems (level 1) in mobility, self-care, and usual activities, whereas pain/discomfort and anxiety/depression were more frequently affected, with CAPD patients generally showing a slightly higher proportion reporting “no problems” in these symptom-related domains. By week 2 and week 4, no patients in either group reported extreme problems (level 5) in any domain and the overall distributions across severity levels remained broadly similar between HD and CAPD, although CAPD patients tended to report fewer problems in pain/discomfort and anxiety/depression and HD patients occasionally reported fewer limitations in usual activities. Overall, these patterns were modest, not entirely consistent across visits, and are presented as descriptive support for the longitudinal mixed-effects models rather than as the basis for formal significance testing.

Table 1 EQ-5D-5L Research Subjects (Baseline Data)

Table 2 EQ-5D-5L Research Subjects (Follow up 1)

Table 3 EQ-5D-5L Research Subjects (Follow up 2)

EQ-5D-5L Utility and EQ-VAS Score

Mean EQ-5D-5L utility scores are summarised in Table 4. At baseline, mean utility score was 0.81 ± 0.25 for HD patients and 0.83 ± 0.19 for CAPD patients. Utility values increased slightly at week 2 and then declined modestly by week 4 in both groups (HD: 0.85 ± 0.19 and 0.79 ± 0.22; CAPD: 0.86 ± 0.17 and 0.82 ± 0.16), indicating relatively stable but modest HRQoL over the four-week period without large separation between modalities. EQ-VAS score (Table 5) showed a similar pattern: baseline means were comparable for HD and CAPD (0.74 ± 0.14 vs 0.76 ± 0.12), increased at week 2 in both groups, and at week 4 remained in a similar range, with CAPD patients reporting numerically higher self-rated health than HD patients (0.83 ± 0.12 vs 0.76 ± 0.12). Taken together, these descriptive results suggest broadly comparable HRQoL between modalities over the short follow-up, with only small differences in mean scores that should be interpreted cautiously in view of the limited sample size.

Table 4 Utility Value of Research Subjects

Table 5 Visual Analog Scale Values of Research Subjects

Linear Mixed-Effects Models

To examine longitudinal changes in HRQoL more rigorously and to account for within-patient correlation, repeated measures were analysed using linear mixed-effects models with a random intercept for each patient. EQ-5D-5L utility scores showed no significant main effect of time (p = 0.439), suggesting overall stability during follow-up. However, significant age × comorbidity (p = 0.002) and time × comorbidity (p = 0.032) interactions indicated that HRQoL trajectories varied according to comorbidity status, with patients having multiple comorbidities showing different patterns of change over time. EQ-VAS scores demonstrated similarly stable subjective health perceptions, with no significant main effect of time (p = 0.132) and no significant interaction terms (all p > 0.05).

Detailed model estimates are presented in Tables S3, S4, Figures 2 and 3. For EQ-5D-5L utility (Table S3), none of the predictors in the primary model—time, age or comorbidity—was statistically significant (time β −0.011, 95% CI −0.039 to 0.017; p = 0.439; age β −0.001, 95% CI −0.005 to 0.003; p = 0.665; comorbidity β −0.021, 95% CI −0.046 to 0.004; p = 0.102), indicating no clear overall trend in utility and no simple linear association with age or comorbidity. In Model 2, which added an age × comorbidity interaction, age (β 0.009, 95% CI 0.002 to 0.016; p = 0.016), comorbidity (β 0.166, 95% CI 0.049 to 0.283; p = 0.007) and their interaction term (β −0.004, 95% CI −0.006 to −0.001; p = 0.002) were statistically significant, suggesting that among patients without comorbidities higher age was associated with slightly better utility, whereas in patients with comorbidities the combination of older age and comorbidity was linked to lower utility. In Model 3, which included a time × comorbidity interaction, the interaction term was significant (β −0.016, 95% CI −0.030 to −0.002; p = 0.032), indicating that utility tended to decline more over time in patients with comorbidities than in those without, even though the main effects of time, age and comorbidity individually remained non-significant.

Figure 2 The estimated marginal mean utility score shows a slight increase from Time 0 (baseline) to Time 1 (follow up 1), followed by a decrease at Time 2 (follow up 2), returning to a level comparable to baseline. This pattern reflects only minimal temporal variation in utility, without evidence of a sustained improvement or decline.

Figure 3 The estimated marginal mean VAS score increases modestly from Time 0 (baseline) to Time 1 (follow up 1), followed by a decrease at Time 2 (follow up 2). Taken together, these visualizations suggest that participants’ self-reported health status is largely stable over the study period, with only small fluctuations between measurement occasions.

For EQ-VAS (Table S4), none of the examined predictors—time, age, comorbidity or their interaction terms—reached statistical significance in any of the three models (all p > 0.13), implying that self-rated health remained relatively stable across the four-week period and was not strongly explained by these variables in this cohort. The estimated marginal means from the mixed-effects models, plotted in Figures 2 and 3, are consistent with these findings: for EQ-5D-5L utility, the adjusted mean increased from baseline to week 2 and then decreased by week 4 to a value close to or slightly below baseline, suggesting a modest and transient improvement; for EQ-VAS, the adjusted mean rose from baseline to week 2 and was largely maintained at week 4, with only a minimal decline.

Taken together, the mixed-effects analyses support the plausibility of the descriptive HRQoL patterns but do not provide strong evidence of systematic improvement or deterioration in overall HRQoL over four weeks, nor of large differences driven by the measured covariates. Instead, the significant interaction terms for EQ-5D-5L utility highlight that the combined effects of age and comorbidity—as well as comorbidity over time—may be more important than any single factor alone, particularly for patients with multiple comorbidities. Given the modest sample size and short follow-up, these interaction findings should be interpreted as exploratory and hypothesis-generating rather than definitive.

Discussion

This prospective cohort study examined demographic, clinical and HRQoL characteristics among patients with ESKD and hypertension receiving HD or CAPD at a tertiary hospital in Indonesia. Using the EQ-5D-5L and EQ-VAS, analysed with linear mixed-effects models that accounted for repeated measurements and key baseline imbalances, the principal finding was that short-term overall HRQoL was broadly comparable between HD and CAPD: neither time nor dialysis modality showed statistically significant main effects on EQ-5D-5L utility or EQ-VAS scores, indicating that, over the four-week observation period, dialysis modality alone did not substantially modify global HRQoL in this population. Descriptive analyses using the validated EQ-5D-5L instrument suggested that CAPD patients tended to report fewer problems in pain/discomfort and anxiety/depression and had numerically higher EQ-VAS scores at the second follow-up, but these differences were small and should be regarded as exploratory in light of the limited sample size and the adjusted model results. Baseline differences were also observed between modalities in age, education, marital and employment status, health insurance, comorbidity burden, antihypertensive drug use and rehospitalisation rates, supporting the view that modality choice and HRQoL outcomes are shaped by a complex interplay of clinical and socio-demographic factors rather than modality alone. These findings are consistent with the global literature, which suggests that dialysis modality influences patients’ physical and psychosocial outcomes in nuanced and context-dependent ways.^28,29

Most participants were middle-aged (40–59 years) and male. Previous studies indicate that male patients are more likely to experience ESKD with cardiovascular comorbidities, whereas female patients may have faster disease progression.³⁰ Marital status is also an important social factor influencing both mental health and survival; unmarried patients with kidney disease have higher risks of depression and mortality than their married counterparts.³¹ Employment status is another determinant of psychological well-being, with unemployed ESKD patients demonstrating greater psychological challenges than those in paid work. In our cohort, nearly half of participants were unemployed, 5.49% worked part-time and 45.05% were employed in various occupations, and patients aged ≥45 years were more likely to stop working than those aged 25–44 years, consistent with previous reports.³² Furthermore, participants living in more prosperous areas and with higher levels of education appear more motivated and able to remain employed, helping them maintain living standards and sustain access to health insurance.³³

CAPD was more frequently chosen by participants with higher educational attainment and those under 60 years of age, whereas older patients were less likely to choose CAPD, in keeping with prior work suggesting that comorbidity burden and financial or practical limitations may discourage CAPD use in older adults.³⁴ Nearly all participants were covered by the National Health Insurance programme, and 13.19% had undergone dialysis for more than 10 years, underscoring the long-term economic and social implications of treatment. Taken together, age, marital status, education, occupation, duration of dialysis and access to health insurance appear to influence the choice of renal replacement therapy modality. At Dr Hasan Sadikin General Hospital, 86.8% of ESKD patients were reported to have hypertension along with other comorbidities, yet only 62 of 260 hypertensive ESKD patients on chronic dialysis (23.8%) were treated with CAPD. This low CAPD uptake is consistent with previous reports indicating that modality selection is not determined solely by comorbidities and may be constrained by limited facilities and trained personnel, high discontinuation rates and limited public awareness of CAPD as a treatment option.^35,36

The current findings also underscore the central role of hypertension and its complications in influencing clinical outcomes among ESKD patients. Hypertensive nephrosclerosis emerged as the leading aetiology, consistent with evidence that long-standing uncontrolled hypertension contributes to progressive renal injury.³⁷ Over time, uncontrolled blood pressure contributes to the development of additional comorbidities, which in turn affect ESKD progression and patient outcomes. In this study, CAPD patients had a higher comorbidity burden, more frequent use of multiple antihypertensive agents and higher rehospitalisation rates than HD patients. Polypharmacy is well documented in dialysis populations, particularly among those with hypertension,^38,39 and was more pronounced among CAPD patients in this cohort. These patterns suggest that comorbidity burden, polypharmacy and rehospitalisation are key dimensions of clinical complexity that may influence both HRQoL and prognosis.

Hypertension in ESKD patients undergoing HD is multifactorial, often driven by volume overload, vascular stiffness and activation of the renin–angiotensin–aldosterone system.^40,41 In our cohort, the most frequently prescribed agents were calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs) and beta-blockers, used alone or in combination; CCBs were the most commonly prescribed in both HD and CAPD. In HD, CCBs are particularly attractive because they help control volume-related hypertension and do not require post-dialysis supplementation.⁴² Although we did not systematically classify reasons for rehospitalisation, higher rehospitalisation rates among patients with greater comorbidity are consistent with literature linking multimorbidity, vascular access complications and dialysis-related events to recurrent hospital admissions.^43–47 Collectively, these findings highlight the complex interplay between hypertension, comorbidities, dialysis modality and pharmacological management in shaping clinical trajectories in ESKD.

Across the three assessments, EQ-5D-5L domain profiles were broadly similar between HD and CAPD, with no large differences in the overall distribution of severity levels. HD patients tended to report slightly better outcomes in mobility and self-care, which may reflect the structured support and assistance available during in-centre sessions, whereas CAPD patients more often reported fewer problems in pain/discomfort and anxiety/depression. These patterns are consistent with previous studies showing that CAPD patients frequently report better psychological well-being and less pain, potentially due to reduced travel requirements, greater treatment autonomy and a stronger sense of control over treatment.^42,48 At the same time, HD patients may demonstrate greater independence in self-care within the clinical environment, supported by regular professional supervision.

At baseline (Table 1), EQ-5D-5L results indicated that patients undergoing HD and CAPD reported broadly comparable HRQoL across all five domains. In both groups, most patients reported “no problems” (level 1) in mobility, self-care, usual activities, pain/discomfort and anxiety/depression, and CAPD patients showed only slightly higher levels of mobility limitations and self-care difficulties than HD patients. These findings suggest that, at the start of observation, HRQoL impairments were generally mild in both groups and align with previous research reporting broadly similar baseline HRQoL profiles among patients treated with different dialysis modalities.^49,50 At the first follow-up (Table 2), overall HRQoL remained largely stable, with most patients continuing to report “no problems” or “slight problems” in mobility and self-care. CAPD patients tended to show more favourable patterns in pain/discomfort than HD patients, which may reflect the greater haemodynamic stability associated with peritoneal dialysis and fewer intradialytic blood pressure fluctuations often linked to discomfort in HD.^51,52 Anxiety/depression scores were also similar between modalities, consistent with evidence that psychological distress is common in dialysis patients regardless of treatment type.⁵³ By the second follow-up (Table 3), subtle differences between modalities became more apparent: HD patients more frequently reported problems in pain/discomfort than CAPD patients, possibly reflecting the cumulative impact of intradialytic symptoms, vascular access complications and treatment-related discomfort over time,^54,55 whereas CAPD patients more often reported difficulties in usual activities, which may be related to the time demands and technical requirements of self-administered peritoneal dialysis.^54,56 Taken together, these observations illustrate nuanced trade-offs between modalities: CAPD may be associated with more favourable symptom control and psychological well-being, but entails greater demands on daily activities and self-management, whereas HD offers structured, facility-based professional support yet may be accompanied by a higher burden of treatment-related discomfort over time.

Utility scores derived from the EQ-5D-5L index were broadly comparable between HD and CAPD across all assessments, with only small numerical differences between modalities. Utility values showed a slight increase at the first follow-up and a modest decline by the second follow-up in both groups, suggesting that ongoing disease progression and cumulative treatment burden may have attenuated any modality-specific impact on global HRQoL, in line with previous reports of stable but modest utility values across dialysis types.^57,58 In contrast, EQ-VAS scores displayed a somewhat more favourable trajectory for CAPD, with CAPD patients reporting numerically higher self-perceived health status than HD patients at the final assessment, although these differences were not supported as statistically significant in the mixed-effects models. This pattern may indicate that, while standardised preference-based measures do not clearly distinguish between modalities, subjective patient perceptions can favour CAPD over time, potentially reflecting its greater flexibility, independence and reduced need for hospital visits, particularly among working-age individuals.^58,59

To interpret these descriptive trajectories more rigorously and to account for within-patient correlation and baseline heterogeneity, we applied linear mixed-effects models (LMMs) to the EQ-5D-5L utility and EQ-VAS data. From a methodological standpoint, LMMs provide important refinement to the interpretation of HRQoL trajectories in this cohort.⁶⁰ By specifying a random intercept for each patient, the models explicitly recognise that individuals commence follow-up with different underlying HRQoL levels and that repeated observations within the same patient are correlated. In both the EQ-5D-5L utility and EQ-VAS models, the random intercept explained a substantial proportion of the total variance, indicating marked between-patient heterogeneity that would likely be obscured by simpler approaches such as repeated-measures ANOVA or separate cross-sectional analyses.⁶¹ This observation is consistent with longitudinal HRQoL theory, which posits that patients differ in their “set points” and adaptation processes, and that changes over time are best interpreted relative to each individual’s baseline rather than assuming a homogeneous trajectory.^62–64

The pattern of fixed effects in the LMMs suggests that short-term fluctuations in global HRQoL were modest and that time, age and comorbidity status, considered as main effects, did not exert large, linear influences on either utility or self-rated health over the four-week period. For EQ-VAS in particular, none of the examined covariates—including time—showed evidence of a systematic association with global health ratings, supporting the notion that self-reported health may remain relatively stable over short intervals and may be less sensitive to clinical parameters that evolve slowly. This finding accords with theoretical distinctions between evaluative HRQoL measures (such as EQ-VAS), which are susceptible to response shift, coping processes and changing expectations, and descriptive, preference-based indices (such as EQ-5D-5L utility), which are more tightly anchored to health-state descriptions and population value sets.^65–67

The more complex LMM specifications incorporating interaction terms offer additional insight into the determinants of utility trajectories. In the model including an age×comorbidity interaction, the combined pattern of coefficients indicates that age and comorbidity act jointly rather than additively: utility tends to be better preserved with advancing age among patients without comorbidities, whereas among those with comorbid conditions, increasing age is associated with lower utility. This pattern is congruent with concepts from geriatric nephrology regarding “physiological reserve” and “multimorbidity burden,” whereby older individuals who remain relatively free of comorbid disease can maintain satisfactory HRQoL, while those with multiple conditions experience steeper functional decline and greater treatment burden.^68–71 Similarly, in the model including a time×comorbidity interaction, the results are compatible with a scenario in which HRQoL declines more over time among patients with comorbidities than among those without, even when average time effects appear small at the population level. This supports theoretical frameworks that emphasise cumulative stress and vulnerability, in which comorbid conditions amplify the impact of even short-term dialysis-related symptoms and logistical demands on perceived health.^72–75

Taken together, these LMM findings reinforce the conclusion that dialysis modality per se is not the principal determinant of short-term HRQoL in this setting; rather, heterogeneity in baseline status and the interaction between age and comorbidity appear to be more salient. In other words, the models support a stratified view of HRQoL in ESKD, in which patient-level factors and their interactions shape trajectories more strongly than treatment category. This interpretation is consistent with the broader HRQoL and survivorship literature in chronic kidney disease, which consistently identifies multimorbidity, functional impairment and psychosocial disadvantage as key determinants of adverse outcomes, and underscores the need to tailor supportive interventions to high-risk subgroups rather than expecting uniform HRQoL benefits from modality choice alone.^45,76–78

he current study therefore suggests that routine HRQoL assessment should be incorporated into the care of ESKD patients with hypertension to support individualised treatment planning and risk stratification. Although CAPD patients showed numerically more favourable patient-perceived health status and symptom profiles than HD patients, these differences were small and not confirmed as statistically significant in the mixed-effects models and should therefore be interpreted as exploratory rather than definitive evidence of modality superiority. Even so, these patterns underline the importance of strengthening patient education and support systems to enable informed, preference-sensitive modality choice. At the policy and service-delivery level, efforts to improve access to CAPD and to address structural barriers to its uptake may still be warranted, particularly for clinically suitable patients who may value its greater flexibility, provided such initiatives are accompanied by robust training and ongoing support.

This study has several limitations that should be acknowledged. The prospective observational cohort design, with a relatively short four-week follow-up and three measurement points, limits causal inference, although it provides valuable real-world insight into HRQoL among hypertensive ESKD patients, a population rarely studied in Indonesia. The single-centre setting and modest sample size, particularly in the CAPD group, may restrict generalisability, but the tertiary hospital context allowed for standardised procedures and consistent data collection. A major limitation is that the sample size calculation was based solely on the HD population and did not specifically power the study for between-modality comparisons; consequently, the CAPD group (n = 33) was relatively small and the study was underpowered to detect anything other than large differences in HRQoL between modalities. Thus, findings of “no statistically significant difference” should not be interpreted as evidence of equivalence or non-inferiority, and the possibility of Type II error cannot be excluded. The use of self-reported HRQoL measures introduces potential recall and response bias, although such instruments are essential for capturing patients’ subjective experiences. In addition, data collectors were not blinded to dialysis modality when assisting patients with the EQ-5D-5L, which may have introduced further response bias despite the use of a standardised data collection procedure. Finally, residual confounding from unmeasured factors such as socioeconomic status, treatment adherence and family support cannot be ruled out. Despite these limitations, the study contributes novel evidence by applying the validated Indonesian EQ-5D-5L in a well-defined cohort of ESKD patients with comorbid hypertension and highlights the need for larger, adequately powered multicentre studies to confirm or refute these exploratory observations.

Conclusions

In this prospective cohort of hypertensive ESKD patients, we did not detect statistically significant differences in overall HRQoL, as measured by EQ-5D-5L utility, between those treated with haemodialysis and continuous ambulatory peritoneal dialysis, indicating broadly comparable short-term physical, psychological and social well-being across modalities. Interpretation of these null findings is limited by the relatively small CAPD sample and marked baseline imbalances, so the study was underpowered to detect anything other than large between-group effects and the possibility of Type II error cannot be excluded. Numerically more favourable trajectories of EQ-VAS scores and selected symptom-related domains among CAPD patients should therefore be regarded as hypothesis-generating rather than evidence of modality superiority, underscoring the need for larger, methodologically robust studies to more definitively inform clinical decision-making and dialysis modality choice in hypertensive ESKD.