Cross-Sectional Analysis of Physical Function and Quality of Life Among Non-Dialysis Chronic Kidney Disease Patients in North Central Province, Sri Lanka

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A.T. Nisansala, J. M.K.B. Jayasekara, D. C.R. Weerakoon, H. M.M. Herath, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8314360/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Chronic kidney disease in the absence of diabetes and hypertension, or CKD with uncertain etiology (CKDu), is prevalent in tropical regions and increasing globally. The prevalence of CKD/CKDu in adults is as high as 15.1% to 22.9% in some districts in Sri Lanka, and research to date has not examined the functional impact of early stage disease. Methods Diagnosed CKD/CKDu patients, not undergoing dialysis, in a high CKDu prevalence area in the North Central Province, Sri Lanka (n = 180), as well as a non-CKD comparison sample (n = 42), completed physical performance assessments and reported measures of health-related quality of life in a cross-sectional study. CKD/CKDu severity wss staged according to the Kidney Disease Outcomes Quality Initiative (KDOQI). District-level medical records were used to identify patients and to establish stage of disease and kidney function parameters. Results 63% of CKD/CKDu participants were male, with age 62.25 (+ 9.63) years. In regression models, more advanced CKD/CKDu was associated with greater impact, including significantly lower physical function and poorer health-related quality life beginning at KDOQI stage 3a/b. Conclusions While most research suggests that poor function is evident only in advanced stages of CKD/CKDu, this study demonstrates decrements in physical function and QOL early in the disease and need for early occupational intervention. Trial registration This observational study was not preregistered and was completed as part of a MPhil at the University of Peradeniya, Sri Lanka. CKD/CKDu Physical Function Quality of Life Sri Lanka Kidney Disease Outcomes Quality Initiative Introduction Chronic Kidney Disease (CKD) is now recognized as a major public health challenge worldwide, associated with premature mortality and disability [1]. Globally, CKD has a disease prevalence of greater than 10%, amounting to more than 800 million individuals. CKD affects occupational status and quality of life (QOL) [2, 3]. According to the Global Burden of Disease (GBD) study, CKD was ranked 27th on the list of primary contributors to global mortality in 1990. Its rank has escalated to 18th by 2010 and further to 12th by 2015. CKD is defined as kidney damage or reduction of glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m 2 for three months or more, irrespective of etiology [4]. Long-standing hypertension and diabetes mellitus are the main etiologies for CKD. Since the mid-1990s, however, CKD without these defining etiologies has become common in tropical regions, giving rise to designation of kidney disease of uncertain etiology (CKDu). Over the past three decades, CKD/CKDu has become highly prevalent in the North Central, Uva, and North-Western Provinces of Sri Lanka [5]. The histopathology of the disease involves tubular interstitial nephrites [6]. The prevalence of CKD/CKDu among adults is as high as 15.1% to 22.9% in some districts in Sri Lanka [7]. Agricultural workers in low-income communities are the most susceptible, and the disease is predominantly seen among males, with a mean age of about 55 years among prevalent cases (Jayasekara et al., 2015, Athy et al., 2020). 70% of the CKD patients in Sri Lanka’s high prevalence area meet criteria for CKDu [6]. According to Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, CKD can be classified into stages based on decreased estimated glomerular filtration rate (eGFR, or other markers of kidney damage) for 3 months or more and level of albuminuria (albumin to creatinine ratio, ACR). Stages 1 and 2 are mostly asymptomatic. Most patients meet criteria for Stage 3, which is categorized into two substages, 3a (eGFR 45-59 ml/min/1.73m 2 ) and 3b (eGFR 30-44 ml/min/1.73m 2 ). It is unclear if patients with Stage 3 disease experience disability severe enough to interfere with daily occupation. Impairment of physical function is clearer at severe stages of CKD/CKDu [8, 9]. Also, individuals with any stage of CKD have a 1.5 - 2-fold increased risk of hospitalization and mortality [10]. KDOQI guidelines for CKD patients describe the benefits of maintaining regular physical function. Limitations in physical function increase risk of morbidity and mortality [11]. Low QOL has also been identified as an independent risk factor for mortality in people with CKD [12]. Low QOL in CKD/CKDu can adversely impact the course of the disease and increase psychological distress [13]. Systematic reviews have identified lower QOL in patients with CKD compared to non-CKDu samples and identified neglected aspects of CKD care [14, 15]. Hence, measurements of QOL in CKD/CKDu patients could aid healthcare professionals in providing optimal supportive care. Most studies of disability in CKD/CKDu have focused on patients undergoing dialysis. Research on disability is limited for CKD/CKDu patients with less severe disease. To our knowledge, the association between physical function/QOL and CKD/CKDu has not been investigated in the Sri Lankan context. Therefore, this study aimed to assess physical function and QOL over the spectrum of CKD stages to identify when functional impairment becomes apparent. This effort may aid in patient management. Methods and Materials Study Setting and Population This descriptive cross-sectional study was conducted in the Anuradhapura district of the North Central Province of Sri Lanka from December 2020 to December 2022. The particular area is identified as a high prevalence CKDu area (more than 10% of the total population with CKD/CKDu). Patients residing in the Wilachchiya area, aged 35–75 years, with diagnosed CKD (either known or uncertain etiology), and who were not undergoing dialysis, were selected according to the register of the Divisional Secretariat Office in the North Central Province of Sri Lanka. Residents of the Wilachchiya area were enumerated, and 180 CKD/CKDu patients were randomly selected. Patients with unstable cardiac disease; history of myocardial infarction (MI), coronary artery bypass graft (CABG), or other cardiac surgery within the past 6 months; neurological diseases, such as stroke or Parkinson’s disease; history of fracture; total joint replacement, abdominal surgery; dementia or depression; surgery, chemotherapy, or radiation therapy within the past 6 months; and acute illness or injury on the day of assessment were excluded from the study. A group of individuals without a CKD/CKDu diagnosis, matched by age and sex, was also recruited in a neighboring area. The comparison sample was selected for absence of diagnosed chronic conditions potentially related to CKD/CKDu. The study proposal was reviewed and approved by the Directors of Health in the North Central Province, Sri Lanka, and ethical clearance was obtained from the Ethical Review Committee of the Faculty of Allied Health Sciences, University of Peradeniya, Sri Lanka (AHS/ERC/2021/001). While patients were not involved in the design of the research, the research team established relationships with participating villages in advance to explain the goals of the study and to solicit community input. Measures After participants provided informed consent, they completed a questionnaire consisting of sociodemographic indicators (age, sex, marital status, occupation), health behaviors, and co-morbidity. CKD/CKDu stage was extracted from patient medical records. We also recorded serum creatinine and estimated GFR to validate assigned CKD/CKDu stage. The comparison sample was required to have two UACR normal values over prior months reported in a population screening effort, also identified from patients’ medical records. The Short Form Health Survey (SF-36) questionnaire, which is a translated and validated tool [ 16 ] for the assessment of health-related quality of life (QOL), was administered to each participant in their native language. Height (cm), weight (kg), waist circumference (cm), hip circumference (cm), and mid-arm circumference (cm) of the patient’s dominant arm were measured by well-trained research assistants under the supervision of the principal investigator. Weight was measured using a digital weight scale (Camry EB1653-S11) and height and circumference were measured using a measuring tape (Accu Fitness MT05 MyoTape). Physical performance tests were carried out according to the following sequence: 3-m gait speed, 4-stage balance, and 30s chair stand test from the Short Physical Performance Battery, and hand grip strength using a hydraulic hand grip dynamometer (JAMAR Fabrication Enterprises INC.SKU-120221). Physical tests were conducted by two co-investigators to reduce the risk of falling. Before each functional test, test procedures were clearly explained to participants. Data Analysis Data analyses were completed in STATA (StataNow/SE 18.5). Descriptive statistics for all parameters were computed and data were assessed for quality. ANOVA was used to determine mean differences in physical function and QOL across CKD/CKDu stages with reference to the non-patient group. Pearson correlation tests were used to assess the strength of the relationship between physical function and QOL among patients. Separate regression models were estimated to identify correlates of physical function and QOL of CKD/CKDu patients. This was an exploratory study and sample size was driven by availability of staff to conduct assessments. Results One hundred and eighty (n = 180) CKD /CKDu patients, from the Wilachchiya area in the Anuradhapura district in the North Central Province, Sri Lanka, were included in this study. All eligible patients approached provided consent. The majority were male (63%, n = 114) with an average age of 62.25 (+ 9.63) years. Forty-two non-CKD/CKDu individuals without chronic conditions were assessed as well, 35% male with mean age of 58.21 (± 11.58) years. The CKD/CKDu stage of participants by gender is shown in Table 1 . Demography, lifestyle characteristics of patients, and comorbidity are shown in Table 2 for a subset of 137 of the 180 patients. Missing data were the result of reductions in staffing over the course of the study, but an analysis of patients with and without these assessments showed the two groups did not differ in age or kidney function parameters. The main occupation of the CKD/CKDu population, 62.7%, was farming. The majority of CKD/CKDu participants (80.3%) had one or more comorbid medical conditions with onset in the last 5–10 years. The most common condition was hypertension (74%), which was mostly diagnosed after the CKD diagnosis. The main occupation of the non-CKD/CKDu group was also farming, 45.2%. Physical and functional measures of the study groups are presented in Table 3 . In the CKD/CKDu group. the average body mass index (BMI) was 21.4 (± 3.8) and 23.8 (± 5.0) kg/m 2 in males and females, respectively. In the non-CKD/CKDu group, BMI was 24.3 ( ± 3.1) and 25.8 ( ± 4.1) in males and females, respectively. On the whole, CKD/CKDu patients had lower values in arm circumference and other anthropometric measures. They performed less well in lower extremity physical performance and grip strength. As shown in Table 4 , Short Physical Performance Battery (SPPB) scores and handgrip strength were associated with CKD stage. Patients with stage 3a or more severe disease did more poorly in gait speed than patients with stage 2. For handgrip strength and total SPPB performance, stage 3a did not significantly differ from stage 2. Significant decrements in these measures were evident only beginning with stage 3b. Similar results were seen in the progressive balance tests. The decline in balance was apparent after stage 3a (data available upon request). Health-Related Quality of Life Among CKD/CKDu patients, advanced CKD stage was significantly associated with self-reported physical function (r=-0.350, p = 0.000), role physical (r=-0.408, p = 0.000), role emotional (r=-0.333, p = 0.000), vitality (r=-0.355, p = 0.000), social function (r=-0.319, p = 0.000), and bodily pain (r=-0.330, p = 0.000). There was a significant relationship between SF-36 total score and GFR value (r = .454, p = 0.000), and a significant negative correlation between the SF-36 score and serum creatinine (r = − .253, p = .001). The Physical Component Summary (PCS) score in the CKD/CKDu Samples was 34.25 ( ± 24.9), and the Mental Component Summary (MCS) score 43.05 ( ± 25.4). In a regression model, kidney function (GFR) and Short Physical Performance Battery scores were each independently associated with SF-36 total score after adjusting for age, gender, BMI, and chronic conditions. Correlates of Impaired Physical Function in CKD/CKDu In a final regression model for patients with CKD/CKDu, serum creatinine (p = .01), CKD/CKDu stage (p = .05), and total SF-36 score (p = .001) were independent correlates of physical function, as measured by the SPPB total score. This model adjusted for age, gender, BMI, and chronic conditions. Discussion The North Central Province (NCP) of Sri Lanka is a predominantly agricultural region, with farming as the main source of income. Our study involved a higher number of male patients, which is corroborated with prior studies on CKD/CKDu [ 6 , 10 , 17 ], indicating a male to female ratio of 2:1 among CKD/CKDu patients in the NCP Region. Among anthropometric measures, only waist circumference and mid upper arm circumference were significantly lower among patients with CKD/CKDu, consistent with prior research [ 18 , 19 ]. In keeping with their greater age and disease burden, the CKD/CKDu patient group performed more poorly in measures of physical performance and grip strength. Among reported comorbidities, prior studies have identified hypertension as the most common comorbidity. Similarly, in our cohort 74% of the CKD/CKDu cohort had diagnosed hypertension in our study, and 70% of the population received the diagnosis after or with the onset of CKD/CKDu. Sharma et al. found that diabetes mellitus contributed 61.9% to CKD/CKDu comorbidity in India [ 20 ]. To the best of our knowledge, this is the first study to assess the relationship between physical function and CKD stage in the Sri Lankan CKD/CKDu population. Most research suggests that poor physical function is evident only in the advanced stages of disease. However, our study demonstrates decrements in physical function and QOL early in the disease. The notion that declines in physical performance linked to CKD could occur earlier in the disease process than has previously been recognized is consistent with limited prior research [ 21 – 23 ]. Using standardized methods to measure physical function, this research shows that declines in physical function in CKD/CKDu patients are evident as early as stage 3a. In the U.S. National Health and Nutrition Examination Survey (NHANES), including 8554 individuals without CKD and CKD patients of all the stages, declines in gait speed were associated with advanced CKD stages [ 24 ]. In the NHANES, gait speed in patients with stages 3a and 3b (0.73 ms − 1 ) was similar to gain speed in the Sri Lankan sample (3a = 0.74 ms − 1 , 3b = 0.72 ms − 1 ), but other stages demonstrated lower values than our study. The cross-sectional study of Michishita et al. [ 25 ] did not find a significant association between low walking speed and stages of CKD. In our study, the gait speed values of both men and women fell below the cut-off levels established by the Asian Working Group for Sarcopenia (AWGS) beginning with stage 3a (3a = 0.74 ms − 1 , 3b = 0.72 ms − 1 , 4 = 0.71 ms − 1 , 5 = 0.66 ms − 1 ). Reduced gait speed increases the likelihood of balance issues, which leads to the risk of falls [ 26 ]. In our study, after stage 3a, less than 65% of the CKD patients were able to complete the one-legged stand test, indicating reduced physical function and falls risk with the advance of CKD/CKDu. Low handgrip strength is defined as < 26 kg for men and < 18kg for women by the (AWGS). In our study, hand grip strength of male CKD/CKDu patients fell below the AWGS’s cut-off values after stage 3a (3a = 25.1, 3b = 21.75, 4 = 23.68, 5 = 18.52) while in female CKD patients, it is fell below the level of AWGS’s cutoff values after stage 3b (3b = 17.56, 4 = 15.8, 5 = 17.67). Song et al. [ 26 ] also found lower hand grip strength in patients after CKD stage 3, and it significantly decreased with disease progression. The results of our study indicate that QOL of CKD/CKDu patients declines significantly across the spectrum of disease stages. Other studies have estimated QOL of the CKD population [ 27 ], but none have categorized QOL along the complete spectrum of the disease. Even though there are substantial regional differences from one country to another, these results regarding QOL scores for each stage of CKD will be beneficial to the growing literature on QOL of CKD/CKDu patients. The mean SF-36 PCS (34.3) and MCS (43.1) scores of CKD/CKDu patients in our study was lower than reports from prior studies (PCS-39.5/MCS-49.1 [ 28 ]), PCS-40.3/MCS-47.3 [ 29 ]), PCS-38.1/ MCS-46.0 [ 30 ]). Senanayake et al. [ 27 ] found a PCS score of 35.5, which is similar to our score of 34.3, and an MCS score of 39.1, which is lower than our score of 43.1. In this research, QOL for individuals with CKD was associated with SPPB scores and GFR levels, indicating the value of physical performance testing in clinical settings. The significant association with GFR shows that CKD stage is associated with QOL. Considering the substantial impact of CKD on public health in Sri Lanka, it is essential to deepen our understanding of the complications of this non-communicable disease to efficiently guide management approaches for this growing population. While diminished physical function is a significant aspect of CKD, the evaluation of physical function has not yet been integrated into standard clinical management. There are several strengths in our research study. Most research investigations have concentrated on dialysis patients with End Stage Renal Disease (ESRD) and kidney-transplant patients. Including non-dialysis CKD patients across the spectrum of CKD and using both objective and subjective assessments give this study particular value. One of the study's limitations is the unequal representation of the patients in each stage of CKD. The study is constrained by the small number of patients in each category, especially those with stage 1 and stage 5 CKD. The reduced number of stage 1 patients may be attributed to a lack of screening tests during the COVID-19 pandemic, while the limited number of stage 5 patients reflects the low survival rate at the end stage of the disease, limiting the number of eligible patients within our criteria. Future research should focus on carrying out longitudinal studies to measure QOL and physical function of the CKD population and design a specific exercise routine based on the physical performance measures of this study. Conclusion In this cross-sectional analysis, we found a substantial reduction in both physical function and QOL with advanced stages of CKD. Our study further confirms the importance of identifying the CKD/CKDu population at early stages, as the deterioration in QOL and physical function begins after CKD stage 2. Healthcare practitioners should focus on minimizing the effects of modifiable factors affecting QOL and physical function. Age, CKD stage, and SF-36 total score are significant independent correlates of lower extremity performance. GFR, number of comorbidities, and SPPB score are each independent correlates of SF-36 total score. These results highlight the importance of evaluating patients' QOL and physical function for CKD/CKDu and for using that assessment to guide multidisciplinary management. Declarations Ethics: The study proposal was reviewed and approved by the Directors of Health in the North Central Province, Sri Lanka, and ethical clearance was obtained from the Ethical Review Committee of the Faculty of Allied Health Sciences, University of Peradeniya, Sri Lanka (AHS/ERC/2021/001). No identifiable patient information is included in this research. Consent: All participants provided informed consent after discussion with research assistants and were provided time to ask questions about the research. Availability of data: The dataset and codebook for this research are available from the corresponding author upon request. Competing interests : The authors report no competing interests or disclosures. Funding : This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author contributions: W.A.T. Nisansala [email protected] Data collection, analyses, writing J.M.K.B. Jayasekara [email protected] Study design, data collection and supervision, analyses, review D.C.R. Weerakoon [email protected] Writing, review of manuscript H.M.M. Hearath [email protected] Data collection, review of manuscript R. Tudugala [email protected] Statistical analysis, review of manuscript E.P.E.D.Z. Siriwardena [email protected] Data collection , review of manuscript R.T. Karunarathna [email protected] Data access, Facilitate patients H.D.W.T. Damayanthi [email protected] Study design, Supervision, review of manuscript S.M. Albert [email protected] Study design, analyses, writing, review of manuscript Acknowledgments : Field district offices, Village Headman and all patients who participate for the study. References Paniagua-Sierra JR, Galván-Plata ME. Chronic kidney disease. Rev Med Inst Mex Seguro Soc. 2017;55(Suppl 2):S116–7. Jadoul MY, Labriola L. Fracture Risk in Patients on Hemodialysis: the Lower the Parathyroid Hormone the Better? Kidney Int Rep. 2024;9(10):2854–6. 10.1016/j.ekir.2024.08.023 . Kovesdy CP, Davis JR, Duling I, Little DJ. Prevalence of anaemia in adults with chronic kidney disease in a representative sample of the United States population: analysis of the 1999–2018 National Health and Nutrition Examination Survey. 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(2024) 'Symptom Burden and Its Impact on Quality of Life in Patients With Moderate to Severe CKD: The International Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps),' American Journal of Kidney Diseases [Preprint]. https://doi.org/10.1053/j.ajkd.2024.06.011 Kefale B, et al. Quality of life and its predictors among patients with chronic kidney disease: A hospital-based cross sectional study. PLoS ONE. 2019;14(2):e0212184. https://doi.org/10.1371/journal.pone.0212184 . Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Weerakoon","email":"","orcid":"","institution":"General Sir John Kotelawala Defence University","correspondingAuthor":false,"prefix":"","firstName":"D.","middleName":"C.R.","lastName":"Weerakoon","suffix":""},{"id":558932527,"identity":"8af405bd-7e05-40f7-a21e-df9f5b04469d","order_by":3,"name":"H. M.M. Herath","email":"","orcid":"","institution":"General Sir John Kotelawala Defence University","correspondingAuthor":false,"prefix":"","firstName":"H.","middleName":"M.M.","lastName":"Herath","suffix":""},{"id":558932528,"identity":"989d4656-7951-416b-8579-e13717aceb4f","order_by":4,"name":"Ranga Tudugala","email":"","orcid":"","institution":"General Sir John Kotelawala Defence University","correspondingAuthor":false,"prefix":"","firstName":"Ranga","middleName":"","lastName":"Tudugala","suffix":""},{"id":558932529,"identity":"2969a029-766d-47b5-ba96-3c61a8dd4ef3","order_by":5,"name":"E. P.E.D.Z. Siriwardana","email":"","orcid":"","institution":"General Sir John Kotelawala Defence University","correspondingAuthor":false,"prefix":"","firstName":"E.","middleName":"P.E.D.Z.","lastName":"Siriwardana","suffix":""},{"id":558932530,"identity":"f2ae7286-61d4-4c51-9339-8de000c7de8c","order_by":6,"name":"R. T. Karunarathna","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"R.","middleName":"T.","lastName":"Karunarathna","suffix":""},{"id":558932534,"identity":"1b771013-f6a9-4033-82cb-f43ade3470fc","order_by":7,"name":"H. D.W.T. Damayanthi","email":"","orcid":"","institution":"University of Peradeniya","correspondingAuthor":false,"prefix":"","firstName":"H.","middleName":"D.W.T.","lastName":"Damayanthi","suffix":""},{"id":558932536,"identity":"4a158cde-f022-4f86-9a10-f53e3b7431ef","order_by":8,"name":"S. M. Albert","email":"","orcid":"","institution":"University of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"S.","middleName":"M.","lastName":"Albert","suffix":""}],"badges":[],"createdAt":"2025-12-09 07:23:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8314360/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8314360/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":98284960,"identity":"513b6ac3-ad67-4e63-a1e0-f41028bc3c1d","added_by":"auto","created_at":"2025-12-16 06:47:15","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":36580,"visible":true,"origin":"","legend":"","description":"","filename":"Tableandfigures.docx","url":"https://assets-eu.researchsquare.com/files/rs-8314360/v1/6b572b7a0bdf669f0a16565e.docx"},{"id":98284959,"identity":"3041475d-dba8-4711-a90b-3371c8de28f4","added_by":"auto","created_at":"2025-12-16 06:47:15","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":60080,"visible":true,"origin":"","legend":"","description":"","filename":"NewMnuscriptBMC.docx","url":"https://assets-eu.researchsquare.com/files/rs-8314360/v1/eb526fdc88c675d1877143b4.docx"},{"id":98284961,"identity":"beee127d-a165-430d-bf18-f61853490fcf","added_by":"auto","created_at":"2025-12-16 06:47:16","extension":"json","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10255,"visible":true,"origin":"","legend":"","description":"","filename":"91aea28b778a426db3d7572b540ce99c.json","url":"https://assets-eu.researchsquare.com/files/rs-8314360/v1/5343787529768c4af7f44283.json"},{"id":98284963,"identity":"d92fa897-1556-4578-9a02-a0a26cb22ccb","added_by":"auto","created_at":"2025-12-16 06:47:16","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":117500,"visible":true,"origin":"","legend":"","description":"","filename":"91aea28b778a426db3d7572b540ce99c1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8314360/v1/e4db429ad5d891e0d85f0d0a.xml"},{"id":98284964,"identity":"c6051847-c1a5-4644-9fda-2a293762254b","added_by":"auto","created_at":"2025-12-16 06:47:16","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":112769,"visible":true,"origin":"","legend":"","description":"","filename":"91aea28b778a426db3d7572b540ce99c1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8314360/v1/9e87f5381393854832837116.xml"},{"id":98435260,"identity":"1e68b8e9-e2d2-4b3c-8061-ecced33fce76","added_by":"auto","created_at":"2025-12-17 16:53:23","extension":"html","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":132173,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8314360/v1/45c2f0057813bd8c412129b6.html"},{"id":99789218,"identity":"70a0a934-023e-4e77-bd66-d08fc0d5e43a","added_by":"auto","created_at":"2026-01-08 12:49:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":502302,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8314360/v1/aaf8c866-da2e-467b-9a7f-789357007d76.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eCross-Sectional Analysis of Physical Function and Quality of Life Among Non-Dialysis Chronic Kidney Disease Patients in North Central Province, Sri Lanka\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic Kidney Disease (CKD) is now recognized as a major public health challenge worldwide, associated with premature mortality and disability [1]. Globally, CKD has a disease prevalence of greater than 10%, amounting to more than 800 million individuals. CKD affects occupational status and quality of life (QOL) [2, 3]. According to the Global Burden of Disease (GBD) study, CKD was ranked 27th on the list of primary contributors to global mortality in 1990. Its rank has escalated to 18th by 2010 and further to 12th by 2015.\u003c/p\u003e\n\u003cp\u003eCKD is defined as kidney damage or reduction of glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e for three months or more, irrespective of etiology [4]. \u0026nbsp;Long-standing hypertension and diabetes mellitus are the main etiologies for CKD. Since the mid-1990s, however, CKD without these defining etiologies has become common in tropical regions, giving rise to designation of kidney disease of uncertain etiology (CKDu).\u003c/p\u003e\n\u003cp\u003eOver the past three decades, CKD/CKDu has become highly prevalent in the North Central, Uva, and North-Western Provinces of Sri Lanka [5]. The histopathology of the disease involves tubular interstitial nephrites [6]. The prevalence of CKD/CKDu among adults is as high as 15.1% to 22.9% in some districts in Sri Lanka [7]. Agricultural workers in low-income communities are the most susceptible, and the disease is predominantly seen among males, with a mean age of about 55 years among prevalent cases (Jayasekara et al., 2015, Athy et al., 2020). 70% of the CKD patients in Sri Lanka\u0026rsquo;s high prevalence area meet criteria for CKDu [6].\u003c/p\u003e\n\u003cp\u003eAccording to Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, CKD can be classified into stages based on decreased estimated glomerular filtration rate (eGFR, or other markers of kidney damage) for 3 months or more and level of albuminuria (albumin to creatinine ratio, ACR). Stages 1 and 2 are mostly asymptomatic. Most patients meet criteria for Stage 3, which is categorized into two substages, 3a (eGFR 45-59 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e) and 3b (eGFR 30-44 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e). It is unclear if patients with Stage 3 disease experience disability severe enough to interfere with daily occupation.\u003c/p\u003e\n\u003cp\u003eImpairment of physical function is clearer at severe stages of CKD/CKDu [8, 9]. Also, individuals with any stage of CKD have a 1.5 - 2-fold increased risk of hospitalization and mortality [10]. \u0026nbsp;KDOQI guidelines for CKD patients describe the benefits of maintaining regular physical function. \u0026nbsp;Limitations in physical function increase risk of morbidity and mortality [11].\u003c/p\u003e\n\u003cp\u003eLow QOL has also been identified as an independent risk factor for mortality in people with CKD [12]. \u0026nbsp;Low QOL in CKD/CKDu can adversely impact the course of the disease and increase psychological distress [13]. Systematic reviews have identified lower QOL in patients with CKD compared to non-CKDu samples and identified neglected aspects of CKD care [14, 15]. Hence, measurements of QOL in CKD/CKDu patients could aid healthcare professionals in providing optimal supportive care.\u003c/p\u003e\n\u003cp\u003eMost studies of disability in CKD/CKDu have focused on patients undergoing dialysis. Research on disability is limited for CKD/CKDu patients with less severe disease. To our knowledge, the association between physical function/QOL and CKD/CKDu has not been investigated in the Sri Lankan context. \u0026nbsp; Therefore, this study aimed to assess physical function and QOL over the spectrum of CKD stages to identify when functional impairment becomes apparent. \u0026nbsp;This effort may aid in patient management.\u003c/p\u003e"},{"header":"Methods and Materials","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eStudy Setting and Population\u003c/h2\u003e \u003cp\u003eThis descriptive cross-sectional study was conducted in the Anuradhapura district of the North Central Province of Sri Lanka from December 2020 to December 2022. The particular area is identified as a high prevalence CKDu area (more than 10% of the total population with CKD/CKDu). Patients residing in the Wilachchiya area, aged 35\u0026ndash;75 years, with diagnosed CKD (either known or uncertain etiology), and who were not undergoing dialysis, were selected according to the register of the Divisional Secretariat Office in the North Central Province of Sri Lanka. Residents of the Wilachchiya area were enumerated, and 180 CKD/CKDu patients were randomly selected. Patients with unstable cardiac disease; history of myocardial infarction (MI), coronary artery bypass graft (CABG), or other cardiac surgery within the past 6 months; neurological diseases, such as stroke or Parkinson\u0026rsquo;s disease; history of fracture; total joint replacement, abdominal surgery; dementia or depression; surgery, chemotherapy, or radiation therapy within the past 6 months; and acute illness or injury on the day of assessment were excluded from the study. A group of individuals without a CKD/CKDu diagnosis, matched by age and sex, was also recruited in a neighboring area. The comparison sample was selected for absence of diagnosed chronic conditions potentially related to CKD/CKDu.\u003c/p\u003e \u003cp\u003eThe study proposal was reviewed and approved by the Directors of Health in the North Central Province, Sri Lanka, and ethical clearance was obtained from the Ethical Review Committee of the Faculty of Allied Health Sciences, University of Peradeniya, Sri Lanka (AHS/ERC/2021/001). While patients were not involved in the design of the research, the research team established relationships with participating villages in advance to explain the goals of the study and to solicit community input.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cp\u003e After participants provided informed consent, they completed a questionnaire consisting of sociodemographic indicators (age, sex, marital status, occupation), health behaviors, and co-morbidity. CKD/CKDu stage was extracted from patient medical records. We also recorded serum creatinine and estimated GFR to validate assigned CKD/CKDu stage. The comparison sample was required to have two UACR normal values over prior months reported in a population screening effort, also identified from patients\u0026rsquo; medical records.\u003c/p\u003e \u003cp\u003eThe Short Form Health Survey (SF-36) questionnaire, which is a translated and validated tool [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] for the assessment of health-related quality of life (QOL), was administered to each participant in their native language.\u003c/p\u003e \u003cp\u003eHeight (cm), weight (kg), waist circumference (cm), hip circumference (cm), and mid-arm circumference (cm) of the patient\u0026rsquo;s dominant arm were measured by well-trained research assistants under the supervision of the principal investigator. Weight was measured using a digital weight scale (Camry EB1653-S11) and height and circumference were measured using a measuring tape (Accu Fitness MT05 MyoTape).\u003c/p\u003e \u003cp\u003ePhysical performance tests were carried out according to the following sequence: 3-m gait speed, 4-stage balance, and 30s chair stand test from the Short Physical Performance Battery, and hand grip strength using a hydraulic hand grip dynamometer (JAMAR Fabrication Enterprises INC.SKU-120221). Physical tests were conducted by two co-investigators to reduce the risk of falling. Before each functional test, test procedures were clearly explained to participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData analyses were completed in STATA (StataNow/SE 18.5). Descriptive statistics for all parameters were computed and data were assessed for quality. ANOVA was used to determine mean differences in physical function and QOL across CKD/CKDu stages with reference to the non-patient group. Pearson correlation tests were used to assess the strength of the relationship between physical function and QOL among patients. Separate regression models were estimated to identify correlates of physical function and QOL of CKD/CKDu patients. This was an exploratory study and sample size was driven by availability of staff to conduct assessments.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOne hundred and eighty (n\u0026thinsp;=\u0026thinsp;180) CKD /CKDu patients, from the Wilachchiya area in the Anuradhapura district in the North Central Province, Sri Lanka, were included in this study. All eligible patients approached provided consent. The majority were male (63%, n\u0026thinsp;=\u0026thinsp;114) with an average age of 62.25 (+\u0026thinsp;9.63) years. Forty-two non-CKD/CKDu individuals without chronic conditions were assessed as well, 35% male with mean age of 58.21 (\u0026plusmn;\u0026thinsp;11.58) years. The CKD/CKDu stage of participants by gender is shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDemography, lifestyle characteristics of patients, and comorbidity are shown in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e for a subset of 137 of the 180 patients. Missing data were the result of reductions in staffing over the course of the study, but an analysis of patients with and without these assessments showed the two groups did not differ in age or kidney function parameters. The main occupation of the CKD/CKDu population, 62.7%, was farming. The majority of CKD/CKDu participants (80.3%) had one or more comorbid medical conditions with onset in the last 5\u0026ndash;10 years. The most common condition was hypertension (74%), which was mostly diagnosed after the CKD diagnosis. The main occupation of the non-CKD/CKDu group was also farming, 45.2%.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePhysical and functional measures of the study groups are presented in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. In the CKD/CKDu group. the average body mass index (BMI) was 21.4 (\u0026plusmn;\u0026thinsp;3.8) and 23.8 (\u0026plusmn;\u0026thinsp;5.0) kg/m\u003csup\u003e2\u003c/sup\u003e in males and females, respectively. In the non-CKD/CKDu group, BMI was 24.3 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;3.1) and 25.8 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;4.1) in males and females, respectively. On the whole, CKD/CKDu patients had lower values in arm circumference and other anthropometric measures. They performed less well in lower extremity physical performance and grip strength.\u003c/p\u003e\n\u003cp\u003eAs shown in Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e, Short Physical Performance Battery (SPPB) scores and handgrip strength were associated with CKD stage. Patients with stage 3a or more severe disease did more poorly in gait speed than patients with stage 2. For handgrip strength and total SPPB performance, stage 3a did not significantly differ from stage 2. Significant decrements in these measures were evident only beginning with stage 3b. Similar results were seen in the progressive balance tests. The decline in balance was apparent after stage 3a (data available upon request).\u003c/p\u003e\n\u003ch3\u003eHealth-Related Quality of Life\u003c/h3\u003e\n\u003cp\u003eAmong CKD/CKDu patients, advanced CKD stage was significantly associated with self-reported physical function (r=-0.350, p\u0026thinsp;=\u0026thinsp;0.000), role physical (r=-0.408, p\u0026thinsp;=\u0026thinsp;0.000), role emotional (r=-0.333, p\u0026thinsp;=\u0026thinsp;0.000), vitality (r=-0.355, p\u0026thinsp;=\u0026thinsp;0.000), social function (r=-0.319, p\u0026thinsp;=\u0026thinsp;0.000), and bodily pain (r=-0.330, p\u0026thinsp;=\u0026thinsp;0.000). There was a significant relationship between SF-36 total score and GFR value (r\u0026thinsp;=\u0026thinsp;.454, p\u0026thinsp;=\u0026thinsp;0.000), and a significant negative correlation between the SF-36 score and serum creatinine (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.253, p\u0026thinsp;=\u0026thinsp;.001). The Physical Component Summary (PCS) score in the CKD/CKDu Samples was 34.25 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;24.9), and the Mental Component Summary (MCS) score 43.05 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;25.4).\u003c/p\u003e\n\u003cp\u003eIn a regression model, kidney function (GFR) and Short Physical Performance Battery scores were each independently associated with SF-36 total score after adjusting for age, gender, BMI, and chronic conditions.\u003c/p\u003e\n\u003ch3\u003eCorrelates of Impaired Physical Function in CKD/CKDu\u003c/h3\u003e\n\u003cp\u003eIn a final regression model for patients with CKD/CKDu, serum creatinine (p\u0026thinsp;=\u0026thinsp;.01), CKD/CKDu stage (p\u0026thinsp;=\u0026thinsp;.05), and total SF-36 score (p\u0026thinsp;=\u0026thinsp;.001) were independent correlates of physical function, as measured by the SPPB total score. This model adjusted for age, gender, BMI, and chronic conditions.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe North Central Province (NCP) of Sri Lanka is a predominantly agricultural region, with farming as the main source of income. Our study involved a higher number of male patients, which is corroborated with prior studies on CKD/CKDu [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], indicating a male to female ratio of 2:1 among CKD/CKDu patients in the NCP Region.\u003c/p\u003e \u003cp\u003eAmong anthropometric measures, only waist circumference and mid upper arm circumference were significantly lower among patients with CKD/CKDu, consistent with prior research [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In keeping with their greater age and disease burden, the CKD/CKDu patient group performed more poorly in measures of physical performance and grip strength.\u003c/p\u003e \u003cp\u003eAmong reported comorbidities, prior studies have identified hypertension as the most common comorbidity. Similarly, in our cohort 74% of the CKD/CKDu cohort had diagnosed hypertension in our study, and 70% of the population received the diagnosis after or with the onset of CKD/CKDu. Sharma et al. found that diabetes mellitus contributed 61.9% to CKD/CKDu comorbidity in India [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, this is the first study to assess the relationship between physical function and CKD stage in the Sri Lankan CKD/CKDu population. Most research suggests that poor physical function is evident only in the advanced stages of disease. However, our study demonstrates decrements in physical function and QOL early in the disease. The notion that declines in physical performance linked to CKD could occur earlier in the disease process than has previously been recognized is consistent with limited prior research [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Using standardized methods to measure physical function, this research shows that declines in physical function in CKD/CKDu patients are evident as early as stage 3a.\u003c/p\u003e \u003cp\u003eIn the U.S. National Health and Nutrition Examination Survey (NHANES), including 8554 individuals without CKD and CKD patients of all the stages, declines in gait speed were associated with advanced CKD stages [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In the NHANES, gait speed in patients with stages 3a and 3b (0.73 ms\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e) was similar to gain speed in the Sri Lankan sample (3a\u0026thinsp;=\u0026thinsp;0.74 ms\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e, 3b\u0026thinsp;=\u0026thinsp;0.72 ms\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e), but other stages demonstrated lower values than our study. The cross-sectional study of Michishita et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] did not find a significant association between low walking speed and stages of CKD. In our study, the gait speed values of both men and women fell below the cut-off levels established by the Asian Working Group for Sarcopenia (AWGS) beginning with stage 3a (3a\u0026thinsp;=\u0026thinsp;0.74 ms\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e, 3b\u0026thinsp;=\u0026thinsp;0.72 ms\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e, 4\u0026thinsp;=\u0026thinsp;0.71 ms\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e, 5\u0026thinsp;=\u0026thinsp;0.66 ms\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e).\u003c/p\u003e \u003cp\u003eReduced gait speed increases the likelihood of balance issues, which leads to the risk of falls [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In our study, after stage 3a, less than 65% of the CKD patients were able to complete the one-legged stand test, indicating reduced physical function and falls risk with the advance of CKD/CKDu.\u003c/p\u003e \u003cp\u003eLow handgrip strength is defined as \u0026lt;\u0026thinsp;26 kg for men and \u0026lt;\u0026thinsp;18kg for women by the (AWGS). In our study, hand grip strength of male CKD/CKDu patients fell below the AWGS\u0026rsquo;s cut-off values after stage 3a (3a\u0026thinsp;=\u0026thinsp;25.1, 3b\u0026thinsp;=\u0026thinsp;21.75, 4\u0026thinsp;=\u0026thinsp;23.68, 5\u0026thinsp;=\u0026thinsp;18.52) while in female CKD patients, it is fell below the level of AWGS\u0026rsquo;s cutoff values after stage 3b (3b\u0026thinsp;=\u0026thinsp;17.56, 4\u0026thinsp;=\u0026thinsp;15.8, 5\u0026thinsp;=\u0026thinsp;17.67). Song et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] also found lower hand grip strength in patients after CKD stage 3, and it significantly decreased with disease progression.\u003c/p\u003e \u003cp\u003eThe results of our study indicate that QOL of CKD/CKDu patients declines significantly across the spectrum of disease stages. Other studies have estimated QOL of the CKD population [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], but none have categorized QOL along the complete spectrum of the disease. Even though there are substantial regional differences from one country to another, these results regarding QOL scores for each stage of CKD will be beneficial to the growing literature on QOL of CKD/CKDu patients.\u003c/p\u003e \u003cp\u003eThe mean SF-36 PCS (34.3) and MCS (43.1) scores of CKD/CKDu patients in our study was lower than reports from prior studies (PCS-39.5/MCS-49.1 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]), PCS-40.3/MCS-47.3 [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]), PCS-38.1/ MCS-46.0 [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]). Senanayake et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] found a PCS score of 35.5, which is similar to our score of 34.3, and an MCS score of 39.1, which is lower than our score of 43.1.\u003c/p\u003e \u003cp\u003eIn this research, QOL for individuals with CKD was associated with SPPB scores and GFR levels, indicating the value of physical performance testing in clinical settings. The significant association with GFR shows that CKD stage is associated with QOL.\u003c/p\u003e \u003cp\u003eConsidering the substantial impact of CKD on public health in Sri Lanka, it is essential to deepen our understanding of the complications of this non-communicable disease to efficiently guide management approaches for this growing population. While diminished physical function is a significant aspect of CKD, the evaluation of physical function has not yet been integrated into standard clinical management.\u003c/p\u003e \u003cp\u003eThere are several strengths in our research study. Most research investigations have concentrated on dialysis patients with End Stage Renal Disease (ESRD) and kidney-transplant patients. Including non-dialysis CKD patients across the spectrum of CKD and using both objective and subjective assessments give this study particular value.\u003c/p\u003e \u003cp\u003eOne of the study's limitations is the unequal representation of the patients in each stage of CKD. The study is constrained by the small number of patients in each category, especially those with stage 1 and stage 5 CKD. The reduced number of stage 1 patients may be attributed to a lack of screening tests during the COVID-19 pandemic, while the limited number of stage 5 patients reflects the low survival rate at the end stage of the disease, limiting the number of eligible patients within our criteria.\u003c/p\u003e \u003cp\u003eFuture research should focus on carrying out longitudinal studies to measure QOL and physical function of the CKD population and design a specific exercise routine based on the physical performance measures of this study.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this cross-sectional analysis, we found a substantial reduction in both physical function and QOL with advanced stages of CKD. Our study further confirms the importance of identifying the CKD/CKDu population at early stages, as the deterioration in QOL and physical function begins after CKD stage 2. Healthcare practitioners should focus on minimizing the effects of modifiable factors affecting QOL and physical function. Age, CKD stage, and SF-36 total score are significant independent correlates of lower extremity performance. GFR, number of comorbidities, and SPPB score are each independent correlates of SF-36 total score. These results highlight the importance of evaluating patients' QOL and physical function for CKD/CKDu and for using that assessment to guide multidisciplinary management.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics:\u0026nbsp;\u003c/strong\u003eThe study proposal was reviewed and approved by the Directors of Health in the North Central Province, Sri Lanka, and ethical clearance was obtained from the Ethical Review Committee of the Faculty of Allied Health Sciences, University of Peradeniya, Sri Lanka (AHS/ERC/2021/001). \u0026nbsp;No identifiable patient information is included in this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent:\u003c/strong\u003e All participants provided informed consent after discussion with research assistants and were provided time to ask questions about the research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data:\u003c/strong\u003e The dataset and codebook for this research are available from the corresponding author upon request. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors report no competing interests or disclosures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eW.A.T. Nisansala\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eData collection, analyses, writing\u003c/p\u003e\n\u003cp\u003eJ.M.K.B. Jayasekara\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eStudy design, data collection and supervision, analyses, review\u003c/p\u003e\n\u003cp\u003eD.C.R. Weerakoon\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eWriting, review of manuscript\u003c/p\u003e\n\u003cp\u003eH.M.M. Hearath\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eData collection, review of manuscript\u003c/p\u003e\n\u003cp\u003eR. Tudugala\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eStatistical analysis, review of manuscript\u003c/p\u003e\n\u003cp\u003eE.P.E.D.Z. Siriwardena\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eData collection , review of manuscript\u003c/p\u003e\n\u003cp\u003eR.T. Karunarathna\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eData access, Facilitate patients\u003c/p\u003e\n\u003cp\u003eH.D.W.T. Damayanthi\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eStudy design, Supervision, review of manuscript\u003c/p\u003e\n\u003cp\u003eS.M. Albert\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eStudy design, analyses, writing, review of manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e: \u0026nbsp; Field district offices, Village Headman and all patients who participate for the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePaniagua-Sierra JR, Galv\u0026aacute;n-Plata ME. Chronic kidney disease. Rev Med Inst Mex Seguro Soc. 2017;55(Suppl 2):S116\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJadoul MY, Labriola L. 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PLoS ONE. 2019;14(2):e0212184. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0212184\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0212184\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"CKD/CKDu, Physical Function, Quality of Life, Sri Lanka, Kidney Disease Outcomes Quality Initiative","lastPublishedDoi":"10.21203/rs.3.rs-8314360/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8314360/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChronic kidney disease in the absence of diabetes and hypertension, or CKD with uncertain etiology (CKDu), is prevalent in tropical regions and increasing globally. The prevalence of CKD/CKDu in adults is as high as 15.1% to 22.9% in some districts in Sri Lanka, and research to date has not examined the functional impact of early stage disease.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eDiagnosed CKD/CKDu patients, not undergoing dialysis, in a high CKDu prevalence area in the North Central Province, Sri Lanka (n\u0026thinsp;=\u0026thinsp;180), as well as a non-CKD comparison sample (n\u0026thinsp;=\u0026thinsp;42), completed physical performance assessments and reported measures of health-related quality of life in a cross-sectional study. CKD/CKDu severity wss staged according to the Kidney Disease Outcomes Quality Initiative (KDOQI). District-level medical records were used to identify patients and to establish stage of disease and kidney function parameters.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e63% of CKD/CKDu participants were male, with age 62.25 (+\u0026thinsp;9.63) years. In regression models, more advanced CKD/CKDu was associated with greater impact, including significantly lower physical function and poorer health-related quality life beginning at KDOQI stage 3a/b.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWhile most research suggests that poor function is evident only in advanced stages of CKD/CKDu, this study demonstrates decrements in physical function and QOL early in the disease and need for early occupational intervention.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003eThis observational study was not preregistered and was completed as part of a MPhil at the University of Peradeniya, Sri Lanka.\u003c/p\u003e","manuscriptTitle":"Cross-Sectional Analysis of Physical Function and Quality of Life Among Non-Dialysis Chronic Kidney Disease Patients in North Central Province, Sri Lanka","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-16 06:47:11","doi":"10.21203/rs.3.rs-8314360/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"88435f08-1617-4dd7-8e65-2b46a15115f4","owner":[],"postedDate":"December 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-01T10:53:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-16 06:47:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8314360","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8314360","identity":"rs-8314360","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}