Employment among patients with end stage renal disease on maintenance dialysis at a tertiary care centre in North India- a cross-sectional study.

Employment among patients with end stage renal disease on maintenance dialysis at a tertiary care centre in North India- a cross-sectional study. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Employment among patients with end stage renal disease on maintenance dialysis at a tertiary care centre in North India- a cross-sectional study. vishal pooniya, abhilash chandra, S Namrata Rao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4501323/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 Employment is associated with a host of benefits including better self esteem, quality of life and financial independence. Maintenance dialysis is a major barrier to employment in patients with ESRD. This observational cross-sectional study was conducted to determine the proportion of patients suffering from ESRD on maintenance dialysis who were employed and various factors associated with loss of employment. Methods Patients suffering from ESRD, aged 18 to 65 years, who were on maintenance dialysis for ≥ 3 months were included. Their clinical and demographic characteristics, employment status before dialysis and change in employment after initiating dialysis was recorded and various factors associated with change in employment were analyzed. Results We observed that 39 (15.6%) out of 225 study subjects were employed on maintenance dialysis, whereas 155 (68.9%) patients were employed before initiating dialysis. Patients who lost employment were significantly younger and a higher proportion were on HD. Being on maintenance PD, residing in a nuclear family and at a shorter distance from the dialysis centre, self financing of treatment and professional employment category were associated with a greater likelihood of retaining employment after initiating dialysis. Conclusion This study revealed that only a small proportion of patients on maintenance dialysis are employed and a large number of patients lose employment after initiating dialysis. Nuclear family, PD as dialysis modality, professional category job before initiating dialysis, self-financing of treatment and living closer to dialysis centres was associated with retaining employment on maintenance dialysis. Dialysis Employment End stage renal disease Introduction Initiation of dialysis in patients with end stage renal disease (ESRD) is commonly associated with loss of employment or reduction in work hours. Employment rates may differ in different populations and different geographic areas due to differences in social support systems, socioeconomic status and different proportions of patients on hemodialysis (HD) and peritoneal dialysis (PD). Employment rates of patients with ESRD on maintenance dialysis varies from 11 to 31% in USA and 20% in Sweden (Holley and Nespor 1994 , Iffudu et al. 1994, Kutner et al. 1991 , Curtin et al. 1996 , Theorell et al. 1991 ). In a study from India, 44% of HD patients and 51.2% of PD patients lost employment after initiation of dialysis (Lakshmi et al. 2017). Patients with ESRD face many barriers to employment after initiating dialysis. These include poor employment opportunities because of disadvantaged socioeconomic status, fatigue and other symptoms of renal failure, depression and feeling of social isolation, comorbid diseases, transportation issues (need to go to the dialysis centre twice or thrice a week in patients on HD), potential loss of disability and/or medical assistance benefits with employment, scheduling conflicts with dialysis, and the assumption of some employers that patients on dialysis are too sick or undependable to work (Hallab and Wish 2018 ). Similarly, the need to perform exchanges multiple times daily in PD patients may interfere with the job. Unemployment is associated with low self-esteem, anxiety, depression and a poor quality of life. It is also associated with financial burden on the individual as well as the family. There are many advantages of being employed while being on maintenance dialysis. Patients who are employed generally have a better quality of life and higher self-esteem. They are able to financially support themselves and their family and remain economically productive for society at large (Theorell et al. 1991 , Rasgon et al 1997 ). Understanding the factors associated with loss of employment and disincentives to employment is the first step in this direction (Hallab and Wish 2018 ). Factors associated with loss of employment after initiating dialysis are not well defined. Investigators have tried to look into the factors affecting the employment of patients on maintenance dialysis e.g. modality of dialysis, anemia, use of erythropoiesis stimulating agents (ESAs), social support system or financial support etc. But due to the cross-sectional nature of most of the studies performed in this area, it is difficult to ascribe the role of these factors in employment status of patients with ESRD (Holley and Nespor 1994 , Curtin et al. 1996 , Lakshmi et al. 2017). This study was planned with the primary objective of estimating the proportion of patients suffering from ESRD on maintenance dialysis who are employed, in view of the dearth of data on the employment status of patients with ESRD in the Indian context, especially so, in a public sector tertiary care setting, which largely caters to uninsured patients from the lower socioeconomic classes. The secondary objectives were to determine the proportion of patients with ESRD employed at the start of maintenance dialysis, change in employment status after the start of maintenance dialysis, and factors affecting loss of employment after starting maintenance dialysis Materials and Methods Present study was a cross-sectional observational study performed at a 1250-bedded public sector tertiary care hospital in northern India, between 01 January 2020 and 30 September 2021. All consecutive patients suffering from ESRD presenting to the outpatient department or being dialysed in the dialysis unit were screened for inclusion in the study and the patients who met the following inclusion criteria were included. i. Patients with ESRD undergoing maintenance dialysis for at least 3 months. ii. Age between 25 and 65 years. Informed consent was obtained from all individual participants included in the study. Patients on maintenance dialysis for < 3 months, patient switching from HD to PD or vice versa, patient being admitted to hospital or suffering from peritonitis (in case of PD) during 1 month prior to enrolment, recipients of a renal allograft in the past and patients not giving consent were excluded. Demographic and clinical profile of the patients was noted from their clinical records. Employment was defined as any trade, economic activity and profession in the organised as well as unorganised sector or any trade that would provide with some monetary remuneration (Mohapatra 2004). The employment status of all the study subjects at the time of inclusion in the study was recorded and they were asked about their employment status at the beginning of dialysis. Employment status was categorized according to the modified Kuppuswamy scale (Sharma 2017 ). The functional status of the study subjects was classified according to the Karnofsky performance status scale (Altilio and Otis-Green 1993 ) and socioeconomic status as per the modified Kuppuswamy scale (Sharma 2017 ). Patients were categorised into comorbidities risk groups according to Khan et al (Khan et al. 1993 ). The source of expenditure on the treatment of the patient was noted as being self-funded, funding by family members, funding by government schemes, non-governmental organisations and/or covered by health insurance. The distance of the dialysis centre from the patients’ usual place of residence in patients was also recorded with the help of Google Maps (registered trademark Google LLC). Ethical clearance was obtained from Institute Ethics Committee and informed consent was obtained from all the study participants before enrolment in study. Continuous variables were presented as mean ± standard deviation (SD) (if following normal distribution) or median (interquartile range) (if not following normal distribution). Discrete variables were presented as number (percentage). Student’s t-test (for data which was distributed normally) and Mann-Whitney U test (for data which did not have a normal distribution) were used to compare means. Chi-square test was used to compare categorical variables between groups. Multiple logistic regression was done for finding out variables associated with employment status. Statistical analysis was performed using SPSS version 24.0. Results Patient characteristics: During the study period, 522 patients suffering from ESRD were screened and a total of 225 patients who met the inclusion criteria, were included. The baseline demographic and clinical characteristics of these patients are depicted in Table 1 . The mean age of the study population was 39.2 (± 12.1) years and 192 (85.3%) were males. The most common comorbidity among the study population was hypertension (n = 208, 92.4%). Other comorbidities were relatively uncommon, including diabetes mellitus (19.1%), hypothyroidism (5.3%), chronic obstructive pulmonary disease (COPD) (5.3%), chronic liver disease (CLD) (4.0%), coronary artery disease (CAD) (3.6%) and cerebrovascular accident (CVA) (0.9%). The median duration of CKD in the study population was 18 months (IQR 32 months) and the median duration of maintenance dialysis was 8 months (IQR 21 months). Table 1 Baseline characteristics (n = 225) Characteristics N (%) Mean ( ± SD) Age (in years) 39.2 (12.1) Sex Male Female 192 (85.3) 33 (14.7) Comorbidities Hypertension Diabetes mellitus Hypothyroidism COPD/Asthma Chronic liver disease Coronary artery disease Cerebrovascular accident 208 (92.4) 43 (19.1) 12 (5.3) 12 (5.3) 9 (4.0) 8 (3.6) 2 (0.9) BMI (kg/m2) 20.3 (3.2) Karnofsky performance status score 90 (10)* Duration of CKD (months) 18 (32)* Duration on dialysis (months) 8 (21)* Dialysis modality Hemodialysis Peritoneal dialysis 206 (91.6) 19 (8.4) Number of patients employed 35 (15.6) *Median (inter quartile range) Prevalence of employment in maintenance dialysis A total of 35 (15.6%) patients were found to be employed while receiving maintenance dialysis (Table 2 ). Most common employment category was arithmetic skill job (who need some training in arithmetic and reading and writing e.g. shopkeepers, farm owners, salesman, insurance agents etc) (18/35, 51.4%). Table 2 Change in employment after initiation of maintenance dialysis (n = 225). On maintenance dialysis [n (%)] Professional Job Semi-professional job Arithmetic skill job Skilled job Semi-skilled job Unskilled job Student Home-maker Unemployed Before initiating dialysis Professional Job (n = 12) 7 (58.3) 0 0 0 0 0 0 0 5 (41.7) Semi professional job (n = 12) 0 2 (16.7) 0 0 0 0 0 0 10 (83.3) Arithmetic skill job (n = 76) 0 0 16 (21.1) 0 2 (2.6) 3 (4.0) 0 0 55 (72.4) Skilled job (n = 23) 0 0 1 (4.4) 0 0 1 (4.4) 0 0 21 (91.2) Semi-skilled job (n = 22) 0 0 0 0 2 (9.1) 0 0 0 20 (90.9) Unskilled job (n = 10) 0 0 0 0 0 0 0 0 10 (100) Student (n = 22) 0 0 0 0 0 0 6 (27.3) 0 16 (72.7) Home-maker (n = 21) 0 0 1 (4.8) 0 0 0 0 14 (66.7) 6 (28.6) Unemployed (n = 27) 0 0 0 0 0 0 0 0 27 (100) Total 7 2 18 0 4 4 6 14 170 Change in employment status Prior to initiating maintenance dialysis, 155 (68.9%) study subjects were employed. This proportion decreased drastically to 15.6% after the initiation of dialysis (Table 2 ). Loss of employment was universal (100%) among unskilled workers. Loss of job in other categories was 91.2% in skilled workers, 90.9% in semi-skilled workers, 83.3% in semi-professional jobs, 72.4% in arithmetic skill jobs and lowest (41.7%) among the patients employed in professional jobs. Five patients in arithmetic skilled jobs moved to a lower category job after initiating dialysis; 2 patients moved to semi-skilled jobs and 3 to unskilled jobs. One patient in skilled job category moved to unskilled job category after initiating dialysis. Two patients had a gain in employment after starting dialysis; 1 moved from a skilled job to arithmetic job category and one lady who was a homemaker before starting dialysis also moved to an arithmetic skill job category. Sixteen out of 22 (72.7%) students stopped studying after initiating dialysis whereas 6 of 21 (28.6%) homemakers were unable to perform household chores after initiating dialysis. Factors affecting loss of employment after maintenance dialysis Out of the 155 patients who were employed before initiation of maintenance dialysis, 34 (21.9%) continued working at the time of inclusion in the study, whereas 121 (78.1%) lost their employment (Table 3 ). On comparison of these 2 groups, patients who lost jobs were significantly older with higher proportion of females. Among the patients who stopped working after starting dialysis, a significantly lower proportion had performance status scores between 80 and 100 and a significantly lower number were on PD. A lesser number of patients who lost employment lived in nuclear families and belonged to the upper socioeconomic class and a higher proportion were dependent on government schemes for treatment. The proportion of patients in professional jobs was significantly greater among patients who retained employment as compared to those who lost employment, but the proportion of patients in other job categories was comparable. The proportion of patients being dialyzed at HD centres with provision of evening shifts (after 5:00 PM) was significantly higher among those who retained employment on dialysis as compared to those who did not (p = 0.025). Moreover, patients who lost employment resided at a greater median distance from their dialysis centre (p = 0.002) as compared to those who retained employment (Table 3 ). Table 3 Comparison of patients who retained employment with those who lost employment after starting maintenance dialysis (n = 155). Factors Employment retained (n= 34) Employment lost (n = 121 ) p value Age in years* 44.2 (9.3) 38.8 (11.7) 0.015 Sex Males Females 33 (97.1%) 1 (2.9%) 114 (94.2%) 7 (5.8%) 0.686 Comorbidities Hypertension Diabetes mellitus COPD/Asthma Coronary artery disease Cerebrovascular accident Chronic liver disease Hypothyroidism 31 (91.2%) 11 (32.4%) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2.9%) 114 (94.2%) 23 (19.0%) 8 (6.6%) 5 (4.1%) 1 (0.8%) 8 (6.6%) 7 (5.8%) 0.458 0.097 0.201 0.586 1.000 0.201 0.686 Comorbidity risk group Low risk Medium risk High risk 3 (8.8%) 19 (55.9%) 12 (35.3%) 5 (4.1%) 79 (65.3%) 37 (30.6%) 0.430 Karnofsky performance status score 50–70 80–100 1 (2.9%) 33 (97.1%) 21 (17.4%) 100 (82.6%) 0.048 Duration of CKD (months)** 23 (35.3) 14.0 (28.5) 0.069 Duration on dialysis (months)** 8.5 (14.3) 7.0 (17.0) 0.761 Dialysis modality Hemodialysis Peritoneal dialysis 24 (70.6%) 10 (29.4%) 118 (97.5%) 3 (2.5%) 0.000 Educational qualification PG or professional Graduate Higher secondary High school Middle school Literate (less than middle school) Illiterate 9 (26.5%) 9 (26.5%) 1 (2.9%) 8 (26.5%) 1 (2.9%) 6 (14.7%) 0 (0) 18 (14.9%) 26 (21.5%) 23 (19.0%) 15 (12.4%) 15 (12.4%) 15 (12.4%) 9 (7.4%) 0.298 0.539 0.022 0.107 0.198 0.408 0.208 Type of family Nuclear Joint 24 (70.6%) 10 (29.4%) 59(48.8%) 62 (51.2%) 0.049 Socioeconomic status Upper class Upper middle class Lower middle class Upper lower class 7 (20.6%) 23 (67.6%) 4 (11.8%) 0 (0) 5 (4.1%) 64 (52.9%) 33 (27.3%) 19 (15.7%) 0.005 0.126 0.061 0.014 Financial support for treatment Self Family members Govt schemes Charity/NGO 29 (85.3%) 2 (5.9%) 3 (8.8%) 0 (0) 64 (52.9%) 22 (18.2%) 33 (27.3%) 2 (1.7%) 0.001 0.080 0.024 Employment category Professional Semi-professional Arithmetic skill job Skilled job Semi-skilled job Unskilled 7 (20.6%) 2 (5.9%) 21 (61.8%) 2 (5.9%) 2 (5.9%) 0 (0) 5 (4.1%) 10 (8.3%) 55 (45.5%) 21 (17.4%) 20 (16.5%) 10 (8.3%) 0.005 1.000 0.093 0.096 0.165 0.119 Hemoglobin (g/dl) 9.4 (1.8) 9.6 (1.9) 0.636 Serum Calcium (mg/dl) 8.9 (0.9) 9.0 (0.9) 0.556 Serum phosphorus (mg/dl) 4.5 (1.0) 4.5 (1.2) 0.984 Serum alkaline phosphatase (IU/L) 140.4 (30.6) 131.0 (39.3) 0.203 Serum iPTH (pg/ml)** 231.9 (165.0) 226.3 (150.5) 0.577 Serum albumin (g/dl) 3.5 (0.5) 3.6 (0.6) 0.769 Regarding patients on HD (n = 143) Type of HD Centre Government Private Weekly HD frequency Once Twice Thrice Facility for HD after 5:00 PM Distance of HD centre from place of residence (km)** 6 (25.0%) 18 (75.0%) 3 (12.5%) 20 (83.3%) 1 (4.2%) 19 (79.2%) 10.0 (12.8) 51 (42.9%) 68 (57.1%) 4 (3.4%) 102 (85.7%) 13 (10.9%) 65 (54.6%) 25.0 (42.0) 0.103 0.113 0.026 0.002 * Mean (standard deviation); **Median (Interquartile range) Logistic regression was performed to ascertain the effects of age, dialysis modality, educational qualification, type of family, socioeconomic status, financial support for treatment and employment category on the likelihood that participants retained employment after initiating dialysis (Table 4 ). The logistic regression model was statistically significant [explained 46.9% (Nagelkerke R2 ) of the variance in employment and correctly classified 82.6% of cases]. Factors associated with a higher likelihood of retaining employment after initiating dialysis included being on maintenance PD, patients living in nuclear families, patients financing their treatment themselves and patients employed in professional jobs. Table 4: Multiple logistic regression analysis of factors associated with likelihood of retaining employment after initiating dialysis. Discussion The present study analysing the employment status of patients suffering from ERSD showed that less than 1/6th of the study population was employed in a prevalent dialysis population. Prior to starting maintenance dialysis, 69% of the study population was employed and loss of employment was up to 78% among those who were previously employed. Initiating dialysis also affected the students as 3/4th of the students enrolled in the present study did not continue their studies after starting dialysis. A quarter of the homemakers (all females) was unable to do household chores after initiating dialysis. Most of the data on employment status of patients on maintenance dialysis comes from studies performed in Western countries. Studies from North America and Europe have found employment rates from 23–31.2% among patients on maintenance dialysis (Holley and Nespor 1994 , van Manen et al. 2001). But the situation may not be the same in the Indian context because in the USA, nearly all ESRD patients are under Medicare coverage and European nations also have a strong social support network (Erickson et al. 2018 ). Data from India is scarce and we could find only one study which analysed the ESRD patients on maintenance dialysis from South India and found that 33.5% of HD and 26% of PD patients were employed. They postulated that the institute where study was conducted is a part of an organization which runs many temples, orphanages and educational institutes and most of their patients are employees or dependents of that organization, which could have led to a higher employment rate (Lakshmi et al. 2017). We observed a very low employment rate (15.6%) among patients on maintenance dialysis. Other studies have found that 23–31% patients maintain employment after initiating dialysis, hence the loss of employment is substantial (Curtin et al. 1996 , Julius et al. 1989 , Rasgon et al 1993 , Evans et al. 1985 , Rasgon et al. 1996 , Antonoff and Mallinger 1990 , Buckley et al. 1985 , Kutner and Cardenas 1981, Sherwood 1983 ). Laxmi et al also observed that proportion of ESRD patients employed reduced from 61.1–29.9% after initiating dialysis (Lakshmi et al. 2017). The present study also revealed that 72.7% of students stopped studying and 28.6% of homemakers were unable to do household chores after initiating dialysis. Loss of studies may further hamper the future employability of these individuals. Only 2 patients had a gain in employment after initiating dialysis in the current study. This is similar to the observation made by van Manen et al in Dutch ESRD patients among whom 2% of patients gained employment after initiating dialysis. They postulated that probably dialysis does not promote vocational rehabilitation by itself and we should direct our efforts to prevent loss of jobs among patients who are already employed before initiating dialysis (van Manen et al. 2001). Regarding factors affecting loss of employment after initiating dialysis, our study found that being on maintenance PD, living in a nuclear family, self-financing of treatment and a professional job predicted employment after initiating dialysis. Prior studies also show contradictory observations regarding factors predicting employment after initiating dialysis. Lee et al also observed that ESRD patients who were employed full time were significantly younger (Lee and Jin 2020 ). Comorbidities, performance status, duration of CKD and dialysis vintage are likely to be associated with employment, but their effect has been inconsistent in previous studies (Holley and Nespor 1994 , Curtin et al. 1996 , Lakshmi et al. 2017, van Manen et al. 2001, Rasgon et al 1993 , Helanterä et al. 2012 ). We did not find any difference in comorbidities, duration of CKD and dialysis vintage among employed and unemployed patients on maintenance dialysis. Effect of dialysis modality on employment status of patients on maintenance dialysis has never been proven conclusively. Some studies have reported that dialysis modality has no effect on employment (Holley and Nespor 1994 , van Manen et al. 2001) whereas others have found that patients on PD are more likely to be employed as compared to those on HD (Julius et al. 1989 , Wolcott and Nissenson 1988 , Fragola et al 1983 , Evans et al 1985 , Bremer et al. 1989 ). We found that patients on PD were significantly more likely to retain employment as compared to those on HD. It has been suggested that treatment modality does not affect change in employment, rather employment status may affect the choice of treatment modality. Patients who are employed when maintenance dialysis therapy is initiated probably tend to choose PD as the treatment modality because it enables ambulatory treatment with flexible working schedules (van Manen et al. 2001). Dialysis centre characteristics may affect employment in patients undergoing maintenance HD. An inflexible dialysis schedule may act as a barrier to vocational rehabilitation and presence of a late dialysis shift was found to be the strongest predictor of employment in a study performed by (Kutner et al. 2008 ). But a facility for evening HD was not associated with employment on multiple regression analysis in our study. Distance of the dialysis centre from place of residence may also affect employment as patients need to travel 2 to 3 times a week which may hinder their work. Longer distance from the dialysis centre predicted lesser likelihood of employment in the present study. Laxmi et al found that illiteracy was a strong predictor of loss of employment after initiating dialysis in ESRD patients. It may be because less educated persons have limited job opportunities, less flexible working hours and have jobs which require more physical labour (Lakshmi et al. 2017). But we did not observe a difference in the proportion of patients with different educational qualifications between those who retained employment as compared to those who did not. Patients living in nuclear families were more likely to retain employment than those living in joint families. The reason underlying this observation may be the fact that patients in joint families may have a stronger social and financial support and may feel a lesser need to earn. Self-finance and dependence on government schemes were found to be predictive of retaining employment and loss of job, respectively. In this part of our country, various government schemes are available to support treatment of patients of lower socioeconomic status. In social support systems where government provides financial assistance to unemployed or chronically ill, low paid employment may not provide more income as compared to social security benefits, and hence it may be a barrier to employment (Helanterä et al. 2012 ). Well educated patients with a good work history are more likely to continue employment after initiating dialysis (Kutner et al. 1991 , Ferrans and Powers 1985 , Buckley et al. 1985 ). In the present study also, self financed subjects had higher educational qualifications, better jobs and belonged to higher socioeconomic status. Being in a professional job was predictive of employment after initiating dialysis. Laxmi et al also observed that loss of employment after dialysis initiation was significantly affected by predialysis employment level and was significantly higher among patients with blue collar jobs as compared to those with white collar jobs. Many factors have been postulated to account for this difference. Higher category jobs require less physical labour and have flexible working hours which may be adjusted according to dialysis schedule. Whereas people in lower category jobs lack openings to shift to jobs requiring less physical labour, have less flexible working hours and are unable to obtain social support due to their marginalized status (Lakshmi et al. 2017). Presence of anemia and MBD in patients with CKD may be associated with weakness, fatigue, bone pains leading to poor functional status and difficulty to maintain employment. Our study did not find any difference in haemoglobin, albumin, MBD parameters (calcium, phosphorus, iPTH and alkaline phosphatase) between patients who retained employment and those who lost employment after initiating dialysis. There are a few limitations of the present study. First, it is a cross sectional study and hence it is difficult to assess the risk of loss of employment as the time on maintenance dialysis increases. Moreover, the relationship of most of the factors with employment has been inconsistent because these factors may be associated with employment longitudinally and most of the previous studies also have been cross sectional studies. Second, we did not assess the attitude of patients towards employment as it may also affect the employment of patients on maintenance dialysis. There are significant differences between the attitudes of employed versus non-employed patients with regard to health-related barriers to employment. Third, it is a single centre study and the study population represents patients visiting a public-sector hospital, hence the results may not be generalized to the general ESRD population. Conclusion A small proportion of patients with ESRD on maintenance dialysis are employed and a large number of ESRD patients stopped working after initiating maintenance dialysis. Nuclear family, PD as dialysis modality, professional category job before initiating dialysis, self-financing of treatment and living closer to dialysis centres was associated with retaining employment on maintenance dialysis. Declarations Acknowledgements: None Conflict of interest: none Funding: none Ethics Approval and Consent: Ethical clearance was obtained from Institute Ethics Committee (IEC No. 30/19 dated 02/01/2020) and informed consent was obtained from all the study participants before enrolment in study. Availability of Data and Material: on demand Authors‘ contributions: VP collected and analyzed the data and drafted the manuscript. AC conceptualized the study, revised the manuscript and approved the final version for publication. NRS revised the manuscript and approved the final version for publication. NP analysed the data, revised the manuscript critically. AKS collected the data, revised the manuscript critically. References Altilio T, Otis-Green S. 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J Intern Med 1991; 230:501–9. van Manen JG, Korevaar JC, Dekker FW, Reuselaars MC, Boeschoten EW, Krediet RT; NECOSAD Study Group. Netherlands Cooperative Study on Adequacy of Dialysis. Changes in employment status in end-stage renal disease patients during their first year of dialysis. Perit Dial Int. 2001 Nov-Dec;21(6):595-601. Wolcott DL, Nissenson AR. Quality of life in chronic dialysis patients: a critical comparison of continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis. Am J Kidney Dis 1988; 11:402–12. Additional Declarations The authors declare no competing interests. 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4501323","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":308552119,"identity":"c8493bc4-d8d0-48a7-ac51-dd5f6dd42296","order_by":0,"name":"vishal pooniya","email":"data:image/png;base64,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","orcid":"","institution":"king georges' medical university, Lucknow-226003, India","correspondingAuthor":true,"prefix":"","firstName":"vishal","middleName":"","lastName":"pooniya","suffix":""},{"id":308552120,"identity":"163da367-d5c9-4b8a-b521-4660eba361ce","order_by":1,"name":"abhilash chandra","email":"","orcid":"","institution":"Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India","correspondingAuthor":false,"prefix":"","firstName":"abhilash","middleName":"","lastName":"chandra","suffix":""},{"id":308552121,"identity":"2cb1f674-0361-4aff-bb3f-ee5c3b4a9ce8","order_by":2,"name":"S Namrata Rao","email":"","orcid":"","institution":"Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India","correspondingAuthor":false,"prefix":"","firstName":"S","middleName":"Namrata","lastName":"Rao","suffix":""}],"badges":[],"createdAt":"2024-05-30 08:04:32","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4501323/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4501323/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57471972,"identity":"5766411b-a733-4392-bbef-8ba4a62a2e92","added_by":"auto","created_at":"2024-05-31 06:55:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":746023,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4501323/v1/1967af49-cc0c-418f-8b62-b0283eaa434f.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eEmployment among patients with end stage renal disease on maintenance dialysis at a tertiary care centre in North India- a cross-sectional study.\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eInitiation of dialysis in patients with end stage renal disease (ESRD) is commonly associated with loss of employment or reduction in work hours. Employment rates may differ in different populations and different geographic areas due to differences in social support systems, socioeconomic status and different proportions of patients on hemodialysis (HD) and peritoneal dialysis (PD). Employment rates of patients with ESRD on maintenance dialysis varies from 11 to 31% in USA and 20% in Sweden (Holley and Nespor \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e1994\u003c/span\u003e, Iffudu et al. 1994, Kutner et al. \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e1991\u003c/span\u003e, Curtin et al. \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e1996\u003c/span\u003e, Theorell et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1991\u003c/span\u003e). In a study from India, 44% of HD patients and 51.2% of PD patients lost employment after initiation of dialysis (Lakshmi et al. 2017). Patients with ESRD face many barriers to employment after initiating dialysis. These include poor employment opportunities because of disadvantaged socioeconomic status, fatigue and other symptoms of renal failure, depression and feeling of social isolation, comorbid diseases, transportation issues (need to go to the dialysis centre twice or thrice a week in patients on HD), potential loss of disability and/or medical assistance benefits with employment, scheduling conflicts with dialysis, and the assumption of some employers that patients on dialysis are too sick or undependable to work (Hallab and Wish \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Similarly, the need to perform exchanges multiple times daily in PD patients may interfere with the job.\u003c/p\u003e \u003cp\u003eUnemployment is associated with low self-esteem, anxiety, depression and a poor quality of life. It is also associated with financial burden on the individual as well as the family. There are many advantages of being employed while being on maintenance dialysis. Patients who are employed generally have a better quality of life and higher self-esteem. They are able to financially support themselves and their family and remain economically productive for society at large (Theorell et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1991\u003c/span\u003e, Rasgon et al \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1997\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUnderstanding the factors associated with loss of employment and disincentives to employment is the first step in this direction (Hallab and Wish \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Factors associated with loss of employment after initiating dialysis are not well defined. Investigators have tried to look into the factors affecting the employment of patients on maintenance dialysis e.g. modality of dialysis, anemia, use of erythropoiesis stimulating agents (ESAs), social support system or financial support etc. But due to the cross-sectional nature of most of the studies performed in this area, it is difficult to ascribe the role of these factors in employment status of patients with ESRD (Holley and Nespor \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e1994\u003c/span\u003e, Curtin et al. \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e1996\u003c/span\u003e, Lakshmi et al. 2017). This study was planned with the primary objective of estimating the proportion of patients suffering from ESRD on maintenance dialysis who are employed, in view of the dearth of data on the employment status of patients with ESRD in the Indian context, especially so, in a public sector tertiary care setting, which largely caters to uninsured patients from the lower socioeconomic classes. The secondary objectives were to determine the proportion of patients with ESRD employed at the start of maintenance dialysis, change in employment status after the start of maintenance dialysis, and factors affecting loss of employment after starting maintenance dialysis\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003ePresent study was a cross-sectional observational study performed at a 1250-bedded public sector tertiary care hospital in northern India, between 01 January 2020 and 30 September 2021. All consecutive patients suffering from ESRD presenting to the outpatient department or being dialysed in the dialysis unit were screened for inclusion in the study and the patients who met the following inclusion criteria were included.\u003c/p\u003e\n\u003cp\u003ei. Patients with ESRD undergoing maintenance dialysis for at least 3 months.\u003c/p\u003e\n\u003cp\u003eii. Age between 25 and 65 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ewas obtained from all individual participants included in the study. Patients on maintenance dialysis for \u0026lt;\u0026thinsp;3 months, patient switching from HD to PD or vice versa, patient being admitted to hospital or suffering from peritonitis (in case of PD) during 1 month prior to enrolment, recipients of a renal allograft in the past and patients not giving consent were excluded. Demographic and clinical profile of the patients was noted from their clinical records. Employment was defined as any trade, economic activity and profession in the organised as well as unorganised sector or any trade that would provide with some monetary remuneration (Mohapatra 2004). The employment status of all the study subjects at the time of inclusion in the study was recorded and they were asked about their employment status at the beginning of dialysis. Employment status was categorized according to the modified Kuppuswamy scale (Sharma \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e). The functional status of the study subjects was classified according to the Karnofsky performance status scale (Altilio and Otis-Green \u003cspan class=\"CitationRef\"\u003e1993\u003c/span\u003e) and socioeconomic status as per the modified Kuppuswamy scale (Sharma \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e). Patients were categorised into comorbidities risk groups according to Khan et al (Khan et al. \u003cspan class=\"CitationRef\"\u003e1993\u003c/span\u003e). The source of expenditure on the treatment of the patient was noted as being self-funded, funding by family members, funding by government schemes, non-governmental organisations and/or covered by health insurance. The distance of the dialysis centre from the patients\u0026rsquo; usual place of residence in patients was also recorded with the help of Google Maps (registered trademark Google LLC). Ethical clearance was obtained from Institute Ethics Committee and informed consent was obtained from all the study participants before enrolment in study.\u003c/p\u003e\n\u003cp\u003eContinuous variables were presented as mean \u0026plusmn; standard deviation (SD) (if following normal distribution) or median (interquartile range) (if not following normal distribution). Discrete variables were presented as number (percentage). Student\u0026rsquo;s t-test (for data which was distributed normally) and Mann-Whitney U test (for data which did not have a normal distribution) were used to compare means. Chi-square test was used to compare categorical variables between groups. Multiple logistic regression was done for finding out variables associated with employment status. Statistical analysis was performed using SPSS version 24.0.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics:\u003c/h2\u003e \u003cp\u003eDuring the study period, 522 patients suffering from ESRD were screened and a total of 225 patients who met the inclusion criteria, were included. The baseline demographic and clinical characteristics of these patients are depicted in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean age of the study population was 39.2 (\u0026plusmn;\u0026thinsp;12.1) years and 192 (85.3%) were males. The most common comorbidity among the study population was hypertension (n\u0026thinsp;=\u0026thinsp;208, 92.4%). Other comorbidities were relatively uncommon, including diabetes mellitus (19.1%), hypothyroidism (5.3%), chronic obstructive pulmonary disease (COPD) (5.3%), chronic liver disease (CLD) (4.0%), coronary artery disease (CAD) (3.6%) and cerebrovascular accident (CVA) (0.9%). The median duration of CKD in the study population was 18 months (IQR 32 months) and the median duration of maintenance dialysis was 8 months (IQR 21 months).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics (n\u0026thinsp;=\u0026thinsp;225)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (in years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.2 (12.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e192 (85.3)\u003c/p\u003e \u003cp\u003e33 (14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidities\u003c/p\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003cp\u003eHypothyroidism\u003c/p\u003e \u003cp\u003eCOPD/Asthma\u003c/p\u003e \u003cp\u003eChronic liver disease\u003c/p\u003e \u003cp\u003eCoronary artery disease\u003c/p\u003e \u003cp\u003eCerebrovascular accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e208 (92.4)\u003c/p\u003e \u003cp\u003e43 (19.1)\u003c/p\u003e \u003cp\u003e12 (5.3)\u003c/p\u003e \u003cp\u003e12 (5.3)\u003c/p\u003e \u003cp\u003e9 (4.0)\u003c/p\u003e \u003cp\u003e8 (3.6)\u003c/p\u003e \u003cp\u003e2 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.3 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKarnofsky performance status score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90 (10)*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of CKD (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (32)*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration on dialysis (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (21)*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDialysis modality\u003c/p\u003e \u003cp\u003eHemodialysis\u003c/p\u003e \u003cp\u003ePeritoneal dialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e206 (91.6)\u003c/p\u003e \u003cp\u003e19 (8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of patients employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35 (15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*Median (inter quartile range)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePrevalence of employment in maintenance dialysis\u003c/h2\u003e \u003cp\u003eA total of 35 (15.6%) patients were found to be employed while receiving maintenance dialysis (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Most common employment category was arithmetic skill job (who need some training in arithmetic and reading and writing e.g. shopkeepers, farm owners, salesman, insurance agents etc) (18/35, 51.4%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChange in employment after initiation of maintenance dialysis (n\u0026thinsp;=\u0026thinsp;225).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"9\" nameend=\"c11\" namest=\"c3\"\u003e \u003cp\u003eOn maintenance dialysis [n (%)]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProfessional Job\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSemi-professional job\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eArithmetic skill job\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSkilled job\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSemi-skilled job\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUnskilled job\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eHome-maker\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003e\u003cb\u003eBefore initiating dialysis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eProfessional Job\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e(58.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e(41.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSemi professional job\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e10 (83.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eArithmetic skill job\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;76)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e55 (72.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSkilled job\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e21 (91.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSemi-skilled job\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;22)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e20 (90.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUnskilled job\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;10)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e10 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eStudent\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;22)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e16 (72.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHome-maker\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;21)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e14 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e6 (28.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUnemployed\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;27)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e27 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eChange in employment status\u003c/h2\u003e \u003cp\u003ePrior to initiating maintenance dialysis, 155 (68.9%) study subjects were employed. This proportion decreased drastically to 15.6% after the initiation of dialysis (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Loss of employment was universal (100%) among unskilled workers. Loss of job in other categories was 91.2% in skilled workers, 90.9% in semi-skilled workers, 83.3% in semi-professional jobs, 72.4% in arithmetic skill jobs and lowest (41.7%) among the patients employed in professional jobs. Five patients in arithmetic skilled jobs moved to a lower category job after initiating dialysis; 2 patients moved to semi-skilled jobs and 3 to unskilled jobs. One patient in skilled job category moved to unskilled job category after initiating dialysis. Two patients had a gain in employment after starting dialysis; 1 moved from a skilled job to arithmetic job category and one lady who was a homemaker before starting dialysis also moved to an arithmetic skill job category. Sixteen out of 22 (72.7%) students stopped studying after initiating dialysis whereas 6 of 21 (28.6%) homemakers were unable to perform household chores after initiating dialysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eFactors affecting loss of employment after maintenance dialysis\u003c/h2\u003e \u003cp\u003eOut of the 155 patients who were employed before initiation of maintenance dialysis, 34 (21.9%) continued working at the time of inclusion in the study, whereas 121 (78.1%) lost their employment (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). On comparison of these 2 groups, patients who lost jobs were significantly older with higher proportion of females. Among the patients who stopped working after starting dialysis, a significantly lower proportion had performance status scores between 80 and 100 and a significantly lower number were on PD. A lesser number of patients who lost employment lived in nuclear families and belonged to the upper socioeconomic class and a higher proportion were dependent on government schemes for treatment. The proportion of patients in professional jobs was significantly greater among patients who retained employment as compared to those who lost employment, but the proportion of patients in other job categories was comparable. The proportion of patients being dialyzed at HD centres with provision of evening shifts (after 5:00 PM) was significantly higher among those who retained employment on dialysis as compared to those who did not (p\u0026thinsp;=\u0026thinsp;0.025). Moreover, patients who lost employment resided at a greater median distance from their dialysis centre (p\u0026thinsp;=\u0026thinsp;0.002) as compared to those who retained employment (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of patients who retained employment with those who lost employment after starting maintenance dialysis (n\u0026thinsp;=\u0026thinsp;155).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployment retained (n= 34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmployment lost (n\u0026thinsp;=\u0026thinsp;121 )\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge in years*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44.2 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.8 (11.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003cp\u003eMales\u003c/p\u003e \u003cp\u003eFemales\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (97.1%)\u003c/p\u003e \u003cp\u003e1 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e114 (94.2%)\u003c/p\u003e \u003cp\u003e7 (5.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.686\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidities\u003c/p\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003cp\u003eCOPD/Asthma\u003c/p\u003e \u003cp\u003eCoronary artery disease\u003c/p\u003e \u003cp\u003eCerebrovascular accident\u003c/p\u003e \u003cp\u003eChronic liver disease\u003c/p\u003e \u003cp\u003eHypothyroidism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (91.2%)\u003c/p\u003e \u003cp\u003e11 (32.4%)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003cp\u003e1 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e114 (94.2%)\u003c/p\u003e \u003cp\u003e23 (19.0%)\u003c/p\u003e \u003cp\u003e8 (6.6%)\u003c/p\u003e \u003cp\u003e5 (4.1%)\u003c/p\u003e \u003cp\u003e1 (0.8%)\u003c/p\u003e \u003cp\u003e8 (6.6%)\u003c/p\u003e \u003cp\u003e7 (5.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.458\u003c/p\u003e \u003cp\u003e0.097\u003c/p\u003e \u003cp\u003e0.201\u003c/p\u003e \u003cp\u003e0.586\u003c/p\u003e \u003cp\u003e1.000\u003c/p\u003e \u003cp\u003e0.201\u003c/p\u003e \u003cp\u003e0.686\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidity risk group\u003c/p\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003cp\u003eMedium risk\u003c/p\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (8.8%)\u003c/p\u003e \u003cp\u003e19 (55.9%)\u003c/p\u003e \u003cp\u003e12 (35.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (4.1%)\u003c/p\u003e \u003cp\u003e79 (65.3%)\u003c/p\u003e \u003cp\u003e37 (30.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.430\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKarnofsky performance status score\u003c/p\u003e \u003cp\u003e50\u0026ndash;70\u003c/p\u003e \u003cp\u003e80\u0026ndash;100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.9%)\u003c/p\u003e \u003cp\u003e33 (97.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (17.4%)\u003c/p\u003e \u003cp\u003e100 (82.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.048\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of CKD (months)**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (35.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.0 (28.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.069\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration on dialysis (months)**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.5 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.0 (17.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.761\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDialysis modality\u003c/p\u003e \u003cp\u003eHemodialysis\u003c/p\u003e \u003cp\u003ePeritoneal dialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (70.6%)\u003c/p\u003e \u003cp\u003e10 (29.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e118 (97.5%)\u003c/p\u003e \u003cp\u003e3 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational qualification\u003c/p\u003e \u003cp\u003ePG or professional\u003c/p\u003e \u003cp\u003eGraduate\u003c/p\u003e \u003cp\u003eHigher secondary\u003c/p\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003cp\u003eMiddle school\u003c/p\u003e \u003cp\u003eLiterate (less than middle school)\u003c/p\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (26.5%)\u003c/p\u003e \u003cp\u003e9 (26.5%)\u003c/p\u003e \u003cp\u003e1 (2.9%)\u003c/p\u003e \u003cp\u003e8 (26.5%)\u003c/p\u003e \u003cp\u003e1 (2.9%)\u003c/p\u003e \u003cp\u003e6 (14.7%)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (14.9%)\u003c/p\u003e \u003cp\u003e26 (21.5%)\u003c/p\u003e \u003cp\u003e23 (19.0%)\u003c/p\u003e \u003cp\u003e15 (12.4%)\u003c/p\u003e \u003cp\u003e15 (12.4%)\u003c/p\u003e \u003cp\u003e15 (12.4%)\u003c/p\u003e \u003cp\u003e9 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.298\u003c/p\u003e \u003cp\u003e0.539\u003c/p\u003e \u003cp\u003e0.022\u003c/p\u003e \u003cp\u003e0.107\u003c/p\u003e \u003cp\u003e0.198\u003c/p\u003e \u003cp\u003e0.408\u003c/p\u003e \u003cp\u003e0.208\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of family\u003c/p\u003e \u003cp\u003eNuclear\u003c/p\u003e \u003cp\u003eJoint\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (70.6%)\u003c/p\u003e \u003cp\u003e10 (29.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59(48.8%)\u003c/p\u003e \u003cp\u003e62 (51.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.049\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocioeconomic status\u003c/p\u003e \u003cp\u003eUpper class\u003c/p\u003e \u003cp\u003eUpper middle class\u003c/p\u003e \u003cp\u003eLower middle class\u003c/p\u003e \u003cp\u003eUpper lower class\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (20.6%)\u003c/p\u003e \u003cp\u003e23 (67.6%)\u003c/p\u003e \u003cp\u003e4 (11.8%)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (4.1%)\u003c/p\u003e \u003cp\u003e64 (52.9%)\u003c/p\u003e \u003cp\u003e33 (27.3%)\u003c/p\u003e \u003cp\u003e19 (15.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003cp\u003e0.126\u003c/p\u003e \u003cp\u003e0.061\u003c/p\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinancial support for treatment\u003c/p\u003e \u003cp\u003eSelf\u003c/p\u003e \u003cp\u003eFamily members\u003c/p\u003e \u003cp\u003eGovt schemes\u003c/p\u003e \u003cp\u003eCharity/NGO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (85.3%)\u003c/p\u003e \u003cp\u003e2 (5.9%)\u003c/p\u003e \u003cp\u003e3 (8.8%)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 (52.9%)\u003c/p\u003e \u003cp\u003e22 (18.2%)\u003c/p\u003e \u003cp\u003e33 (27.3%)\u003c/p\u003e \u003cp\u003e2 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003cp\u003e0.080\u003c/p\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment category\u003c/p\u003e \u003cp\u003eProfessional\u003c/p\u003e \u003cp\u003eSemi-professional\u003c/p\u003e \u003cp\u003eArithmetic skill job\u003c/p\u003e \u003cp\u003eSkilled job\u003c/p\u003e \u003cp\u003eSemi-skilled job\u003c/p\u003e \u003cp\u003eUnskilled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (20.6%)\u003c/p\u003e \u003cp\u003e2 (5.9%)\u003c/p\u003e \u003cp\u003e21 (61.8%)\u003c/p\u003e \u003cp\u003e2 (5.9%)\u003c/p\u003e \u003cp\u003e2 (5.9%)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (4.1%)\u003c/p\u003e \u003cp\u003e10 (8.3%)\u003c/p\u003e \u003cp\u003e55 (45.5%)\u003c/p\u003e \u003cp\u003e21 (17.4%)\u003c/p\u003e \u003cp\u003e20 (16.5%)\u003c/p\u003e \u003cp\u003e10 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003cp\u003e1.000\u003c/p\u003e \u003cp\u003e0.093\u003c/p\u003e \u003cp\u003e0.096\u003c/p\u003e \u003cp\u003e0.165\u003c/p\u003e \u003cp\u003e0.119\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin (g/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.4 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.6 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.636\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum Calcium (mg/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.9 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.0 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.556\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum phosphorus (mg/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.5 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.5 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.984\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum alkaline phosphatase (IU/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e140.4 (30.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e131.0 (39.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.203\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum iPTH (pg/ml)**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e231.9 (165.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e226.3 (150.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.577\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum albumin (g/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.5 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.6 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.769\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegarding patients on HD (n\u0026thinsp;=\u0026thinsp;143)\u003c/p\u003e \u003cp\u003e\u003cb\u003eType of HD Centre\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eGovernment\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ePrivate\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eWeekly HD frequency\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eOnce\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eTwice\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eThrice\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eFacility for HD after 5:00 PM\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eDistance of HD centre from place of residence (km)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (25.0%)\u003c/p\u003e \u003cp\u003e18 (75.0%)\u003c/p\u003e \u003cp\u003e3 (12.5%)\u003c/p\u003e \u003cp\u003e20 (83.3%)\u003c/p\u003e \u003cp\u003e1 (4.2%)\u003c/p\u003e \u003cp\u003e19 (79.2%)\u003c/p\u003e \u003cp\u003e10.0 (12.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (42.9%)\u003c/p\u003e \u003cp\u003e68 (57.1%)\u003c/p\u003e \u003cp\u003e4 (3.4%)\u003c/p\u003e \u003cp\u003e102 (85.7%)\u003c/p\u003e \u003cp\u003e13 (10.9%)\u003c/p\u003e \u003cp\u003e65 (54.6%)\u003c/p\u003e \u003cp\u003e25.0 (42.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.103\u003c/p\u003e \u003cp\u003e0.113\u003c/p\u003e \u003cp\u003e0.026\u003c/p\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* Mean (standard deviation); **Median (Interquartile range)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eLogistic regression was performed to ascertain the effects of age, dialysis modality, educational qualification, type of family, socioeconomic status, financial support for treatment and employment category on the likelihood that participants retained employment after initiating dialysis (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The logistic regression model was statistically significant [explained 46.9% (Nagelkerke \u003cem\u003eR2\u003c/em\u003e) of the variance in employment and correctly classified 82.6% of cases]. Factors associated with a higher likelihood of retaining employment after initiating dialysis included being on maintenance PD, patients living in nuclear families, patients financing their treatment themselves and patients employed in professional jobs.\u003c/p\u003e \n\u003cp\u003e\u003cstrong\u003eTable 4: Multiple logistic regression analysis of factors associated with likelihood of retaining employment after initiating dialysis.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cimg 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\" alt=\"image\" width=\"627\" height=\"446\"\u003e\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study analysing the employment status of patients suffering from ERSD showed that less than 1/6th of the study population was employed in a prevalent dialysis population. Prior to starting maintenance dialysis, 69% of the study population was employed and loss of employment was up to 78% among those who were previously employed. Initiating dialysis also affected the students as 3/4th of the students enrolled in the present study did not continue their studies after starting dialysis. A quarter of the homemakers (all females) was unable to do household chores after initiating dialysis.\u003c/p\u003e \u003cp\u003eMost of the data on employment status of patients on maintenance dialysis comes from studies performed in Western countries. Studies from North America and Europe have found employment rates from 23\u0026ndash;31.2% among patients on maintenance dialysis (Holley and Nespor \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e1994\u003c/span\u003e, van Manen et al. 2001). But the situation may not be the same in the Indian context because in the USA, nearly all ESRD patients are under Medicare coverage and European nations also have a strong social support network (Erickson et al. \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Data from India is scarce and we could find only one study which analysed the ESRD patients on maintenance dialysis from South India and found that 33.5% of HD and 26% of PD patients were employed. They postulated that the institute where study was conducted is a part of an organization which runs many temples, orphanages and educational institutes and most of their patients are employees or dependents of that organization, which could have led to a higher employment rate (Lakshmi et al. 2017). We observed a very low employment rate (15.6%) among patients on maintenance dialysis.\u003c/p\u003e \u003cp\u003eOther studies have found that 23\u0026ndash;31% patients maintain employment after initiating dialysis, hence the loss of employment is substantial (Curtin et al. \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e1996\u003c/span\u003e, Julius et al. \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e1989\u003c/span\u003e, Rasgon et al \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e1993\u003c/span\u003e, Evans et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e1985\u003c/span\u003e, Rasgon et al. \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1996\u003c/span\u003e, Antonoff and Mallinger \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e1990\u003c/span\u003e, Buckley et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e1985\u003c/span\u003e, Kutner and Cardenas 1981, Sherwood \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e1983\u003c/span\u003e). Laxmi et al also observed that proportion of ESRD patients employed reduced from 61.1\u0026ndash;29.9% after initiating dialysis (Lakshmi et al. 2017). The present study also revealed that 72.7% of students stopped studying and 28.6% of homemakers were unable to do household chores after initiating dialysis. Loss of studies may further hamper the future employability of these individuals. Only 2 patients had a gain in employment after initiating dialysis in the current study. This is similar to the observation made by van Manen et al in Dutch ESRD patients among whom 2% of patients gained employment after initiating dialysis. They postulated that probably dialysis does not promote vocational rehabilitation by itself and we should direct our efforts to prevent loss of jobs among patients who are already employed before initiating dialysis (van Manen et al. 2001).\u003c/p\u003e \u003cp\u003eRegarding factors affecting loss of employment after initiating dialysis, our study found that being on maintenance PD, living in a nuclear family, self-financing of treatment and a professional job predicted employment after initiating dialysis. Prior studies also show contradictory observations regarding factors predicting employment after initiating dialysis. Lee et al also observed that ESRD patients who were employed full time were significantly younger (Lee and Jin \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eComorbidities, performance status, duration of CKD and dialysis vintage are likely to be associated with employment, but their effect has been inconsistent in previous studies (Holley and Nespor \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e1994\u003c/span\u003e, Curtin et al. \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e1996\u003c/span\u003e, Lakshmi et al. 2017, van Manen et al. 2001, Rasgon et al \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e1993\u003c/span\u003e, Helanter\u0026auml; et al. \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). We did not find any difference in comorbidities, duration of CKD and dialysis vintage among employed and unemployed patients on maintenance dialysis.\u003c/p\u003e \u003cp\u003eEffect of dialysis modality on employment status of patients on maintenance dialysis has never been proven conclusively. Some studies have reported that dialysis modality has no effect on employment (Holley and Nespor \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e1994\u003c/span\u003e, van Manen et al. 2001) whereas others have found that patients on PD are more likely to be employed as compared to those on HD (Julius et al. \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e1989\u003c/span\u003e, Wolcott and Nissenson \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e1988\u003c/span\u003e, Fragola et al \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e1983\u003c/span\u003e, Evans et al \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e1985\u003c/span\u003e, Bremer et al. \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e1989\u003c/span\u003e). We found that patients on PD were significantly more likely to retain employment as compared to those on HD. It has been suggested that treatment modality does not affect change in employment, rather employment status may affect the choice of treatment modality. Patients who are employed when maintenance dialysis therapy is initiated probably tend to choose PD as the treatment modality because it enables ambulatory treatment with flexible working schedules (van Manen et al. 2001).\u003c/p\u003e \u003cp\u003eDialysis centre characteristics may affect employment in patients undergoing maintenance HD. An inflexible dialysis schedule may act as a barrier to vocational rehabilitation and presence of a late dialysis shift was found to be the strongest predictor of employment in a study performed by (Kutner et al. \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). But a facility for evening HD was not associated with employment on multiple regression analysis in our study. Distance of the dialysis centre from place of residence may also affect employment as patients need to travel 2 to 3 times a week which may hinder their work. Longer distance from the dialysis centre predicted lesser likelihood of employment in the present study.\u003c/p\u003e \u003cp\u003eLaxmi et al found that illiteracy was a strong predictor of loss of employment after initiating dialysis in ESRD patients. It may be because less educated persons have limited job opportunities, less flexible working hours and have jobs which require more physical labour (Lakshmi et al. 2017). But we did not observe a difference in the proportion of patients with different educational qualifications between those who retained employment as compared to those who did not. Patients living in nuclear families were more likely to retain employment than those living in joint families. The reason underlying this observation may be the fact that patients in joint families may have a stronger social and financial support and may feel a lesser need to earn. Self-finance and dependence on government schemes were found to be predictive of retaining employment and loss of job, respectively. In this part of our country, various government schemes are available to support treatment of patients of lower socioeconomic status. In social support systems where government provides financial assistance to unemployed or chronically ill, low paid employment may not provide more income as compared to social security benefits, and hence it may be a barrier to employment (Helanter\u0026auml; et al. \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Well educated patients with a good work history are more likely to continue employment after initiating dialysis (Kutner et al. \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e1991\u003c/span\u003e, Ferrans and Powers \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e1985\u003c/span\u003e, Buckley et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e1985\u003c/span\u003e). In the present study also, self financed subjects had higher educational qualifications, better jobs and belonged to higher socioeconomic status.\u003c/p\u003e \u003cp\u003eBeing in a professional job was predictive of employment after initiating dialysis. Laxmi et al also observed that loss of employment after dialysis initiation was significantly affected by predialysis employment level and was significantly higher among patients with blue collar jobs as compared to those with white collar jobs. Many factors have been postulated to account for this difference. Higher category jobs require less physical labour and have flexible working hours which may be adjusted according to dialysis schedule. Whereas people in lower category jobs lack openings to shift to jobs requiring less physical labour, have less flexible working hours and are unable to obtain social support due to their marginalized status (Lakshmi et al. 2017).\u003c/p\u003e \u003cp\u003ePresence of anemia and MBD in patients with CKD may be associated with weakness, fatigue, bone pains leading to poor functional status and difficulty to maintain employment. Our study did not find any difference in haemoglobin, albumin, MBD parameters (calcium, phosphorus, iPTH and alkaline phosphatase) between patients who retained employment and those who lost employment after initiating dialysis.\u003c/p\u003e \u003cp\u003eThere are a few limitations of the present study. First, it is a cross sectional study and hence it is difficult to assess the risk of loss of employment as the time on maintenance dialysis increases. Moreover, the relationship of most of the factors with employment has been inconsistent because these factors may be associated with employment longitudinally and most of the previous studies also have been cross sectional studies. Second, we did not assess the attitude of patients towards employment as it may also affect the employment of patients on maintenance dialysis. There are significant differences between the attitudes of employed versus non-employed patients with regard to health-related barriers to employment. Third, it is a single centre study and the study population represents patients visiting a public-sector hospital, hence the results may not be generalized to the general ESRD population.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eA small proportion of patients with ESRD on maintenance dialysis are employed and a large number of ESRD patients stopped working after initiating maintenance dialysis. Nuclear family, PD as dialysis modality, professional category job before initiating dialysis, self-financing of treatment and living closer to dialysis centres was associated with retaining employment on maintenance dialysis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e none\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e none\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent:\u003c/strong\u003e Ethical clearance was obtained from Institute Ethics Committee (IEC No. 30/19 dated 02/01/2020) and informed consent was obtained from all the study participants before enrolment in study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Material:\u003c/strong\u003e on demand\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026lsquo; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVP collected and analyzed the data and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eAC\u0026nbsp;conceptualized the study, revised the manuscript and approved the final version for publication.\u003c/p\u003e\n\u003cp\u003eNRS revised the manuscript and approved the final version for publication.\u003c/p\u003e\n\u003cp\u003eNP analysed the data, revised the manuscript critically.\u003c/p\u003e\n\u003cp\u003eAKS collected the data, revised the manuscript critically.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAltilio T, Otis-Green S. \u003cem\u003eOxford Textbook of Palliative Medicine\u003c/em\u003e. Oxford University Press; 1993. 109. \u003c/li\u003e\n\u003cli\u003eAntonoff A, Mallinger M: Vocational rehabilitation: Limitations and resistance of the renal patient. Perspectives 11 :43-52, 1990. \u003c/li\u003e\n\u003cli\u003eBremer BA, McCauley CR, Wrona RM, Johnson JP. Quality of life in end-stage renal disease: a reexamination. Am J Kidney Dis 1989; 13:200\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eBuckley N, Paff W, Tenner! M, Moutstatsos J: Rehabilitation among Florida in-center dialysis patients. Contemp Dial 30:42, 1985. \u003c/li\u003e\n\u003cli\u003eCurtin RB, Oberley ET, Sacksteder P, Friedman A. Differences between employed and nonemployed dialysis patients. Am J Kidney Dis. 1996 Apr;27(4):533-40. \u003c/li\u003e\n\u003cli\u003eErickson KF, Zhao B, Ho V, Winkelmayer WC. Employment among Patients Starting Dialysis in the United States. Clin J Am Soc Nephrol. 2018 Feb 7;13(2):265-273. \u003c/li\u003e\n\u003cli\u003eEvans RW, Manninen DL, Garrison LP Jr, Hart LG, Blagg CR, Gutman RA, Hull AR, Lowrie EG. The quality of life of patients with end-stage renal disease. N Engl J Med. 1985 Feb 28;312(9):553-9. \u003c/li\u003e\n\u003cli\u003eFerrans CE, Powers MJ. The employment potential of hemodialysis patients. Nurs Res. 1985 Sep-Oct;34(5):273-7. PMID: 3850487. \u003c/li\u003e\n\u003cli\u003eFragola JA, Grube S, Von Bloch L, Bourke E. Multicentre study of physical activity and employment status of continuous ambulatory peritoneal dialysis (CAPD) patients in the United States. Proc Eur Dial Transplant Assoc 1983; 20:243\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eHallab A, Wish JB. Employment among Patients on Dialysis: An Unfulfilled Promise. Clin J Am Soc Nephrol. 2018 Feb 7;13(2):203-204. \u003c/li\u003e\n\u003cli\u003eHelanter\u0026auml; I, Haapio M, Koskinen P, Gr\u0026ouml;nhagen-Riska C, Finne P. Employment of patients receiving maintenance dialysis and after kidney transplant: a cross-sectional study from Finland. Am J Kidney Dis. 2012 May;59(5):700-6. \u003c/li\u003e\n\u003cli\u003eHolley JL, Nespor S. An analysis of factors affecting employment of chronic dialysis patients. Am J Kidney Dis 1994; 23:681\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eIfudu O, Paul H, Mayers JD, Cohen LS, Brezsnyak WF, Herman AI, et al. Pervasive failed rehabilitation in center-based maintenance hemodialysis patients. Am J Kidney Dis 1994; 23:394\u0026ndash;400. \u003c/li\u003e\n\u003cli\u003eJulius M, Kneisley JD, Carpentier-Alting P, Hawthorne VM, Wolfe RA, Port FK. A comparison of employment rates of patients treated with continuous ambulatory peritoneal dialysis vs in-center hemodialysis (Michigan End-Stage Renal Disease Study). Arch Intern Med. 1989 Apr;149(4):839-42. \u003c/li\u003e\n\u003cli\u003eKhan IH, Catto GR, Edward N, Fleming LW, Henderson IS, MacLeod AM. Influence of coexisting disease on survival on renal-replacement therapy. Lancet. 1993 Feb 13;341(8842):415-8. \u003c/li\u003e\n\u003cli\u003eKutner NG, Cardenas DO: Rehabilitation status of chronic renal disease patients undergoing dialysis: Variations by age category. Arch Phys Med Rehabil 62:626-630,1981. \u003c/li\u003e\n\u003cli\u003eKutner NG, Brogan D, Fielding B. Employment status and ability to work among working-age chronic dialysis patients. Am J Nephrol 1991; 11:334\u0026ndash;40. \u003c/li\u003e\n\u003cli\u003eKutner N, Bowles T, Zhang R, Huang Y, Pastan S. Dialysis facility characteristics and variation in employment rates: a national study. Clin J Am Soc Nephrol. 2008 Jan;3(1):111-6. \u003c/li\u003e\n\u003cli\u003eLakshmi BS, Kumar ACV, Reddy HK, Gopal J, Chaitanya V, Chandra VS, Sandeep P, Nagaraju RD, Ram R, Kumar VS. Employment Status of Patients Receiving Maintenance Dialysis - Peritoneal and Hemodialysis: A Cross-sectional Study. Indian J Nephrol. 2017 Sep-Oct;27(5):384-388. \u003c/li\u003e\n\u003cli\u003eLee JY, Jin DC. Patient characteristics according to rehabilitation and employment status in Korean hemodialysis patients. Kidney Res Clin Pract. 2020 Sep 30;39(3):356-364. \u003c/li\u003e\n\u003cli\u003eMohapatra CS, Disability management in India challenges and commitments. Available from: http://niepid.nic.in/Disability%20Management.pdf [Accessed 27 November 2019]. \u003c/li\u003e\n\u003cli\u003eRasgon S, Schwankovsky L, James-Rogers A, Widrow L, Glick J, Butts E. An intervention for employment maintenance among blue-collar workers with end-stage renal disease. Am J Kidney Dis. 1993 Sep;22(3):403-12.\u003c/li\u003e\n\u003cli\u003eRasgon SA, Chemleski BL, Ho S, Widrow L, Yeoh HH, Schwankovsky L, Idroos M, Reddy CR, Agudelo-Dee L, James-Rogers A, Butts E. Benefits of a multidisciplinary predialysis program in maintaining employment among patients on home dialysis. Adv Perit Dial. 1996;12:132-5.\u003c/li\u003e\n\u003cli\u003eRasgon S, James-Rogers A, Chemleski B, Ledezma M, Mercado L, Besario M, Trivedi J, Miller M, Dee L, Pryor L, Yeoh H. Maintenance of employment on dialysis. Adv Ren Replace Ther. 1997 Apr;4(2):152-9. \u003c/li\u003e\n\u003cli\u003eSharma R. Revised Kuppuswamy\u0026apos;s Socioeconomic Status Scale: Explained and Updated. Indian Pediatr. 2017 Oct 15;54(10):867-870. \u003c/li\u003e\n\u003cli\u003eSherwood RJ: The impact of renal failure and dialysis treatments on patients\u0026apos; lives and on the compliance behavior, in Levy NL (ed): Psychonephrology: Psychological Problems in Kidney Failure and their Treatment, vol 2. New York, NY, Phenum, 1983, pp 52-70. \u003c/li\u003e\n\u003cli\u003eTheorell T, Konarski\u0026ndash;Svensson JK, Ahlmen J, Perski A. The role of paid work in Swedish chronic dialysis patients\u0026mdash;a nation-wide survey: paid work and dialysis. J Intern Med 1991; 230:501\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003evan Manen JG, Korevaar JC, Dekker FW, Reuselaars MC, Boeschoten EW, Krediet RT; NECOSAD Study Group. Netherlands Cooperative Study on Adequacy of Dialysis. Changes in employment status in end-stage renal disease patients during their first year of dialysis. Perit Dial Int. 2001 Nov-Dec;21(6):595-601. \u003c/li\u003e\n\u003cli\u003eWolcott DL, Nissenson AR. Quality of life in chronic dialysis patients: a critical comparison of continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis. Am J Kidney Dis 1988; 11:402\u0026ndash;12. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"dr ram manohar lohia institute of medical sciences, lucknow, india","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":"Dialysis, Employment, End stage renal disease","lastPublishedDoi":"10.21203/rs.3.rs-4501323/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4501323/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEmployment is associated with a host of benefits including better self esteem, quality of life and financial independence. Maintenance dialysis is a major barrier to employment in patients with ESRD. This observational cross-sectional study was conducted to determine the proportion of patients suffering from ESRD on maintenance dialysis who were employed and various factors associated with loss of employment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients suffering from ESRD, aged 18 to 65 years, who were on maintenance dialysis for ≥ 3 months were included. Their clinical and demographic characteristics, employment status before dialysis and change in employment after initiating dialysis was recorded and various factors associated with change in employment were analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe observed that 39 (15.6%) out of 225 study subjects were employed on maintenance dialysis, whereas 155 (68.9%) patients were employed before initiating dialysis. Patients who lost employment were significantly younger and a higher proportion were on HD. Being on maintenance PD, residing in a nuclear family and at a shorter distance from the dialysis centre, self financing of treatment and professional employment category were associated with a greater likelihood of retaining employment after initiating dialysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study revealed that only a small proportion of patients on maintenance dialysis are employed and a large number of patients lose employment after initiating dialysis. Nuclear family, PD as dialysis modality, professional category job before initiating dialysis, self-financing of treatment and living closer to dialysis centres was associated with retaining employment on maintenance dialysis.\u003c/p\u003e","manuscriptTitle":"Employment among patients with end stage renal disease on maintenance dialysis at a tertiary care centre in North India- a cross-sectional study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-31 06:47:07","doi":"10.21203/rs.3.rs-4501323/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":"8285d869-8cce-4830-b134-9beb9faac027","owner":[],"postedDate":"May 31st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-31T06:47:07+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-31 06:47:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4501323","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4501323","identity":"rs-4501323","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}