Chronic kidney disease (CKD) is defined as a progressive and irreversible decline in renal function, often asymptomatic until advanced stages. As kidney function deteriorates, patients require renal replacement therapies such as hemodialysis, peritoneal dialysis, or kidney transplantation to survive. Among these treatments, hemodialysis is the most commonly used modality in Burundi. Although hemodialysis prolongs life, it is not curative and imposes a substantial daily burden on patients [1][2].

Beyond clinical aspects, patients undergoing hemodialysis face physical, psychological, social, and economic challenges. Quality of life (QoL), a multidimensional concept incorporating patients’ perceived well-being across various life domains, has become an important criterion for evaluating treatment effectiveness. In low-resource settings, few studies have explored QoL among hemodialysis patients. Burundi, where renal health infrastructure remains limited, is no exception.

This study aims to fill this gap by assessing the quality of life of chronic hemodialysis patients in Burundi using the KDQOL-SF™ questionnaire, a tool specific to chronic kidney disease, in order to identify the main determinants of QoL impairment and propose avenues for improvement.

The study sample consisted of 66 chronic hemodialysis patients nationwide, with a mean age of 49.27 ± 12.13 years, reflecting a relatively young population compared with Western cohorts [6]. The predominance of male (male/female ratio = 4.07) suggests either a higher incidence of CKD among men or inequality in access to care for women. According to Jungers P. et al. [7][8], this male predominance may be attributed to a higher incidence of kidney diseases in men as well as a faster progression to end-stage disease. Indeed, men are more likely to adopt risk behaviors such as smoking and excessive alcohol consumption, which are risk factors for kidney disease. In addition, biological, hormonal, and genetic differences, such as testosterone levels, may influence the progression of kidney disease [9]. However, female predominance has also been reported in some studies, such as that of Kane et al. [10] in Senegal in 2019, with a male/female ratio of 0.88.

The majority of patients had health coverage, although it remained partial and did not cover indirect costs, which may negatively influence quality of life. This situation is common in several sub-Saharan African countries [11][12].

The SF-36 overall mean score of 47.14 ± 19.73 confirms significant impairment of QoL, with the mental component (48.99 ± 23.10) slightly higher than the physical component (45.29 ± 21.41). These results reflect the considerable burden of CKD and its replacement therapy on autonomy, functional capacity, and overall well-being. Comparison with other similar African studies shows a consistent trend. Nasr et al. [1] reported an overall mean score of 51.4 ± 24.3, with 65% impaired QoL, while Gataa et al. [13] observed impaired QoL in 75.2% of patients, with a mean score of 55.1 ± 11.7. A study conducted in Cameroon [14] reported a mean score of 44.34, and 76.2% of patients had a QoL score < 50. The study by Shumbusho et al. [11], reporting an even lower SF-36 mean score of 38.3, illustrates the severity of impairment in certain contexts. Thus, despite worsening physical health, the mental health of dialysis patients remains relatively preserved, as shown in other studies [15]-[17]. This may reflect the ability of patients with end-stage renal disease to psychologically adapt to their condition over time. Furthermore, a Romanian multicenter study [18] observed that among patients who maintained their initial dialysis modality, physical quality of life progressively declined, whereas mental quality of life tended to remain stable.

The severe impairment in vitality (16.28 ± 32.07) and physical functioning (38.25 ± 33.01) is consistent with the high prevalence of anemia, the burden of comorbidities, and suboptimal dialysis modalities. These factors are known to increase chronic fatigue and reduce functional capacity [15][16][19]. It is also known that, among hemodialysis patients, the use of erythropoiesis-stimulating agents significantly contributes to improving the physical health component.

The dimensions related to occupational status (21.96 ± 35.22) and burden of kidney disease (36.64 ± 24.33) reflect the significant socioeconomic burden of end-stage renal disease, particularly in low-resource settings [15][17]. In contrast, the high scores observed for quality of social interactions (79.58 ± 18.11), social support (66.41 ± 25.23), and encouragement from the dialysis team (80.11 ± 25.66) suggest a protective role of social networks and healthcare staff—factors recognized as improving psychological adaptation and quality of life among hemodialysis patients [20]. In the literature, social support is associated not only with psychological benefits but also with better physical outcomes in hemodialysis patients.

The relatively satisfactory scores for cognitive functioning (71.45 ± 20.80) and overall satisfaction (73.98 ± 14.65) may reflect psychosocial resilience despite the chronic nature of the disease. Compared with data from developed countries, physical scores remain lower, probably due to limited access to rehabilitation services and comprehensive multidisciplinary care [21]. Overall, these findings confirm the multidimensional nature of quality of life in hemodialysis and highlight the importance of integrated interventions targeting physical, psychological, and social dimensions.

The present analysis highlights that both socio-demographic and clinical factors significantly influence quality of life (QoL) among hemodialysis patients in Burundi. In the bivariate analysis, older age and longer duration on hemodialysis were significantly associated with poorer QoL, a finding that remained robust after multivariate adjustment. This is consistent with existing literature, as aging is often accompanied by increased comorbidities, functional decline, and reduced physical capacity, all of which negatively impact QoL [22]-[24]. Similarly, prolonged exposure to hemodialysis may lead to treatment fatigue, complications, and psychosocial burden.

Conversely, several socio-economic factors—educational level, occupation, living conditions, and health insurance coverage—were positively associated with QoL in both analyses. These associations persisted after adjustment, indicating that they are independent predictors. Higher education may improve health literacy and adherence to treatment, while stable employment and better living conditions likely enhance financial security and access to care [14][25]. Health insurance coverage plays a crucial role in reducing the economic burden of chronic treatment, particularly in low-resource settings like Burundi.

Hemoglobin level emerged as a strong positive predictor of QoL in the multivariate model, confirming the importance of anemia management in hemodialysis patients. Adequate hemoglobin levels are associated with improved physical functioning, reduced fatigue, and better overall well-being [26].

In contrast, sex, diabetes, and hypertension were not significantly associated with QoL after adjustment. The lack of association with diabetes may be explained by confounding factors or limited statistical power, despite a negative trend observed in the bivariate analysis. But is known that the presence of diabetes and hypertension is associated with the negative impact of comorbidities on both physical and mental dimensions, as reported in several studies [27]-[29]. Vascular access showed a borderline association, suggesting that catheter use may be linked to poorer QoL compared to arteriovenous fistula, possibly due to higher complication rates. Therefore, the arteriovenous fistula is associated with better survival and lower morbidity compared with catheters, thus positively impacting QoL [30].

These findings underscore the multifactorial nature of QoL in hemodialysis patients and highlight the need for comprehensive interventions addressing both clinical and socio-economic determinants.

This study has certain limitations. The complexity of adapting the SF36 questionnaire into Kirundi and the use of a questionnaire not validated in the Burundian population may introduce social desirability bias. Also, the absence of a comparative group (peritoneal dialysis, kidney transplantation, or general population) limits the scope of comparative conclusions. A further limitation is the potential for residual confounding due to unmeasured variables, as well as possible selection and survivor bias inherent to this cross-sectional sample, which may limit the generalizability and causal interpretation of the findings.

The quality of life of chronic hemodialysis patients in Burundi is globally impaired, particularly in physical dimensions. Despite this, mental health appears relatively preserved, suggesting adaptive coping mechanisms. Socio-economic factors such as education, occupation, living conditions, and health insurance play a major role in QoL. Clinical factors, especially anemia and duration on dialysis, significantly influence patient outcomes. Older age and prolonged dialysis are associated with poorer QoL. Social support and healthcare team involvement provide important protective effects. The findings highlight the multidimensional nature of QoL in this population. Comprehensive strategies addressing both clinical management and socio-economic support are essential to improve patient well-being.

We would like to thank all the staff of dialysis units who facilitated the data collection.