What is renal disease, as we know renal disease also known as kidney failure or end-stage renal disease (ESRD), is the final stage of chronic kidney disease.Chronic kidney disease can occurs when the kidneys fail, preventing the body from removing wastes and fluids. There is no known cure, although certain procedures can help patients live longer and alleviate pain.
We know that chronic kidney disease includes conditions that damage your kidneys and decrease their ability to keep you healthy by doing the jobs listed. If kidney disease gets worse, wastes can build to high levels in your blood and make you feel sick and uncomfortable. You may develop complications like high blood pressure, anemia (low blood count), weak bones, poor nutritional health and nerve damage. Also, kidney disease increases your risk of having heart and blood vessel disease. These problems may happen slowly over a long period of time. Chronic kidney disease may be caused by diabetes, high blood pressure and other disorders. Early detection and treatment can often keep chronic kidney disease from getting worse. When kidney disease progresses, it may eventually lead to kidney failure, which requires dialysis or a kidney transplant to maintain life.Dialysis is a techniques include intermittent hemodialysis, continuous hemofiltrat ion and hemodialysis, and peritoneal dialysis. All modalities exchange solute and remove fluid from the blood, using dialysis and filtration across permeable membranes.

What is quality of life?. According to Ontario Social Development Council, (1997) quality of life is the purpose is to provide a tool for community development which can be used to monitor key indicators that encompass the social, health, environmental and economic dimensions of the quality of life in the community. The quality of life can be used to comment frequently on key issues that affect people and contribute to the public debate about how to improve the quality of life in the community. It is intended to monitor conditions which affect the living and working conditions of people and focus community action on ways to improve health. Indicators for the quality of life is include social,health,economic and environmental. Quality of Life is the product of the interplay among social, health, economic and environmental conditions which affect human and social development.

According to Mc Call “Quality of life ” Social Indicators Research page 229-248 (1975) the meaning of quality of life is the best way of approaching quality of life measurement is to measure the extent to which people’s ‘happiness requirements’ are met those requirements which are a necessary (although not sufficient) condition of anyone’s happiness – those ‘without which no member of the human race can be happy.’

The quality of life has been defined by the World Health Organization as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. Health-related quality of life can be defined as the extent to which one’s usual or expected physical, social, or emotional well-being is affected by a medical condition and/or its treatment. Quality of life includes physical, social, psychological, and therapy-related components.

By research article title ‘Forecasting the Incidence and Prevalence of Patients with End-Stage Renal Disease in Malaysia up to the Year 2040″ its show in Malaysia, the incidence and prevalence of patients with End Stage Renal Disease(ESRD) has been on an upward trend for the past 20 years. The increase in the dialysis population is attributable to the increasing availability of haemodialysis treatment facilities and easier access to public or subsidised funding, especially in the nongovernmental sector. The 22nd Report of the Malaysian Dialysis and Transplant Registry in 2013 recorded a total of 32,026 patients receiving dialysis treatment, 29,192 on haemodialysis (91%) and 2,834 on peritoneal dialysis (9%) . In 1993, 358 new ESRD patients were treated with dialysis, 2,629 in 2003, while in 2013 the number steeply increased to 6,985. The incidence of patients with ESRD on dialysis was 18 per million population (pmp) in 1993. Subsequently, the numbers doubled from ?104 pmp in 2003 to 231?pmp in 2013. The prevalence of patients with ESRD on dialysis was 71?pmp in 1993, rising subsequently more than two fold from 415?pmp in 2003 to 1,059?pmp in 2013 .When we saw this article the conclusion of patients with ESRD every year has been upward.

2. FACTORS AFFECTING THE QUALITY OF LIFE OF RENAL PATIENTS.

Chronic kidney disease (CKD) is one of the main public health issues now in Malaysia. Every year it increases the morbidity and mortality of patients. Treatment includes multiple aspects such as dialysis and hemodylisis can changed patients lifestyle . Patients on hemodialysis and dialysis must adjust their life plans arccoding to the treatment. They are aware of losing their health and independence. Therefore, acceptance of illness is important and allows the patient to adjust to new situation and alleviates negative emotions.There are three factors affecting the quality of life of renal patients.Three aspects are physical ,mental and social activities.

What is physical aspects affecting the quality of life of renal patients? As we know that regular physical exercise is mandatory for the prevention and treatment of obesity, diabetes and insulin resistance which are increasing factors of new onset and of progression of CKD. Body weight lowering strategies should include, as first step, a combination of mild energy reduction and an increase of energy expenditure by aerobic exercise. Unfortunately, this strategy is not always successful.During the course of CKD, physical activity and capacity are largely reduced. Physical inactivity is a long-standing clinical problem among CKD patients especially those undergoing dialysis treatment .According to Cochrane (2011) says that the effect of regular exercise training in adults with CKD and in kidney transplant recipients on several outcomes, including dietary nutrient intake and parameters of nutritional status. It emerged that physical fitness and physical functioning defined as the ability and capacity to perform activities of daily living is severely reduced in adults with CKD and progressively declines from the early stages of CKD to End Stage Renal Disease.

According to S.Karger AG ,Basel(2014) Chronic kidney disease(CKD) patients are at risk for protein-energy wasting, abnormal body composition and impaired physical capacity. These complications lead to increased risk of hospitalization, morbidity and mortality.In CKD patient as well as in healthy people, there is a close association between nutrition and physical activity. Inadequate nutrient intake impairs physical performance thus favoring a sedentary lifestyle: this further contributes to loss of muscle strength and mass, which limit the quality of life and rehabilitation of CKD patients. In CKD as well as in end-stage-renal-disease patients, regular physical activity coupled with adequate energy and protein intake counteracts protein-energy wasting and related comorbidity and mortality. In summary, exercise training can positively influence nutritional status and the perception of well-being of CKD patients and may facilitate the anabolic effects of nutritional interventions.

What is about mental activities that affecting factors the quality of life of renal patients? Chronic Kidney Disease is a continuous psychological process for patients and their families in order to accept their new image and to be adjusted to the new condition of haemodialysis and dialysis. The quality of life of patients requiring dialysis and haemodialysis since it is associated with changes in their daily habits and in their lifestyle for both themselves and their families. At the same time, their physical health, their functional status, their personal relationships and their social and economic status are greatly affected. According to Gerogianni,limitation of liquids and foods is the most frequent stressor for these patients. That is because the daily consumption of fluids should not exceed of 500 ml per day due to the risk of causing pulmonary edema. An equally distressing factor is the requiring effort to follow the dietary guidelines, as the excessive intake of potassium and phosphorus is responsible for causing heart failure and possible itching or renal osteodystrophy respectively.

According to research study conducted in Greece by Kaitelidou et al., showed that unemployment is a significant stressor for haemodialysis patients. According to that study, 60.2% of patients receiving dialysis were not able to keep their profession and 36.7% had to retire after the beginning of dialysis. Loss of employment is responsible for the appearance of intense anxiety and problems of sexual function while employment positively affects the psychological status and libido of spouses.

How about social activities that affecting factors the quality of life of renal patients? Chronic Renal Disease is a public health problem and has serious impact on the quality of life of patients undergoing haemodialysis and dialysis and its affects significally their social life. Specific variables, such as age, gender, frequency and duration of dialysis, education, family, financial and professional status, physical and social functioning, mental health, health effects and symptoms of the disease, can affect either favorably or adversely the quality of life of these patients.
According to Gerogianni and Babatsikou(2014) the quality of life is significantly associated with changes in daily habits and lifestyle for patients requiring dialysis and their families. At the same time, patients’ physical health, functional status, personal relationships, social and economic prosperity are greatly affected .According to Cohen et al., (2007), Brissette et al., (2000) Christensen et al.,( 1992), Christensen et al., (1994); Kimmel et al.(1998) for patients with chronic diseases, daily activities and social support are of great importance for maintaining a satisfactory quality of life. Social support and integration in the community are important factors, which help patients to be adjusted to a chronic illness .

3. STRATEGIES TO IMPROVE QUALITY OF LIFE OF RENAL PATIENTS FROM ASPECTS PHYSICAL,MENTAL AND SOCIAL ACTIVITIES.

As we know treating chronic kidney failure is related to receiving long-term dialysis therapy to the patients. Both hemodialysis and peritoneal dialysis significantly change patients life -style. Actually family support is very important to improve quality of life of renal patients from aspects physical,mental and social activities and the nurses is the second person closed with the patients .To improve quality of life to our renal patients we must have strategies from aspects physical ,mental and social activities.

There are many strategies to improve our renal patients from aspects physical .Such as regular exercise training can improve arterial blood pressure control and heart rate, physical fitness walking capacity and several nutritional parameters and quality of life. CKD patients should be stimulated to increase their physical activity, including coordination and flexibility exercises associated with aerobic and resistance training .Exercise programs may be implemented in the dialysis and/or in the non-dialysis day, depending on the patient’s need and willing. According to Kouidie et al. evaluated the effects of long-term physical training on Hemodialisis (HD) patients’ fitness, perception of health and overall life situation .They found that HD patients are able to adhere to long-term physical training programs both on dialysis- and non-dialysis days, with significant increase in exercise capacity especially after the first year. The perception of health was higher in the majority of the patients .The ability of exercise training to alleviate depression and to increase the perception of feeling better improved appetite and contributed to counteract the reduction of energy and protein intake frequently found in HD patients .

According to Sakkas et al. had investigated the effect of 6 months of aerobic exercise training on muscle morphology in HD patients and found beneficial effects on muscles with an increment of cross sectional area, reduction of myofiber atrophy and changes in capillarization. They observed that skeletal muscles of uraemic patients responded to exercise stimulus in the same way as the normal population .A correct nutritional approach and regular physical activity also represent very important aspects of the clinical care management in renal transplanted patients .

According to S.Karger AG,Basel (2014) Chronic kidney disease (CKD) patients are at risk for protein-energy wasting, abnormal body composition and impaired physical capacity. These complications lead to increased risk of hospitalization, morbidity and mortality.In CKD patient as well as in healthy people, there is a close association between nutrition and physical activity. Namely, inadequate nutrient (energy) intake impairs physical performance thus favoring a sedentary lifestyle: this further contributes to loss of muscle strength and mass, which limit the quality of life and rehabilitation of CKD patients. In CKD as well as in end-stage-renal-disease patients, regular physical activity coupled with adequate energy and protein intake counteracts protein-energy wasting and related comorbidity and mortality. In summary, exercise training can positively influence nutritional status and the perception of well-being of CKD patients and may facilitate the anabolic effects of nutritional interventions.

As we know although the modern treatment of chronic kidney disease (CKD) is addressed to reduce progression of renal and cardiovascular damage, to prevent uremic complications and to improve survival, new challenges must be considered. In order to prevent disability, to improve quality of life and to maintain physical performance, it is important a proper nutritional approach and a regular physical activity.For CKD patients, diet and exercise are widely recommended not only for improving the efficacy of drug and dialysis treatment, but also for offering specific benefits on physical performance, quality of life and health status perception. Nutrition and physical activity can also influence each other and closely interact both in healthy and in CKD population.When we know the benefits that the renal patients can get so we can suggest and make renal patients happy because the first in their mind although they are have CKD but they want to make their life meaningful.

How about to improve our renal patients from aspects mental?.The psychosocial impact of pain for chronic kidney disease patients is another area that needs further exploration .Chronic pain is a common complaint for patients with ESRD. The pain is often moderate or severe, and significantly impacts virtually every aspect of quality of life.Stress for patients with kidney disease may be burdensome. There are a variety of stressors that impact on the life of a dialysis patient.These stressors may include the impact of the illness on overall functioning, dietary issues, loss of supportive structures and relationships, loss of employment, financial difficulties, time constraints, mood fluctuations, functional limitations, and fear of disability and death. Adaptive coping mechanisms are needed to deal with these complex changes in patients’ lives. In the absence of adequate coping strategies, these stressors can aggravate the patients’ perception of their quality of life. It is important, therefore, for the nephrology team to be aware of these areas of difficulty and explore coping mechanisms with the patient.
Anxiety is also commonly noted in ESRD patients 27% of urban HD patients have a major anxiety disorder.The presence of an anxiety disorder is associated with a significantly lower overall perceived quality of life Evaluating and understanding anxiety in the ESRD patient may open therapeutic avenues to explore, which may positively impact on HRQOL.

Social support has been shown to correlate with a variety of HRQOL domains, including depressive symptoms, perception of illness effects, satisfaction with life, and overall quality of life of ESRD patients.53,54 Marital and family discord are commonly observed in ESRD patients and may negatively impact on HRQOL.45., 55., 56. Active community support, including spiritual involvement, has been associated with improved HRQOL assessments.57,58 However, as pointed out by Cohen et al.,54 few studies have examined the impact of social support interventions in ESRD patients and these studies have been limited by small sample size, lack of appropriate controls, and a retrospective analysis.
The impact on the caregivers who provide support for patients with CKD and ESRD is an area that has received surprising little attention.59,60 Of note is a recent systematic literature review that noted only three articles that describe interventions for caregivers of CKD patients; all assess the effect of educational material given to the caregiver and describe an improvement of knowledge with no report of other outcomes.54 Importantly, lessons from other chronic diseases have suggested that exploring ways of supporting caregivers can have beneficial effects on the outcomes for both the patient and the caregiver.59,60

4. CONCLUSION
In summary, there is an increasing interest in assessing HRQOL in patients with chronic kidney disease. Importantly, it is now mandated in the United States that HRQOL measurements be done routinely on all ESRD patients. The interpretation and use of the information obtained from these HRQOL assessments pose certain challenges for the nephrology care team. The focus clearly needs to be on developing strategies to improve the compromised HRQOL of the patient with chronic kidney disease. To address this properly requires that careful assessments be done in a variety of domains (outlined in Table 1) and that the interventions use the resources of the entire patient care team (physicians, nurses, social workers, dieticians, psychologists, technicians, physical rehabilitation therapists, family, community resources, religious organizations, and so on). It will be important to document that interventions can positively impact on the HRQOL, as they have in other health care arenas. Enlisting patient cooperation in participating in these investigations and interventions will require careful attention and thought; this may well prove to be difficult and require creative ways of engaging the patient. In addition, identifying the financial resources to provide appropriate interventions will require strategic planning. Certainly, if the interventions translate into improved medical outcomes and reduced hospitalizations, then funding to support these programs should not be difficult to arrange. Thus, carefully tracking the impact of these interventions on not only HRQOL but also medical outcomes, hospitalizations, and the global cost of care is essential.