Quality of life after kidney and pancreas transplantation: a review

doi:10.1016/S0272-6386(03)00740-6

American Journal of Kidney Diseases

Volume 42, Issue 3, September 2003, Pages 431-445

https://doi.org/10.1016/S0272-6386(03)00740-6 Get rights and content

Abstract

There is an increasing amount of data on quality of life (QOL) in most chronic illnesses; some of the instruments used are generic, but recently, there is a tendency to use disease-specific instruments. We propose that recipients of organ transplants be assessed routinely for QOL by means of the 36-Item Short-Form Health Survey or a disease-specific instrument; for compliance, by means of the Long-Term Medication Behavior Self-Efficacy Scale; and for psychological status, by means of the Beck Depression Inventory Brief Symptom Inventory or the Symptom Checklist. The widespread use of QOL data in recipients of organ transplants will increase accountability of service providers and eventually increase patient satisfaction because these instruments are patient reported.

Section snippets

Psychosocial assessment of patients for kidney transplantation

Kahan8 recently summarized selection criteria for transplantation as follows: “accepted notion of benefit” (medical need, life remaining, and posttransplantation QOL), “patient's rights” (based on the right of every patient to transplantation if they so wish), “cost-effectiveness” (on the basis of best economic outcome), and “scientific progress” (whether the patient's treatment will advance medical science). These concepts are designed to assist the physician in allocating scarce resources of

QOL in relationship to medical compliance

Psychosocial issues and compliance are discussed increasingly in relation to QOL. Traditionally, compliance behavior has been considered in terms of the physician's ability to influence the patient and the patient's willingness to respond. However, in an attempt to move away from connotations of the all-powerful physician and the powerless patient, there was a move to replace the term compliance with that of adherence and, more recently, concordance. Adherence and concordance play to the

QOL in relation to psychosocial well-being

Skotzko et al17 performed a survey to determine the views of the transplant community on psychosocial issues. They found overwhelming support for providing psychosocial support both pretransplantation and posttransplantation to increase patient rehabilitation. There also was broad support for substance abuse treatment programs for recipients of organ transplants; most respondents also acknowledged the impact of psychosocial factors on compliance, QOL, and survival. Respondents to this survey

Review of the literature

There are numerous studies examining QOL after kidney and pancreas transplantation. We searched MEDLINE, the Cochrane Library, EMBASE, Cinahl, PsycINFO, ASSIA, RCN journals, SERFILE 202, and World Information Nursing and the World Wide Web using the terms “quality of life and kidney transplants” and “quality of life and pancreas transplants.” Only articles in English were included. Priority was given to articles that were prospective and randomized and used controls and articles after 1995. We

Critique of the literature

The studies we reviewed used a variety of questionnaires; selection of a QOL instrument was dependent on the bias of the investigators, making it difficult to compare studies across centers. The majority of studies are retrospective and there are wide differences in cultural patterns, sample sizes, and durations of follow-up. Another problem with self-reported studies is the poor response from patients. None of the studies reported the effect of self-reported questionnaires on the patient's

Patient empowerment

There is an increasing trend to involve patients directly in treatment planning, which, in turn, may lead to increased compliance. However, there has been little legislative support for this position. Empowerment does not come about by some miraculous process of osmosis, but through the acquisition of communicative and behavioral competence on the part of both the staff and patient—skills that may be lacking in patients from lower socioeconomic groups, who might easily be overwhelmed by the

5-year prediction

An important issue is availability of organs. Griva et al20 from University College, London, UK, compared health-related QOL in 76 living related and 271 cadaveric organ recipients, looking at social, medical, and psychological improvements after transplantation. They observed improved emotional well-being in all patients. However, living related transplant recipients expressed greater levels of feeling guilt, probably because they continue to see the donors. In another such study from Japan,

Conclusion

We propose that all recipients of organ transplants be routinely assessed for QOL by means of the SF-36 or a disease-specific instrument; for compliance, by means of the LTMBS Scale; and for psychological status, by means of the BDI, BSI, or SCL-90-R (Table 5). Adequate funding should be provided for the additional expense in implementing a program of assessment and intervention in appropriate cases. Over time, we may be able to construct a universal instrument that will capture these 3

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Long-Term Functional Recovery, Quality of Life, and Pregnancy After Solid Organ Transplantation
2016, Medical Clinics of North America
Citation Excerpt :
The inability to pursue their original line of work, such as manual labor, can be a major factor for unemployment.14 Appropriate use of vocational training can increase the rate of return to the work force for transplant recipients.15 HR-QOL is defined as an individual’s self-assessment of their health and encompasses physical status, mental health, and social well-being.
Mortality on the kidney waiting list and after transplantation in patients with peripheral arterial disease: An analysis of the United States Renal Data System
2016, Transplantation Proceedings
Citation Excerpt :
These findings may be due to a higher rate of severe arterial disease in DD recipients, with implications for patient selection and education prior to transplantation. Although data specifically in patients with PAD who undergo transplantation is lacking, quality of life is known to improve after renal transplantation in patients with end-stage renal disease [9,26,27]. We did not see a survival benefit in patients with PAD, especially those with amputation who underwent DD transplantation, however, the positive impact of improved quality of life after transplantation should be considered in the selection process of potential recipients.
Reports from the United States Renal Data System (USRDS) indicated that kidney transplantation, whether from a living donor (LD) or deceased donor (DD), offers survival advantage over being on the waiting list. Whether this is true for patients with peripheral arterial disease (PAD) is unknown given that patients with PAD have significant comorbidities.
We used a cohort of USRDS incident dialysis patients from 2001 to 2007, with follow-up through 2008. Patients with PAD younger than the age of 70 were included and divided into 3 groups; PAD waitlisted, PAD patients who received a first transplant from a DD, or PAD patients who received a first transplant from a LD. Time-dependent Cox regression models were used to compare differences in mortality.
In this study, 23,699 incident dialysis patients met inclusion criteria; only 16.7% (n = 3964) were waitlisted, of which 8.9 % (n = 2121) underwent transplantation. Patient survival in the LD group at any time point was significantly better than being on the waiting list (P < .001). For DD, mortality was higher in the first year compared with waitlisted patients (P < .001), however, after 1 year survival did not differ as compared with remaining on the waiting list. After adjusting for confounders, the relative risk (RR) of dying was significantly higher for patients with history of severe vascular disease requiring amputation (RR, 1.45; 95% confidence interval [CI], 1.15–1.84) in the DD group.
Kidney transplantation from a DD did not offer survival advantage over being on the waiting list, in part due to a higher rate of severe vascular disease. Careful patient selection may improve outcomes in the DD group.
High rate of unemployment after kidney transplantation: Analysis of the united network for organ sharing database
2014, Transplantation Proceedings
Despite an increased quality of life after transplant, in the United States, recipients participate less in employment compared to the general population. Employment after kidney transplantation is an important marker of clinically significant individual health recovery. Furthermore, it has been shown that employment status in the post-transplant period has a strong and independent association with patient and graft survival.
Using the United Network for Organ Sharing (UNOS) database, we identified all adults (between 18 and 64 years of age) who underwent kidney transplantation between 2004 and 2011. Patients with a stable renal allograft function and with full 1-, 3-, and 5-year follow-up were included. For recipients of multiple transplants, the most recent transplant was considered the target transplant. The data collected included employment rate after kidney transplantation in recipients employed and unemployed before transplant. The employment data were stratified for insurance payer (private, Medicaid, and Medicare). The results of categorical variables are reported as percentages. Comparisons between groups for categorical data were performed using the χ² test with Yates continuity correction or Fisher test when appropriate.
The UNOS database available for this study included a total of 100,521 patients. The employment rate at the time of transplant was 23.1% (n = 23,225) under private insurance and 10% (n = 10,032) under public insurance (Medicaid and Medicare, P < .01, compared to private insurance). Over a total of 29,809 recipients analyzed, alive and with stable renal allograft function who were working at time of transplantation, the employment rate was 47% (n = 14,010), 44% (n = 13,115), and 43% (n = 12,817) at 1, 3, and 5 years after transplant under private insurance and 16% (n = 4769), 14% (n = 4173), and 12% (n = 3567), respectively, under public insurance (P < .01, compared to private insurance). Over a total of 46,363 recipients alive and with stable renal function who were not working at time of transplant, the employment rate was 5.3% (n = 2457), 5.6% (n = 2596), and 6.2% (n = 2874) at 1, 3, and 5 years after transplant under private insurance and 6.5% (n = 3013), 7.8% (n = 3616), and 7.5% (n = 3477), respectively, under public insurance (P < .01, compared to private insurance).
The employment rates at the time of transplant in the United States are generally low, although privately insured patients are significantly more likely than patient with public insurance to have employment. Only a portion of these patients returns to work after transplantation. For the patients unemployed at the time of transplantation, the chance to find a job afterward is quite low even in privately insured patients. A concerted effort should be made by the transplant community to improve the ability of successful kidney transplant recipients to return to work or find a new employment. It had been shown that employment status in the post-transplant period has a strong and independent association with the graft and recipient survival.
Cost Utility of Sirolimus versus Tacrolimus for the Primary Prevention of Graft Rejection in Renal Transplant Recipients in Mexico
2012, Value in Health Regional Issues
Citation Excerpt :
Approximately 25,000 patients currently receive chronic dialysis, with the majority receiving continuous ambulatory peritoneal dialysis [4]. Renal transplantation is the treatment of choice for ESRD because, if successful, the quality and duration of life is better than that achieved with long-term dialysis [5–9]. ESRD has not only clinical consequences but also economic implications.
Therapies for end-stage renal disease improve quality of life, and survival. In Mexico, clinicians often must choose between different therapies without the availability of comparative outcomes evaluation. The present study evaluates the comparative cost-utility of sirolimus (SIR) versus tacrolimus (TAC) for the primary prevention of graft rejection in renal transplant recipients in Mexico.
We used modeling techniques to estimate the cost-effectiveness of SIR versus TAC to prevent graft rejection in patients with end-stage renal disease in the Mexican setting. The model estimates the cost of quality-adjusted life-year (QALY) per patient. We applied a 20-year horizon (1-year Markov cycles). Cost-effectiveness was expressed in terms of cost per QALY. All costs are presented in 2011 US dollars. Probabilistic sensitivity analyses were conducted.
The total cost for the SIR treatment arm over the 20-year duration of the model is estimated to be $136,778. This compares with $142,624 for the TAC treatment arm, resulting in an incremental cost of SIR compared with that of TAC of−$5,846. Over 20 years, SIR was estimated to have 8.18 QALYs compared with 7.33 QALYs for TAC. The resulting incremental utility of SIR compared with that of TAC is 0.84 QALY gained. SIR is estimated to be both less costly and more effective than TAC, indicating that it is the dominant strategy. Notably, results suggest that SIR has a 78% probability of being dominant over the TAC strategy and a 100% probability of having an incremental cost-effectiveness ratio at or below $10,064 (1 GDP) per QALY.
These analyses suggest that in the Mexican setting, the use of SIR in place of TAC for the prevention of graft rejection in this population is likely to be cost saving.
Health-related quality of life and clinical outcomes in kidney transplant recipients
2011, American Journal of Kidney Diseases
Citation Excerpt :
Moreover, depression is an important predictor of quality of life and mortality in kidney transplant recipients.3,46 Feelings of hopelessness and worthlessness, difficulties with concentration and memory, and loss of interest in daily activities may result in treatment nonadherence behaviors that include forgetting to take pills or missing regular follow-up appointments.59-61 Depression also may result in loss of appetite and malnutrition.62
Health-related quality of life (HRQoL) is an important outcome measure in patients with chronic kidney disease. It also has been shown repeatedly to predict mortality in various patient populations. In a prospective cohort study, we assessed the association between HRQoL and long-term clinical outcome in kidney transplant recipients.
Prospective prevalent cohort study.
We collected sociodemographic parameters, medical and transplant history, and laboratory data at baseline from 879 prevalent kidney transplant recipients (mean age, 49 ± 13 [standard deviation] years; 58% men; and 17% with diabetes mellitus).
We assessed HRQoL using the KDQoL-SF (Kidney Disease Quality of Life Short Form) questionnaire and assessed depressive symptoms using the Center for Epidemiologic Studies–Depression Scale.
All-cause mortality and death-censored transplant loss or death with functioning transplant. Cox regression models and semiparametric competing-risks regression analyses were used to measure associations between HRQoL scores and outcomes.
Most examined HRQoL domains were associated with clinical outcome in unadjusted models. After adjusting for several important confounders, the 36-Item Short Form Health Survey (SF-36) Physical Composite Score and Physical Functioning and General Health Perception subscale scores remained independently associated with clinical outcomes. Every 10-point increase in SF-36 Physical Composite Score and Physical Functioning and General Health Perception scores was associated with 18% (HR, 0.82; 95% CI, 0.71-0.95), 11% (HR, 0.89; 95% CI, 0.84-0.94), and 7% lower risks of mortality (HR, 0.93; 95% CI, 0.88-1.00), respectively.
Single-center study.
We showed that the SF-36 Physical Composite Score and Physical Functioning and General Health Perception KDQoL-SF domain scores are associated independently with increased risk of mortality in kidney transplant patients. Regular assessment of HRQoL may be a useful tool to inform health care providers about the prognosis of kidney transplant recipients. Additional studies are needed to assess whether interventions aimed at improving HRQoL would improve clinical outcomes in this patient population.
Modern indications for referral for kidney and pancreas transplantation
2023, Current Opinion in Nephrology and Hypertension

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Systematic reviewQuality of life after kidney and pancreas transplantation: a review

Abstract

Section snippets

Psychosocial assessment of patients for kidney transplantation

QOL in relationship to medical compliance

QOL in relation to psychosocial well-being

Review of the literature

Critique of the literature

Patient empowerment

5-year prediction

Conclusion

Soc Sci Med

Am J Kidney Dis

Transplant Proc

Am J Kidney Dis

Transplant Proc

Transplant Proc

Transplant Proc

Urology

Transplant Proc

Transplant Proc

Int J Nurs Stud

Transplant Proc

Am J Kidney Dis

Transplant Proc

Kidney Int

Am J Surg

Am J Kidney Dis

Am J Surg

Arch Pediatr

Urology

Quality of life after solid organ transplantation

Transplant Rev

Quality of life studiesDefinitions and conceptual issues

The Sickness Impact ProfileDevelopment and final version of a health status measure

Med Care

The MOS 36-Item Short Form Health Survey (SF-36)

Med Care

Disease-specific questionnaire for patients with a renal transplant

Nephron

Quality of life in end-stage renal disease patients after successful kidney transplantation—Development of the ESRD Symptom Checklist transplantation module

Nephron

Psychiatric considerations

Beck Depression Inventory

SCL-90-R, Administration, Scoring and Procedures Manual-II for the Revised Version and Other Instruments of the Psychopathology Rating Scale Series

Brief Symptom Inventory (BSI), Administration, Scoring, and Procedures Manual

The evaluation of renal transplant candidatesClinical guidelines

Am J Transplant

Barriers to cadaveric renal transplantation among blacks, women, and the poor

JAMA

Five preventable causes of kidney graft loss in the 1990sA single center analysis

Kidney Int

Approaching a consensusPsychosocial support services for solid organ transplantation programs

Prog Transplant

Non-compliance in patients receiving haemodialysisAn in-depth review

Nephron

Does transplantation produce quality of life benefits?A quantitative analysis of the literature

Transplantation

Quality of life and emotional responses in cadaver and living related renal transplant recipients

Nephrol Dial Transplant

Quality of life in kidney recipientsComparison of tacrolimus and cyclosporine-microemulsion

Clin Transplant

Emotional issues after kidney transplantationA prospective psychotherapeutic study

Clin Transplant

Life satisfaction and adverse effects in renal transplant recipientsA longitudinal analysis

Clin Transplant

Effects of clinical and individual variables on quality of life in chronic renal failure patients

J Nephrol

Effect of family environment and donor source on patient equality of life following renal transplantation

Health Psychol

Health promoting behaviors, quality of life, and hospital resource utilization of patients receiving kidney transplants

Nephrol Nurs J

Socio-economic evaluation of kidney transplantation in Germany

Arch Hell Med

Increase of physical activity level after successful renal transplantationA 5 year follow-up study

Nephrol Dial Transplant

Quality of life in patients before and after kidney transplantation

Psychol Health

Systematic review
Quality of life after kidney and pancreas transplantation: a review