EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Objectives: Health-related quality of life is increasingly used as an important measurement of treatment outcome. Here, quality of life parameters in renal transplant recipients were evaluated and compared with patients with chronic kidney disease on maintenance hemodialysis and with those who were not on dialysis.

Materials and Methods: This cross-sectional study included patients seen at a number of tertiary renal care hospitals (there were 15 renal transplant recipients, 20 patients on maintenance hemodialysis, and 28 patients with chronic kidney disease not on dialysis). Forty healthy individual were also included as the control group. Different biochemical parameters were analyzed. Quality of life was assessed with the KDQOL-SF-36 (version 1.3) questionnaire.

Results: Mean age was 39 ± 11 for transplant patients, 43 ± 11 years for patients on hemodialysis, 49 ± 12 years for patients with chronic kidney disease not on dialysis, and 34 ± 11 years for the healthy control group. Distribution of sex was similar. Transplant recipients had higher quality of life scores, with some scores similar to healthy controls patients, like physical function (P = .85) and social function (P = .25). Scores were 100 ± 12, 69 ± 27, 37 ± 28, and 91 ± 10 (P < .001) for physical function; 94 ± 12, 44 ± 17, 30 ± 14, and 69 ± 29 (P < .001) for pain; 99 ± 11, 61 ± 46, 24 ± 15, and 70 ± 28 (P < .001) for social function; and 91 ± 11, 51 ± 13, 40 ± 7, and 66 ± 11 (P < .001) for energy/fatigue in healthy control, chronic kidney disease patients not on dialysis, hemodialysis patients, and transplant recipients, respectively.

Conclusions: Quality of life is poor in patients with chronic kidney disease. However, renal transplant can improve quality of life. Transplant patients showed many quality of life scores similar to healthy individuals.

Key words : End-stage renal disease, Hemodialysis, Kidney transplant, Patient well-being, Renal replacement therapy

Quality of life (QoL) is frequently assessed for evaluating treatment outcomes among patients with chronic kidney disease (CKD) receiving different modalities of renal replacement therapies (RRTs). Patients with kidney disease on RRT are greatly affected by alterations in lifestyle, emotional disturbances, dependency, and physical and psychosocial symptoms. All of these significantly affect QoL. Different QoL assessment tools are being tested by clinical investigators and health care providers to find ways to improve patient outcomes.¹

Renal transplant has advantages over dialysis as it consumes less time for therapeutic purposes, has fewer restrictions for the patient, and allows absence of uremia, more freedom, and better social rehabilitation.² It is generally advocated that all patients with end-stage renal disease and those on dialysis should be offered transplant as this modality offers a better life expectancy and QoL than other treatment options.³ Some earlier prospective studies that observed QoL parameters both before and after transplant showed convincingly that transplant provides more improvements to well being than maintenance dialysis.⁴ In addition, these improvements are independent of pretransplant modality, whether on hemodialysis or peritoneal dialysis, involving all major domains of QoL parameters.⁵

In this study, we evaluated QoL parameters in renal transplant recipients and compared these results with those shown in CKD patients on maintenance dialysis and those not requiring dialysis (CKD-ND).

Materials and Methods

This was a cross-sectional study and included patients enrolled from tertiary renal care centers in Bangladesh (Sir Salimullah Medical College & Mitford Hospital, National Institute of Kidney Diseases and Urology, and the Center for Kidney Diseases and Urology Hospital, Dhaka, Bangladesh).

The renal transplant recipients were selected from those who were at least 6 months posttransplant. All were living related-donor transplant recipients and on a 3-drug immunosuppressant regimen. Hemodialysis patients were included if they were on therapy for at least 3 months with native arteriovenous fistula. The nondialysis CKD patients were patients with stable CKD (stage 3-5) who were attending nephrology outpatient departments for follow-up. The healthy control group included healthy individuals free from diabetes, hypertension, and kidney diseases. Study participants were excluded if they had acute infection, terminal illness, or cognitive impairment. For all study participants, clinical history and records of medical data were gathered, with relevant information recorded in data collection sheets.

Quality of life was measured by a specific questionnaire (the KDQOL). The KDQOL-36, used here, is a short form that includes the SF-12 as generic core scales from the KDQOL-SF (version 1.3).6 It has 8 domains, which include physical functioning (10 questions), role physical (4 questions), pain (2 questions), general health (5 questions), energy/fatigue (4 questions), social function (2 questions), emotional well-being (5 questions), and role emotional (3 questions). The scores of the KDQOL-SF-36 questionnaire were transformed as scores of 0 to 100, with higher scores reﬂecting better QoL. Scale scores were computed with the KDQOL-SF-36 scoring guideline.

The specific questionnaire used in this study was the translated Bengali (Bangla) version of KDQOL-SF-36, which has been pretested, validated, and used previously in other study participants in Bangladesh. All data were collected through face-to-face interviews.

Study approvals were obtained from the ethical authority of the respective institutes. All participants provided informed written consent. The ethical guidelines of the Helsinki Declaration were followed.

Statistical analyses
Statistical analyses were performed with SPSS software (SPSS: An IBM Company, version 15, IBM Corporation, Armonk, NY, USA). Data were checked by frequency run. Quantitative data were analyzed using analysis of variance with post hoc analysis to compare between multiple groups. Qualitative data were analyzed by chi-square test. Pearson correlations were applied to see associations among variables.

Our study group included 15 renal transplant recipients, 20 CKD patients on maintenance hemodialysis, and 28 CKD-ND patients. In addition, 40 healthy individuals were included as the healthy control group. In total, 65% were male and 35% were female participants. Although male-to-female distribution was dissimilar in study subgroups, chi-square test showed no meaningful differences between the groups (P = .09).

Table 1 compares the clinical data among the study subgroups. Post hoc analyses showed that age in the healthy control group was different (P < .001) versus the CKD-ND group but similar to age in the hemodialysis and renal transplant groups (P = .91). Participants in the healthy control and transplant group had similar body mass index (BMI) (P = .83) and percent hemoglobin (P = .37), with differences in these parameters from the other groups. Serum creatinine levels were lower in the transplant group, corresponding to high estimated glomerular filtration rate.

Domains of QoL, including physical functioning, role physical, pain, general health, emotional well being, role emotional, social function, and energy/fatigue, were compared among the study groups (Table 2). The major QoL parameters in general showed higher scores in the transplant group in relation to the CKD-ND and hemodialysis groups. Patients in the hemodialysis group showed the poorest QoL in most of the domains compared with the other study groups. In some of these domains, the healthy control and renal transplant groups had similar scores, including physical function (P = .85) and social function (P = .25).

Associations among QoL domains were investigated versus selected clinical variables. Strong positive correlations of all QoL parameters were shown versus BMI and hemoglobin, and negative correlation were shown with serum creatinine levels (Table 3).

Quality of life parameters are significantly improved after renal transplant versus that shown during pretransplant dialysis or maintenance dialysis. In their study, Fujisawa and associates⁷ showed that renal transplant patients had higher scores for QoL parameters in the physical functioning, bodily pain, general health, and social functioning domains compared with patients on hemodialysis. The improvements were largely attributed to changes in renal function, as higher scores had a reverse association with serum creatinine level. Similarly, in our study, a higher QoL score was seen among transplant patients compared with patients on hemodialysis, with Pearson correlation also showing that these high scores had strong association with lower creatine levels.

Transplant is always the best option among all RRT modalities. Even preemptive transplant is better to avoid dialysis and its complications. Many QoL parameters in the pretransplant period have been shown to be better in patients who received preemptive transplant versus those transplanted late, and this improvement continues after transplant.⁸ Some long-term follow-up parameters showed continued and persistent improvements in QoL posttransplant. In a 10-year follow-up of patients on dialysis versus a transplant group, transplant patients had sustained more social activities, better job retention, and greater improvements in QoL scores.⁹

Improved outcomes of transplant patients are due to multidimensional alterations. After transplant, changes occur in major clinical parameters like blood pressure, which is better controlled with less need for antihypertensive agents. There are also improvements in anemia by achievement of higher hemoglobin level (mostly without erythropoiesis-stimulating agents) and better nutritional status reflected by raised serum albumin levels and BMI. All of these improvements may be attributed to higher glomerular filtration rate.¹⁰ In our study, we also showed that higher QoL parameter scores as a whole had positive associations with better BMI and hemoglobin and negative association with rising creatinine level.

Other than the traditional clinical and laboratory variables, additional issues may also influence a patient’s perception of well being. In a French study that evaluated psycho-social variables, health-related QoL was negatively influenced by poor social support and antidepressant use, which were both associated with low QoL scores; however, access to the Internet was associated with higher scores.¹¹ A Chinese study showed that decreased routine transplant center follow-up visits over time significantly affected QoL. Additional factors that were shown to affect QoL were income/reimbursement, job status, and psychologic support.¹²

Benefits to QoL after transplant are shown in all age groups; these benefits in QoL are mainly evident compared with other RRTs like hemodialysis and peritoneal dialysis, but not to the level shown in healthy individuals. A study on young recipients (age range, 18-35 y) showed satisfactory lifestyle and adaptation to surroundings, although QoL scores were still lower than those shown in a matched healthy population.¹³ An elderly Norwegian transplant population (70 y) showed significantly improved QoL scores, with many QoL domains similar to those shown in healthy counterparts after 1 year posttransplant.¹⁴ In another study, in which patients treated with all RRT modalities were included, patients on hemodialysis and peritoneal dialysis had inferior QoL scores versus renal transplant recipients and healthy individuals. The study showed that transplant patients had scores in some domains of QoL similar to those shown in healthy individuals, like social functioning, mental function, and energy.¹⁵ In our study, we had a similar finding, in which renal transplant recipients had significantly higher and similar QoL scores in physical function and social function areas versus healthy counterparts.

Although QoL is expected and evidenced to get better posttransplant, a benefit of renal transplant over other modalities is sometimes not shown.¹⁶ The true benefits in QoL also depend on patient selection, age at transplant, years on dialysis, employment status, donor type, and the socioeconomic condition of the recipient.

Quality of life is generally poor among patients with CKD, with even poorer QoL in patients on dialysis. Renal transplant improves QoL. Transplant may allow patients to have similar QoL to healthy individuals.

Volume: 18 Issue: 1 January 2020 - Supplement - 1

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