Crosssectional study of quality of life after renal transplant in end stage renal disease.

BACKGROUND: End stage renal disease (ERD) is a psychologically debilitating illness with considerable emotional morbidity. There is variation in quality of life and mental health status among recipients and donor at different stages of kidney transplantation.
MATERIALS AND METHODS: The study is an observational analytic study. Sample for the study comprised of forty (40) consecutive patients including 20 recipients and 20 donors of 20 kidney transplantations, male and female, and who themselves/whose relatives provided written informed consent were included in the study. Both recipients and donors were followed-up from 2 weeks prior to transplant surgery to 6 months post-operatively by phone and when they came for review in Nephrology Out-Patient Department (OPD). Quality of life and mental health status was compared between the two groups.
RESULTS: Study groups were homogeneous on age, education, gender and marital status. After transplantation recipient's mean score in all parameters had increased and all changes were statistically significant (<0.05).
CONCLUSION: In this study significant changes in quality of life (QOL), and mental health status in recipients and donors before and after transplantation were noted. It is recommended to evaluate mental health related aspects of both donors and recipients.

End stage renal disease (ERD) is a psychologically debilitating illness with considerable emotional morbidity. The shock of the initial diagnosis, changes in body image with subsequent lower self-esteem and descent to dependence on a machine, fluid bag or partner can produce profound stress and adjustment problems. Various psychological coping strategies may be used during this time to help the recipient and family negotiate this period of disease and dialysis adjustment. Following renal transplantation a chronic multi-factorial physical and mental condition persists for the recipients. Life with the best functioning transplanted kidney is a life with uncertainty, however. The fear and possibility of rejection are constant. Immunosuppressive therapy can lead to psychiatric and psychological morbidity, and necessary shifts in family dynamics and readjustment into society can cause emotional difficulties.[1]

There is variation in quality of life, coping and mental health status among recipients and donor at different stages of kidney transplantation which is reflected in various studies.

James R. Rodrigue et al.,[2] in their study found, it is possible to improve quality of life, psychological functioning and social intimacy with quality of life therapy (QOLT) in patients with end stage renal disease who are awaiting kidney transplantation and are at risk for low quality of life, high psychological disturbance and relationship distress.

Pawar A.A et al., in their study on the cognitive and emotional changes in recipients undergoing renal transplantation in India, found depression was present in as many as 86.7% of the total recipients before transplant, the average score being 22.03 and decreasing to 9.83 after transplantation taking a cut-off of 17 on the Beck's Depressive Inventory (BDI) score.[3]

Only a few researchers mentioned QOL frameworks in their studies. Herrman's[4] definition of QOL, which refers to quality of life as a person's perception of his/her position in life within the culture and value systems and in relation to individual goals, expectations, values, and concerns, was used as a framework in some studies.[5]

Ortuzar in 2001[6] proposed that evaluation of QOL of the transplant recipient should include “his or her self-determination, control, and responsibility over his or her own life” along with the level of functional capabilities of the person. Ortuzar also mentioned that the psychosocial dimension is fundamental in understanding QOL of renal transplant recipients. Hence. A study was designed to evaluate the changes if any in the QOL, and mental health status among the kidney recipients before and after kidney transplantation.

MATERIALS AND METHODS

The study was conducted in the Department of Psychiatry in collaboration with the Department of Nephrology of large tertiary care hospital. The Psychiatric Wing has an outpatient department, 30 in-patient beds, as well as psychological counselling and laboratory facilities. Department of Nephrology also has outpatient department, 22 in-patient beds, dialysis unit with eight hemo-dialysis machines, and one transplantation intensive care unit (ICU). All the out-patient and in-patient treatments including investigations, surgical procedure and drugs are free of cost to the recipients and donors.

In the present study all the prospective donors had to take psychological clearance from psychiatrist before kidney transplantation. All the kidney donors who came to psychiatry OPD for psychological evaluation before kidney transplantation ware taken up for the present study and respective recipients were taken from either from Nephrology ward or from dialysis center. After transplantation they were followed up in Nephrology OPD. All the recipient and donor of live kidney transplantation were included in this study. Any psychiatric disorder in recipient or donor was excluded. The study was carried out over 27 months (Aug 2011-Oct 2013).

Sample for the study comprised of 40 consecutive patients including 20 recipients and 20 donors of 20 kidney transplantations, male and female, and who themselves/whose relatives provided written informed consent were included in the study. Both recipients and donors were followed up from 2 weeks prior to transplant surgery to 6 months post-operatively by phone and when they came for review in Nephrology OPD. The study was an observational analytic study.

RESULTS

[Table 1] shows four recipients (20%) are in age-group <30 years, 12 recipients (60%) are in 30-45 years and four recipients (20%) are in >45 years. There is no statistical significance in different age group of recipients and donors in this study. The 16 (80%) recipient are males and 4 (20%) are females. In donors 11 (55%) are male and 9 (45%) are females. There is no statistical significance in gender difference in recipient and donors. There is no statistical significance in education level also in recipient and donors. As far as employment is considered it shows 16 (80%) recipients are employed and 4 (20%) are unemployed. In donors 10 (50%) are employed and 10 (50%) are unemployed. However there is statistically significant difference in recipients and donors. The marital status also did not reveal significant differences between the two groups.

Table 1

Age, education, gender, marital status and occupation, wise distribution of recipients and donors sociodemographic correlates table 1

Table 2 shows D1-Physical health, D2-Psychological, D3-Social relationship and D4-Environment scores converted in to 0-100 score as per chart given in scoring instructions and total score. After transplantation recipient's mean score in all parameters has increased and all changes are statistically significant. [Table 3] shows decrease in mean score of nine primary symptom dimensions after transplantation. All the changes in nine primary symptom dimensions were statistically significant.

Table 2

Change in quality of life as per WHOQOL-BREF scale in recipients before and after transplantation

Table 3

Change in mental health status as per SCL-90-R scale in 9 dimensions in recipients before and after transplantation

DISCUSSION

This study is an observational analytic study conducted in the tertiary care hospital in collaboration with department of nephrology. In this study mean age of recipients was 36.7 years and for donors 41.1 years. Mean age of recipients was also seen to be 36 ± 11yr in a study by Mini A.M. et al.,[7] which is consistent with this study. Most of the recipients and donors belonged to 30-45 years of age-group. In present study 80% of the recipients were male and in case of donors 55% were male [Table 1]. The number of males exceeded the females was seen in a study by Tomasz W. et al.,[8] which is consistent with this study. Of the recipients and donors maximum were educated up to tenth and above [Table 1]. As far as economic independence is concerned 80% of the recipients were economically independent where as in case of donors only 50% were employed which is statistically significant. All the recipients were married and 15% of the donors were unmarried [Table 1]. Relationship between recipients and donors were grouped into related and unrelated. Among related parents, siblings and children were included and among unrelated wife, distance siblings and any other relation was included. 65% of recipients and donors were in related group [Table 1].

In this study QOL was measured by WHOQOL-BREF scale. Total score and converted (0-100) score for four domains was used for statistical comparison. Fons J. et al., in 2005 in their study measured the validity and reliability of psychometric properties of the WHOQOL-BREF and concluded that the content validity, construct validity, and the reliability of the WHOQOL-BREF were good.[9]

The QOL in recipients was significantly improved after kidney transplantation in this study and total mean score was pre-op 78.35 ± 8.16 and post-op 105.6 ± 9.04 [Table 2]. There was significant improvement in all four domains of WHOQOL-BREF among the recipients after transplantation (Physical health = pre-op 47.3 ± 10.37 and post-op 76.15 ± 11.48, Psychological = pre-op 46.95 ± 11.71 and post-op 83.85 ± 9.44, Social relationship = pre-op 62.15 ± 18.7 and post-op 76.95 ± 11.93 and Environment = pre-op- 54.8 ± 10.46 and post-op 74.15 ± 13.17).

Findings of the present study concur with the similar findings reported by Sreejitha N.S. et al.,[10] who in their study found the WHOQOL score for the transplant group was significantly higher than the patients on maintenance hemodialysis. There was statistically significant difference in scores in all four domains (physical, psychological, social, environmental) between hemodialysis and transplant group (P < 0.001). Joseph JT et al.,[11] also showed that a successful transplantation provides a better quality of life to the recipients.

It was assessed by SCL-90-R scale, a psychiatric self-report inventory. The 90 items in the questionnaire are scored on a five-point Likert scale (0 = not at all, 1 = a little bit, 2 = moderately, 3 = quite a bit and 4 = extremely), indicating the rate of occurrence of the symptom during the time reference. It is intended to measure symptom intensity on nine different sub scales.

The SCL-90 is well-suited for measuring general mental health and changes in symptoms. The SCL-90 has been used as a central outcome measure in numerous clinical trials. The SCL-90-R has received the most support for wide-ranging use as a screening instrument of global psychological distress.[12]

In this study before transplantation highest mean score was seen in depression and even after transplantation it was highest though mean score decreased [Table 3]. Mean score in all 9 primary symptom dimensions has decreased in this study that reflects improvement in mental health status after transplantation in recipients. All the changes were statistically significant (somatization = pre-op 7.15 ± 5.24 and post-op 4.45 ± 4.07, obsessive-compulsive = pre-op 6.35 ± 5.66 and post-op 4.15 ± 4.37, interpersonal sensitivity = pre-op 5.55 ± 4.32 and post-op- 3.15 ± 3.31, depression = pre-op- 12.2 ± 6.32 and post-op 4.7 ± 3.45, anxiety = pre-op- 7.55 ± 4.89 and post-op 3.6 ± 3.39, hostility = pre-op- 3.65 ± 2.85 and post-op 1.2 ± 1.44, phobic anxiety = pre-op 3.4 ± 3.05 and post-op 1.25 ± 1.41, paranoid ideation = pre-op- 3.3 ± 3.18 and post-op 1.6 ± 2.6 and psychoticism = pre-op- 4.6 ± 4.76 and post-op 1.8 ± 2.4).

Depression and anxiety in recipients before transplantation have been seen in other studies. A. Lopes et al.,[13] found before transplantation 100% of the recipients had anxiety and 38.7% had moderate/serious depression. Improvement in mental health status after transplantation was also seen in a study by A. Virzì et al., in 2007[14] on depression and quality of life in living related renal transplantation. Forty-eight donor-recipient couples were evaluated before and four months after transplantation and found a significant Hamilton depression variation among recipients, with improvement in the gained score and reduction of depressive symptom (Hamilton score >7) frequency from 45.8-32%, and a decreased proportion of patients with a score >18 from 16.4-0%. Reddy S.K.V et al.,[15] in their study, designed to assess the QOL of living related donors in India, showed a significant improvement in the QOL among three of the four domains. The surgical technique, education status, and marital status did not make any difference in the change in the QOL (19).

CONCLUSION

In this study significant changes in QOL, and mental health status in recipients and donors before and after transplantation were noted. All the findings were almost similar with other studies though scales used were either similar or different. In view of this conclusion and results from this study it can be recommended that screening for mental health problems should be done. Study with larger sample size and long follow-up study may prove helpful for donor evaluation and follow-up. Donors with an increased risk of problems after donation may be indentified for additional counsel and support.