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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 2  |  Page : 159-167
Attitude of Physicians towards the Follow-up of Renal Transplant Patients: A Questionnaire Survey in Saudi Arabia


Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia

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   Abstract 

The goal of this study was to evaluate the attitude of the physicians towards the follow-up of the renal transplant patients in the Kingdom of Saudi Arabia (KSA). We sent a questionnaire to 168 physicians working in 148 active dialysis centers in the KSA. The study was conducted from June­October 2005. There were 140 physicians (83.3%) who answered the questionnaire; they represented 136 (91.9%) dialysis centers. There were 43 (31.2%) respondents who had a transplant clinic for follow­up of transplant recipients. Of the 96 (69.1%) who did not have a clinic, 29 (30.2%) claimed expertise for follow-up of transplant recipients, six (6.2%) had a laboratory set-up to monitor the immunosuppressive drug levels and 40 (44.4%) felt the need for one. There were 121 (89%) respondents who would consider the chronic renal failure (CRF) patients for transplantation because it is the best form of therapy. Seventy­seven respondents (55%) had a protocol for work-up of the CRF patients for transplantation, 31 (22.3%) had a coordinator for the work-up of the transplant candidates, 34 (24.5%) had regular meetings to decide on the waiting list for transplantation, and 51 (37.8%) had affiliation with, or worked at a transplant center. Nevertheless, 127 (90.7%) respondents believed that the results of renal transplantation were good enough to recommend the procedure to all patients as early as possible. There were 133 (97.1%) respondents who believed that organ shortage was the major factor for the low percentage of renal transplantation. Only 52 (37.1%) respondents knew about the recent regulations established by the World Health Organization (WHO) for organ donation. There were 63 (48.1%) respondents who believed that seeking commercial renal transplantation outside the KSA to be unacceptable because of the medical and ethical complications involved. Many respondents (71.4%) from non-MOH hospitals, and those who had transplant clinics believed that the tacrolimus + mycophenolate combination was the most popular immunosuppressive regimen for renal transplant patients. Our survey suggests that the current practices concerning the work­up and follow-up of transplant patients in the dialysis centers in the KSA require refinement in terms of the need to enforce the use of a protocol to guide evaluation and therapy in each dialysis unit.

Keywords: Transplantation, Survey, Dialysis, Protocol.

How to cite this article:
Souqiyyeh MZ, Shaheen FA. Attitude of Physicians towards the Follow-up of Renal Transplant Patients: A Questionnaire Survey in Saudi Arabia. Saudi J Kidney Dis Transpl 2006;17:159-67

How to cite this URL:
Souqiyyeh MZ, Shaheen FA. Attitude of Physicians towards the Follow-up of Renal Transplant Patients: A Questionnaire Survey in Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2017 Nov 24];17:159-67. Available from: http://www.sjkdt.org/text.asp?2006/17/2/159/35784

   Introduction Top


Surveys of the attitudes of physicians toward their practices in the dialysis units are one of the tools used to evaluate the quality of care provided to patients on regular dialysis. [1],[2],[3]

Work-up for, and follow-up after renal trans­plantation in this population has been laid down in guidelines by the American Society of Transplantation as well as the European Renal Association (European Best Practice of Transplantation).[4],[5],[6] The goals and means of therapy are defined according to the best evidence available in the medical literature. The practices of the physicians can be im­proved according to these guidelines in order to augment the patients' care and has founded a unified base for better communications among the caretakers. There are certain pra­ctices currently in the dialysis centers in the Kingdom of Saudi Arabia (KSA) that may require modification; these include establishing an active waiting list for transplantation and imparting belief that transplantation is the best therapeutic option for patients with chronic renal failure (CRF).

The aim of this study is to survey the attitude of the heads of dialysis units in Saudi Arabia towards the work-up and follow-up of renal transplant patients. We addressed the perception of the physicians on the significance of the follow-up of the transplanted patients, the factors necessary to implement reasonable follow-up of the transplanted patients. In addition we explored the perception of the importance of affiliation with the transplant centers and establishing waiting lists for CRF patients, transplantation as the best treatment option of CRF patients, and the different sources of allograft donation.


   Materials & Methods Top


We sent a questionnaire to 168 physicians, including the heads of the 148 active dialysis centers in the KSA as well as 20 other con­sultants working in these units. This group covered decision makers in 109 centers (73.6 %) in the Ministry of Health (MOH), 18 centers (12.2%) in governmental, non­-MOH sector and 21 centers (14.2 %) in private hospitals; in total, these facilities care for a population of more than 7800 chronic dialysis patients. The questionnaire was mailed to the targeted physicians in June 2005 and responses were received at the Saudi Center for Organ Transplantation (SCOT), Riyadh, KSA between July and September 2005.

The questionnaire was intended to evaluate the following categories in the practice of physicians who care for CRF patients in the KSA:

a) The physicians' perception of the significant factors involved in the follow-up of the transplant patients, such as the presence of a transplant clinic and a set-up for laboratory monitoring of immunosuppressive drug levels.

b) The presence of a protocol to guide the physicians in their work-up of the potential recipients of renal allografts and the presence of a team to coordinate this.

c) The presence of proper affiliation between the dialysis and transplant centers.

d) The physicians' strategies towards the consideration of sources of organ donation for their patients.

e) The physicians' knowledge of the latest developments in the immunosuppressive therapy used in the prevention of renal allograft rejection.

In addition, we compared the responses according to the affiliation of the dialysis center (MOH, non-MOH, private) and according to the presence of a transplant clinic, the latter of which reflecting the maturity of the transplant services in those centers. We considered the best answers to be those that were in accordance with the common denominator of the esta­blished guidelines and practices in the United States of America (USA) [4],[5] and Europe; [6],[7] they include:

a) A recommendation for organized follow-up of the renal transplant recipients including the presence of a transplant clinic and established laboratory monitoring of the immunosuppressive drug levels.

b) A recommendation to give all the CRF patients the option of transplantation, since it is the best form of therapy. This entails the presence of a protocol for work-up of the potential recipients.

c) A recommendation that the approach for the work-up of new CRF patients should be systematic and coordinated through teamwork.

d) All possible ethically acceptable sources of renal allograft donation should be explored.

e) The expertise with the trends of immuno­therapy and recognition of the possible complications and their management are crucial factors in the outcome of the renal transplant recipients.


   Statistical Methods Top


We used Microsoft Excel for data entry; however, the description of data and analyses were performed using the statistical program, SPSS.

Pearson Chi-Square test was used throughout the analysis to test the significance of differences between groups and sub-groups. Significance is set as P< 0.05.


   Results Top


A total of 140 of 168 physicians (83.3%) answered the questionnaire; these physicians represented 136 (91.9%) dialysis centers that cover 7113 (92%) of the dialysis patients in the KSA; there were 109/113 respondents (96.4%) from the MOH centers, 17/34 (52.9 %) from the non-MOH centers and 14/21 (66.6%) from the private centers.

[Table - 1] shows answers related to the current status of having an organized follow­up of the renal transplant recipients. There were 43 (31.2%) respondents who had a designated transplant clinic to follow-up trans­plant recipients. Of the 96 (68.8%) who did not have a transplant clinic, 29 (30.2%) claimed expertise that would enable them to follow­up transplant recipients, only six (6.2%) had a laboratory set-up to monitor the immuno­suppressive drug levels and 40 (44.4%) said that they would like to have a laboratory to monitor the immunosuppressants.

[Table - 2] shows the issues related to the work­up of CRF patients for renal transplantation. There were 121 (89%) respondents who would consider CRF patients for transplantation because it is the best option of therapy. A total of 77 respondents (55%) had a protocol for work-up of the CRF patients for transplantation, 31 (22.3%) had a coordinator for the work-up of the transplant candidates, 34 (24.5%) had regular meetings to decide on the waiting list for transplantation, and 51 (37.8%) had affiliation with, or worked at a transplant center. Nevertheless, 127 (90.7%) respondents believed that the results of renal transplantation were good enough to recommend it to all patients as early as possible.

[Table - 3] shows physicians' beliefs about the source of renal allografts for transplantation. There were 133 (97.1%) respondents who believed that organ shortage was the major factor to explain the low percentage of renal transplantation. There were 93 respondents (66.4%) who believed that the source of renal allografts should include cadaver (deceased), and living genetically-related as well as un­related donation. Only 52 respondents (37.1%) knew about the recent regulations established by the World Health Organization (WHO) for organ donation. There were 63 (48.1%) respondents who believed that seeking renal transplantation outside the KSA was un­acceptable because of the high incidence of medical complications, while 31 (23.1%) considered transplantation abroad to be a good idea for patients, because of the prevailing organ shortage in the KSA. However, 92 (71.4%) respondents believed that the results of renal transplantation outside the KSA, in general, warranted supervision of the work­up of the patients, while seven (5.4%) believed that the results warranted banning sending patients for transplantation abroad.

[Table - 4] shows the opinion about currently popular regimens of immunosuppressive therapy. There were 60 (43.5%) respondents who believed that cyclosporine + mycopheno­late was the most popular regimen, while 31 (22.5%) believed that tacrolimus + myco­phenolate was the most popular one followed, by other regimens.

[Table - 5] shows the differences of the responses of the study participants according to their affiliation. In comparison to non-MOH and private dialysis centers, there was a significantly lower percentage of MOH centers that had designated transplant clinics and expertise as well as a laboratory set-up to follow-up transplant recipients. In addition, significantly fewer MOH centers had: a protocol for pre-transplant work-up, coordi­nators for follow-up of the work-up, regular meetings to decide on the waiting list and/or affiliation with transplant centers. In addition, MOH physicians had significantly less aware­ness of the recent WHO resolutions that regulate organ donation. Furthermore, a significantly lower percentage of the MOH physicians believed that tacrolimus + mycophenolate was the most popular regimen for immuno­suppression in the transplant recipients in comparison with the non-MOH and private centers.

[Table - 6] shows the differences of the responses of the study participants according to the presence or absence of a designated clinic for follow-up of transplant recipients. In comparison with those who had transplant follow-up clinics, the centers that had no such clinics were significantly less likely to have protocols and coordinators for work-up of CRF patients for renal transplantation or periodic meetings to decide on the waiting list for renal transplantation.


   Discussion Top


The current study attempted to detect the attitude of the physicians in charge of the HD centers in the KSA towards the work-up and follow-up of renal transplant patients.

The results of this study show some good practices, compatible with the practice guide­lines in the USA and Europe. [4],[5],[6],[7] The majority of the respondents would consider CRF patients for transplantation because it is the best option of therapy, and they believed that the results of renal transplantation were good enough to recommend it to all patients as early as possible. Furthermore, the majority of the respondents believed that organ shortage was the major factor explaining the low rate of renal transplantation and that the sources of renal allografts should include cadaver (deceased), and living, genetically-related and unrelated, donation.

On the other hand, some practices reflected a lag in the optimal application of the guide­lines and a lack of organized follow-up of the renal transplant recipients. Only a minority of the renal centers in the KSA had a transplant clinic for the follow-up of transplant recipients; the majority that did not have one lacked the necessary expertise and set-up to implement such services on their premises. Moreover, almost half of the renal centers did not have a protocol for work-up of CRF patients for transplantation and only a minority had regular meetings to decide on the waiting list for transplantation or had a coordinator for the work-up for fitness for transplantation.

The transplant community benefited recently by WHO 's recognition of the importance of regulations that organize relationships between the donors and recipients of organs around the world. Resolution 57-18 of the 57 th World Health Assembly (WHA) protects the rights of the donors and organizes organ donation and transplantation around the world.[8] However, only a minority of the respondents knew about this resolution that supports renal transplantation worldwide.

Many patients still seek commercial renal transplantation outside the KSA, especially in countries where supervision of the health authorities is lacking. The majority of the respondents in our study considered seeking renal transplantation outside the KSA to be unacceptable because of the associated medical complications; they also believed that the results of renal transplantation outside the KSA, in general, warranted intense supervision of the work-up of the patients.

The annual reports about transplantation in the USA and Europe demonstrate the emergence of new immunosuppressive regimens to maintain the allografts after implantation in the recipients in order to suppress rejection and ensure longevity of the grafts with the least adverse effects on the patients. The tacrolimus + mycophenolate combination has recently gained popularity over the cyclosporine + mycophenolate combination.[9],[10] Tacrolimus is preferred to cyclosporine in the Western countries based on studies that demonstrated a better side-effect profile, especially the cosmetic ones (less hirsutism and gingival hypertrophy), in addition to its greater potency than cyclosporine. [11],[12],[13],[14] In our study, the majority of the respondents from the non­MOH and from centers that have transplant clinics knew about these facts.

The great majority of the dialysis centers in the KSA belonged to the MOH, which lagged behind the non-MOH centers in the knowledge of the guidelines related to transplantation and transplantation services (transplant clinics, expertise and protocols for work-up of patients). The MOH dialysis centers tended to have less laboratory set-ups for monitoring immunosuppression than the other sectors. This may add to the inconvenience of the transplant patients in the form of traveling long distances for follow-up.

The comparison between centers that had designated transplant clinics and those who did not, revealed significant differences in the presence of protocols and coordinators for the work-up of the CRF patients for trans­plantation; besides the regular meetings to decide on the waiting list and affiliation with the transplant centers. This also reflected the physicians' awareness of the international regulations of transplantation and of the immunosuppressive regimens.

Finally, the use of protocol to guide the work­up and follow-up of CRF patients and transplant recipients may impose a significant, positive impact on the practice. About half of the respondents in our study did not have such a protocol, and most were from the MOH centers. This may point to a need for national guidelines that can be used as a basis for such protocols. We believe it is the SCOT, which should provide such guidelines for the KSA.

We conclude that the current practices concerning the work-up and follow-up of transplant patients in the dialysis centers in the KSA require refinement in terms of the need to enforce the use of a protocol to guide evaluation and therapy in each dialysis unit. There is also a need to increase the awareness of physicians in those centers to the importance of the details of management and the national guidelines in this regard.

 
   References Top

1.Kane MT. The assessment of professional competence. Evaluation Health Prof 1992; 15:163-82.  Back to cited text no. 1    
2.Bender FH, Holley JL. Most nephrologists are primary care providers for chronic dialysis patients: results of a national survey. Am J Kidney Dis 1996;28(1):67-71.  Back to cited text no. 2    
3.Parry RG, Crowe A, Stevens JM, Mason JC, Roderick P. Referral of elderly patients with severe renal failure: questionnaire survey of physicians. BMJ 1996;313 (7055):466.  Back to cited text no. 3    
4.Kasiske BL, Ramos EL, Gaston RS, et al. The evaluation of renal transplant candi­dates: clinical practice guidelines. Patient Care and Education Committee of the American Society of Transplant Physicians. J Am Society Nephrol 1995;6(1):1-34.  Back to cited text no. 4    
5.Kasiske BL, Vazquez MA, Harmon WE, et al. Recommendations for the outpatient surveillance of renal transplant recipients. J Am Society Nephrol 2000;(11) Suppl 15:1­86.  Back to cited text no. 5    
6.The EBPG Expert Group on Renal Transplant­ation. European Best Practice Guidelines for Renal Transplantation (part 1). Nephrol Dial Transplant 2000;(15) suppl 7: 1-85.  Back to cited text no. 6    
7.The EBPG Expert Group on Renal Transplantation. European Best Practice Guidelines for Renal Transplantation (part 2). Nephrol Dial Transplant 2000;(17) suppl 4:1-67.  Back to cited text no. 7    
8.Delmonico FL. Commentary: the WHO resolution on human organ and tissue transplantation. Transplantation 2005;79(6): 639-40.  Back to cited text no. 8    
9.Shapiro R, Young JB, Milford EL, Trotter JF, Bustami RT, Leichtman AB. Immuno­suppression: evolution in practice and trends,1993-2003. Am J Transplant 2005; 5(Part 2):874-86  Back to cited text no. 9    
10.United States Renal Data System (USRDS) annual report 2005.  Back to cited text no. 10    
11.Irish W, Sherrill B, Brennan DC, Lowell J, Schnitzler M. Three-year posttransplant graft survival in renal-transplant patients with graft function at 6 months receiving tacrolimus or cyclosporine microemulsion within a triple-drug regimen. Transplantation 2003;76(12):1686-90.  Back to cited text no. 11    
12.Bunnapradist S, Daswani A, Takemoto SK. Graft survival following living-donor renal transplantation: a comparison of tacrolimus and cyclosporine microemulsion with mycophenolate mofetil and steroids. Transplantation 2003;76(1):10-5.  Back to cited text no. 12    
13.Meier-Kriesche HU, Kaplan B. Cyclosporine microemulsion and tacrolimus are associated with decreased chronic allograft failure and improved long-term graft survival as compared with sandimmune. Am J Transplant 2002;2(1):100-4.  Back to cited text no. 13    
14.Gonwa T, Johnson C, Ahsan N, et al. Randomized trial of tacrolimus + myco­phenolate mofetil or azathioprine versus cyclosporine + mycophenolate mofetil after cadaveric kidney transplantation: results at three years. Transplantation 2003;75(12): 2048-53.  Back to cited text no. 14    

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Correspondence Address:
Muhammad Ziad Souqiyyeh
The Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh, 11417
Saudi Arabia
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PMID: 16903621

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    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6]

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    Abstract
    Introduction
    Materials & Methods
    Statistical Methods
    Results
    Discussion
    References
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