| Abstract|| |
Data regarding the socioeconomic status in Iranian kidney transplant (KT) recipients is lacking. In this cross sectional descriptive study we evaluated the socio-economic status of 100 KT recipients in Shiraz organ transplantation center. In a cross-sectional design, we randomly selected and interviewed 100 RT recipients (50 males and 50 females). Data regarding age, gender, martial status, occupation, level of education, number of children, type of insurance, monthly household income, place of residence, ownership of a personal transportation device, duration and frequency of pre-transplant dialysis, family history of CRF (Chronic renal failure), and etiology of renal disease were obtained. There were 50 (50%) patients aged between 16 and 35 years, 55 had a family history of CRF, 60 had been on dialysis for more than a year, 61 were married, 47 did not have any children, 41 had more than 3 children, and 65 were unemployed due to physical and emotional impairment as a result of their disease. The majority (73%) did not have a high school diploma, 15% were illiterate, 85% were below the poverty line, 52% were from rural areas, and 98% were covered by insurance. We conclude that patients with CKD in our study had acquired this condition possibly due to negligence and lack of basic health care in the lower socioeconomic class. In addition, KT is an available therapeutic modality to lower socio-economic level in Iran.
Keywords: Transplantation, Chronic, Kidney, Iran, Socioeconomic
|How to cite this article:|
Roozbeh J, Jalaeian H, Banihashemi MA, Rais-Jalali GA, Sagheb MM, Salehipour M, Faghihi H, Malek-Hosseini SA. The Socioeconomic Status of 100 Renal Transplant Recipients in Shiraz. Saudi J Kidney Dis Transpl 2008;19:286-90
|How to cite this URL:|
Roozbeh J, Jalaeian H, Banihashemi MA, Rais-Jalali GA, Sagheb MM, Salehipour M, Faghihi H, Malek-Hosseini SA. The Socioeconomic Status of 100 Renal Transplant Recipients in Shiraz. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2020 Jul 8];19:286-90. Available from: http://www.sjkdt.org/text.asp?2008/19/2/286/39047
| Introduction|| |
When renal function levels reach 10-15%, renal replacement therapy (RRT) is necessary. This can be in the form of dialysis (both hemodialysis and peritoneal dialysis) and kidney transplant (KT), from a living or a deceased donor. Many of patients with chronic renal failure (CRF) are initially admitted to a dialysis program; the majority are maintained on hemodialysis. If deemed fit, they are later placed on the kidney transplant waiting list.
Evidence demonstrated that kidney transplantation is the treatment of choice for patients with end-stage renal disease (ESRD) because it significantly improves the quality of life more than dialysis.  Socioeconomic status affects predisposition to CRF, , the underlying cause of CRF, and post-transplant adherence to medical therapy. 
We aim in our study to evaluate the socioeconomic status (as assessed by income and education) of a random sample of renal transplant recipients during their admission to the transplant ward in order to understand the association between the etiology, prevalence of their original disease, and their living conditions.
| Methods and Materials|| |
In a cross-sectional design, 100 KT recipients (50 males and 50 females) in the transplant ward were interviewed from April 2003 to March 2004. Data regarding the socioeconomic status and disease-related issues were consolidated into a single questionnaire that included age, gender, martial status, occupation, level of education, number of children, type of insurance, monthly household income, place of residence, ownership of a private transportation device, duration of dialysis, frequency of dialysis, family history of CRF, etiology of renal disease, and history of previously sought transplanted. In order to emphasize the economic class we used the inquiry about "ownership of a private transportation device". All the patients were interviewed in order to fill the questionnaire, and the information was mainly obtained from the parents in case of pediatric patients.
| Results|| |
The age distribution of our cohort included 8% of the patients < 15 years, 25% from 16-25 years, 25% from 26-35 years, 18% from 3645 years, 19% from 46-55 years, and 5% > 56 years. There were 61 married patients; 47% did not have any children, 6% had 1 child, 6% had 2 and 41% had more than 3 children.
Sixty-five percent of the patients was unemployed, 6% was retired, and only 29% was employed. Regarding their educational level, 15% of KT recipients was illiterate, 20% completed elementary school, 38% completed middle school, and 20% acquired a high school diploma, and 7% held a university degree; 73% had education below the high school diploma level.
The majority of the patients were below the poverty line, earning less than 2 million Rials (less than 215 US dollars) a month; 8% had no source of income, 4% earned 0.5 million Rials a month, 25% from 0.51-1 million Rials, 27% from 1.01-1.5 million Rials, 21% from 1.51-2 million, and 15% > 2.01 million Rials.
Regarding residence, 52% resided in rural towns around Shiraz, 38% of the patients lived in Shiraz City, and 10% in a village. Thirtytwo percent of the patients owned a personal means of transportation. of the study patients, 72% previously sought KT, and 98% of the patients were covered by some form of Iranian insurance that included Medical Services Insurance Organizations (Khadamat Darmani) for 39% of the patients, social security medical insurance (Tamin Ejtema-ee) for 42%, Imam Khomeini's Relief Committee (Komite Emdad-e Emam Khomeini) for 5%, and others for 12%.
The most common underlying etiologies of CRF in our transplanted patients included infectious and/or obstruction (30%), hypertension (29%), hereditary diseases (11%), diabetes (6%), lupus (6%), drug toxicity (2%), and unknown causes (16%). Fifty-five percent of the patients had a family history of CRF, and some even had KT recipients in their family (data not available).
The distribution of the duration of pretransplant dialysis included 40% of the patients < 1year, 37% from 1-2 years, 16% from 2-4 years, and 7% > 4 years. The distribution frequency of dialysis included 49%, 37%, and 14% of the patients who received 3 times, twice, and once a week, respectively.
| Discussion|| |
In this study, 85% of interviewees were living below the poverty line. As many of them did not have any job, it seems likely that their small income had been from handouts of relatives, or for those under the cover of Imam Khomeini's Relief Committee (a non-profit charity for the poor) from the disability allowances. The economic and educational level of our KT recipients was similar to a report on the socioeconomic status of living-unrelated (LUR) donors and KT recipients in Iran. 
Although the majority of KT recipients were married and were from a low socioeconomic level, nearly half of them did not have any children. This could probably be explained by the fact that the majority were young and perhaps only recently wed. In addition, the rate of unemployment was high in KT recipients, therefore, they were unable to support a family and the costs of their disease at the same time. This could be a motivation to seek KT for rehabilitation that enable regaining better living status and income.
Our results regarding the frequency of hemodialysis was similar to a nationwide study by Haghighi et al  who reported 49% and 37% of patients received hemodialysis 3 times and twice a week, respectively. Overall, time spent on hemodialysis precludes full rehabilitation and gaining enough income to support life of patient and family.
As observed in our study, 62% of the patients was not residents in the city of Shiraz and had no means of a personal transportation, which adds to the expenditures of many CRF patients. In addition, long distances could also compromise the frequency of followups for patients due to lack of medical resources in rural areas.
In our study, 72% of the patients had sought KT before being transplanted. Although this study was conducted on a small population size consisting of patients who eventually received KT, the small number of people who had not sought early referral (10%) was interesting, since other studies in the developed countries reported low socioeconomic class associated with late referrals and a less chance of transplantation.  A study on 41,596 patients registered for kidney and kidney-pancreas waiting lists in the United States concluded that racial and ethnic minorities, the less well educated patients, and those with fewer financial resources were less likely than their counterparts to be listed for renal transplantation before dialysis, possibly due to socioeconomic inequity.  A matched case-control study in New Jersey by Winkelmayer et al illustrated that delayed referral of renal patients to a nephrologist before RRT was significantly associated with reduced access to renal transplantation independent of age, gender, race, socioeconomic, and co-morbidity status. At the same time, lower socioeconomic status itself was associated with an 82% less likelihood of transplantation.  In a three phase international study in the United States, Europe, and Japan, results consistently revealed higher transplantation rates for younger, healthier, better-educated, and better income patients.  Although our study only reflects the status of patients who actually received a KT, further studies should be conducted on this issue as socioeconomic status may not be a strong independent limiting factor for KT in Iran, since the national KT program offers relatively cost- free transplantation and longterm immunosuppression therapy.  Furthermore, nearly all the KT are covered by a form of insurance. All patients with ESRD including renal transplant recipients belong to a group of patients called "Patients with Special Diseases" and are eligible for a government-provided medical insurance. Immunosuppressant drugs are also heavily subsidized. Additionally, if patients are poor they are supported by charitable organizations and, therefore, pay only a minimal amount for these drugs. As a result, the majority of transplant recipients receive KT, and their immunosuppressive drugs is relatively free of charge. 
A significant number of patients in our study had received dialysis for less than a year prior to transplantation. This is due to the fact that the transplantation waiting list has been eliminated in the Iranian Model for KT with the help of the LUR program.  This is in contrast to studies in the developed world where a late referral is associated with a lower chance of transplantation. 
The progression and prevalence of CRF have consistently been higher in the low socioeconomic class in various studies around the world. A population-based case-control study on the status of CRF patients in Sweden revealed that socio-economic status was an independent risk factor for CRF.  Another Australian report suggested that low socioenvironmental and predisposing factors such as age negatively influence the onset and progression of CKD.  The epidemiology of chronic renal failure (CRF) in Iran is different from developed countries. The patients are younger, many of these patients receive a KT, and the main source of donor kidney is a living unrelated (LUR) donor.  The latter point has been the center of controversy in recent years, since many have expressed concerns regarding the ethical and morals of our allocation system for living unrelated donors. ,,,
We conclude that the socioeconomic status of KT recipients in Shiraz differs from developed countries' patterns. Patients with ESRD have acquired this condition possibly due to negligence and lack of basic health care in the lower socioeconomic class rather than chronic conditions such as diabetes. However, there is equal chance of receiving a KT in our program regardless of patients' socioeconomic status.
| References|| |
|1.||Schnuelle P, Lorenz D, Trede M, Van Der Woude FJ. Impact of renal cadaveric transplantation on survival in endstage renal failure: Evidence for reduced mortality risk compared with hemodialysis during long-term followup. J Am Soc Nephrol 1998;9(11):2135-41. |
|2.||Fored CM, Ejerblad E, Fryzek JP, et al. Socioeconomic status and chronic renal failure: a population-based case-control study in Sweden. Nephrol Dial Transplant 2003;18(1):82-8. |
|3.||The report published by the Australian Institute of Health and Welfare on Chronic Kidney Disease in Australia in 2005. Chapter on "Risk factors and causes of chronic kidney disease" accessible at http://www.aihw.gov.au/publications/phe/ckda05/ckda05-c03.pdf. |
|4.||Denhaerynck K, Dobbels F, Cleemput I, et al. Prevalence, consequences and determinants of nonadherence in adult renal transplant patients: A literature review. Transplant Int 2005;18(10):1121-33. |
|5.||Ghods AJ, Ossareh S, Khosravani P. Comparison of some socioeconomic characteristics of donors and recipients in a controlled living unrelated donor renal transplantation program. Transplant Proc 2001;33(5):2626-7. |
|6.||Haghighi AN, Broumand B, D'Amico M, Locatelli F, Ritz E. The epidemiology of endstage renal disease in Iran in an international perspective Nephrol Dial Transplant 2002;17 (1):28-32. |
|7.||Winkelmayer WC, Glynn RJ, Levin R, Mittleman MA, Pliskin JS, Avorn J. Late nephrologist referral and access to renal transplantation. Transplantation 2002;73(12): 1918-23. |
|8.||Kasiske BL, London W, Ellison MD. Race and socioeconomic factors influencing early placement on the kidney transplant waiting list. J Am Soc Nephrol 1998;9(11):2142-7. |
|9.||Satayathum S, Pisoni RL, McCullough KP, et al. Kidney transplantation and wait-listing rates from the international Dialysis Outcomes and Practice Patterns Study (DOPPS). Kidney Int 2005;68(1):330-7. |
|10.||Ghods AJ, Savaj S. Live Kidney Organ Donation: Is It Time for a Different Approach? Iranian Model of Paid and Regulated LivingUnrelated Kidney Donation Clin J Am Soc Nephrol 2006;1:1136-45. |
|11.||Ghods AJ. Renal transplantation in Iran. Nephrol Dial Transplant 2002;17(2):222-8. |
|12.||Zargooshi J. Iranian kidney donors: Motivations and relations with recipients. J Urol 2001; 165(2):386-92. |
|13.||Zargooshi J. Quality of life of Iranian kidney "donors". J Urol 2001;166(5):1790-9. |
|14.||Jha V, Chugh KS. The case against a regulated system of living kidney sales Nat Clin Pract Nephrol 2006;2:466-7. |
|15.||Daar AS. The case for a regulated system of living kidney sales. Nat Clin Pract Nephrol 2006;2(11):600-1. |
Associate Professor of Nephrology, Shiraz Organ Transplantation center, Nemazee Hospital, Shiraz, 71935-1119