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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2005  |  Volume : 16  |  Issue : 3  |  Page : 311-320
Health-Related Quality of Life in Emotionally Related Kidney Transplantation: Deductions from a Comparative Study

1 Renal Unit, Department of Medicine, Obafemi Awolowo University, Ile-Ife, P.M.B 5538, Ile-Ife, Osun State, Nigeria
2 King Fahd Unit, Cairo University Hospital, Cairo, Egypt
3 Cairo Kidney Center, 3 Hussein El Memar Street, Antikhana, P.O.Box 91, Bab El - Louk, Cairo 11513, Egypt

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The health related quality of life (HRQOL) has not been compared between live related and un-related donations. We set out to assess the HRQOL in 52 recipients and compare them to 68 HD patients using the Karnofsky performance status scale. Statistical package for social sciences (SPSS) was used for data analysis. The duration of end-stage renal disease was 7.14 + 3.8 years and 5.30 + 4.15 years for transplant and HD patients respectively. The HRQOL was similar in both living and emotionally related recipients but both were significantly better than that of HD patients (P < 0.0001). There was significant negative correlation between HRQOL and age (r = -0.363, P < 0.0001), serum creatinine (r = -0.502, P = 0.0001), serum urea (r = -0.493, P < 0.0001), serum phosphate (r = -0.363, P = 0.003) and calcium-phosphate product (r = -0.305, P < 0.0001). There was significant positive correlation between HRQOL and haemoglobin (r = +0.495, P < 0.0001) and serum calcium (r = +0.247, P = 0.017). Age of the patients appears to be the most important determinant of HRQOL in the studied population. HRQOL was similar in the related and unrelated donors and was better than in hemodialysis patients.

Keywords: Health-related quality of life, Emotionally related recipients, Haemodialysis, Comparison, Outcomes.

How to cite this article:
Arogundade F A, Abd-Essamie M A, Barsoum R S. Health-Related Quality of Life in Emotionally Related Kidney Transplantation: Deductions from a Comparative Study. Saudi J Kidney Dis Transpl 2005;16:311-20

How to cite this URL:
Arogundade F A, Abd-Essamie M A, Barsoum R S. Health-Related Quality of Life in Emotionally Related Kidney Transplantation: Deductions from a Comparative Study. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2021 Apr 22];16:311-20. Available from: https://www.sjkdt.org/text.asp?2005/16/3/311/32860

   Introduction Top

The incidence and prevalence of chronic renal failure (CRF) and consequently end-stage renal disease (ESRD) had steadily increased in the last two decades. Global ESRD population was estimated to be 1.6 million at the end of year 2002, with an annual growth rate of 7%. [1] These patients require renal replacement therapy and other supportive treatment moda­lities for their survival, the absence of which inevitably result in death from advanced uremia or its recognized complications. [2] Out of these 1.6 million patients, more than 1.2 million were undergoing dialysis (haemo­dialysis or continuous ambulatory peritoneal dialysis) and about 360,000 people were esti­mated to be living with kidney transplants. [1] Renal transplantation is no doubt the gold standard therapy for ESRD patients offering the best quality of life and survival. [3] A major limitation to renal transplantation is the shortage of organs mainly because cadaveric transplant­ation is not widely practiced in developing countries because logistic support and facilities are lacking. [3],[4] There is thus, a resultant increase in waiting time for organs, which has necessitated the evolution of living-related and living-unrelated (emotionally related) renal transplantation, particularly in the last 10 years. [4],[5] It is well established that living kidney recipients have better graft function, graft and patient-survival compared with cada­veric kidney recipients; however, only few studies have compared the quality of life in these groups. [4],[5],[6] Emotionally related renal transplantation, though still contentious in some programs, has now gained widespread accept­ability. However, commercialization as is practised in some countries, is not only un­acceptable to the transplant community but is also adjudged unethical. [7],[8],[9],[10]

With the increasing acceptability of emotionally related transplantation, clinicians now need to focus on the quality of the provided life and ethical issues. This has become increasingly important, as better quality of life has been associated with lower morbidity and morta­lity. [11] The major ethical issue that need be resolved is distinguishing rewarded (gifted) donation from overt commercialization as suggested by Daar et al. [12]

Quality of life is defined as "the value assigned to duration of life as modified by impairments, functional states, perceptions and social oppor­tunities that are affected by disease, injury, treatment or policy". [13] Both generic- and disease-specific instruments have been used in the assessment of Health-related Quality of Life (HRQOL) in CRF patients, each with specific advantages. In this report, a generic instrument "Karnofsky performance status scale" was used, principally because it is a physician-rating scale that guarantees an objective assessment of the patient's clinical state. [14] Some of its demerits are that it is independent of the patient's judgement and that psychological state is downplayed. The scale ranges from scores of zero which implies death to 100, which implies full functional capability to carry out normal daily activities without clinical evidence (symptoms or signs) of disease. A score below 70 represents a functional capacity that requires some assist­ance but the patient could still care for most personal needs while that below 50 represents incapacitation that requires hospitalization. [14]

Hemodialysis (HD) and renal transplantation are readily available modalities of renal replace­ment therapy in Egypt with transplantation using emotionally related donors being rela­tively more common. Previous workers have compared the HRQOL in HD and transplant patients and have established that renal trans­plantation provided better HRQOL. However, no one has compared the HRQOL among emotionally and living related transplant reci­pients. [15],[16],[17] This prompted us to compare the HRQOL in our emotionally related recipients with that of living related recipients as well as patients on HD.

   Patients and Methods Top


Fifty-two renal transplant patients being followed-up at the nephrology outpatient clinic of the Cairo University Hospital between July 2001 and February 2002 were recruited for the study. Also, 69 maintenance HD patients of similar age distribution were recruited as controls. All the patients were recruited after an informed consent.

Hemodialysis Protocol

All HD patients had a fistula, usually in the left forearm, which served as the vascular access. Dialysis machines used were Fresenius 4008B and Gambro AK90. Biocompatible polysulfone dialyzers F6-9 made by Hydelena­Egypt were used in majority of the sessions while cuprophane dialyzers were rarely used. The HD was bicarbonate based with blood flow rates that ranged between 300 and 400 mls per minute based on patient's tolerability. The patients were on regular thrice or twice weekly HD sessions with the duration of sessions being four and six hours respectively. They were assessed during their regular HD sessions and detailed socio-demographic data were obtained from all the recruited patients. Their case records were also reviewed to validate the accuracy of the data. Biochemical investigations namely blood urea, serum creatinine, sodium (Na), potassium (K), bicarbonate (HCO3), calcium, phosphate and total protein were obtained. Hemoglobin (Hb) was also determined for all the patients. The blood urea was determined just before and 45 minutes to one hour after completion of a HD session. The volume of ultra-filtration volume and post­dialysis weight during these sessions were also recorded. Adequacy of HD was assessed using Daugirdas II formula. [18] This was determined for two sessions, four weeks apart and the average computed. Age was approxi­mated to age at last birthday while body weight was taken using RTZ 120A Health Scale with sensitivity of ± 50 grams.

Transplant Patient's Assessment

The 52 renal transplant patients were assessed during their regular clinic follow-up. Their case records were retrieved for validation of clinical information. Biochemical investigations were also carried out. They were reviewed again after four weeks and the average of the HRQOL scores and laboratory values computed.

Health-Related Quality of Life Assessment

The Karnofsky performance status scale was used to assess the quality of life in both patient populations. The detailed scoring using this scale is as shown in [Table - 1]. All patients and controls had HRQOL assessment done twice, at least four weeks apart, and the average scores computed.

Statistical Analysis

Statistical package for social sciences (SPSS) Version 9.01 by Microsoft Corporation, USA was used for data analysis. Values are expressed as means +/- standard deviation while Chi­square and Fisher's exact tests were used for comparing discreet variables. Continuous variables were compared using independent student T-tests. To ease data reporting the patients were sub-divided into various groups as follows:

Group I : HD patients

Group II : Living related renal trans­plant recipients

Group III : Emotionally related renal transplant recipients

Group IV : Living and emotionally related transplant recipients combined

Pearson bivariate correlation was used to test the relationship between HRQOL scores and various demographic and laboratory para­meters while multiple regression analysis was used to determine the relative contributions of the various parameters to the significance observed with HRQOL scores on bivariate correlation. The higher the 'Beta' values, the more the contributions of the items considered to the observed statistical significance. P values of less than 0.05 were taken as statistically significant.

   Results Top

All the 52 transplant patients (Group IV) completed the study while eight of the HD patients could not complete the investigations and hence had incomplete data. They were thus excluded from data analysis.

Thirty-two patients (61.5%) had living emo­tionally related transplantation (Group III) while the remaining 20 (38.5%) of the trans­planted patients had living related transplantation (Group II). Ten (19.2%) of them had had an episode of acute rejection at one time or the other, two (3.8%) had features of chronic rejection while 40 patients (76.9%) had no episode of clinical rejection. The co-morbid features manifested by the transplanted patients included hypertension in 34 (65.4%), bone abnormalities in four (7.6%), diabetes mellitus in three (5.4%), ischemic heart disease and recurrent glomerulonephritis in two (3.8%) each and liver cirrhosis in one (1.9%) patient. On the contrary, co-morbid conditions found in the HD patients (Group I) included anemia (hemoglobin < 11 g/dL) in 80.4%, clinical features of osteodystrophy in 12% and hyper­tension in 62%.

Thirty-eight transplant recipients were on triple regime comprising azathioprine, cyclo­sporin A and prednisolone while six recipients were on mycophenolate mofetil, steroids and cyclosporin A combination. Three patients each were on steroid and azathioprine combination or cyclosporin A and azathioprine combination. Only one patient was on steroid alone or steroid/cyclosporin A combination.

The age range for the transplant patients was 20-64 years (mean 38.23 ± 10.37 years) while that of HD patients was 20-72 years (mean 42.96 ± 12.45 years) (P = 0.093). There were 38 males and 30 females in the HD group while the numbers for the transplant group were 31 males and 21 females (P = 0.698). The duration of ESRD was 7.14 ± 3.8 years and 5.30 ± 4.15 years for transplant and HD patients respectively (P = 0.023). The detailed socio­demographic data is as displayed in [Table - 1].

The body mass index was 26.52 ± 4.35 kg/m 2 in the transplant group while it was 22.77 ± 4.05 kg/m2 in the HD group (P<0.001) [Table - 2]. [Table - 2] also shows that the serum urea, creatinine, potassium were more physiological in the transplanted patients. There was better calcium and phos­phate homeostasis in the transplant group with significantly higher levels of calcium­phosphate product in the HD group (P<0.0001). The detailed clinical and biochemical profile in the different patient populations are docu­mented in [Table - 2] with transplant patients having significantly higher Hb concentrations than HD patients. The serum chemistry, calcium, phosphate, calcium-phosphate product and other parameters were similar in the living related kidney recipients and their emotionally related counterparts though the latter had higher body mass index [Table 3].

The HRQOL scores were found to be signi­ficantly higher in the transplanted patients; one of them had a score of 70, nine had 80 and 42 transplanted patients had scores of 90. On the contrary, for the HD patients seven had scores of 50, 12 had score of 60, 13 had 70, 22 had 80 and only 12 had score of 90 (P < 0.001) [Figure - 1]. Gender was found to significantly influence HRQOL in the trans­plant group as nine of the 31 males had score less than 90 while only one of the 21 females had score less than 90 (P = 0.014). However, the rejection episodes suffered by the patients, marital status and the educational level did not appear to significantly influence the HRQOL with P-values of 0.117, 0.064 and 0.331 respectively. In the HD group, gender, educational level and dialysis adequacy were not found to significantly influence the HRQOL. However, marital status was found to signi­ficantly influence the HRQOL in the HD patients with all the widowed and divorced patients having score of 70 or less while majority of married and single patients had score of 80 and 90 (P = 0.001)

In the entire studied population, we found significant negative correlation between HRQOL and age (r = -0.363, P < 0.0001) [Figure - 2], serum creatinine (r = -0.502, P < 0.0001) [Figure - 3], serum calcium (r = -0.247, P = 0.017), calcium-phosphate product (r = -0.305, P = 0.003) and serum urea (r = -0.493, P < 0.0001). Also, in the entire studied population there was positive correlation between HRQOL and Hb concentration (r = 0.705, P < 0.0001) [Figure - 4], and serum calcium (r = 0.247, P = 0.017). The significant correlation between HRQOL and serum calcium was not sustained on multiple regression analysis while that of haemoglobin remained significant (p-value = 0.594, P < 0.0001).

Amongst the transplanted patients, we found significant negative correlation between HRQOL and age (r = -0.287, P = 0.039), serum creatinine (r = -0.601, P < 0.0001), serum urea (r = -0.655, P < 0.0001), serum phosphate (r = -0.274, P = 0.049) and calcium­phosphate product (r = -0.313, P = 0.024). In this same group, we found a significant positive correlation between HRQOL and Hb (r = 0.304, P < 0.029). On further subjecting the data to multiple regression analysis, the HRQOL still significantly negatively correlated with serum creatinine, calcium-phosphate product, age and serum phosphate with (3 values of - 0.601, -0.313, -0.287 and -0.274 and corres­ponding P-values of < 0.0001, 0.024, 0.039 and 0.049 respectively.

In the HD patients, we found significant negative correlation between HRQOL and age (r = -0.372, P = 0.003) as well as between HRQOL and serum calcium (r = -0.312, P = 0.047). On further analysis using multiple regression analysis, only age significantly correlated with HRQOL ((3 = 0.342, P = 0.008). There was a significant positive correlation between Hb and HRQOL (r = 0.541, P < 0.0001). No correlation was found between HRQOL and calcium-phosphate product, serum urea, serum creatinine and dialysis adequacy (Kt/V) in this group.

   Discussion Top

Emotionally related renal transplantation has gained widespread acceptability despite ethical, legal and logistic concerns. [4],[6],[8],[9],[10],[12] Living renal transplantation is clearly superior to cadaveric transplantation, as it has been unequivocally shown to offer better graft and patient survival. [3],[4],[6],[7] Also, renal transplant­ ation provides better HRQOL than other renal replacement therapies. [3],[17],[18],[19] There are scanty reports on the HRQOL in the different transplant groups amongst Arabs, although there have been several comparative studies on HRQOL across renal replacement therapies world wide. [3],[11],[15] The major thrust of this study is comparing HRQOL in emotionally related recipients with that of living related recipients and HD patients.

Assessment of health related quality of life has become a vital tool in the monitoring of treatment outcomes in patients on various modalities of renal replacement therapy. [3],[11],[15] In this comparative review, we found that HRQOL was significantly higher in trans­planted patients when compared with those on HD; this is in agreement with previous studies. [3],[11],[15] A comparison of living related and emotionally related recipients revealed similarities in serum chemistry, Hb and quality of life scores, all of which were significantly better than that of HD patients.

The higher BMI found in transplanted patients possibly reflect better nutritional status in them. The higher BMI noted in the emotionally related recipients may have been due to higher doses of immunosuppressive medications, particularly steroids. In agreement with previous reports, we did not find any correlation between BMI and HRQOL scores. [19]

The serum chemistry in the transplanted patients also revealed significant negative correlation between HRQOL and serum crea­tinine and urea, even after multiple regression analysis. In fact serum creatinine was the most important factor that influenced HRQOL in the transplanted patients; this is consistent with the finding of Fujisawa et al [17] and supports assertion that elevated serum creatinine in transplanted patients reveal some graft dys­function either in form of subacute, acute or even chronic rejection or cyclosporin toxicity. In our HD patients, there was a negative cor­relation between HRQOL and serum creatinine but this was not sustained when the confounding effect of age was assessed using multivariate analysis.

Hemoglobin was found not only to be significantly higher but also to positively correlate with HRQOL in the transplanted patients. Erythropoietin secretion is known to improve with renal transplantation, consequently leading to improvement in haematocrit, exercise tolerance, myocardial function and quality of life as well as a reduction in mortality. [19],[20],[21] In agreement with other studies, we found a positive correlation between HRQOL and Hb in HD patients though the values were significantly lower than that of transplanted patients. [22],[23] This is in spite of the fact that target levels of 11-12 g/dL recommended by National Kidney Foun­dation-Dialysis Out-comes Quality Initiative (NKF-DOQI) [24] was not achieved in most of the HD patients.

In agreement with other studies that esta­blished that age of patients negatively correlated with HRQOL using various instruments [19] , this study also found a negative correlation between age and HRQOL in both transplanted and HD patients.

Female gender was found to exhibit a signi­ficantly higher HRQOL in the transplant group compared with males unlike earlier reports. [25],[26] This may be a reflection of psychological, moral and possibly financial support from others. In the HD cohort, marital status was found to significantly influence the HRQOL with all the widowed and divorced patients having lower scores compared with married and single patients.

Surprisingly, though in agreement with the findings of others, [19] index of dialysis adequacy (Kt/V) was not found to influence HRQOL in the HD population; this may be as a result of other co-morbid factors influencing HRQOL in this population. In addition, there was a negative correlation between Kt/V and serum creatinine, this could be understandable as more efficient dialysis will naturally lead to better clearance of uremic toxins consequently leading to improvement in appetite. This is known to lead to better nutritional status, development of larger muscle mass, strength and vitality, all of which tend to later raise the level of serum creatinine. [27]

In conclusion, HRQOL was similar in both living related renal transplant recipients and the emotionally related ones. It was significantly higher in both transplant groups compared with HD patients. While serum creatinine was the most important factor negatively influencing quality of life in our subset of renal transplant recipients, age was found to be the most significant factor influencing the HRQOL in HD patients. Haemoglobin remained the single most important factor that significantly positively impacted on HRQOL in all studied patients combined and in the cohorts.

Emotionally related transplantation provides excellent HRQOL. Hence, it should be further encouraged to increase the donor pool for our ESRD patients. Of course, there is still the need for a globally acceptable ethical and legal protocol for acceptance of emotionally related donors.

   References Top

1.Fresenius Medical Care Publication. ESRD Patients in 2002. A global perspective 2003: p1-10.  Back to cited text no. 1    
2.Berweck S, Hennig L, Sternberg C, et al. Cardiac mortality prevention in uremic patients. Therapeutic strategies with particular attention to complete correction of renal anemia. Clin Nephrol 2000;53:S80-S5.  Back to cited text no. 2    
3.Cameron JI, Whiteside C, Katz J, Devins GM. Differences in quality of life across renal replacement therapies: a meta-analytic comparison. Am J Kidney Dis 2000;35(4): 629-37.  Back to cited text no. 3    
4.Cortesini R, Pretagostini R, Bruzzone P, Alfani D. Living unrelated kidney trans­plantation. World J Surg 2002;26(2):238-42.  Back to cited text no. 4    
5.Kamran T, Zaheer K, Hussain SW, Zahid KH, Akhtar MS. Are live kidney donors at risk? J Coll Physicians Surg Pak 2003; 13(3):153-6.  Back to cited text no. 5    
6.Voiculescu A, Ivens K, Hetzel GR, et al. Kidney transplantation from related and unrelated living donors in a single German centre. Nephrol Dial Transplant 2003;18(2):418-25.  Back to cited text no. 6    
7.Binet I, Bock AH, Vogelbach P, et al. Outcome in emotionally related living kidney donor transplantation. Nephrol Dial Transplant 1997;12(9):1940-8.  Back to cited text no. 7    
8.Zargooshi J. Iranian kidney donors: motivations and relations with recipients. J Urol 2001; 165(2):386-92.  Back to cited text no. 8    
9.Colakoglu M, Yenicesu M, Akpolat T, et al. Nonrelated living-donor kidney transplant­ation: medical and ethical aspects. Nephron 1998;79(4):447-51.  Back to cited text no. 9    
10.The Living Non-Related Renal Transplant Study Group. Commercially motivated renal transplantation: results in 540 patients transplanted in India. Clin Transplant 1997; 11(6):536-44.  Back to cited text no. 10    
11.Knight EL, Ofsthun N, Teng M, Lazarus M, Curhan GC. The association between mental health, physical function and hemodialysis mortality. Kidney Int 2003;63:1843-51.  Back to cited text no. 11    
12.Daar AS, Salahudeen AK, Pingle A, Woods HF. Ethics and commerce in live donor renal transplantation: classification of the issues. Transplant Proc 1990;22(3):922-4.  Back to cited text no. 12    
13.Patrick DL, Erickson P. Health Status and Health Policy. Allocating Resources to Health care. Oxford. Oxford University Press, 1993.  Back to cited text no. 13    
14.Ifudu O, Paul HR, Homel P, Friedman EA. Predictive value of functional status for mortality in patients on maintenance hemo­dialysis. Am J Nephrol 1998;18(2):109-16.  Back to cited text no. 14    
15.Rebollo P, Ortega F, Baltar JM, et al. Health related quality of life (HRQOL) of kidney transplanted patients: variables that influence it. Clin Transplant 2000;14(3):199-207.  Back to cited text no. 15    
16.Shidler NR, Peterson RA, Kimmel PL. Quality of life and psychosocial relationships in patients with chronic renal insufficiency. Am J Kidney Dis 1998;32(4):557-66.  Back to cited text no. 16    
17.Fujisawa M, Ichikawa Y, Yoshiya K, et al. Assessment of health related quality of life in renal transplant and hemodialysis patients using SF-36 health survey. Urology 2000; 56 2):201-6.  Back to cited text no. 17    
18.Daugirdas JT. Second generation logarithmic estimates of single-pool variable volume Kt/V: an analysis of error. J Am Soc Nephrol 1993;4:1502-13.  Back to cited text no. 18    
19.Mingardi G, Cornalba L, Cortinovis E, Ruggiata R, Mosconi P, Apolone G. Health -related quality of life in dialysis patients. A report from an Italian study using the SF-36 Health Survey. Nephrol Dial Transplant 1999;14:1503-10.  Back to cited text no. 19    
20.Llan Y, Dranitzki-Elhallel M, Rubinger D, et al. Erythrocytosis after renal transplant­ation the response to theophylline treatment. Transplantation 1994;57:661-4.  Back to cited text no. 20    
21.Paganini EP. In search of an optimal hematocrit level in dialysis patients: rehabilitation and quality-of-life implications. Am J Kidney Dis 1994;24(1 Suppl 1):S10-6; Discussion S31-2.  Back to cited text no. 21    
22.Moreno F, Sanz-Guajardo D, Lopez-Gomez JM, Jofre R, Valderrabano F. Increasing the hematocrit has a beneficial effect on quality of life and is safe in selected hemodialysis patients. Spanish Cooperative Renal Patients Quality of Life Study Group of the Spanish Society of Nephrology. J Am Soc Nephrol 2000;11(2):335-42.  Back to cited text no. 22    
23.Nissenson AR, Besarab A, Bolton WK, Goodkin DA, Schwab SJ. Target Hematocrit during erythropoietin therapy. Nephrol Dial Transplant 1997;12:1813-6.  Back to cited text no. 23  [PUBMED]  [FULLTEXT]
24.NKF-K/DOQI Clinical Practice Guidelines for Anemia of Chronic Kidney Disease: update 2000. Am J Kidney Dis 2001;37(1 Suppl 1):S182-238. Erratum in: Am J Kidney Dis 2001;38(2):442.  Back to cited text no. 24    
25.Valdes C, Mendoza MG, Rebollo P, et al. The health related quality of life impact caused by starting hemodialysis is lower in elderly than in younger patients (Abstract). Nephrol Dial Transplant 2003; 18(4):461.  Back to cited text no. 25    
26.Lindqvist R, Carlsson M, Sjoden PO. Coping strategies and quality of life among patients on haemodialysis and continuous ambulatory peritoneal dialysis. Scand J Caring Sci 1998;12(4):223-30.  Back to cited text no. 26    
27.Wolfsen M. Assessment of nutritional status in end stage renal disease. In Rose BD (eds) Up-to-Date Version 2002;10:2.  Back to cited text no. 27    

Correspondence Address:
F A Arogundade
Renal Unit, Department of Medicine, Obafemi Awolowo University, Ile-Ife, P.M.B 5538 Ile-Ife, Osun State
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