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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2020  |  Volume : 31  |  Issue : 2  |  Page : 473-481
Quality of life for kidney transplant palestinian patients

1 Department of Clinical Pharmacy, Faculty of Pharmacy, Al-Quds University, Abu Deis, West Bank, Palestine
2 Department of Pharmacology, Faculty of Medicine, Al-Quds University, Abu Deis, West Bank, Palestine

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Date of Submission06-May-2019
Date of Acceptance12-Jun-2019
Date of Web Publication09-May-2020


The purpose of kidney transplantation is to improve the quality of life (QoL) for patients with end-stage renal disease. This study aims to measure QoL in renal transplant patients in Bethlehem and Hebron in Palestine. A descriptive, cross-sectional study was performed on 109 renal transplant patients referred to Palestinian Ministry of Health - primary health-care clinics of Bethlehem and Hebron in Palestine from December 2016 to April 2017, by using Kidney Transplant Questionnaire (KTQ-25) for the assessment of QoL and determining the effect of sociodemographic variables on QoL. The reliability of KTQ-25 was determined to be 0.74 by Cronbach’s alpha method. Data were analyzed by Statistical Package for Social Sciences version 19.0 and descriptive analytic statistics. The mean QoL for kidney transplant patients was 4.02 ± 0.84. The highest score of the KTQ was the appearance dimension (5.40 ± 1.23), whereas the lowest was related to the uncertainty/fear dimension (3.36 ± 1.23). The sample consisted of mostly males (79.8%), and their mean age was (41 ± 24) years. Most were married (81.7%), 45.9% were without work, and 66.1% of kidney donors’ type were biologically blood related. No statistically significant difference was observed (P ≥ 0.05) between the sociodemographic variables and QoL. Surprisingly, the majority of kidney transplant patients (83.3%) were on prednisone. The QoL for kidney transplant patients was moderate. The society, government, family, and medical staff need to support patients to alleviate fear and uncertainty they feel. Furthermore, high reliance on corticosteroids in treatment needs to be reconsidered.

How to cite this article:
Dweib K, Jumaa S, Khdour M, Hallak H. Quality of life for kidney transplant palestinian patients. Saudi J Kidney Dis Transpl 2020;31:473-81

How to cite this URL:
Dweib K, Jumaa S, Khdour M, Hallak H. Quality of life for kidney transplant palestinian patients. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2021 Jul 28];31:473-81. Available from: https://www.sjkdt.org/text.asp?2020/31/2/473/284023

   Introduction Top

Kidney transplantation is recognized as the treatment of choice among renal replacement therapies (RRTs) due to it is proven positive outcome on survival, morbidity, and cost.[1],[2] Patients with kidney transplant have 68% lower risk of death compared with those on dialysis waiting for a transplant. This positive effect is afforded to all patients, even the elderly and diabetics, who could have more than 10 years of extra life with kidney trans- plantation.[3] In addition, KT is proven to have a greater positive influence on health-related quality of life (HRQoL) in comparison with other RRTs.[2],[4],[5],[6] When KT patients were compared with patients on dialysis, patients after KT show greater independence, higher engagement in social activities, and an enhanced ability to work.[7] Quality of life (QoL) is defined as the degree to which the experience of an individual’s life meets that individual’s wants and needs.[8] HRQoL has become a very important health indicator for treatment policies.[9] According to literature, adult kidney transplants performed in the United Kingdom during 2015-2016 showed a 5% increase compared to that in 2014-2015.[10] In Palestine, the average number of transplant patients is estimated to be at 45-50 cases per year,[11] while the number of transplants performed until 2001 from live donors was 420 trans-plants.[12] According to the Palestinian Ministry of Health (MOH), about 255 kidney transplant procedures were performed successfully from 2010 until 2017. End-stage renal disease (ESRD) is clearly an important issue for health-care professionals; health policy strategies are developed to decrease the burden of kidney failure and maximize HRQoL through prevention strategies, early detection, and better disease management. Palestinian MOH is the main health-care provider for the kidney transplant patient management program, and treatments are free for patients. The purpose of kidney transplantation is to improve the QoL for patients with ESRD. Unfortunately, many patients may develop vascular problems, graft rejection, and viral infections. The World Health Organization reports that lifestyle-related diseases and kidney disorders are in the top twenty leading causes of deaths in 2004.[13] Choosing more powerful immunosuppressive drugs has resulted in better QoL for patients by increasing graft survival, improvement in the cardiovascular complications, and reduction in the side effects. Adherence to immunosuppressive therapy is necessary to prevent graft rejection, which causes an increase in the number of hospitalizations and health costs.[14] Adherence to therapy is affected by socioeconomic and cultural factors,[15] therefore understanding patients’ QoL has significant inference on treatment and therapy decisions.

In Palestine, more than one study characterized QoL of ESRD patients undergoing dialysis. All studies suggested that there is a need to find other RRTs such as transplantation because of the low QoL for patients undergoing dialysis.[16],[17],[18] On the other hand, data on the QoL for Palestinian kidney transplant patients are limited.

The aim of our study is to measure QoL among renal transplant patients who visit Palestinian MOH facilities in Bethlehem and North Hebron and to identify the effect of sociodemographic variables on the QoL of these patients.

   Method Top

Data collection

This study was designed as a descriptive, nonexperimental, cross-sectional study of QoL for kidney transplant patients that received care at the MOH primary health-care clinics of Bethlehem and North Hebron in Palestine. Data were collected by interviews between December 2016 and April 2017. According to the MOH records, the average number of kidney transplant patients in both clinics was 116 patients. Based on the inclusion criteria, the sample size was 109 patients. The inclusion criteria for the recipients were kidney transplant patients aged ≥20 and <71 years of age, those who receive health care in primary health-care clinics of Bethlehem and Hebron, with a functioning kidney (free from dialysis), and more than three months posttransplant (after the acute phase of transplant).

Data collection tool

The data collection tool consisted of two parts:

  1. Sociodemographic characteristics included age, gender, marital status, employment status, educational level, and financial income and clinical variables including cause of ESRD, duration of previous replacement therapy (dialysis), type of donor, the time period since transplantation, comorbid disease, immunosuppres- sive therapy, and smoking.
  2. Kidney Transplant Questionnaire (KTQ) for measuring the QoL of kidney transplant patients. KTQ is a quality-of-life instrument designed specifically for kidney transplant recipients, consisting of 25 items that are divided into the following five domains: physical symptoms (six items), fatigue (five items), uncertainty/ fear (four items), appearance (four items), and emotional (six items). A mean score ranging from 1 to 7 is reported for each of the five domains.[22],[23] A low score ranges from 1 to 3.5 (a lot of discomfort), while above 3.5 is considered moderate (moderate degree of discomfort) and more than 5 is high QoL (little degree or no discomfort).

   Results Top

Description of the Kidney Transplant Questionnaire-25 data of the participant

The overall mean ± SD QoL score for kidney transplant patients was 4.02 ± 0.84, which indicates that patients in our sample have a moderate degree of discomfort after undergoing the renal transplantation. The highest score of the KTQ was the appearance dimension (5.40 ± 1.23), whereas the lowest score in this study was related to the uncertainty/fear dimension (3.36 ± 1.23). Physical symptoms dimension (3.55 ± 0.94), fatigue (4.06 ± 1.30), and emotional (3.78 ± 1.32) dimensions had moderate score [Table 1].
Table 1: Descriptive statistics of quality-of-life scores based on the Kidney Transplant Questionnaire 5 dimensions (one-sample description statistics) (n = 109).

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Physical symptoms dimension (P = 0.000) and uncertainty/fear dimension (P = 0.000) had significant statistical effect on QoL and negatively affected the patients. Fatigue dimension (P = 0.636) and emotional dimension had no statistically significant impact on QoL. Appearance dimension (P = 0.000) had statistically significant impact on QoL and positively affected patients.

Description of the sociodemographic data of the participants

The sociodemographic data are summarized in [Table 2]. Most kidney transplant recipients were males, with a percentage of 79.8%; their mean age was 41 ± 24 years, 7.3% were <25 years old, 37.6% were 26-40 years, while most of the participants (50.5%) were between 41 and 65 years old, and only 4.6% of patients were aged above 65 years. Most of the patients were married (81.7%), while 0.9% were widowed and 17.4% were unmarried. Patient education status [Table 2] indicates that majority of patients had school degree, while 32.1% of patients are college graduates. When asked about the employment status, 45.9% indicated that they did not work and 4.6% of patients were retired. The vast majority of patients (85.3%) were nonsmokers, while about 14.7% were smokers.
Table 2: Patient description expressed as percent of total patient sample (n = 109).

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As shown in [Figure 1], ESRD was attributed to hypertension (18.3%), diabetic nephropathy (10.1%), glomerulonephritis (15.6%), or cystic kidney disease (15.6%). Surprisingly, 47.7% of patients in our sample attributed ESRD to other reasons.
Figure 1: Causes of end-stage renal disease expressed as percent of total sample (n = 109).

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As shown in [Table 2], the majority (66.1%) of kidney donors were biological blood relatives (father, mother, brother, or sister); the number of cadaveric transplant patients was limited to one patient that was too small to draw a valid conclusion about cadaveric recipients.

Evaluation of immunosuppressive medications used at the time of the study indicates that the majority of kidney transplant patients (83.3%) used prednisone, 45.4% used cyclos- porine, 70.4% used mycophenolate mofetil (MMF), and 53.7% of the patients used tacrolimus (Prograf®) [Figure 2]. Nearly 21.3% of the patients did not have dialysis procedure before renal transplantation, whereas 52.8% of the patients did have <1- year dialysis procedure and only 12.0% of the patients did have ≥2 years’ dialysis [Table 2]. The majority of patients (88.9%) had only one renal transplant, and 38.9% of the patients had the renal transplant 6-10 years ago, and only 3.7% of the patients performed the renal transplant within <1 year ago.
Figure 2: Description of antirejection medications expressed as percent of samples (n = 109).

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Marital status was the only socio-demo- graphic variable that had a negative statistical significant effect on QoL for married recipients and positive for single [Table 3]. None of the other socio-demographic variables such as gender, age, education level, job status, donor type, immunosuppressive therapy, time after transplant, duration of dialysis before renal transplantation, causes of ESRD, physical problems, if undergone more than one renal transplant, smoking, and comorbid disease had any significant effect on QoL.
Table 3. The relationship between clinical variables and quality of life by using independent sample t-test and one-way ANOVA test.

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   Discussion Top

Kidney Transplant Questionnaire results

Internationally, many studies characterize HRQoL in kidney transplant patients worldwide. In a 2009 study conducted in Tehran to measure QoL of 220 renal transplant patients, KTQ-25 questionnaire was used to collect the data; the highest score in this study was the dimension of body appearance and the lowest score was the fear dimension. The average QoL was significantly higher in men. The authors concluded that Tehran city kidney transplant patients’ QoL was moderate.[19] Another study was conducted in China in 2014 on 136 kidney transplantation recipients and the Chinese version of KTQ was used. The highest score of the KTQ was found in the appearance dimension, whereas the lowest score was found in the uncertainty/fear dimension.[20] A similar study was conducted in the USA in 2011 which included 114 renal transplant recipients. KTQ-physical was the lowest. A substantial ceiling effect was present for the KTQ-appearance subscale, with 84% of renal transplant recipients receiving the highest possible score.[21]

In our study, mean ± SD QoL was moderate 4.02 ± 0.84, which was considerably lower than that a study done in Spain (5.58), the USA (5.5), Iran (4.9), and China (4.8),[20],[21],[24],[25] but also arguably higher than another study conducted in Iran (2.8).[22] All the studies mentioned used the same questionnaire (KTQ).

In our study, the highest score was related to the dimension of body appearance (5.40 ± 1.234), which agrees with all previously mentioned studies. The lowest score in this study was the fear/uncertainty (3.36 ± 1.225) dimension, which was consistent with the studies done in Iran and China.[24],[20] Internationally, the lowest score was that of the physical symptoms in both Spanish[25] and USA studies.[21] Fear of rejection and uncertainty about the future were the chief concerns of the kidney transplant recipients, which can be indicative of high rates of anxiety and stress, particularly regarding graft rejection and resuming dialysis.[26]

Sociodemographic characteristics

Data regarding the effect of gender on QoL appear to be variable; one study was consistent with our results showing no significant effect of QoL.[27] Other studies were inconsistent with our result and showed that gender has a significant effect on the QoL with higher QoL for men.[28],[24]

The mean age was 41 ± 24 years, which establishes that most kidney transplant recipients were at the middle age of their lives. There were no QoL differences between transplant patients under and over 65 years of age; these findings were quite similar to some literature reports.[23] However, findings of the present study were inconsistent with other results reported in the literature.[24],[28].[29] Level of education had no significant effect on QoL of KT patients; similar results were reported by Lemos et al.[30] In contrast to our results, some studies have linked higher educational level with better QoL.[28],[29] This study showed that there is a significant effect of marital status on QoL and single patients had better QoL than married patients; this result could be explained that single patients live with their family; most of them experience good support from family according to the traditional Palestinian culture. On the other hand, another study indicated that married patients showed significantly better QoL than single patients.[31] There was no relationship between QoL and the choice of mandatory immunosuppressive therapy, which is consistent with the study by Jofre et al.[32] In another study, the choice of immunosuppressive therapy was associated with better QoL.[33] One surprising finding from the study was the excessive use of cortico- steroids, with 83.3% of patients being on pred- nisone. This high percentage seems excessive. While initial use of corticosteroids post- transplant may be justified, chronic use does not seem to be justified.

Furthermore, there was no observed statistically significant relationship between the time since transplantation and QoL scores. These results appear consistent with the results of Tayebi et al.[2] No significant difference was observed between the duration of dialysis before renal transplantation and QoL, while other studies reported that longer times spent on dialysis were associated with lower QoL after transplantation.[36],[37]

Patients were asked about disease conditions before kidney transplant that may have contributed to ESRD: 18.3% had hypertension, while 10.1% had diabetic nephropathy. Surprisingly, 47.7% of patients in our sample attributed ESRD to other reasons, which is higher than the range worldwide (5%-20%). There was a considerable number of patients with unknown cause (27.6%). This result disagreed with results obtained from studies in Palestine that showed hypertension and diabetes mellitus as the most common causes of ESRD.[38],[39] Finally, most of the patients received the transplanted kidney from blood relatives; the number of cadaveric transplant patients was too small to draw a valid conclusion on the impact of donor type. Previous publication indicates that there was no effect on types of donor and the QoL scores[40].

   Conclusion Top

QoL for kidney transplant patients in our sample was moderate (4.02), while the lowest and highest scores of KTQ dimensions were related to fear/uncertainty and appearance, respectively. This low score of fear/uncertainty dimension may be attributed to the fact that most transplants are from relative donors, with the recipients having feelings of fear, stress, and guilt about their relative donors. Developing a system that encourages organ donation is a medical necessity for Palestinian patients. A surprising high percentage of patients were on corticosteroids; this does not appear to be consistent with the recommended clinical practice. While corticosteroids maybe recommended soon after the transplant and in periods of rejection, they do not need to be maintained once patients are stable.

Marital status was the only sociodemographic variable that has a negative statistical significant effect on QoL for married recipients. The majority of kidney transplant recipients were married male, without work, with low or even no income, and had a lot of responsibilities toward their health and families. The unknown cause of ESRD points to the necessity of improved pre-ESRD workup. Our patients need the psychological consultation before and after the transplant surgery that needs to be maintained on regular intervals as recommended by experts. Our study is the first study assessing QoL among kidney transplant Palestinian patients; this data will serve as baseline measurement for future QoL evaluation.

Conflict of interest. None declared.

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Correspondence Address:
Hussein Hallak
Department of Pharmacology, Faculty of Medicine, Al-Quds University, P. O. Box 20002, Abu Deis, West Bank

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DOI: 10.4103/1319-2442.284023

PMID: 32394921

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