Health-related quality of life outcomes after kidney transplantation

Treatment of anxiety in patients with coronary heart disease: Rationale and design of the UNderstanding the benefits of exercise and escitalopram in anxious patients WIth coroNary heart Disease (UNWIND) randomized clinical trial

BACKGROUND

Anxiety is highly prevalent among patients with coronary heart disease (CHD), and there is growing evidence that high levels of anxiety are associated with worse prognosis. However, few studies have evaluated the efficacy of treating anxiety in CHD patients for reducing symptoms and improving clinical outcomes. Exercise and selective serotonin reuptake inhibitors have been shown to be effective in treating patients with depression, but have not been studied in cardiac patients with high anxiety.

METHODS

The UNWIND trial is a randomized clinical trial of patients with CHD who are at increased risk for adverse events because of comorbid anxiety. One hundred fifty participants with CHD and elevated anxiety symptoms and/or with a diagnosed anxiety disorder will be randomly assigned to 12 weeks of aerobic exercise (3×/wk, 35 min, 70%-85% VO2peak), escitalopram (5-20 mg qd), or placebo. Before and after 12 weeks of treatment, participants will undergo assessments of anxiety symptoms and CHD biomarkers of risk, including measures of inflammation, lipids, hemoglobin A1c, heart rate variability, and vascular endothelial function. Primary outcomes include post-intervention effects on symptoms of anxiety and CHD biomarkers. Secondary outcomes include clinical outcomes (cardiovascular hospitalizations and all-cause death) and measures of quality of life.

CONCLUSIONS

The UNWIND trial (ClinicalTrials.gov NCT02516332) will evaluate the efficacy of aerobic exercise and escitalopram for improving anxiety symptoms and reducing risk for adverse clinical events in anxious CHD patients.

Validation of the psychometrics properties of a French quality of life questionnaire among a cohort of renal transplant recipients less than one year

BACKGROUND

Renal transplantation is considered as the treatment of choice for patients with end-stage renal disease. Health-related quality of life (HRQoL) of renal transplant recipients (RTR) is very important to assess, especially during the first year after transplantation. To provide new evidence about the suitability of HRQoL measures in RTR during the first post-transplant year, we explored the internal structure, reliability and external validity of a French specific HRQoL instrument, the Renal Transplant Quality of life Questionnaire Second Version (RTQ V2).

METHODS

The data were issued from the French multicenter cohort of renal transplant patients followed during 4 years (EPIGREN). The HRQoL of RTR was assessed five times (at 1, 3, 6, 9 and 12 months after transplantation) with the RTQ V2, a specific instrument consisting of 32 items describing five dimensions. Socio-demographic information, clinical characteristics and HRQoL (i.e., RTQ V2 and SF-36) were collected. For the five times, psychometric properties of the RTQ V2 were compared to those reported from the reference population assessed in the validation study.

RESULTS

Three hundred and thirty-four patients were enrolled. The proportions of well-projected items, item-internal consistency, item-discriminant validity, floor and ceiling effects, Cronbach's alpha coefficients and item goodness-of-fit statistics were satisfactory for each dimension at the five times of the study. The suitability indices of construct validity were higher than 90 % for each time (minimum-maximum: 90.8-97.4 %). The external validity was less satisfactory, with a suitability indices ranged from 46.7 % at M1 to 66.7 % at M12. However, the discrepancies with the reference population (mainly for the gender) appeared logical considering the scientific literature on HRQoL of RTR during the first post-transplant year and may not compromise the external validity.

CONCLUSION

These results support the validity and reliability of the RTQ V2 for evaluating HRQoL in RTR during the first post-transplant year, and confirm that the RTQ V2 is a useful tool to assess the HRQoL precociously after transplant.

Study of the relationship between quality of life and socioeconomic status in Isfahan at 2011

BACKGROUND

Quality of life (QOL) is one of the health indexes for which many efforts have been made to define and measure during the last four decades of the 20(th) century in many countries. This paper is aimed at studying the QOL in relation to socioeconomic status of the general population of Isfahan in 1390.

MATERIALS AND METHODS

We applied a descriptive-analytical and sectional method. In this research, 385 women and men over 15 years of age from 14 regions of Isfahan's municipality were studied using multi-stage quota sampling. We examined QOL using the SF-36 standard questionnaire, along with two domains of mental and physical health and eight subscales within the validity domain of 65-90%. Social (81%) and economical (70%) status was also measured by the questionnaire instrument in both objective and subjective domains after confirming the validity and reliability of the instruments. The given data were analyzed by SPSS 17 software and using descriptive and statistical tests.

RESULTS

The indicators of QOL showed that a score deviation of the SF-36 questionnaire in physical health (SD = 2.31) and mental health (SD = 3.22) domains was obtained from the population. Of the eight subscales, bodily pains and limitations on functioning as physical and mental had an inverse relationship with socioeconomic status. However, physical health, mental health, social activities, public health, and vitality had a significant positive relationship, including different strengths and weaknesses, with socioeconomic status. Also, sexuality and housing status had no relationship with QOL.

CONCLUSION

There is a direct and significant relationship between quality of life and socioeconomic status variables in Isfahan.

Depression, Anxiety, Resilience and Coping Pre and Post Kidney Transplantation - Initial Findings from the Psychiatric Impairments in Kidney Transplantation (PI-KT)-Study

PURPOSE

Depression/anxiety, impaired Health-Related Quality of Life (HRQoL) and coping and resilience structures, are associated with increased mortality/poor outcome in chronic kidney disease (CKD) patients before (CKD/pre-KT) and after kidney (CKD-T) transplantation. Less is known about prevalence rates of psychiatric symptoms and impaired HRQoL of non-transplanted compared with transplanted patients.

METHODS

In a cross-sectional study comparing 101 CKD/pre-KT patients with 151 cadaveric-transplanted (CKD-T) patients, we examined prevalence of depression/anxiety (HADS questionnaire) and coping, resilience and HRQoL (SF-12, Resilience-Scale and FKV-questionnaire).

RESULTS

The prevalence of both depressive and anxiety symptoms was not significantly different between different pre-/and CKD-T patient groups. In CKD-T no significant relations of coping strategies with kidney function were identified. Furthermore, the Resilience Scales for acceptance and competence did not suggest any differences between the CKD/pre-KT and CKD-T subgroup. In the CKD/pre-KT patients, significant correlations were identified between the acceptance subscale and partnership, as well as between the competence subscale and older age/partnership.

CONCLUSIONS

Both the CKD/pre-KT and CKD-T patients exhibited notable impairments in the HRQoL which which showed a comparable pattern of results. KT itself does not appear to be the main risk factor for the development of mental impairments.

Cost-effectiveness of modern mTOR inhibitor based immunosuppression compared to the standard of care after renal transplantation in Germany

OBJECTIVES

Standards of immunosuppression in renal transplantation have changed dynamically in recent years. We here provide a refined advanced pharmacoeconomic model which uses state-of-the-art methods including a mixed treatment comparison (MTC) analysis. The aim was to assess the cost-effectiveness of current immunosuppressive therapy regimens (TR): "sirolimus + early withdrawal of cyclosporine + steroids" (TR1), "sirolimus-early transition" (TR2), "everolimus-early transition" (TR3) and "tacrolimus low dose + mycophenolate mofetil (MMF) + steroids" (TR4).

METHODS

An up-to-date Markov model with current source data was employed to assess the cost-effectiveness of modern immunosuppressive regimens over 12-month and 10-year time periods. Transition probabilities for the occurrence of events for the first year were based on an MTC analysis. The robustness of the model was tested in extensive sensitivity analyses.

RESULTS

Within the 12-month time period TR2 yields the highest life years (0.987 LY), generating costs of 17,500 <euro>. In terms of years with functioning graft (FG), TR4 yields the best efficacy over the 12-month model duration (0.970 years with FG). For the 10-year time period, TR2 yields the lowest costs (107,246 <euro>) and dominates both TR3 and TR1, as it is simultaneously more effective. Within the 10-year model duration, TR4 reaches slightly higher effects compared with TR2 (6.493 vs. 6.474 LY) resulting in an incremental cost-effectiveness ratio of 387,684 <euro> per LY gained.

CONCLUSIONS

The early transition to sirolimus provides long-term efficiency results comparable with a tacrolimus-based regimen, which represents a common treatment standard after kidney transplantation. Both are superior to other investigated immunosuppressive regimens.

Beneficial effect of belatacept on health-related quality of life and perceived side effects: results from the BENEFIT and BENEFIT-EXT trials

BACKGROUND

Patient-reported outcomes are increasingly incorporated in drug evaluation trials. Whether new immunosuppressive drugs result in an improved health-related quality of life (HRQoL) and a reduced side effect experiences remains unknown. Moreover, the relationship between HRQoL and kidney function has never been investigated in kidney transplant recipients.

METHODS

Using the BENEFIT and BENEFIT-EXT trials, we investigated the following: (a) evolution of HRQoL, assessed by the Medical Outcomes Short Form Health Survey (SF-36) in the first 3 years (baseline, 12, 24, and 36 months) after kidney transplantation; (b) association among kidney function (chronic kidney disease stage), HRQoL, and patient-reported side effects (Modified Transplant Symptom Occurrence and Symptom Distress Scale-59R; BENEFIT trial only); and (c) impact of belatacept and cyclosporine on side effect experience and HRQoL.

RESULTS

In the BENEFIT trial, all subjects reported clinically meaningful improvements compared with baseline and returned to general population scores, both for physical composite score (PCS) and mental composite score Short Form (36) Health Survey at 12 to 36 months after transplantation. In the BENEFIT-EXT trial, this was observed for PCS only. Belatacept-treated patients reported better absolute PCSs compared with cyclosporine-treated patients. The differences were small but statistically significant at all times. Belatacept-treated patients tended to experience less side effects compared with cyclosporine-treated patients, except for dry skin. Worsening kidney function was associated with a significant decrease in HRQoL.

CONCLUSION

Worsening in kidney function was associated with lower HRQoL. Compared with cyclosporine, belatacept was associated with improved HRQoL, suggesting that use of non-nephrotoxic immunosuppressants may affect the patient's side effect experience and improve their HRQoL.

The impact of acute rejection in kidney transplantation on long-term allograft and patient outcome

BACKGROUND

Patients with end stage renal disease (ESRD) can be sustained with dialysis therapy.

OBJECTIVES

In this study, we followed up the effect of early acute and late acute rejections on survival rates of patients' grafts.

PATIENTS AND METHODS

We investigated the timing and frequency of acute rejection episodes related to long-term patient-graft survival in Taleghani hospital between 1990 and 2011. Recipients were divided into three groups as Group-1 (no rejection), Group-2 (early acute rejection [EAR]: less than 3-months) and Group-3 (late acute rejection [LAR]: after 3 months of transplant).

RESULTS

One and five-year patient's survival rates were 94.87% and 93.8%, and graft survival (GS) rates were 92.6% and 81.9%. EAR and LAR occurred in 125 (18.8%) and 77 (11.7%) patients, respectively. Graft and patient survival rates at one and five years were as follows; Group-1 (Graft 96.7% and 94.5% patient: 97.4% and 96.8%), Group-2 (Graft: 72% and 61%, patient: 85.6% and 84%), Group-3 (Graft: 84.4% and 36.8%, patient: 92.2% and 89.4%). Recipient age, type and length of dialysis, number of transplantations and the status of panel reactivity antibody (PRA) had no effect on the type of rejection. LAR was more commonly associated with males (P = 0.001) and donors' age was associated with rejection (P = 0.0002). Five-year GS rate among the three groups was lower in the LAR group (P < 0.0001).

CONCLUSIONS

LAR had a negative impact on long-term renal allograft survival and the risk of chronic graft dysfunction increased in patients with a history of LAR.

Long-term quality of life and social outcome of childhood end-stage renal disease

OBJECTIVE

To assess quality of life (QoL) and social status after 30 years of renal-replacement therapy (RRT) and to explore determinants of this QoL.

STUDY DESIGN

The cohort comprised all Dutch patients, born before 1979, who started RRT at age<15 years in 1972-1992. All patients still alive in 2010 were asked to complete questionnaires on QoL (RAND-36) and sociodemographic outcomes. Scores were compared with those in the age-matched general population and with previous patient scores obtained in 2000. We performed logistic regression analysis for prediction of QoL outcomes.

RESULTS

A total of 89 of 152 patients still alive in 2010 participated. Compared with the general population, QoL more often was impaired in patients receiving dialysis for most physical domains, in transplanted patients only on general health perception. Both transplanted and dialysis patients had normal or high scores on mental health. Scores in most physical domains were lower than in 2000. Patients were employed less often (61.8% vs 81.0%), had fewer offspring (31.5 vs 64.8%), and were less likely to have an income equal to or above average (34.8% vs 55.7%) compared with the general population. Disabilities, comorbidity, and unemployment were associated with impaired QoL.

CONCLUSIONS

After 30 years of RRT, adult survivors of pediatric end-stage renal disease have an impaired physical but a good mental QoL. The decrease of general health perception and physical functioning over time is worrying and may further hamper employment status and social functioning of these relatively young patients.

Calcineurin inhibitor sparing strategies in renal transplantation, part one: Late sparing strategies

Kidney transplantation improves quality of life and reduces the risk of mortality. A majority of the success of kidney transplantation is attributable to the calcineurin inhibitors (CNIs), cyclosporine and tacrolimus, and their ability to reduce acute rejection rates. However, long-term graft survival rates have not improved over time, and although controversial, evidence does suggest a role of chronic CNI toxicity in this failure to improve outcomes. Consequently, there is interest in reducing or removing CNIs from immunosuppressive regimens in an attempt to improve outcomes. Several strategies exist to spare calcineurin inhibitors, including use of agents such as mycophenolate mofetil (MMF), mycophenolate sodium (MPS), sirolimus, everolimus or belatacept to facilitate late calcineurin inhibitor withdrawal, beyond 6 mo post-transplant; or using these agents to plan early withdrawal within 6 mo; or to avoid the CNIs all together using CNI-free regimens. Although numerous reviews have been written on this topic, practice varies significantly between centers. This review organizes the data based on patient characteristics (i.e., the baseline immunosuppressive regimen) as a means to aid the practicing clinician in caring for their patients, by matching up their situation with the relevant literature. The current review, the first in a series of two, examines the potential of immunosuppressive agents to facilitate late CNI withdrawal beyond 6 mo post-transplant, and has demonstrated that the strongest evidence resides with MMF/MPS. MMF or MPS can be successfully introduced/maintained to facilitate late CNI withdrawal and improve renal function in the setting of graft deterioration, albeit with an increased risk of acute rejection and infection. Additional benefits may include improved blood pressure, lipid profile and serum glucose. Sirolimus has less data directly comparing CNI withdrawal to an active CNI-containing regimen, but modest improvement in short-term renal function is possible, with an increased risk of proteinuria, especially in the setting of baseline renal dysfunction and/or proteinuria. Renal outcomes may be improved when sirolimus is used in combination with MMF. Although data with everolimus is less robust, results appear similar to those observed with sirolimus.

Validity and reliability of a novel immunosuppressive adverse effects scoring system in renal transplant recipients

Background

After renal transplantation, many patients experience adverse effects from maintenance immunosuppressive drugs. When these adverse effects occur, patient adherence with immunosuppression may be reduced and impact allograft survival. If these adverse effects could be prospectively monitored in an objective manner and possibly prevented, adherence to immunosuppressive regimens could be optimized and allograft survival improved. Prospective, standardized clinical approaches to assess immunosuppressive adverse effects by health care providers are limited. Therefore, we developed and evaluated the application, reliability and validity of a novel adverse effects scoring system in renal transplant recipients receiving calcineurin inhibitor (cyclosporine or tacrolimus) and mycophenolic acid based immunosuppressive therapy.

Methods

The scoring system included 18 non-renal adverse effects organized into gastrointestinal, central nervous system and aesthetic domains developed by a multidisciplinary physician group. Nephrologists employed this standardized adverse effect evaluation in stable renal transplant patients using physical exam, review of systems, recent laboratory results, and medication adherence assessment during a clinic visit. Stable renal transplant recipients in two clinical studies were evaluated and received immunosuppressive regimens comprised of either cyclosporine or tacrolimus with mycophenolic acid. Face, content, and construct validity were assessed to document these adverse effect evaluations. Inter-rater reliability was determined using the Kappa statistic and intra-class correlation.

Results

A total of 58 renal transplant recipients were assessed using the adverse effects scoring system confirming face validity. Nephrologists (subject matter experts) rated the 18 adverse effects as: 3.1 ± 0.75 out of 4 (maximum) regarding clinical importance to verify content validity. The adverse effects scoring system distinguished 1.75-fold increased gastrointestinal adverse effects (p = 0.008) in renal transplant recipients receiving tacrolimus and mycophenolic acid compared to the cyclosporine regimen. This finding demonstrated construct validity. Intra-class correlation was 0.81 (95% confidence interval: 0.65-0.90) and Kappa statistic of 0.68 ± 0.25 for all 18 adverse effects and verified substantial inter-rater reliability.

Conclusions

This immunosuppressive adverse effects scoring system in stable renal transplant recipients was evaluated and substantiated face, content and construct validity with inter-rater reliability. The scoring system may facilitate prospective, standardized clinical monitoring of immunosuppressive adverse drug effects in stable renal transplant recipients and improve medication adherence.

Depression and kidney transplantation

While kidney transplantation offers several advantages in terms of improved clinical outcomes and quality of life compared to dialysis modalities, depressive symptoms are still present in approximately 25% of patients, rates comparable to that of the hemodialysis population. Correlates of depressive symptoms include marital status, income, kidney function, history of affective illness, malnutrition, and inflammation. Depressive symptoms are also associated with poor outcomes following kidney transplantation including nonadherence to immunosuppressant medication, graft failure, and all-cause mortality. Efforts to detect and treat depression should be a priority if one is to improve treatment adherence, quality of life, and outcomes in transplant recipients.

Can education alter attitudes, behaviour and knowledge about organ donation? A pretest-post-test study

OBJECTIVE

The emergence of evidence suggests that student nurses commonly exhibit concerns about their lack of knowledge of organ donation and transplantation. Formal training about organ donation has been shown to positively influence attitude, encourage communication and registration behaviours and improve knowledge about donor eligibility and brain death. The focus of this study was to determine the attitude and behaviour of student nurses and to assess their level of knowledge about organ donation after a programme of study.

DESIGN

A quantitative questionnaire was completed before and after participation in a programme of study using a pretest-post-test design.

SETTING

Participants were recruited from a University based in Northern Ireland during the period from February to April 2011.

PARTICIPANTS

100 preregistration nurses (female : male=96 : 4) aged 18-50 years (mean (SD) 24.3 (6.0) years) were recruited.

RESULTS

Participants' knowledge improved over the programme of study with regard to the suitability of organs that can be donated after death, methods available to register organ donation intentions, organ donation laws, concept of brain death and the likelihood of recovery after brain death. Changes in attitude postintervention were also observed in relation to participants' willingness to accept an informed system of consent and with regard to participants' actual discussion behaviour.

CONCLUSIONS

The results provide support for the introduction of a programme that helps inform student nurses about important aspects of organ donation.

Analysis, evaluation and adaptation of the ReTransQoL: a specific quality of life questionnaire for renal transplant recipients

BACKGROUND

End stage renal disease (ESRD) profoundly impacts the lives of patients. Kidney transplantation provides the greatest health-related quality of life (HRQOL) improvement. Its measurement has become an important outcome parameter and a very important criterion in the evaluation of any type of medical treatment, especially in the field of renal transplantation.In 2007, a specific self-administered questionnaire for renal transplant recipients was developed in the French language: the ReTransQol (RTQ).After 5 years of use, the properties of the RTQ needed to be re-evaluated in a larger sample.This paper describes the analysis of the ReTransQol and its adaptation to achieve an improved and revised version.

METHODS

The study design included three analysis phases for two samples of adult renal transplant recipients which came from two cross-sectional multicenter studies carried out in France in 2007 and 2012. Psychometrics properties like construct validity, acceptability and feasibility, reliability and convergent validity were evaluated and every analysis resulted in a new version of the questionnaire: the RTQ V2. The construct validity of the new RTQ was assessed with a Confirmatory Factor Analysis on a large sample of patients.

RESULTS

The study samples included 1,059 patients and 1,591 patients, respectively. After a principal component analysis, item reduction was performed and a total of 13 items were deleted. A final version of the RTQ V2 was created and comprised of 32 items describing 5 domains: Physical Health, Social Functioning, Medical Care, Treatment and Fear of Losing Graft.The explained variance between the first and second RTQ versions improved from 46.3% to 53.1%. All psychometric properties of RTQ V2 were satisfactory: IIC >0.4, IDV (%) of 100% and Cronbach's Alpha >0.7 in every dimension. The confirmatory analysis showed that the overall scalability of the RTQ V2 was satisfactory; all items showed a good fit to the Rasch model within each dimension, and showed INFIT statistics inside the acceptable range.

CONCLUSIONS

Psychometric properties allow this new version of the questionnaire to be used to assess different specific dimensions for the renal transplant population, more effectively than previously possible.

Posttraumatic stress symptoms after solid-organ transplantation: preoperative risk factors and the impact on health-related quality of life and life satisfaction

Background

Solid-organ transplantations (SOT) are usually life-saving high-tech medical procedures. The transplantation itself and the intensive care unit stay could be traumatic stressors triggering posttraumatic stress symptoms (PTSS). Our retrospective follow-up study aimed to explore preoperative risk factors of PTSS in a cohort of SOT recipients, and we investigated how PTSS are associated with health-related quality of life (HRQOL) and life satisfaction.

Methods

126 SOT recipients were enrolled in this investigation. Psychiatric examination of all SOT candidates based on the Transplant Evaluation Rating Scale was carried out before SOT, and after SOT, recipients completed the PTSS-10, the SF-36 and the FLZ.

Results

After the surgical intervention 19 (15.1%) SOT recipients had clinical significant PTSS. Preoperative risk factors for developing postoperative PTSS were: 1.) preexisting psychiatric morbidity, 2.) history of retransplantation, 3.) chronic benzodiazepine consumption, 4.) age, and 5.) type of transplantation.

SOT-related PTSS were associated with maximal decrements in HRQOL and life satisfaction. The following HRQOL and life satisfaction domains were affected: Physical Functioning, Role Physical, Pain, General Health, Vitality, Social Functioning, Role Emotional, Mental Health, Occupation/Work and Character/Own Skills.

Conclusion

SOT recipients may face a major risk of transplantation- and treatment-related PTSS and the development of impairments to HRQOL and life satisfaction.

Factors associated with health-related quality of life in renal transplant recipients: results of a national survey in France

Background

This study aims to identify factors associated with health related quality of life (HRQOL) through a comprehensive analysis of sociodemographic and clinical variables among a representative sample size of renal transplant recipients (RTR) in France.

Methods

A cross-sectional multicenter study was carried out in 2008. All RTR over 18 years old with a functioning graft for at least one year were included. Data included socio-demographic, health status, and treatment characteristics. To evaluate HRQOL, the Short Form-36 Health Survey (SF-36) and a HRQOL instrument for RTR (ReTransQol) were administered. Multivariate linear regression models were performed.

Results

A total of 1061 RTR were included, with a return rate of 72.5%. The variance explained in regression models of SF-36 ranges from 20% to 40% and from 9% to 33% for ReTransQol.

The variables which decreased scores of both HRQOL questionnaires were: females, unemployment, lower education, living alone, high BMI, diabetes, recent critical illness and hospitalization, non-compliance, a long duration of dialysis and treatment side effects.

Specific variables which decreased ReTransQol scores were dismissal and a recent surgery on the graft. These which decreased SF36 scores were being old and a recent infectious disease.

The variables the most predictors of worse HRQOL were: side effects, infectious disease, recent hospitalization and female gender.

Conclusions

The originality of our study’s findings was that novel variables, particularly treatment side effects and unemployment, have a negative effect on quality of life of RTR. The French Biomedicine Agency and the National Health Institute for Public Health Surveillance conduct specific actions for professional reintegration and therapeutic education programs in the national plan to improve the HRQOL of people living with chronic diseases.

Overall mental distress and health-related quality of life after solid-organ transplantation: results from a retrospective follow-up study

Background

Our retrospective follow-up study aimed to explore the degree of overall mental distress in a cohort of solid-organ transplantation (SOT) recipients after liver, heart or lung transplantation. Furthermore, we investigated how overall mental distress is linked to health-related quality of life.

Methods

123 SOT patients treated during the study period were enrolled in this investigation at a mean of 24.6 months (SD=11.6) after transplantation. Before transplantation, the Transplant Evaluation Rating Scale (TERS) was used to classify the level of adjustment in psychosocial functioning among transplantation candidates. After transplantation, recipients completed a research battery, which included the SCL-90-R, and the SF-36.

Results

39 (31.7%) transplantation recipients had clinically significant overall mental distress as measured on the Global Severity Index of the SCL-90-R. Obsessive-compulsive symptoms (92.3%), somatization symptoms (87.2%), anxiety symptoms (84.6%), depression symptoms (82.1%) and phobic anxiety symptoms (69.2%) were a frequent finding.

Transplantation recipients with overall mental distress had significant lower levels of adjustment in psychosocial functioning before transaplantation than those without overall mental distress as measured in the TERS. Transplantation-related overall mental distress symptomatology was associated with maximal decrements in health-related quality of life.

Conclusion

Transplantation recipients may face major transplantation- and treatment-related overall mental distress and impairments to their health-related quality of life. Further, overall mental distress is a high-risk factor in intensifying impairments to patients’ overall quality of life.

Cost Utility of Sirolimus versus Tacrolimus for the Primary Prevention of Graft Rejection in Renal Transplant Recipients in Mexico

OBJECTIVE

Therapies for end-stage renal disease improve quality of life, and survival. In Mexico, clinicians often must choose between different therapies without the availability of comparative outcomes evaluation. The present study evaluates the comparative cost-utility of sirolimus (SIR) versus tacrolimus (TAC) for the primary prevention of graft rejection in renal transplant recipients in Mexico.

METHODS

We used modeling techniques to estimate the cost-effectiveness of SIR versus TAC to prevent graft rejection in patients with end-stage renal disease in the Mexican setting. The model estimates the cost of quality-adjusted life-year (QALY) per patient. We applied a 20-year horizon (1-year Markov cycles). Cost-effectiveness was expressed in terms of cost per QALY. All costs are presented in 2011 US dollars. Probabilistic sensitivity analyses were conducted.

RESULTS

The total cost for the SIR treatment arm over the 20-year duration of the model is estimated to be $136,778. This compares with $142,624 for the TAC treatment arm, resulting in an incremental cost of SIR compared with that of TAC of-$5,846. Over 20 years, SIR was estimated to have 8.18 QALYs compared with 7.33 QALYs for TAC. The resulting incremental utility of SIR compared with that of TAC is 0.84 QALY gained. SIR is estimated to be both less costly and more effective than TAC, indicating that it is the dominant strategy. Notably, results suggest that SIR has a 78% probability of being dominant over the TAC strategy and a 100% probability of having an incremental cost-effectiveness ratio at or below $10,064 (1 GDP) per QALY.

CONCLUSIONS

These analyses suggest that in the Mexican setting, the use of SIR in place of TAC for the prevention of graft rejection in this population is likely to be cost saving.

Knowledge management model for quality improvement in the hemodialysis unit of a non‐profit private hospital, Bangkok, Thailand

Purpose

This study seeks to use a knowledge management (KM) model as a tool to improve the quality of service in a hemodialysis unit.

Design/methodology/approach

A quasi‐experimental, one group pre‐test‐post‐test study was conducted over a period of ten months at a hemodialysis unit. All of the staff in the unit, and all of the patients who came for hemodialysis at the outpatient department during the study period, were invited to participate. Self‐administered questionnaires were used to measure staff job satisfaction and patient satisfaction. SF‐36v2 was used to assess patient quality of life (QoL). Wilcoxon's matched pairs test and paired t‐test were used to compare staff job satisfaction, and patient satisfaction with service quality, before and after implementing KM. A within‐subject repeated‐measure analysis of variance (ANOVA) was used to assess changes in patient QoL. The chi‐square test was used to compare rates of hemodialysis complications before and after implementing KM.

Findings

After implementing KM, staff job satisfaction and patient satisfaction with services, increased significantly. Three QoL domains – role limitations due to physical and emotional problems, and vitality – at three and six months post‐intervention applying KM to daily work, had improved significantly. Complications per hemodialysis episode had also reduced.

Originality/value

The paper focuses on intervention that applied KM to staff providing care for patients with hemodialysis to improve care and outcomes.

Measuring health related quality of life (hrqol) in renal transplant patients: psychometric properties and cross-cultural adaptation of kidney transplant questionnaire (ktq-25) in persian

BACKGROUND

Different measuring tools have been used to understand the outcomes of renal replacement therapies. The goal of renal transplantation is both to ensure survival, and to promote quality of life in the patients. One of the widely used disease-specific instruments to measure the quality of life is the Kidney Transplant Questionnaire (KTQ-25).

OBJECTIVES

The current study aimed to perform a cross-cultural adaptation and assess the psychometric properties of the KTQ-25 to Persian.

MATERIALS AND METHODS

The KTQ-25 was trasnlated according to International Quality of Life Assessment (IQOLA) translation methodology. Cronbach's alpha coefficient, and test-re-test were used to determine internal consistency, and reliability respectively.

RESULTS

In the test-re-test reliability of all questionnaire items, Pearson correlation was r = 0.96 (P < 0.001). Cronbach's alpha coefficient estimated the internal consistency for each scale andalpha equal or more than 0.73 was considered satisfactory. Criterion-related validity, measured by the correlation coefficients between the KTQ-25 and the SF-36 Health Survey, was r = 0.63 (P < 0.001).

CONCLUSIONS

The psychometric properties of the Kidney Transplant Questionnaire (KTQ-25) in Persian have proven to be satisfactory, therefore the application of this questionnaire in clinical practice can be recommended.

Abdominal wall phlebitis due to Prevotella bivia following renal transplantation in a patient with an occluded inferior vena cava

Pre-existing occlusion of the inferior vena cava may complicate renal transplantation. Suppurative abdominal wall phlebitis following renal transplantation was diagnosed in a patient with pre-existing thrombosis of the inferior vena cava of unknown cause. The phlebitis developed in the subcutaneous collateral veins of the abdominal wall contra-laterally to the renal transplant. Cultures from abdominal wall micro-abscesses yielded Prevotella bivia as the causative agent. This complication has not been described before in the context of renal transplantation. The pathogenesis and management of this serious complication are discussed in this paper.

Evaluating service quality dimensions as antecedents to outpatient satisfaction using back propagation neural network

Nowadays the ability to provide outpatient services with exceptional quality is paramount to long-term survival of hospitals, as the revenues from outpatient services are predicted to equal or exceed inpatient revenues in the near future. Identifying the relative weight of different dimensions of healthcare quality service which concur together to determine outpatients satisfaction is very important, as it can help healthcare managers to allocate resources more efficiently and identify managerial actions able to guarantee higher levels of patients' satisfaction. This study proposes the use of Artificial Neural Network (ANN) as a knowledge discovery technique for identifying the service quality factors that are important to outpatient. An ANN model is developed on data from a panel of outpatients of public healthcare services.

Renal transplant acceptance status, health-related quality of life and depression in dialysis patients

Health-related quality of life (HRQOL) and depression in chronic dialysis patients, accepted (n = 122) or rejected (n = 93) for renal transplantation (Tx), were compared, whereas dialysis patients with pending acceptance status (n = 86) were followed for a median time of 3.6 years to assess whether HRQOL or depression predicted the likelihood of receiving a transplant. Clinical significant depression was present in 30% of the study patients. Less depression and better HRQOL were associated with being on the waiting list for Tx after adjusting for comorbidity, age, gender and dialysis vintage. During follow-up, 55% of the dialysis patients in the group with pending acceptance were transplanted. The likelihood of receiving a renal graft was based on comorbidity and not on impaired HRQOL or depression. Follow-up studies should investigate whether improved renal health after Tx translates into further improvement of HRQOL and less depression. Whether clinical depression and impaired HRQOL will impact graft survival needs to be explored.

Concurrent validity of kidney transplant questionnaire in US renal transplant recipients

BACKGROUND

Valid instrumentation in the assessment of health-related quality of life (HQoL) in renal transplant recipients is critical to identifying particular nuances and determinants of HQoL in this population. Therefore, the validity of disease-specific instruments to measure HQoL in renal transplant recipients, such as the Kidney Transplant Questionnaire (KTQ), needs further investigation. The objective of this study was to assess the concurrent validity of the KTQ in adult US renal transplant recipients using the well established SF-12 Health Survey version 2 (SF-12v2) as the comparison instrument.

METHODS

One hundred and fourteen renal transplant recipients met the following inclusion criteria for this study, ie, were at least 21 years of age, more than two years post-transplant, and receiving immunosuppressant therapy. Subjects were asked to complete a series of HQoL instruments, ie, the KTQ and the SF-12v2 (physical component summary [PCS-12] and mental component summary [MCS-12]). Descriptive statistics were calculated, and correlational analyses were conducted to examine the concurrent validity of the HQoL instruments.

RESULTS

Among 100 participants (87.7% response rate), the majority of participants were male (52%), had deceased donor transplants (63%), and received Medicare benefits (84%). PCS-12 was positively correlated with three of five KTQ subscales (P < 0.05), ie, KTQ-physical (r = 0.43), KTQ-fatigue (r = 0.42), and KTQ-uncertainty/fear (r = 0.2). MCS-12 was positively correlated with all KTQ subscales (P < 0.01), ie, KTQ-physical (r = 0.26), KTQ-fatigue (r = 0.48), KTQ-uncertainty/fear (r = 0.33), KTQ-emotional (r = 0.47), and KTQ-appearance (r = 0.28).

CONCLUSION

The findings support the concurrent validity of the KTQ in US renal transplant recipients. Future studies should continue exploring the validity of the KTQ, as well as its practical and research utility in HQoL measurement in the renal transplant population.

Cost-effectiveness of immunosuppressive regimens in renal transplant recipients in Germany: a model approach

BACKGROUND

The choice of immunosuppression regimen is of paramount importance for outcomes and cost of renal transplantation. We compared the cost-effectiveness of triple immunosuppressive regimens in Germany.

METHODS

A strong micro-simulation model was built comparing regimens based on cyclosporine, everolimus, sirolimus, and tacrolimus. Mean cost per patient, incremental cost per life year gained, and incremental cost per additional year with functioning graft were assessed from the perspective of the German statutory health insurance (SHI) after 2 and 10 years.

RESULTS

Over the 2-year period, the model predicted mean total costs per patient of 26,732, 29,352, 33,415, and 49,978 euro for sirolimus, cyclosporine, everolimus, and tacrolimus, respectively. Focusing on the cost per life year gained, the sirolimus-based regimen compared favorably with those based on everolimus and tacrolimus. The incremental cost-effectiveness ratio (ICER) of cyclosporine versus sirolimus is 524,000 euro per life year gained. Regarding the cost per year with functioning graft gained, sirolimus dominated cyclosporine and everolimus, while the ICER for tacrolimus compared to sirolimus amounts to 1,788,154 euro. Over the 10-year time frame, mean total costs per patient were 100,758, 108,300, 120,316, and 183,802 euro for sirolimus, cyclosporine, everolimus, and tacrolimus, respectively. With regard to life years gained, sirolimus dominated both cyclosporine and everolimus. The ICER of tacrolimus versus sirolimus was 1,766,894 euro. Considering the years with functioning graft gained, sirolimus dominated cyclosporine and everolimus, while the ICER for tacrolimus compared to sirolimus amounted to 1,339,419 euro.

CONCLUSIONS

Over both the 2-year and the 10-year time horizon, sirolimus-based immunosuppression represents a cost-effective option in renal transplantation in Germany.

Persistent fatigue in liver transplant recipients: a two-year follow-up study

BACKGROUND

Fatigue after liver transplantation (LTx) is a major problem that is associated with lower daily functioning and health-related quality of life (HRQoL). This study aimed to assess changes over time in fatigue following LTx. We also examined daily functioning and HRQoL changes over time and assessed the influence of fatigue and changes in fatigue on daily functioning and HRQoL. We determined whether sleep quality, anxiety, and depression were associated with fatigue.

METHODS

We identified 70 LTx recipients who had previously participated in a cross-sectional study and reassessed them after two yr to determine changes in level of fatigue, daily functioning, and HRQoL. We also assessed sleep quality, anxiety, and depression after two yr.

RESULTS

Level of fatigue and level of daily functioning were unchanged at follow-up. HRQoL domains remained stable or worsened. Fatigue was a significant predictor of daily functioning and all HRQoL domains (p < 0.01). Change in fatigue was a significant predictor of daily functioning and the HRQoL domains of "physical functioning,""vitality," and "pain" (p < 0.05). Sleep quality, anxiety, and depression were associated with fatigue severity (r = 0.35 to r = 0.60, p < 0.05).

CONCLUSION

This longitudinal study shows that fatigue is a chronic problem after LTx and that daily functioning and HRQoL do not improve over time. This study supports the need for intervention programs to address fatigue after LTx.

Comparison of Azithromycin and Oral Hygiene Program in the Treatment of Cyclosporine-Induced Gingival Hyperplasia

BACKGROUND

It has been shown that azithromycin improves cyclosporine-induced gingival hyperplasia (GH), but its efficacy was never compared against an efficient oral hygiene program (OHP). The aim of this study was to analyze the effects of azithromycin plus OHP versus OHP alone in patients with cyclosporine-induced GH.

METHODS

After periodontal evaluation, 20 renal transplant recipients received detailed oral hygiene instructions and a complete OHP, and were randomized to control (OHP) or azithromycin groups (OHP plus azithromycin). Patients were re-evaluated after 15 and 30 days. Both groups were similar in time after transplant, age, gender, cyclosporine dose, and cyclosporine through level and serum creatinine. The control group had fewer patients using calcium cannel blockers (10% vs. 70%, p = 0.02).

RESULTS

All patients improved in pain, halitosis, and gum bleeding after OHP. The control group did not improve plaque index (PI) or GH. In contrast, baseline PI decreased from 1.52 +/- 0.28 to 0.50 +/- 0.16 on day 15 (p < 0.01) and to 0.46 +/- 0.14 on day 30 (p < 0.01) in the azithromycin group, and the GH score decreased from 1.9 +/- 0.27 to 0.90 +/- 0.27 on day 15 (p < 0.05) and to 0.70 +/- 0.21 on day 30 (p < 0.01).

CONCLUSION

Azithromycin associated to efficient OHP induced a striking reduction in cyclosporine-induced GH, while efficient OHP alone improved oral symptoms but did not decrease cyclosporine-induced GH.

Negative effects of anemia on quality of life and its improvement by complete correction of anemia by administration of recombinant human erythropoietin in posttransplant patients

BACKGROUND

Anemia is a common complication in posttransplant patients (posttransplant anemia: PTA). We tested the hypothesis that targeting hemoglobin (Hb) over 13.3 g/dl by administration of recombinant human erythropoietin (rHuEPO-ad) has positive impact on quality of life (QOL).

METHODS

Twenty-four patients, whose initial Hb and estimated glomerular filtration rate (eGFR) were 10.5 +/- 0.2 g/dl and 48.5 +/- 2.7 ml/(min 1.73 m2), respectively, were enrolled in the present study. Physical and mental QOL in these patients before and after rHuEPO-ad were acquired and summarized as physical summary sore (PSC) and mental summary sore (MSC), respectively, by the 36-item Short Form (SF-36), an international questionnaire for analysis of QOL.

RESULTS

Before rHuEPO-ad, posttransplant patients had preserved MSC (54.1 +/- 2.3) but impaired PSC (32.6 +/- 3.2). rHuEPO-ad for 6 months increased their Hb to 13.7 +/- 0.3 g/dl. This was accompanied by improvement of PSC (49.1 +/- 2.1: P < 0.01 versus before rHuEPO-ad). MSC was preserved during rHuEPO-ad (54.4 +/- 1.6: NS versus before rHuEPO-ad). There was inverse correlation between initial PSC or MSC and responses of these parameters to rHuEPO-ad (PSC, P = 0.007; MSC, P = 0.009). Patients whose initial PSC was lower than 39.6 or whose initial MSC was lower than 39.4 were expected to improve their PSC or MSC by more than 10 by rHuEPO-ad.

CONCLUSIONS

Anemia in posttransplant patients has negative impacts on their QOL. Scoring mental and physical QOL by SF-36 in posttransplant patients is useful to identify groups of patients whose QOL could be improved by rHuEPO-ad.

Symptom experience after solid organ transplantation

OBJECTIVES

Understanding patients' perceptions and responses to immunosuppression-related symptom experiences following solid organ transplantation increases the likelihood that interventions can be designed to support long-term graft survival.

METHODS

This review summarizes and integrates evidence on transplant patients' symptom experiences related to immunosuppression side-effects in terms of symptom occurrence and symptom distress and other aspects of posttransplant treatment regimen. Empirical data of 18 reports on symptom experiences published between 1981 and April 2008 have been analyzed systematically. This report is organized to address the following areas of findings: (1) overview about instruments to assess symptom experiences, (2) descriptive information concerning symptom occurrence and related distress, (3) potential impact of symptom experiences on patient adherence, and (4) review of evidence between symptom experiences and health outcomes in terms of health-related quality of life (HRQoL).

RESULTS

Symptom experience scores remain high among all types of solid organ transplantation including kidney, liver, heart, and lung transplant, with no patterns related to symptom occurrence and distress. "Female gender" is consistently related to higher levels of symptom occurrence and symptom distress. Understanding the patients' appraisal of symptoms and side-effects related to the immunosuppressive therapy is a key to step forward by developing strategies to (1) reducing nonadherence triggered by symptom occurrence and distress, (2) decreasing non-adherence-related rejection, and (3) improving HRQoL by tailored symptom management.

CONCLUSION

As many side-effects are related to particular immunosuppressive drugs and dosages, a more in-depth understanding of the relationships among the concepts of symptom experience, nonadherence, and HRQoL may guide clinical decision making in the future.

PSYCHOSOCIAL FACTORS IN PATIENTS WITH CHRONIC KIDNEY DISEASE: Life After Transplantation: New Transitions in Quality of Life and Psychological Distress

Individuals with kidney failure often elect to undergo kidney transplantation because they believe that they will be more active and return a sense of normality to their lives with a functioning transplant. Therefore it is important to assess whether these objectives are being met. To do so, we can examine health-related quality of life (HRQOL) in transplant recipients. A number of tools have been used for this purpose, including general HRQOL instruments such as the 36-item short-form health survey (SF-36) and transplant-specific surveys such as the Kidney Transplant Questionnaire. In general, HRQOL assessments improve with transplantation in functional and physical domains. However, many factors actually influence HRQOL in a negative way, including comorbid conditions, kidney function per se, rejection episodes and hospitalizations, employment status, and adverse effects of medications. Perceived physical appearance, issues related to sexuality, stress, anxiety, and even guilt complicate the emotional and psychological landscape after transplantation. This constellation of factors may be predictive of posttransplant life events, such as resumption of employment. Posttransplant HRQOL may be exceedingly important in understanding the issues related to adherence with treatment regimens, especially in the pediatric and adolescent transplant populations. HRQOL is now established as an important issue after transplantation. Nonetheless, shortcomings still exist in our ability to address HRQOL after transplantation. In particular, more study of patient-centered interventions is needed. The use of standardized methodologies for patient assessment could improve our ability to identify if such patient-centered interventions actually succeed across populations, and help us further address the panoply of factors encompassed within posttransplant HRQOL.

Three-year health-related quality-of-life outcomes for sirolimus-treated kidney transplant patients after elimination of cyclosporine

This study compared 3-year health-related quality-of-life (HRQL) outcomes of sirolimus (SRL)-treated kidney transplant patients after elimination of cyclosporine (CsA) with patients continuing on a combined CsA and SRL regimen. A randomized, multi-country, open-label, clinical trial was performed. 430 kidney transplant patients were randomly assigned to SRL+corticosteroids (ST) (n = 215) or SRL+CsA+ST (n = 215) therapy after an initial 3-month period of combined SRL+CsA+ST treatment. HRQL was measured using the Kidney Transplant Questionnaire (KTQ) and the SF-36 Health Survey at month 3 (time of randomization) and months 12, 24, and 36 post-transplantation. Mixed-model ancova was used to evaluate treatment differences in HRQL outcomes. HRQL scores were available for 361 (86.4%) eligible study patients. Significant treatment-by-assessment time interactions, favoring SRL+ST, were found on KTQ fatigue (P = 0.0005), emotions (P = 0.028), and appearance scores (P = 0.006). Statistically significant treatment-by-assessment time interactions were observed for SF-36 vitality (P = 0.0001), general health (P = 0.011), social function (P = 0.020), and role-physical scores (P = 0.049). Vitality scores improved in the SRL+ST group (mean 3.5-point change) over 36 months, compared with decreases in the SRL+CsA+ST group (mean -3.2-point change). SRL-based therapy with early CsA-elimination results in fewer appearance-related problems, less fatigue, greater vitality, and improved general health status and social functioning compared with continuous SRL+CsA+ST treatment.

A Logistic Regression Model for Predicting Health-Related Quality of Life in Kidney Transplant Recipients

BACKGROUND

To develop a logistic regression model capable of predicting health-related quality of life (HRQOL) among kidney transplant recipients and determine its accuracy.

METHODS

Three groups of patients were selected: 70 healthy controls, 136 kidney transplant patients as a derivation set, and another 110 kidney transplant patients as a validation set. SF-36 score was used for HRQOL measurement. A cutoff point to define poor versus good HRQOL was calculated using the SF-36 scores of healthy controls. A logistic regression model was used to derive predictive parameters from the derivation set. The derived model was then tested among the validation set. HRQOL predictions made by the model for the patients in the validation set and the SF-36 scores were compared. We calculated sensitivity, specificity, positive and negative predictive values, and model accuracy.

RESULTS

SF-36 scores below 58.8 were defined as an indication of poor HRQOL. The regression model suggested that poor HRQOL was positively associated with lower education (below high school diploma), being single or widowed, and diabetes/hypertension as etiology. It was negatively associated with younger age (<45 years) at the time of transplantation. Optimal sensitivity and specificity were achieved at a cutoff value of 0.74 for the estimated probability of poor HRQOL. Sensitivity, specificity, positive and negative predictive values, and accuracy of the model were 73%, 70%, 80%, 60%, and 72%, respectively.

CONCLUSION

The suggested model can be used to predict poor posttransplant HRQOL among renal graft recipients using simple variables with acceptable accuracy. This modal can be of use in decision making in the recipients for whom achieving good HRQOL is the main aim of transplantation, to select high-risk patients and to start interventional programs to prevent a poor HRQOL.

Geographic variability in access to primary kidney transplantation in the United States, 1996-2005

This article focuses on geographic variability in patient access to kidney transplantation in the United States. It examines geographic differences and trends in access rates to kidney transplantation, in the component rates of wait-listing, and of living and deceased donor transplantation. Using data from Centers for Medicare and Medicaid Services and the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients, we studied 700,000+ patients under 75, who began chronic dialysis treatment, received their first living donor kidney transplant, or were placed on the waiting list pre-emptively. Relative rates of wait-listing and transplantation by State were calculated using Cox regression models, adjusted for patient demographics. There were geographic differences in access to the kidney waiting list and to a kidney transplant. Adjusted wait-list rates ranged from 37% lower to 64% higher than the national average. The living donor rate ranged from 57% lower to 166% higher, while the deceased donor transplant rate ranged from 60% lower to 150% higher than the national average. In general, States with higher wait-listing rates tended to have lower transplantation rates and States with lower wait-listing rates had higher transplant rates. Six States demonstrated both high wait-listing and deceased donor transplantation rates while six others, plus D.C. and Puerto Rico, were below the national average for both parameters.

Quality of life of end-stage renal disease patients and study on the implementation of nocturnal home hemodialysis in Greece

The aim of this study was to measure the overall health-related quality of life of patients receiving hemodialysis in Greece and to assess willingness, motivation, and concerns about participating in a nocturnal home hemodialysis program. This review measured successfully the quality of life of 146 end-stage renal disease (ESRD) patients undergoing hemodialysis in 10 hemodialysis centers all over Greece and studied the factors that affect their choice to adopt a specific treatment. Physical and mental health status and health-related quality of life, measured by the Kidney Disease Quality of Life Short Form accompanied by the demographic data gathered, provide information that can help to improve ESRD patient care in Greece. A comparison with the Greek general population identifies lower physical functioning scores for the ESRD patients, while the mental functioning scores are comparable with those of the Greek general population. Moreover, it is important to notice the willingness expressed by half of the patients to participate in a potential program of nocturnal home hemodialysis.

Yoga: A tool for improving the quality of life in chronic pancreatitis

AIM: To determine the effectiveness of yoga on improving the quality of life in patients of chronic pancreatitis.

METHODS: The patients were randomized to two groups. The control group continued their usual care as directed by their physicians. Patients in the yoga group, in addition, received biweekly yoga sessions for 12 wk. The patients’ demographic and health behaviour variables were assessed before and after the yoga programme using Medical Outcomes Short Form (SF-36) for quality of life, Profile of Mood States for assessing mood and Symptoms of Stress Inventory for measuring stress.

RESULTS: A total of 60 patients were enrolled, with 8 drop-outs.Thirty patients were randomized to the yoga group and 30 to the control group. Significant improvements were seen in overall quality of life, symptoms of stress, mood changes, alcohol dependence and appetite after the 12 wk period apart from the general feeling of well-being and desire to continue with the programme in future in the yoga group, while there was no difference in the control group.

CONCLUSION: Yoga is effective on improving the quality of life in patients of chronic pancreatitis.

Reliability and validity of the ESRD Symptom Checklist--Transplantation Module in Norwegian kidney transplant recipients

Background

The aim of the study was to validate the Norwegian version of a self-administered 43-item questionnaire designed to assess quality of life in kidney transplant recipients, the End-Stage Renal Disease Symptom Checklist – Transplantation Module (ESRD-SCL).

Methods

In total, 53 kidney transplant recipients from one university-affiliated hospital responded to a questionnaire including the ESRD-SCL and the Short Form 36 (SF-36). We assessed internal consistency reliability and test-retest reliability with 2 weeks between assessments. Construct validity was assessed by correlations of the ESRD-SCL subscales with related and unrelated SF-36 scales, demographic, and clinical characteristics.

Results

Subscales of the ESRD-SCL showed good internal consistency reliability (Cronbach's = 0.72–0.81) and for the aggregate total scale α was 0.94. Test-retest reliability median 14 days apart was excellent with intraclass coefficients ranging from 0.87 to 0.95. The pattern of correlations of the ESRD-SCL scales with related and unrelated scales SF-36 scales and demographic and clinical characteristics gave support to the construct validity of the ESRD-SCL.

Conclusion

The Norwegian translation of the ESRD-SCL showed satisfactory internal consistency reliability, test-retest reliability and construct validity, at the level of the original German version.

Preferred methods of excess hair removal in pediatric patients with lung transplantation

BACKGROUND

Hypertrichosis is common among recipients of lung transplantation taking cyclosporine and it poses a special psychosocial problem in children. Children and parents frequently inquire about methods of hair removal.

OBJECTIVE

We sought to determine preferred methods of hair removal in this population.

METHODS

We distributed a questionnaire to 104 pediatric recipients of lung transplantation. A total of 56 questionnaires (54%) were completed.

RESULTS

Of respondents, 91% (51 of 56) experienced hypertrichosis, 75% (38 of 51) of whom attempted treatment. Depilatory cream was the most common hair removal technique (79%, 30 of 38). Shaving, particularly with an electric razor, received the highest ratings of both satisfaction and likelihood of future use.

LIMITATIONS

Generalizability is limited by the response rate. Preferred methods according to different hair locations were not evaluated.

CONCLUSION

In our pediatric transplantation population, depilatory cream was the most commonly used treatment for hypertrichosis whereas electric shaving had the highest ratings of satisfaction and future use.

Disease-Specific Quality of Life in Turkish Patients After Successful Kidney Transplantation

To investigate disease-specific quality of life (QOL) in Turkish patients after successful kidney transplantation, the End-Stage Renal Disease Symptom Checklist Transplantation Module (ESRD-SCL-TM), a multidimensional questionnaire measuring disease-specific QOL, was translated and administered to a sample of successfully transplanted patients. Intercultural differences between Turkish and German patients as well as the influence of demographic (age, gender) and clinical (duration of graft function, living versus cadaver transplantation) data in the Turkish patients were evaluated by multivariate analyses of variance, and correlative techniques. The 152 investigated Turkish patients, including 106 (69.7%) men and 46 (30.3%) women, had a mean age of 34.8 years (SD = 10.8, range, 14 to 67 years). Time since successful kidney transplantation varied between 1 and 297 months (mean = 19.2 months; SD = 36.9). One hundred twelve patients (73.7%) received a kidney from a living donor, and 40 (26.3%) from a cadaver. The Turkish patients suffered statistically significantly more from disease-specific distress than the German patients (19% explanation of variance). They reported higher distress regarding four of six subscales. Turkish women suffered statistically significantly more from "Limited Physical Capacity," and "Side-effects of Corticosteroids" (10% explanation of variance) than men. The demonstrated higher disease-specific distress in successfully transplanted Turkish patients compared to the German samples may be the result of intercultural differences in reporting psychological and disease-specific distress. On the other hand, the higher distress of women compared to men is well known. Both results pointed out the necessity of psychological support.

Predictors of health-related quality of life in hypertensive recipients following renal transplantation

BACKGROUND

Health-related quality of life (HRQoL) improves after renal transplantation. However, it is unclear which variables are the strongest determinants of HRQoL following renal transplantation. In this study, we wanted to assess whether antihypertensive medication, donor type, human leukocyte antigen (HLA)-compatibility or other variables could predict HRQoL 6-12 months after transplantation.

METHODS

The study was a follow up of 124 patients recruited to a single center, randomized, double-blind clinical trial, comparing the effects of lisinopril and nifedipine in hypertensive renal transplant recipients. HRQoL was assessed with the Short Form 36 (SF-36) questionnaire. Bivariate and multiple linear regression analysis were used to assess the relationship between potential predictors and the physical component summary (PCS) and mental component summary (MCS) scales of the SF-36.

RESULTS

Average scores 6-12 months after transplantation did not differ between patients randomized to lisinopril or nifedipine, or between cadaveric and living donor recipients on any of the eight SF-36 scales, or the two summary scales. In multivariate analyses, recipient age (p = 0.01) and cold ischemia time >14.5 h (p = 0.04) were independent predictors of the PCS score. Recipient age (p = 0.05), 2-4 HLA-AB mismatches (p = 0.05) and donor age (p = 0.03) were independent predictors of the MCS score.

CONCLUSIONS

There was no evidence of differences in HRQoL according to lisinopril or nifedipine, or living vs. cadaveric donor transplantation. HRQoL was significantly reduced with longer cold ischemia time and more than one HLA-AB mismatches, after adjusting for age. These donor kidneys related issues need confirmation.

One-Year Observation of Kidney Allograft Recipients Converted From Cyclosporine Microemulsion to Tacrolimus

The results from previous trials suggested that tacrolimus-based treatment in kidney transplantation was associated with a significantly lower incidence of acute rejection, and that cyclosporine microemulsion (CsA-Me)-treated patients converted to tacrolimus had numerically better 6-year graft survival than those remaining on CsA-Me. Death with a functioning graft and chronic graft nephropathy are the leading causes of late allograft loss. While standard cardiovascular risk factors are relevant, renal function itself becomes an important risk factor for cardiovascular morbidity and mortality in kidney transplantation patients. Expected benefits of the conversion from CsA-Me to tacrolimus with respect to renal function and cardiovascular status were the rationale for this observational study. Twenty one patients underwent conversion due to nephrotoxicity of cyclosporine (n = 18) or side effects (n = 3). Two out of 21 patients did not complete the study. The patient survival after 1 year was 100% in this group of patients; graft survival 94.7%. No cases of de novo diabetes mellitus were identified. Mean serum creatinine fell from 2.13 +/- 0.4 to 1.84 +/- 0.3 mg/dL (P < .02) and calculated glomerular filtration rate increased from 49.6 +/- 14.4 to 56.2 +/- 15.5 mL/min (P < .01). Total cholesterol decreased from 229.4 +/- 50.1 to 195.9 +/- 28.5 mg/dL (P < .005) and, low-density lipoprotein cholesterol from 125.7 +/- 37.3 to 104.4 +/- 22.6 mg/dL (P < .02). No significant changes in mean systolic or diastolic pressure or blood glucose levels were observed. The results of this observational study showed that in a group of patients with raised creatinine levels at entry, conversion to tacrolimus resulted in improved graft function and a more favorable cardiovascular risk profile.

The impact of skin disease following renal transplantation on quality of life

BACKGROUND

The immunosuppressive therapy a patient requires to sustain a functioning renal allograft in the long term is associated with various skin complications. While quality of life (QoL) after renal transplantation has been studied, no publications document the effect of post-transplant dermatological complications on QoL.

OBJECTIVES

The objective of the study was to document the prevalence of the skin diseases that commonly occur in association with post-transplant immunosuppression. A general dermatological quality of life questionnaire, the Dermatology Life Quality Index (DLQI), was used to assess the QoL effect of these cutaneous complications. The study was designed to examine further the impact of age, sex, duration since transplant and immunosuppressive regimen on the DLQI score of renal transplant recipients (RTR).

METHODS

One hundred and seventy-three RTR completed the DLQI, were interviewed and examined for evidence of common post-transplant skin diseases.

RESULTS

Sixteen per cent of RTR had DLQI scores >6, reflecting a significant impact on their QoL. Dry skin, itch, hypertrichosis, sebaceous gland hyperplasia, acne, genital warts and a history of >4 herpes simplex virus type 1 infections in the past year were all found to have a significant impact on the quality of life (P < 0.05). Multivariate analysis revealed that the greatest impact on QoL was in RTR who were younger, female and with multiple skin problems (P < 0.05).

CONCLUSIONS

The dermatological complications of immunosuppressive therapy are common in RTR and can significantly impair QoL in certain individuals. Visible, infectious and cosmetic skin problems had most impact on QoL while a history of skin cancer had a lesser impact. Early dermatological referral and careful choice of immunosuppression may enhance the QoL, particularly in young and female RTR.