Transplantation and quality of care for end-stage renal disease: 1993

Qualidade de vida em transplantados renais: importância do enxerto funcionante

Medidas objetivas de avaliação de qualidade de vida vêm aumentando em importância como adjuvante da análise de intervenções terapêuticas. Com o objetivo de analisar a qualidade de vida em pacientes renais crônicos transplantados, com enxerto funcionante ou que retornaram para tratamento dialítico, foi utilizada a versão em português do World Health Organization Quality of Life (WHOQOL-Bref). Foram estudados 132 pacientes, submetidos ao transplante renal, divididos em dois grupos: grupo I, 100 pacientes com enxerto funcionante e grupo II, 32 pacientes que perderam a função do enxerto e retornaram para tratamento dialítico. A avaliação dos diferentes itens do WHOQOL-Bref mostrou uma melhor qualidade de vida para os pacientes com enxerto funcionante nos domínios físico e psicológico, mas não nos domínios de relações sociais e de meio ambiente, valores estes confirmados pela avaliação das questões gerais. Esse instrumento de avaliação mostrou-se eficaz, pois privilegia a opinião dos pacientes, permitindo uma abordagem multidisciplinar do problema.

Quality of life in end-stage renal disease patients

Health-related quality of life (QOL) refers to the measure of a patient's functioning, well-being, and general health perception in each of three domains: physical, psychological, and social. Along with survival and other types of clinical outcomes, patient QOL is an important indicator of the effectiveness of the medical care they receive. QOL of patients with end-stage renal disease is influenced by the disease itself and by the type of replacement therapy. Numerous studies have identified the effect of such factors as anemia, age, comorbidity, and depression on QOL. Most of these factors appear during the predialysis period, and the adequate management of some of them could influence patient outcomes. Among replacement therapies, transplantation appears to give the best QOL for large groups of patients. No conclusive data exist to prove differences in QOL between hemodialysis patients and peritoneal dialysis patients. In the case of elderly patients or those with a high degree of comorbidity, the best treatment option should be assessed in each individual case, taking all possible factors into account. Finally, it has been proven that physical and mental function are inversely correlated with the risk for hospitalization and mortality.

Quality of life in end-stage renal disease patients

Health-related quality of life (QOL) refers to the measure of a patient's functioning, well-being, and general health perception in each of three domains: physical, psychological, and social. Along with survival and other types of clinical outcomes, patient QOL is an important indicator of the effectiveness of the medical care they receive. QOL of patients with end-stage renal disease is influenced by the disease itself and by the type of replacement therapy. Numerous studies have identified the effect of such factors as anemia, age, comorbidity, and depression on QOL. Most of these factors appear during the predialysis period, and the adequate management of some of them could influence patient outcomes. Among replacement therapies, transplantation appears to give the best QOL for large groups of patients. No conclusive data exist to prove differences in QOL between hemodialysis patients and peritoneal dialysis patients. In the case of elderly patients or those with a high degree of comorbidity, the best treatment option should be assessed in each individual case, taking all possible factors into account. Finally, it has been proven that physical and mental function are inversely correlated with the risk for hospitalization and mortality.

Are all successful renal transplants really successful?

We previously described a small group of renal transplant recipients considered to have successful allografts statistically, but who did not benefit clinically. These were patients in whom the grafts survived greater than 6 months but less than 3 years. This expanded study evaluates 179 consecutive renal transplant recipients divided into three groups. Group 1 (n = 18), group 2 (n = 41), and group 3 (n = 120) have patients with graft survival less than 6 months, between 6 months and 3 years, and greater than 3 years, respectively. Mean age, cause of renal failure, HLA match, and immunosuppressive regimen were not statistically different in any group. The number of acute rejection episodes, number of hospitalizations, and number and seriousness of complications were significantly greater in group 2 patients compared with the other groups. Patients in group 2 experienced five times the number of acute rejections (P < 0.0001), three times the number of hospitalizations (P < 0.0001), and two times the number of complications (P < 0.0001) compared with group 3 patients. In conclusion, those transplant recipients whose grafts survived longer than 6 months but less than 3 years were the most unfortunate. They experienced repeated and serious complications and spent many days in the hospital at great expense. A study with more sensitive methods of detecting presensitization might impact on graft performance in the future.

Measuring, managing, and improving quality in the end-stage renal disease treatment setting: committee statement

The Institute of Medicine (IOM) committee that organized the conference reported in this issue of the journal on assessing quality of care and quality of life, wishes to emphasize that it regards the task of measuring quality as one that can be approached systematically, albeit with caution. Outcomes of end-stage renal disease (ESRD) care by dialysis and transplantation (and variations of outcomes among treatment units) and related processes of care need to be measured in ways useful to clinicians. In addition to clinical measures of outcome, the committee also favored giving greater attention to functional outcomes and health-related quality of life. The interest in maintaining and improving quality in the treatment setting reflects an underlying need to encourage its systematic assessment on a sustained basis, with appropriate weight devoted to practical issues.