Determinants of quality of life changes among long-term cardiac transplant survivors: results from longitudinal data

The relationship of socio-demographic factors and satisfaction with social support at five and 10 yr after heart transplantation

BACKGROUND

Despite the fact that social support has been found to be important to cardiovascular health, there is a paucity of information regarding the relationship between social support and outcomes long term after heart transplantation (HT). The purposes of this study were to examine demographic and psychosocial characteristics and their relationship to social support after HT and to identify whether socio-demographic variables are predictors of satisfaction with social support post-HT.

METHODS

Data were collected from 555 HT patients (pts) (78% men, 88% white, mean age = 53.8 yr at time of transplant) at four US medical centers using the following instruments: Social Support Index, QOL Index, HT Stressor Scale, Jalowiec Coping Scale, Sickness Impact Profile, Cardiac Depression Scale, and medical records review. Statistical analyses included t-tests, correlations, and linear and multivariate regression.

RESULTS

There were no associations between education and ethnicity and perception of social support at five and 10 yr after HT. Married and older pts reported higher satisfaction with social support after HT. Being married and having higher education were predictors of better overall satisfaction with social support at 10 yr post-heart transplantation.

CONCLUSIONS

Knowledge of relationships between socio-demographic factors and social support may assist clinicians to address social support needs and resources long term after HT.

Health-related quality of life and exercise tolerance in recipients of heart transplants and left ventricular assist devices: a prospective, comparative study

BACKGROUND

The aim of this study was to evaluate and compare health-related quality of life (HRQoL) and physical exercise tolerance in patients after heart transplantation (HTx) or implantation of a left ventricular assist device (LVAD).

METHODS

A prospective, comparative design was used to characterize changes over time in HRQoL (SF-36) and exercise tolerance in patients after HTx (n = 54) and during LVAD support (n = 36). Nine LVAD patients were lost for follow-up. The majority of patients in both groups were male (97%); the LVAD cohort tended to be younger (p = 0.06).

RESULTS

HRQoL improved significantly in HTx patients in the SF-36 physical (p = 0.02), but not in the psychosocial (p = 0.27) component score during follow-up. In the LVAD group, HRQoL showed improvements for both the SF-36 physical and psychosocial component scores (both p = 0.04). Between-group comparisons revealed better HRQoL for the HTx cohort than the LVAD cohort for 2 of 8 SF-36 subscales. Age-, gender- and body mass index (BMI)-adjusted exercise tolerance (workload; VO(2max)) showed significant improvements for both HTx (p = 0.01) and LVAD (p = 0.01) patients. Adjusted maximum oxygen consumption was higher for HTx patients (p = 0.05) relative to LVAD patients at 8 ± 1 months after implant.

CONCLUSION

HRQoL and exercise capacity increased in both groups over the time-course of the study. After adjusting for relevant variables, HTx patients showed a higher exercise tolerance compared with the LVAD group during follow-up. Thus, future large-scale intervention studies should emphasize the specific needs of these patient cohorts.

Symptom frequency and distress from 5 to 10 years after heart transplantation

BACKGROUND

Patterns of symptom frequency and distress have not been examined long-term after heart transplantation, nor have predictors of long-term symptom frequency and distress. This report identified the most commonly reported and distressful symptoms long-term after transplantation, described patterns of symptom frequency and distress over time, and examined predictors of symptom frequency and distress at 5 and 10 years after heart transplantation.

METHODS

The sample included 555 participants from a prospective, multisite, longitudinal study of quality of life outcomes. Patients were 78% male, 88% white, 79% married, and mean age of 54 years at time of heart transplantation. Data were collected using patient self-report and medical records review. Statistical analyses included descriptive statistics, Pearson correlations, t-tests, and generalized linear models.

RESULTS

Significant predictors of lower symptom frequency after heart transplantation were not having psychological problems and not having cardiac allograft vasculopathy at 5 years, and not having psychological problems and not having infection at 10 years. Significant predictors of less symptom distress were having more than a high school education, having no psychological problems, and having gout at 5 years, and being married at 10 years.

CONCLUSIONS

Symptom frequency is low and symptom distress is moderate long-term after heart transplantation. Significant relationships exist between both demographic and clinical variables and symptom frequency and distress. Identification of the most common and bothersome symptoms after heart transplantation provides clinicians with important information from which to develop a plan of care.

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.

The utility of a specific measure for heart transplant patients: reliability and validity of the Kansas City Cardiomyopathy Questionnaire

BACKGROUND

Health-Related Quality of Life of patients with heart transplantation is an important variable; however, it has received little attention so far, and only two Spanish validated measurement instruments are available. The aim of our study was to validate the Spanish version of the Kansas City Cardiomyopathy Questionnaire (KCCQ) in heart transplant patients.

METHODS

A prospective study was performed in 186 patients awaiting heart transplantation in nine transplant hospitals. Hundred transplant recipients filled out the KCCQ, the Euroqol 5-D (EQ5D), and the Short Form-36 (SF-36) Health Survey at pretransplant, after 3 months, 6 months, and 1 year of follow-up. A complete set of sociodemographic and clinical data were also collected. The validity, reliability, sensitivity to change, and effect size were studied. Two questionnaires, the SF-36 and EQ5D, were used to evaluate the validity.

RESULTS

Mean age of patients was 56.0 years, and 80.5% were men. Twenty-six percent had acute rejection. A five-dimensional factorial structure could be discerned. The questionnaire presented a Cronbach's alpha coefficient of more than 0.7. Correlations between the KCCQ and the other questionnaires and clinical variables were satisfactory.

CONCLUSIONS

The KCCQ features adequate psychometric properties. The KCCQ offers several advantages over other questionnaires because it quantifies symptoms (frequency, severity, and stability) and it is much more sensitive to change, even when compared with the SF-36. The specific questionnaire for heart transplant patients is a useful and user-friendly instrument for measuring the Health-Related Quality of Life related to functional status, quality of life, and social limitation more accurately.

Coping and quality of life in patients awaiting lung transplantation

OBJECTIVE

Patients with end-stage lung disease (ESLD) experience significant decrements in quality of life (QOL). Although coping strategies are related to QOL in patients with ESLD, the extent to which specific native lung disease moderates this relationship is unknown.

METHODS

We investigated the relationship between coping, native lung disease, and QOL among 187 patients awaiting lung transplantation, including 139 patients with chronic obstructive pulmonary disease (COPD) and 48 with cystic fibrosis (CF). Participants completed a psychosocial battery assessing psychological QOL, physical QOL, and coping strategies.

RESULTS

For both COPD and CF patients, higher levels of Active Coping (P< .0001) and lower levels of Disengagement (P< .0001) were associated with better psychological QOL. For physical QOL, we observed a Native Disease x Coping interaction (P=.01) such that Active Coping was associated with better physical QOL in patients with COPD but not in patients with CF.

CONCLUSIONS

The relationship between coping and QOL may vary as a function of native lung disease. Patients' native disease may need to be considered in order to develop effective interventions to help patients cope successfully with ESLD.

Symptom experience after lung transplantation: impact on quality of life and adherence

BACKGROUND

Patients' perceptions of immunosuppression- related symptom experience may impact on quality of life (QoL) and medication adherence.

METHODS

A total of 308 lung transplant recipients were screened for study inclusion. Two hundred eighty-seven patients (response rate 93%) completed a 91-item questionnaire consisting of subscales focusing on symptom experiences (frequency and distress), and adherence. QoL was assessed by a 40-item standardized instrument. Impact of symptom experiences on QoL and adherence were assessed. Potential determinants of immunosuppression induced symptom experiences were evaluated.

RESULTS

The most frequent reported symptoms were tremor (70%) and hirsutism (68.1%), whereas Cushingoid appearance (38.6%) and muscle weakness (31.9%) appeared to be the most distressing symptoms. Women (p < 0.001) and younger patients (<40 yr; p < 0.0001) reported a significantly higher level of symptom experience compared with their counterparts respectively. Symptom experiences negatively influenced QoL in all dimensions (p < 0.006). Those who described experiencing adverse effects reported significantly more "drug holidays" (p < or = 0.004) compared with those reporting minor frequent adverse effects. Patients' self-reported strategies to reduce adverse effects were to postpone medication intake (30%), to drop doses (8%), or to reduce doses (9%).

CONCLUSIONS

This study establishes a relationship between patients' perceptions of immunosuppression-related symptom experiences and the impact on QoL and adherence. Immunosuppression is accompanied by significant adverse effects in both symptom frequency and distress. Most frequently experienced symptoms do not necessarily have the greatest impact on perceived distress, and vice versa. High levels of adverse effects tend to negatively influence patients' QoL and adherence. Future research is required to understand the relationship of these complex variables.

Getting old with a new heart: impact of age on depression and quality of life in long-term heart transplant recipients

BACKGROUND

Limited research has been done on depression and quality of life in long-term survival after heart transplantation. The aim of the present study was to investigate the role of age on depression and quality of life in a sample of long-term heart transplant recipients.

METHODS

We investigated 137 consecutive patients recruited in a single center who were still alive at more than 10 years after transplantation. Quality of life and depression were rated with the Medical Outcome Study Short Form (SF-36) and the Beck Depression Inventory (BDI), respectively. Sociodemographic, clinical, affective, and quality of life data for long-term survival patients stratified by current age younger than 70 years (young) and 70 years or older (old) were compared using Fisher's exact tests and Student's t-tests.

RESULTS

The SF-36 Mental Component Summary did not significantly differ between the young subjects (48.75 +/- 10.2) compared with old (48.47 +/- 10.1; p = 0.897). By contrast, the SF-36 Physical Component Summary was higher in younger subjects (46.88 +/- 10.2 vs 40.81 +/- 10.6, p = 0.008). According to BDI, 37.4% of the young group and 13.3% of the old group scored above the selected threshold of 10 (p = 0.014).

CONCLUSIONS

In the light of our findings, older age does not seem to negatively affect the mental component of quality of life in the long term after heart transplantation, but it does on the physical component, as expected. On the other hand, it may be even associated with a lower prevalence of depressive symptoms more than 10 years after surgery. Hence, age per se does not represent a major limiting factor when considering candidates for this procedure, at least with regard to the issue of psychologic distress.

Patterns and predictors of quality of life at 5 to 10 years after heart transplantation

BACKGROUND

Although studies have provided us with a cross-sectional analysis of long-term quality of life (QOL) after transplantation, relatively few longitudinal studies have been done that allow us to understand changes in QOL over time. The purposes of our study were to describe QOL over time and identify predictors of QOL longitudinally from 5 to 10 years after heart transplantation.

METHODS

All 555 subjects enrolled in this study completed booklets of questionnaires. These patients had a mean age of approximately 54 years (range 21 to 75 years) at time of transplant. Seventy-eight percent were men and 88% were white. Participants completed nine self-report QOL instruments for this study. Statistical analyses included frequencies, means +/- standard deviations (plotted over time), Pearson correlation coefficients and multiple regression coupled with repeated measures.

RESULTS

At 5 to 10 years after heart transplantation, recipients reported high levels of satisfaction with overall QOL and with health-related QOL, which was stable over the 5-year period. Predictors of satisfaction with overall QOL (that individually accounted for 1% variance or more) were primarily psychosocial variables (overall model explaining 71% of variance), whereas predictors of satisfaction with QOL related to health and functioning (that also explained > or =1% variance) included symptom distress and physical function, as well as psychosocial variables (overall model explaining 72% of variance).

CONCLUSIONS

At 5 to 10 years after heart transplantation, QOL remained positive and stable. Bio-psychosocial variables predicted satisfaction with overall QOL and health-related QOL. Understanding of these bio-psychosocial variables provides direction for the development of long-term therapeutic strategies after heart transplantation so that patients can have good post-transplant outcomes.

Functional Status One Year After Heart Transplant

PURPOSE

Although heart transplantation (HT) increases survival of heart failure patients, many patients still experience problems afterward that affect functioning.

PURPOSES

(1) to compare the functional status of HT patients before transplant versus 1 year after transplant, (2) to identify functional problems 1 year post-transplant, and (3) to identify which variables predicted worse functional status 1 year later.

METHODS

The sample was 237 adult HT recipients who completed the 1-year post-transplant study booklet. Functional ability was assessed by the Sickness Impact Profile. Paired t tests compared Sickness Impact Profile scores before and after transplant. Medical and demographic data plus patient questionnaire data on Sickness Impact Profile, symptoms, stressors, and compliance were used in the regression.

RESULTS

Sickness Impact Profile functional scores improved significantly from pre-transplant (23.0%) to post-transplant (13.4%); however, many HT recipients still reported problems in 12 functional areas 1 year after surgery. Major problem areas were the following: work (90% of patients), eating (due to dietary restrictions, 87%), social interaction (70%), recreation (63%), home management (62%), and ambulation (54%). Only 26% were working 1 year after transplant; 59% of those working reported health-related problems performing their job. Predictors of worse functional status were greater symptom distress, more stressors, more neurologic problems, depression, female sex, older age, and lower left ventricular ejection fraction (worse cardiac function).

CONCLUSIONS

Many HT recipients were still having functional problems and had not reached their full rehabilitation potential by the 1-year anniversary after transplant.

Satisfaction with heart transplantation

This research investigated patient satisfaction with heart transplantation (HT) 6 months after surgery. The authors explored whether HT patients would make the decision to have HT again and examined medical, psychosocial, and demographic factors associated with satisfaction or dissatisfaction in 257 HT recipients. Nonparametric statistics were used. Satisfaction with HT could be rated from 1 (not satisfied) to 10 (very satisfied). Eighty-seven percent of the patients were highly satisfied with HT 6 months after surgery (ratings of 8-10); 1% rated their satisfaction as low (1-3), and 12% rated it as moderate (4-7). Factors associated with less satisfaction with HT were: more symptom distress, greater disability, more stress, poor coping ability, feeling that the interventions of the HT team were not very helpful, less life satisfaction, and lower quality of life. Ninety-three percent indicated that they either definitely or probably would decide to have HT again; 7% responded "probably not" or "not sure." Factors associated with a negative perception of having another HT were: poor coping ability, less life satisfaction, lower quality of life, being male, and being married.

Anti-depressive Therapies After Heart Transplantation

OBJECTIVE

Despite an improved quality of life, about 33% of heart transplant recipients will develop depressive symptoms post-operatively. To date, no review has explored the efficacy and safety of pharmacologic or psychologic interventions in this patient group.

METHODS

We conducted a comprehensive Medline, EmBase, Psycinfo search for studies of the treatment of depression in heart transplant recipients.

RESULTS

We identified 34 studies of variable methodologic quality. Selective serotonin re-uptake inhibitors (SSRIs), particularly citalopram and new-generation anti-depressants (mirtazapine), seem to represent the best therapeutic choices for this population. Tricyclic anti-depressants (TCAs), and electroconvulsive therapy (ECT) should be reserved for severe depression unresponsive to other treatments, whereas monoamine oxidase inhibitors (MAOIs) should be avoided. St John's wort, an alternative herbal drug, has been associated with life-threatening immunosuppression. Psychologic therapy offers further advantages after heart transplantation.

CONCLUSIONS

Further well-conducted, randomized, controlled trials are needed to clarify the efficacy and the safety of pharmacologic (SSRIs and atypical anti-depressants) and psychologic interventions in the management of depression after heart transplantation.

Predictors of quality of life at 5 to 6 years after heart transplantation

BACKGROUND

Only a few researchers have examined quality of life (QOL) outcomes more than 5 years after heart transplantation. Therefore, the purpose of this study was to describe QOL (overall, satisfaction with, and perceived importance); identify differences in QOL by age, sex, and race; and identify predictors of QOL at 5 to 6 years after heart transplantation.

METHODS

A nonrandom sample of 231 patients (60 years of age, 76% men, 90% white, 79% married, and fairly well educated) who were 5 to 6 years after heart transplantation were investigated. Patients completed 12 QOL instruments via self-report. Data analyses included descriptive statistics, chi2, independent t-tests, correlations, and stepwise multiple regression. Level of significance was set at 0.05.

RESULTS

Patient satisfaction with all areas of life was high at 5 to 6 years after heart transplantation. Similarly, patients believed that these same areas of life were very important. Yet areas of QOL with lower levels of satisfaction were identified. Patients who were > or =60 years were more satisfied with their QOL than patients <60 years. At 5 to 6 years after heart transplantation, almost 80% of variance in QOL was explained by psychological, physical, social, clinical, and demographic variables.

CONCLUSIONS

At 5 to 6 years after heart transplantation, patients were very satisfied with their QOL, although differences in level of satisfaction were identified by demographic variables, and areas of QOL with lower levels of satisfaction were identified. Understanding those variables that contribute to QOL in the long term after heart transplantation provides direction for assisting patients to improve their QOL.

Prevalence and characteristics of noncompliant behaviour and its risk factors in kidney transplant recipients

Noncompliance with therapy is one possible explanation for the observation that long-term graft survival is not sufficiently improved by the development in immunosuppression. The aim of the study was to explore the prevalence, characteristics and risk factors of noncompliance with immunosuppression. A total of 161 adult kidney transplant recipients were interviewed about their self-rated health, social support, education, stress from adverse effects and compliance with the immunosuppression. The prevalence of subclinical noncompliance was 54%. Noncompliant patients declared significantly worse self-rated health, less satisfaction with social support and higher stress from adverse effects. Male gender (OR 7.5, CI 2.4-23.39), high stress from adverse effects (OR 12.27, CI 2.44-61.88), fair self-rated health (OR 4.45, CI 1.04-19.55) and fair satisfaction with social support (OR 4.55, CI 1.08-19.24) were predictors of noncompliance. Standardized detection methods should be developed with the aim of identifying patients who are at risk of noncompliance in order to prevent graft loss.

Adherence to the Therapeutic Regimen in Heart, Lung, and Heart-Lung Transplant Recipients

Optimal outcome after heart, lung, and heart-lung transplantation can only be obtained if patients are supported in adhering to a lifelong therapeutic regimen. The transplant patient's therapeutic regimen consists of a lifelong medication regimen, including immunosuppressive drugs; monitoring for signs and symptoms related to complications; avoidance of risk factors for cardiovascular disease and cancer (ie, diet and exercise prescriptions, nonsmoking); avoidance of abuse/dependence of alcohol or illegal drugs, as well as attending regular clinical checkups. Nonadherence to all aspects of this regimen is substantial. Nonadherence has been related to negative clinical outcome in view of acute rejections, graft vasculopathy, higher costs, and mortality. This review focuses on the prevalence, correlates, and consequences of nonadherence to the therapeutic regimen in heart, lung, and heart-lung transplantation. The current state of the-art on adherence-enhancing interventions is reported. Priorities for future research are outlined.

Ten years of "extended" life: quality of life among heart transplantation survivors

BACKGROUND

Long-term quality of life (QOL) outcome in heart transplant recipients still remains uncertain. This study evaluates the health status and QOL of survivors with associated predictors 10 years after heart transplantation.

PATIENTS AND METHODS

A total of 276 patients who underwent heart transplantation in the Department of Cardiac Surgery, University of Pavia, between 1985 and 1992 were included in a cross-sectional study. Patients still alive 10 years after transplantation (n=122) were asked to complete the SF36 questionnaire and then received a full clinical examination. All QOL instruments that were used had acceptable reliability and validity. Descriptive statistics, Kaplan-Meier estimate, correlation coefficients, and general linear regression were used to analyze the data.

RESULTS

Survival rates 1, 5, and 10 years after transplantation were 87%, 77%, and 57%, respectively, and the average life expectancy was 9.16 years. The mental QOL of patients 10 years after heart transplantation was similar to that among the general population. The physical QOL was worse among patients when compared with the QOL of the general population, with predictors including older age, being married, the presence of complications, and impaired renal function.

CONCLUSIONS

Heart transplantation ensures a relatively high QOL even 10 years after surgery. Predictors of a poor QOL were determined, which may help to identify those patients for whom a poor outcome is likely so treatment can be tailored accordingly.