Outcomes after kidney transplantation, let's focus on the patients' perspectives

The Gut Microbiome and Symptom Burden After Kidney Transplantation: An Overview and Research Opportunities

Many kidney transplant recipients continue to experience high symptom burden despite restoration of kidney function. High symptom burden is a significant driver of quality of life. In the post-transplant setting, high symptom burden has been linked to negative outcomes including medication non-adherence, allograft rejection, graft loss, and even mortality. Symbiotic bacteria (microbiota) in the human gastrointestinal tract critically interact with the immune, endocrine, and neurological systems to maintain homeostasis of the host. The gut microbiome has been proposed as an underlying mechanism mediating symptoms in several chronic medical conditions including irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia, and psychoneurological disorders via the gut-brain-microbiota axis, a bidirectional signaling pathway between the enteric and central nervous system. Post-transplant exposure to antibiotics, antivirals, and immunosuppressant medications results in significant alterations in gut microbiota community composition and function, which in turn alter these commensal microorganisms' protective effects. This overview will discuss the current state of the science on the effects of the gut microbiome on symptom burden in kidney transplantation and future directions to guide this field of study.

Educational level and gender are associated with emotional well-being in a cohort of Dutch dialysis patients

BACKGROUND

Patients undergoing dialysis have an impaired health-related quality of life (HRQOL). There are conflicting data from small series on whether patient-related factors such as educational level have an impact on experienced HRQOL. The aim of this study was to investigate the association between educational level and HRQOL in dialysis patients.

METHODS

In a single-center retrospective cross-sectional study HRQOL was measured using the Kidney Disease Quality of Life Short Form-36 (KDQOL-SF36) in prevalent chronic dialysis patients. Educational level was categorized into low, intermediate and high subgroups. Univariate and multivariate regression analyses were performed to assess the effects of age, gender, ethnicity, and dialysis vintage on the association between HRQOL and educational level.

RESULTS

One hundred twenty-nine chronic dialysis patients were included. Patients with an intermediate educational level had significantly higher odds of a higher emotional well-being than patients with a low educational level 4.37 (1.-89-10.13). A similar trend was found for a high educational level (OR 4.13 (1.04-16.42), p = 0.044) The odds for women compared to men were 2.83 (1.32-6.06) for better general health and 2.59 (1.15-5,84) for emotional well-being. There was no interaction between gender and educational level for both subdomains. Each year of increasing age significantly decreased physical functioning (OR 0.94 (0.91-0.97)).

CONCLUSIONS

Educational level and sex were associated with emotional well-being, since patients with intermediate and high educational level and females had better emotional well-being in comparison to patients with low educational level and males. Physical functioning decreased with increasing age.

Impact of pandemic mobility restrictions on kidney transplant patients' experience: lessons on quality of care

BACKGROUND

Patient perspectives on their post-operative health are acknowledged as valuable healthcare outcomes and should be scrupulously considered when designing interventions for patient-centered healthcare. Yet, following the COVID-19 lockdown and in the absence of standardized guidelines on how to best provide virtual chronic care to kidney transplant recipients, little is known about how this unique population coped and managed to comply with public health indications during confinement.

METHODS

This study addresses this shortcoming by examining the experiences of patients from a tertiary hospital in Spain during the initial weeks of the lockdown decreed by the national government. Specifically, we focus our attention on the perceptions and experiences of these patients by retrieving robust qualitative and quantitative data: the former based on a thematic analysis of focus group transcripts, the latter obtained from a large-scale survey.

RESULTS

Our findings identify opportunities for improvement in the quality of care and point to the provisions that might be made when facing future pandemics or lockdown-requiring situations.

CONCLUSIONS

As healthcare services navigate evolving landscapes, our findings on the experience of kidney transplant recipients should enable hospital services to improve the quality of care they are able to provide to such patients during periods of restricted mobility, especially those associated with future disease emergencies, and considering that home confinement is often part of the natural course of post-operative care of these patients.

Exploring Patients' Perceptions About Chronic Kidney Disease and Their Treatment: A Qualitative Study

BACKGROUND

Unhelpful illness perceptions can be changed by means of interventions and can lead to improved outcomes. However, little is known about illness perceptions in patients with chronic kidney disease (CKD) prior to kidney failure, and no tools exist in nephrology care to identify and support patients with unhelpful illness perceptions. Therefore, this study aims to: (1) identify meaningful and modifiable illness perceptions in patients with CKD prior to kidney failure; and (2) explore needs and requirements for identifying and supporting patients with unhelpful illness perceptions in nephrology care from patients' and healthcare professionals' perspectives.

METHODS

Individual semi-structured interviews were conducted with purposive heterogeneous samples of Dutch patients with CKD (n = 17) and professionals (n = 10). Transcripts were analysed using a hybrid inductive and deductive approach: identified themes from the thematic analysis were hereafter organized according to Common-Sense Model of Self-Regulation principles.

RESULTS

Illness perceptions considered most meaningful are related to the seriousness (illness identity, consequences, emotional response and illness concern) and manageability (illness coherence, personal control and treatment control) of CKD. Over time, patients developed more unhelpful seriousness-related illness perceptions and more helpful manageability-related illness perceptions, caused by: CKD diagnosis, disease progression, healthcare support and approaching kidney replacement therapy. Implementing tools to identify and discuss patients' illness perceptions was considered important, after which support for patients with unhelpful illness perceptions should be offered. Special attention should be paid towards structurally embedding psychosocial educational support for patients and caregivers to deal with CKD-related symptoms, consequences, emotions and concerns about the future.

CONCLUSIONS

Several meaningful and modifiable illness perceptions do not change for the better by means of nephrology care. This underlines the need to identify and openly discuss illness perceptions and to support patients with unhelpful illness perceptions. Future studies should investigate whether implementing illness perception-based tools will indeed improve outcomes in CKD.

Patient-Centered Research and Outcomes in Cancer and Kidney Transplantation

Cancer has been identified by kidney transplant recipients as a critically important outcome. The co-occurrence of cancer and kidney transplantation represents a complex intersection of diseases, symptoms, and competing priorities for treatments. Research that focuses on biochemical parameters and clinical events may not capture the priorities of patients. Patient-centered research can improve the relevance and efficiency of research and is particularly pertinent in the setting of cancer and kidney transplantation to facilitate shared decision-making in complex clinical situations. In addition, patient-reported outcomes can facilitate the assessment of patients' experiences, symptom burden, treatment side effects, and quality of life. This review discusses patient-centered research in the context of kidney transplantation and cancer, including consumer involvement in research and patient-centered outcomes and their measures and inclusion in core outcome sets.

"It's My Life and It's Now or Never"-Transplant Recipients Empowered From a Service-Dominant Logic Perspective

Patient well-being after an organ transplant is a major outcome determinant and survival of the graft is crucial. Before surgery, patients are already informed about how they can influence their prognosis, for example by adhering to treatment advice and remaining active. Overall, effective selfmanagement of health-related issues is a major factor in successful long-term graft survival. As such, organ transplant recipients can be considered as co-producers of their own health status. However, although keeping the graft in good condition is an important factor in the patient's well-being, it is not enough. To have a meaningful life after a solid organ transplant, patients can use their improved health status to once again enjoy time with family and friends, to travel and to return to work -in short to get back on track. Our assertion in this article is twofold. First, healthcare providers should look beyond medical support in enhancing long-term well-being. Second, organ recipients should see themselves as creators of their own well-being. To justify our argument, we use the theoretical perspective of service-dominant logic that states that patients are the true creators of real value-in-use. Or as Bon Jovi sings, "It's my life and it's now or never."

Perspectives and experiences of kidney transplant recipients with graft failure: A systematic review and meta-synthesis

BACKGROUND

Kidney transplant recipients with graft failure are a rapidly rising cohort of patients who experience high morbidity, mortality, and fragmented transitions of care between transplant and dialysis teams. Current approaches to improving care focus on medical and surgical interventions, increasing re-transplantation, and improving coordination between treating teams with little understanding of patient needs and perspectives.

METHODS

We undertook a systematic literature review of personal experiences of patients with graft failure. Six electronic and five grey literature databases were searched systematically. Of 4664 records screened 43 met the inclusion criteria. Six empirical qualitative studies and case studies were included in the final analysis. Thematic synthesis was used to combine data that included the perspectives of 31 patients with graft failure and 9 caregivers.

RESULTS

Using the Transition Model, we isolated three interconnected phases as patients transition through graft failure: shattering of lifestyle and plans associated with a successful transplant; physical and psychological turbulence; and re-alignment by learning adaptive strategies to move forward. Critical factors affecting coping included multi-disciplinary healthcare approaches, social support, and individual-level factors. While clinical transplant care was evaluated positively, participants identified gaps in the provision of information and psychosocial support related to graft failure. Graft failure had a profound impact on caregivers especially when they were living donors.

CONCLUSIONS

Our review reports patient-identified priorities for improving care and can help inform research and guideline development that strives to improve the care of patients with graft failure.

Sickness Symptoms in Kidney Transplant Recipients: A Scoping Review

Sickness symptoms (depressive symptoms, anxiety, and fatigue) are common among people with chronic illness, often presenting as a symptom cluster. Sickness symptoms persist in many patients with chronic kidney disease, even after kidney transplantation (KT); however, little is known about sickness symptom-induced burden in KT recipients. This scoping review synthesizes available evidence for sickness symptoms in KT recipients, including findings on symptom prevalence, predictors, outcomes, interrelationships, and clustering. Among 38 reviewed studies, none identified sickness symptoms as a cluster, but we observed interrelationships among the symptoms examined. Fatigue was the most prevalent sickness symptom, followed by anxiety and depressive symptoms. Predictors of these symptoms included demographic, clinical, and psychosocial factors, and health-related quality of life was the most researched outcome. Future research should use common data elements to phenotype sickness symptoms, include biological markers, and employ sophisticated statistical methods to identify potential clustering of sickness symptoms in KT recipients.

Understanding Health-Related Quality of Life in Kidney Transplant Recipients: The Role of Symptom Experience and Illness Perceptions

The purpose of our article is to investigate the impact of symptom experience on health related quality of life (HRQOL) in kidney transplant recipients (KTRs) and whether illness perceptions mediated this impact. Symptom experience, illness perceptions, and HRQOL were measured at transplantation and 6 weeks after transplantation in KTRs in an ongoing Dutch cohort study. Multivariable linear regression models were used for the analysis. 90 KTRs were analyzed. Fatigue and lack of energy were the most prevalent and burdensome symptoms at transplantation. Mental HRQOL at 6 weeks after transplantation was comparable to that of the general Dutch population (mean [standard deviation, SD]: 49.9 [10.7]) versus 50.2 [9.2]), while physical HRQOL was significantly lower (38.9 [9.1] versus 50.6 [9.2]). Experiencing more symptoms was associated with lower physical and mental HRQOL, and the corresponding HRQOL reduced by -0.15 (95%CI, -0.31; 0.02) and -0.23 (95%CI, -0.42; -0.04) with each additional symptom. The identified mediation effect suggests that worse symptom experiences could cause more unhelpful illness perceptions and consequently lead to lower HRQOL. Illness perceptions may explain the negative impact of symptom experience on HRQOL. Future studies at later stages after kidney transplantation are needed to further explore the mediation effect of illness perceptions and guide clinical practice to improve HRQOL.

Correlation between CYP3A5 gene polymorphism and BK virus infection in kidney transplant recipients

BACKGROUND

Cytochrome P450 3A5 (CYP3A5) includes two active genotypes, namely CYP3A5*1/*1 or *1/*3 with the fast metabolic activity and CYP3A5*3/*3 with slow metabolic. We retrospectively analyzed the correlation between CYP3A5 gene polymorphism and the susceptibility to the BK virus (BKV) infection in renal transplant recipients.

METHODS

According to the inclusion/ exclusion criteria, we selected 134 recipients who received kidney transplantation at the Renmin Hospital of Wuhan University from January 2019 to December 2019. Based on the pre-operative CYP3A5 sequencing results, 134 recipients were divided into two groups: those expressing the fast metabolic CYP3A5*1/*1 or *1/*3 genotype; and, those expressing slow metabolic CYP3A5*3/*3 genotype. These two recipient groups were then analyzed for the BKV infection rate with different metabolic types to establish the potential relationship between CYP3A5 gene polymorphism and BKV infection.

RESULTS

The overall incidence of BKV viruria was 37.3%, whereas BKV viremia was 4.5% among all 134 recipients. The fast metabolism group had 9.1% incidence of BKV viremia and 49.1% incidence of BKV viruria. In contrast, the slow metabolism group had only 1.3%incidence of BKV viremia (P = 0.031) with only 29.1% BKV viruria (P = 0.011). The incidence of low levels of urinary BKV in the fast metabolism group was higher than that in the slow metabolism group (P = 0.005), while no significant statistical difference in the incidence of high levels of urinary BKV and high and low levels of blood BKV.

CONCLUSION

After kidney transplantation, CYP3A5 gene polymorphism of recipients present a certain relationship with the occurrence of BKV infection, which may be of value for the prediction and prevention of BKV infection.

Validity and reliability of Patient-Reported Outcomes Measurement Information System (PROMIS®) using Computerized Adaptive Testing (CAT) in patients with advanced chronic kidney disease

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS®) has been recommended for computerized adaptive testing (CAT) of health-related quality of life (HRQOL). This study compared the content, validity and reliability of seven PROMIS CATs to the 12-item Short-Form Health Survey (SF-12) in patients with advanced chronic kidney disease (CKD).

METHODS

Adult CKD patients with an eGFR < 30 ml/min.1.73m2 not receiving dialysis treatment completed seven PROMIS CATs (assessing physical function, pain interference, fatigue, sleep disturbance, anxiety, depression, and ability to participate in social roles and activities), the SF-12 and, additionally, the PROMIS Pain Intensity single item and Dialysis Symptom Index (DSI) at inclusion and 2-weeks. A content comparison was performed between PROMIS CATs and SF-12. Construct validity of PROMIS CATs was assessed using Pearson's correlations. Test-retest reliability of all patient-reported outcome measures (PROMs) was assessed by calculating the intra-class correlation coefficient (ICC) and minimal detectable change (MDC).

RESULTS

In total, 207 patients participated in the study. A median of 45 items (10 minutes) was completed for PROMIS CATs. All PROMIS CATs showed evidence for sufficient construct validity. PROMIS CATs, most SF-12 domains and summary scores, and DSI showed sufficient test-retest reliability (ICC ≥ 0.70). PROMIS CATs had a lower MDC compared to the SF-12 (5.7-7.4 compared to 11.2-21.7 across domains, respectively).

CONCLUSION

PROMIS CATs showed sufficient construct validity and test-retest reliability in patients with advanced CKD. PROMIS CATs required more items but showed better reliability than the SF-12. Future research is needed to investigate the feasibility of PROMIS CATs for routine nephrology care.

[Long-term physical and psychological consequences of chronic kidney disease]

Aufgrund der verbesserten Behandlungsoptionen können Patient:innen mit chronischen Nierenerkrankungen heute deutlich länger überleben als noch vor 10 Jahren. Das Überleben ist für die Betroffenen jedoch immer mit einem Verlust an Lebensqualität verbunden. In diesem Beitrag wird eine kurze Übersicht über die körperlichen und psychischen Erkrankungsfolgen, Begleiterkrankungen und Therapienebenwirkungen bei chronischen Nierenerkrankungen gegeben. Auf bisher bekannte Auswirkungen der COVID-19-Pandemie wird hingewiesen. Abschließend wird aufgezeigt, wie die Langzeitbehandlung weiterentwickelt werden sollte, um die Lebensqualität der Patient:innen zu erhöhen.

Funktionseinschränkungen der Niere haben aufgrund der Kontamination des Blutes mit harnpflichtigen Substanzen (Urämie) schwere Auswirkungen auf den Gesamtorganismus. Zusätzlich sind die Patient:innen von Nebenwirkungen betroffen, die im Zusammenhang mit der medikamentösen Therapie, Dialyse oder Nierentransplantation auftreten können. Patient:innen und Angehörige sind einer großen psychischen Belastung ausgesetzt. Infektionen mit SARS-CoV‑2 können die Nierenfunktion beeinträchtigen und auch die Prognose einer bereits bestehenden Erkrankung verschlechtern.

Die ganzheitliche Versorgung der Patient:innen mit chronischen Nierenerkrankungen muss neben der medizinischen Versorgung auch die psychologischen und psychosozialen Aspekte berücksichtigen. Nephrologie und Psychonephrologie müssen Hand in Hand weiterentwickelt werden, um die medizinische Versorgung und Lebensqualität der betroffenen Patient:innen zu verbessern.

Peritoneal Dialysis for Potential Kidney Transplant Recipients: Pride or Prejudice?

Kidney transplantation (KT) is recognized as the gold-standard of treatment for patients with end-stage renal disease. Additionally, it has been demonstrated that receiving a pre-emptive KT ensures the best recipient and graft survivals. However, due to an overwhelming discrepancy between the organs available and the patients on the transplant waiting list, the vast majority of transplant candidates require prolonged periods of dialysis before being transplanted. For many years, peritoneal dialysis (PD) and hemodialysis (HD) have been considered competitive renal replacement therapies (RRT). This dualistic vision has recently been questioned by evidence suggesting that an individualized and flexible approach may be more appropriate. In fact, tailored and cleverly planned changes between different RRT modalities, according to the patient’s needs and characteristics, are often needed in order to achieve the best results. While home HD is still under scrutiny in this particular setting, current data seems to favor the use of PD over in-center HD in patients awaiting a KT. In this specific population, the demonstrated advantages of PD are superior quality of life, longer preservation of residual renal function, lower incidence of delayed graft function, better recipient survival, and reduced cost.

Therapeutic education as a tool to improve patient-reported and clinical outcomes after renal transplantation: results of the EPHEGREN multicenter retrospective cohort study

Patients are not always aware of the inconveniences associated with renal transplantation, which they compare with a « rebirth », and from which they expect complete recovery. Therapeutic education is proposed to prepare patients for their life after transplantation. This study evaluated the impact of pretransplant therapeutic education on patient-reported outcomes and rejection-free survival over the first year. We collected data from 383 renal transplant patients followed-up in seven centers. Patients who benefited from therapeutic education before transplantation (N = 182) were compared with patients who did not (N = 139) for quality-of-life, adherence and adverse events using the Pearson's chi-square test, one-way ANOVA or t-test. The association between therapeutic education and time to acute rejection was investigated using Cox models. The patients who benefited from therapeutic education reported adverse events less frequently (e.g., tremor: 9% vs. 32.4%, P = 0.01) and better quality-of-life (MCS-QOL: 50.7 ± 8.1 vs. 47.7 ± 9.5, P = 0.02; PCS-QOL: 49.1 ± 7.1 vs. 46.0 ± 9.2, P = 0.013). No difference was found on adherence. Rejection-free survival was slightly better in the therapeutic education group (HR = 0.44, 95% CI = [0.19-1.01]). This multicenter retrospective cohort study suggests that integrating therapeutic education to care pathways entails clinical benefit, in terms of quality-of-life, self-reported adverse events and rejection-free survival. Randomized clinical trials are necessary to confirm this.