Patient-reported outcome measures for life participation in kidney transplantation: A systematic review

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.

Validation of a Core Patient-Reported Outcome Measure for Life Participation in Kidney Transplant Recipients: the SONG Life Participation Instrument

Introduction

Life participation has been established as a critically important core for trials in kidney transplantation. We aimed to validate a patient-reported outcome measure for life participation in kidney transplant recipients.

Methods

A psychometric evaluation of the Standardized Outcomes in Nephrology life participation (SONG-LP) measure was conducted in adult kidney transplant recipients. The measure includes 4 items of life participation (leisure, family, work, and social) each with a 5-point Likert scale. Each item is scored from 0 (never) to 4 (always) and the summary measure score the average of each item.

Results

A total of 249 adult kidney transplant recipients from 20 countries participated. The SONG-LP instrument demonstrated internal consistency (Cronbach's α = 0.87; 95% confidence intervals [CI]: 0.83-0.90, baseline) and test-retest reliability over 1 week (intraclass correlation coefficient of 0.62; 95% CI: 0.54-0.70). There was moderate to high correlation (0.65; 95% CI: 0.57-0.72) with the PROMIS Ability to Participate in Social Roles and Activities Short Form 8a that assessed a similar construct, and moderate correlation with measures that assessed related concepts (i.e., EQ5D 0.57; 95% CI: 0.49-0.65), PROMIS Cognitive Functional Abilities Subset Short Form 4a (0.40; 95% CI: 0.29-0.50).

Conclusion

The SONG-LP instrument is a simple, internally consistent, reliable measure for kidney transplant recipients and correlates with similar measures. Routine incorporation in clinical trials will ensure consistent and appropriate assessment of life participation for informed patient-centered decision-making.

Self-Management Interventions for Facilitating Life Participation for Persons with Kidney Failure: A Systematic Review

BACKGROUND

For persons with kidney failure, life participation is a critically important outcome, strongly linked to quality of life and mortality. To support patients' self-management abilities, three domains are typically emphasized: medical management, emotional management, and management of everyday life ( i.e. , role management). Although role management is strongly linked to life participation, there is currently limited research on interventions designed to support it. We explored existing self-management interventions that aim to support everyday life functioning, rather than only medical management.

METHODS

In this systematic review and qualitative meta-synthesis, we searched MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and CENTRAL up to April 2022 for interventional studies involving self-management interventions designed, at least partly, to support management of everyday life. The guidelines by Sandelowski and Barosso were used to analyze and synthesize the results. A taxonomy of everyday self-management strategies was used to further explore intervention content. Study quality was assessed using the Cochrane Collaboration risk-of-bias tools. Evidence of effectiveness was summarized, and a meta-analysis of eligible outcomes was conducted.

RESULTS

Of 22,667 records, 53 studies were included in the meta-synthesis. Most self-management interventions focused on medical management. Included interventions involved strategies to support eight domains: Activities of daily living, Work and school life, Meaningful occupations, Leisure activities, Mobility and travel, Interpersonal relationships, Role functioning, and Social participation. Major interventions focused on providing education, skill training, counseling, and cognitive behavioral therapy. Evidence of effectiveness was reported across a wide range of patient-reported outcomes, including (health-related) quality of life, depression, and self-efficacy. Studies were geographically concentrated and were of moderate to low quality.

CONCLUSIONS

Despite its well-recognized importance, research on interventions to improve life participation mostly consisted of pilot and feasibility studies and studies of low quality. Interventions were reported heterogeneously, limiting comparability, and were restricted to specific regions and cultures, limiting generalizability.

Novel Endpoints in Solid Organ Transplantation: Targeting Patient-reported Outcome Measures

Although solid organ transplantation improves survival and quality of life in many patients with organ failure, treatment complications and side effects can have debilitating consequences for patients. Patient-reported outcome measures (PROMs) capture how patients feel and function, including quality of life, symptoms, and side effects that are assessed directly by patients. Yet, they remain infrequently reported in trials in solid organ transplantation. Barriers to implementing PROMs in trials include uncertainty in selecting appropriate PROMs, concerns about resources limitations, patient burden, and limited evidence to support the psychometric robustness of measures for use in transplant recipients. In recent years, there have been increasing efforts to include patient-reported outcomes that are important to patients in trials to ensure that trials provide patient-centered information for decision-making. This article will provide an overview of PROMs, discuss PROs that are important to solid organ transplant recipients and those that are used in trials in solid organ transplantation, and outline approaches for selecting PROMs for clinical trials.

Knowledge Translation in Glomerulonephritis: Successes in Translational Research From the Bench to Bedside

Purpose of review

Glomerulonephritis refers to a rare group of diseases characterized by glomerular inflammation, which collectively are a common cause of kidney failure. Until recently, there was a lack of high-quality clinical trials to inform the care of patients with glomerulonephritides. We identified examples of successful translational research spanning from basic science to clinical applications, and highlight gaps in implementation science.

Sources of information

The focus of our review was derived from discussions between health care professionals, researchers, and patient partners. We also performed literature searches pertaining to the treatment of glomerulonephritis in PubMed and Google Scholar.

Methods

Examples of successful knowledge translation were generated through review of new evidence in the past 5 years and by iterative discussions by the authors. We then conducted a narrative review of several themes related to knowledge translation in glomerulonephritis. This was complemented by an interview with a patient partner to provide an example of a patient's perspective living with glomerulonephritis.

Key findings

We summarized selected recent advances in glomerulonephritis and its knowledge translation in the following domains: (1) identification of auto-antibodies in membranous nephropathy and minimal change disease; (2) clinical trials of novel targeted therapies for IgA nephropathy and lupus nephritis, which have led to approval of new treatments; (3) developments in research networks and clinical trials in glomerulonephritis; (4) recognition of the importance in developing standardized patient reported outcome measures in clinical trials; and (5) barriers in knowledge translation including access to medication.

Limitations

A systematic search of the literature and formal assessment of quality of evidence were beyond the scope of this review.

Glucose as a Risk Factor for Periodontitis in Kidney Transplantation Patients

BACKGROUND

Various factors including diabetes and oxidative stress are associated with periodontal inflammation. End-stage renal disease causes various systemic abnormalities in patients, including cardiovascular disaese, metabolic abnormalities, and infection. Even after kidney transplantation (KT), these factors are known to be associated with inflammation. Our study, therefore, aimed to study risk factors associated with periodontitis in KT patients.

METHODS

Patients who visited Dongsan Hospital, Daegu, Korea since 2018 and have undergone KT were selected. As of November 2021, 923 participants, with full data including hematologic factors were studied. Periodontitis was diagnosed based on residual bone level in panoramic views. Patients were studied by the presence of periodontitis.

RESULTS

From 923 KT patients, 30 were diagnosed with periodontal disease. Fasting glucose levels were higher in patients with periodontal disease, and total bilirubin levels were lower. When divided by fasting glucose levels, high glucose level showed increase of periodontal disease with odds ratio of 1.031 (95% confidence interval 1.004-1.060). After adjusting for confounders, the results were significant with odds ratio of 1.032 (95% CI 1.004-1.061).

CONCLUSIONS

Our study showed that KT patients, of whom uremic toxin clearance has been revolted, are yet at risk of periodontitis by other factors, such as high blood glucose levels.

Patient-reported outcomes evaluation and assessment of facilitators and barriers to physical activity in the Transplantoux aerobic exercise intervention

Background

Transplantoux’s MVT exercise intervention prepares organ transplant recipients to cycle or hike up France’s Mont Ventoux. We aimed to assess (i) MVT’s effects on patient-reported outcomes (PROs) and (ii) perceived barriers and facilitators to physical activity.

Methods

Using a hybrid design, a convenience sample of transplant recipients participating in MVT (n = 47 cycling (TxCYC); n = 18 hiking (TxHIK)), matched control transplant recipients (TxCON, n = 213), and healthy MVT participants (HCON, n = 91) completed surveys to assess physical activity (IPAQ), health-related quality of life (HRQOL; SF-36 and EuroQol VAS), mental health (GHQ-12), and depressive symptomatology, anxiety, and stress (DASS-21) at baseline, then after 3, 6 (Mont Ventoux climb), 9, and 12 months. TxCYC and TxHIK participated in a 6-month intervention of individualized home-based cycling/hiking exercise and a series of supervised group training sessions. Barriers and facilitators to physical activity (Barriers and Motivators Questionnaire) were measured at 12 months.

Results

Regarding PROs, except for reducing TxHIK stress levels, MVT induced no substantial intervention effects. For both TxCYC and TxHIK, between-group comparisons at baseline showed that physical activity, HRQOL, mental health, depressive symptomatology and stress were similar to those of HCON. In contrast, compared to TxCYC, TxHIK, and HCON, physical activity, HRQOL and mental health were lower in TxCON. TxCON also reported greater barriers, lower facilitators, and different priority rankings concerning physical activity barriers and facilitators.

Conclusion

Barely any of the PROs assessed in the present study responded to Transplantoux’s MVT exercise intervention. TxCON reported distinct and unfavorable profiles regarding PROs and barriers and facilitators to physical activity. These findings can assist tailored physical activity intervention development.

Trial registration

Clinical trial notation: The study was approved by the University Hospitals Leuven’s Institutional Review Board (B322201523602).

Interconnectedness between periodontitis stage, oral hygiene habits, adherence to the Mediterranean diet and nutritional status in Dalmatian kidney transplant recipients: a cross-sectional study

The aim of this cross-sectional study was to determine the associations between the Mediterranean diet (MeDi), nutritional status parameters, muscle strength, and periodontal status in Dalmatian kidney transplant recipients (KTRs). 89 KTRs were included in this analysis, 40 (45%) women, with a mean age of 61 years (IQR = 13) and a mean time since kidney transplantation of 5 years (IQR = 6.6). An OHIP-14 questionnaire and questionnaire-based periodontal history were obtained from all participants, a comprehensive periodontal examination was performed. Body composition data, anthropometric and clinical parameters were collected for each study participant. The Mediterranean Diet Serving Score (MDSS) was used to assess MeDi adherence, and handgrip strength was measured with a hand dynamometer. Our results showed low adherence to MeDi in KTRs (28%) and almost 50% of KTRs suffer from severe forms of periodontitis. We also found a low OHIP-14 score and poor oral hygiene habits. KTRs with a less severe form of periodontitis had higher muscle mass and handgrip strength. MDSS score was associated with a higher number of teeth, and everyday cereal intake was inversely associated with the periodontitis stage. Our results demonstrate the associations between nutritional status, muscle strength, dietary habits, and periodontal health in Dalmatian KTRs.

Patient-Reported Outcomes as Endpoints in Clinical Trials of Kidney Transplantation Interventions

Patient-reported outcomes (PROs) that assess individuals' perceptions of life participation, medication adherence, disease symptoms, and therapy side effects are extremely relevant in the context of kidney transplantation. All PROs are potentially suitable as primary or secondary endpoints in interventional trials that aim to improve outcomes for transplant recipients. Using PRO measures (PROMs) in clinical trials facilitates assessment of the patient's perspective of their health, but few measures have been developed and evaluated in kidney transplant recipients; robust methodologies, which use validated instruments and established frameworks for reporting, are essential. Establishing a core PROM for life participation in kidney transplant recipients is a critically important need, which is being developed and validated by the Standardized Outcomes in Nephrology (SONG)-Tx Initiative. Measures involving electronic medication packaging and smart technologies are gaining traction for monitoring adherence, and could provide more robust information than questionnaires, interviews, and scales. This article summarizes information on PROs and PROMs that was included in a Broad Scientific Advice request on clinical trial design and endpoints in kidney transplantation. This request was submitted to the European Medicines Agency (EMA) by the European Society for Organ Transplantation in 2016. Following modifications, the EMA provided its recommendations in late 2020.

Healthy ageing through participation in community situated activities: A scoping review of assessment instruments to support occupational therapy practice

Introduction

The occupational therapy profession has an essential role to play in healthy ageing that includes enabling participation, a construct that according to The International Classification of Functioning, Disability and Health (ICF), incorporates an environmental context. Environmental barriers and enablers of participation in community‐situated activities for people over the age of 65 have been identified. To support practice, occupational therapists require assessments with demonstrated content validity including comprehensive coverage of the construct. The purpose of this scoping review study was to investigate what instruments are available to assess community participation for people over the age of 65 that included environmental factors.

Methods

A scoping review of the literature was conducted, utilising the Joanna Briggs Institute (JBI) scoping review methodology. The evidence source was review articles and inclusion criteria were that they reviewed instruments to assess participation that could be used for people over the age of 65. Items extracted from included instruments were evaluated against a preset list of community‐participation and environment categories that had been developed from the ICF.

Results

Twenty‐three review studies met inclusion criteria and from these 240 instruments were extracted. Twenty instruments were retained after exclusions and from these, 540 instrument items were extracted. Of these, 280 (47%) were coded as community‐participation, and only 20 (3.4%) as environment items. Fourteen of the instruments included no environment items.

Conclusions

No instrument was identified that comprehensively assessed community participation including the related environmental factors. Such an instrument is required to enable occupational therapy practitioners to support healthy ageing. The development of such an instrument will strengthen the profession's capacity to develop new ways of delivering services to older adults in line with emerging ways that aged care will be delivered and to advance its essential role in healthy ageing.

How to assess quality of life in persons with chronic kidney disease

PURPOSE OF REVIEW

Chronic kidney disease (CKD) significantly impacts many aspects of life, health, and wellbeing. People with CKD have individual priorities for their care which may differ from those valued by clinicians and policy makers. The patient experience is broadly captured by the concept of quality of life (QoL) which is increasing assessed in research and used to guide clinical and policy decision making. Appropriate selection and application of QoL assessment tools are essential for high-quality research and patient care. This article summarises the current approaches to QoL assessment in CKD and outlines aspirations for future improvement.

RECENT FINDINGS

Commonly used tools for assessment of QoL in CKD include the Short Form-36 and -12 and extended versions adapted for specific use in kidney patients (KD-QoL), and the EQ-5D. However, a wide range of other instruments are also reported, making comparisons between research findings challenging. Few of the tools are adequately validated for use in CKD, and relevance to patient values are unclear. Instruments suitable for use in a routine clinical setting are lacking.

SUMMARY

QoL instruments developed and validated with meaningful CKD stakeholder input are required. The Standardised Outcomes in Nephrology initiative is working to address this need.

Patient-reported outcome measures for life participation in peritoneal dialysis: a systematic review

BACKGROUND

Patients receiving peritoneal dialysis (PD) endure an ongoing regimen of daily fluid exchanges and are at risk of potentially life-threatening complications and debilitating symptoms that can limit their ability to participate in life activities. The aim of the study was to identify the characteristics, content and psychometric properties of measures for life participation used in research in PD.

METHODS

We searched MEDLINE, Embase, PsychInfo, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Cochrane Central Register of Controlled Trials from inception to May 2020 for all studies that reported life participation in patients on PD. The characteristics, dimensions of life participation and psychometric properties of these measures were extracted and analyzed.

RESULTS

Of the 301 studies included, 17 (6%) were randomized studies and 284 (94%) were nonrandomized studies. Forty-two different measures were used to assess life participation. Of these, 23 (55%) were used in only one study. Fifteen (36%) measures were specifically designed to assess life participation, while 27 (64%) measures assessed broader constructs, such as quality of life, but included questions on life participation. The 36-Item Short Form Health Survey and Kidney Disease Quality of Life Short Form were the most frequently used measures [122 (41%) and 86 (29%) studies, respectively]. Eight (19%) measures had validation data to support their use in patients on PD.

CONCLUSIONS

The many measures currently used to assess life participation in patients receiving PD vary in their characteristics, content and validation. Further work to pilot and validate potential measures is required to establish a core patient-reported outcome measure to assess life participation in patients receiving PD.

Construction of an index system for evaluating the effectiveness of transitional care in kidney transplant recipients

BACKGROUND

Previous studies showed that transitional care reduces the complication rate and readmission rate and improves the quality of life in kidney transplant receipts, nevertheless, in fact there are no standard evaluation indexes and debatable scientific of existing indexes in kidney transplant recipients. Therefore, the aim of this study was to construct an evaluation index system to assess the effects of transitional care in kidney transplant recipients.

METHODS

Based on Omaha system, an initial evaluation index system about the effects of transitional care in kidney transplant recipients was drafted by the literature review and semi-structured interview. Two rounds of correspondence were conducted in 19 experts and the analytic hierarchy process (AHP) was used to calculate the weights of all indexes.

RESULTS

Five first-level indexes, sixteen second-level indexes, and forty-eight third-level indexes were selected in the initial evaluation index system. The authority coefficient of two-round expert consultations was 0.90 and coordination coefficients of indexes ranged from 0.24 to 0.34.

CONCLUSION

The established evaluation index system for the effectiveness of transitional care for kidney transplant recipients was scientific and reliable. Furthermore, it would be a potential method to evaluate effects of transitional care in kidney transplant recipients after further examination.

Distinct roles for major and minor antigen barriers in chimerism-based tolerance under irradiation-free conditions

Eliminating cytoreductive conditioning from chimerism-based tolerance protocols would facilitate clinical translation. Here we investigated the impact of major histocompatibility complex (MHC) and minor histocompatibility antigen (MiHA) barriers on mechanisms of tolerance and rejection in this setting. Transient depletion of natural killer (NK) cells at the time of bone marrow (BM) transplantation (BMT) (20 × 10⁶ BALB/c BM cells → C57BL/6 recipients under costimulation blockade [CB] and rapamycin) prevented BM rejection. Despite persistent levels of mixed chimerism, BMT recipients gradually rejected skin grafts from the same donor strain. Extending NK cell depletion did not improve skin graft survival. However, F1 (C57BL/6×BALB/c) donors, which do not elicit NK cell-mediated rejection, induced durable chimerism and tolerance. In contrast, if F1 donors with BALB/c background only were used (BALB/c×BALB.B), no tolerance was observed. In the absence of MiHA disparities (B10.D2 donors, MHC-mismatch only), temporal NK cell depletion established stable chimerism and tolerance. Conversely, MHC identical BM (BALB.B donors, MiHA mismatch only) readily engrafted without NK cell depletion but no skin graft tolerance ensued. Therefore, we conclude that under CB and rapamycin, MHC disparities provoke NK cell-mediated BM rejection in nonirradiated recipients whereas MiHA disparities do not prevent BM engraftment but impede skin graft tolerance in established mixed chimeras.

A Canadian Survey on Adverse Symptoms Experienced by Solid Organ Transplant Recipients

INTRODUCTION

Adverse symptoms experienced by solid organ transplant recipients remain largely unexplored despite their purported frequency.

OBJECTIVE

To characterize patient perspectives on adverse symptoms, identifying the most problematic symptoms and the perceived cause and treatability, and to evaluate their impact on quality of life (QoL) and medication adherence.

METHODS

An electronic survey was distributed to members of the Canadian Transplant Association, to characterize perceptions on symptom experience (Modified Transplant Symptom Occurrence and Distress Scale), and QoL (Short Form-12), medication adherence (Basel Assessment of Adherence to Immunosuppressive Medications Scale), demographics, and clinical situation.

RESULTS

The questionnaire was distributed to 249 solid organ transplant recipients and achieved a 51% response rate (N = 127). Respondents reported a mean of 25 (standard deviation 10) adverse symptoms each. In women, the most prevalent and distressing symptoms were tiredness, lack of energy, sleep difficulties, difficulty concentrating or memory problems, diarrhea, joint pain, and depression. In men, they were tiredness, flatulence, lack of energy, sleep difficulties, and erectile problems. With the exception of flatulence, these symptoms were more often perceived to be caused by medical conditions rather than by immunosuppressants or other medications. Quality of life was similar to the general public, with mean physical and mental component scores of 47.4 (9.9) and 52.1 (8.2), respectively (relative to a US average of 50 [10]). However, QoL scores inversely correlated to the number of symptoms reported and were higher in patients who perceived all symptoms to be treatable.

CONCLUSION

Adverse symptoms may impact patient well-being. Perceived cause and treatability should be further explored.

Pathological Characteristics of Periodontal Disease in Patients with Chronic Kidney Disease and Kidney Transplantation

Chronic kidney disease (CKD) is recognized as an irreversible reduction of functional nephrons and leads to an increased risk of various pathological conditions, including cardiovascular disease and neurological disorders, such as coronary artery calcification, hypertension, and stroke. In addition, CKD patients have impaired immunity against bacteria and viruses. Conversely, kidney transplantation (KT) is performed for patients with end-stage renal disease as a renal replacement therapy. Although kidney function is almost normalized by KT, immunosuppressive therapy is essential to maintain kidney allograft function and to prevent rejection. However, these patients are more susceptible to infection due to the immunosuppressive therapy required to maintain kidney allograft function. Thus, both CKD and KT present disadvantages in terms of suppression of immune function. Periodontal disease is defined as a chronic infection and inflammation of oral and periodontal tissues. Periodontal disease is characterized by the destruction of connective tissues of the periodontium and alveolar bone, which may lead to not only local symptoms but also systemic diseases, such as cardiovascular diseases, diabetes, liver disease, chronic obstructive pulmonary disease, and several types of cancer. In addition, the prevalence and severity of periodontal disease are significantly associated with mortality. Many researchers pay special attention to the pathological roles and clinical impact of periodontal disease in patients with CKD or KT. In this review, we provide information regarding important modulators of periodontal disease to better understand the relationship between periodontal disease and CKD and/or KT. Furthermore; we evaluate the impact of periodontal disease on various pathological conditions in patients with CKD and KT. Moreover, pathogens of periodontal disease common to CKD and KT are also discussed. Finally, we examine the importance of periodontal care in these patients. Thus, this review provides a comprehensive overview of the pathological roles and clinical significance of periodontal disease in patients with CKD and KT.