Transplanted children's experiences of daily living: children's narratives about their lives following transplantation

Holistic care and symptom management for pediatric kidney transplant recipients

While many aspects of life may improve substantially for children and young people undergoing kidney transplant, there may be new challenges including symptoms that can be detrimental to health-related quality of life. Addressing symptoms requires attention to patient and family perspectives and a holistic approach grounded in symptom management. The interdisciplinary pediatric nephrology transplant team should be attuned to the prevalence of common symptoms including fatigue, anxiety, depression, post-traumatic stress, pain, and sleep disturbances, as well as poor body image and sexual health. These common symptoms require regular assessment with a focus on appropriate interventions and how care may be impacted by transplant status.

Psychosocial conditions of children after liver transplant: Post-traumatic stress, depression, and anxiety

AIM

This study aimed to determine psychosocial conditions, post-traumatic stress, depression, and anxiety of children who underwent a liver transplant.

METHOD

This is a relational descriptive study, which was conducted between March 2019 and December 2020 in the Inonu University Liver Transplantation Institute Pediatric Liver Transplant Clinic. The "Child Information Form," "Child Post-Traumatic Stress Reaction Index," "State-Trait Anxiety Inventory for Children-Trait Form," and "Children's Depression Inventory" were used to collect data. The study was conducted with 71 children who had a previous liver transplant.

RESULTS

Of the participating children, 56.3% were girls, 63.4% continued their primary school education after the transplant, 32.5% were diagnosed with cirrhosis, 39.4% received the transplant in 2017, 32.4% received it from the mother, and 25.4% received it from a cadaveric donor. Although it had been at least 3 years since the transplant, 47.9% exhibited moderate and 43.7% severe post-traumatic stress responses. There was a significant negative relationship between the age of children with a liver transplant and trait anxiety and post-traumatic stress responses (path coefficients β = -0.268, p = 0.002; β = -0.166, p = 0.023, respectively). There was a significant positive relationship between anxiety and post-traumatic stress responses of the children after the transplant and there was a statistically significant relationship between the path coefficients (β = 0.750; p < 0.001).

CONCLUSION

Children who underwent a liver transplant had post-traumatic stress disorder, depression, and trait anxiety.

Parenting a child with a kidney transplant-A study of everyday life experiences

BACKGROUND

Kidney transplantation in children shows excellent long-term outcomes. However, parents feel responsible for ensuring that their child adheres to complex medical interventions. The dual role - as both parent and medical caregiver - gives rise to fatigue, stress, and emotional pain. Parental and family functioning are critically important to a child's disease course, development and well-being.

OBJECTIVE

To explore the experiences and perspectives of mothers and fathers of children with a kidney transplant.

DESIGN

An explorative study using a qualitative method.

PARTICIPANTS

Twelve parents (seven mothers and five fathers) of seven children with a kidney transplant.

APPROACH

A qualitative exploratory study taking a phenomenological-hermeneutic approach.

METHOD

Semi-structured individual interviews were conducted. The data were analysed using Ricoeur's theory of narrative and interpretation on three levels: naïve reading, structural analysis, and critical interpretation and discussion.

FINDINGS

Four themes were generated: Kidney transplantation as a turning point, the importance of a close collaboration with health care professionals, being the child's voice, and managing the dual role as a parent, and medical caregiver in everyday life.

CONCLUSION

Child kidney transplantation led to a transformation in the child, on the physical, mental, and social levels; however, the child was still in need of special attention and support. Problems with the kidney graft functioning resulted in frustration and disappointment in parents. Teamwork between a child's parents became evident, in coping with the dual role as a parent and medical caregiver. Parents aimed to maintain a clear structure related to medication and disease-related treatment. A close and trustful relationship and collaboration with health care professionals were significant and included listening to the voice of the child.

How do children and adolescents experience healthcare professionals? Scoping review and interpretive synthesis

OBJECTIVE

Explore children's and adolescents' (CADs') lived experiences of healthcare professionals (HCPs).

DESIGN

Scoping review methodology provided a six-step framework to, first, identify and organise existing evidence. Interpretive phenomenology provided methodological principles for, second, an interpretive synthesis of the life worlds of CADs receiving healthcare, as represented by verbatim accounts of their experiences.

DATA SOURCES

Five key databases (Ovid Medline, Embase, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, and Web of Science), from inception through to January 2019, reference lists, and opportunistically identified publications.

ELIGIBILITY CRITERIA

Research articles containing direct first-person quotations by CADs (aged 0-18 years inclusive) describing how they experienced HCPs.

DATA EXTRACTION AND SYNTHESIS

Tabulation of study characteristics, contextual information, and verbatim extraction of all 'relevant' (as defined above) direct quotations. Analysis of basic scope of the evidence base. The research team worked reflexively and collaboratively to interpret the qualitative data and construct a synthesis of children's experiences. To consolidate and elaborate the interpretation, we held two focus groups with inpatient CADs in a children's hospital.

RESULTS

669 quotations from 99 studies described CADs' experiences of HCPs. Favourable experiences were of forming trusting relationships and being involved in healthcare discussions and decisions; less favourable experiences were of not relating to or being unable to trust HCPs and/or being excluded from conversations about them. HCPs fostered trusting relationships by being personable, wise, sincere and relatable. HCPs made CADs feel involved by including them in conversations, explaining medical information, and listening to CADs' wider needs and preferences.

CONCLUSION

These findings strengthen the case for making CADs partners in healthcare despite their youth. We propose that a criterion for high-quality child-centred healthcare should be that HCPs communicate in ways that engender trust and involvement.

Psychological functioning and psychosocial issues in pediatric kidney transplant recipients

Research demonstrates that psychological factors are important for positive transplant outcomes, though there is little literature that synthesizes these factors in a comprehensive model among pediatric kidney transplant patients. This review analyzes psychological and psychosocial factors related to medical outcomes and overall well-being post-transplant by utilizing the PPPHM and referencing the existing literature on risk and resilience. Pediatric kidney transplant recipients are more susceptible to mental health concerns such as depression, anxiety, and ADHD, as well as developmental and neurocognitive delays, compared to healthy peers. Complex medical care and psychosocial needs for patients have implications for family functioning, parental and sibling mental health, and youth readiness to transition to adult care. It is important to carefully monitor patient functioning with empirically validated tools and to intervene in a multidisciplinary setting as early as possible to identify patients at risk and reduce potential negative impact. Psychologists are uniquely trained to assess and address these issues and are a valuable component of multidisciplinary, culturally competent care. While research in this expansive field is improving, more data are needed to establish gold standard approaches to mental health and psychosocial care in this population.

Understanding the Long-Term Impact of Living-Related Liver Transplantation on Youth and Young Adults and their Family

PURPOSE

The purpose of this mixed methods study was to better understand the long term impact of living-related liver donation (LRLD) on youth and young adult (YYA) recipients and their family.

DESIGN AND METHODS

Semistructured interviews were conducted with YYA, aged 11-18 years, who received a living donation from a parent. Interviews were audiotaped, transcribed, and analyzed to aggregate themes that represented the participants' views as live-liver recipients. An ethnographic process was conducted to understand the participants' social behavior. At interview, participants completed a demographics questionnaire and the Youth Quality of Life Instrument-Research Version (YQOL-R).

RESULTS

Thirteen adolescents were interviewed; six were re-interviewed as key informants. Three major categories were created from the data: Developing Identity, Redefining Family Relationships, Feeling Gratitude to Donors. The overarching theme was Resiliency. Findings from the YQOL-R showed no difference in overall scores or separate domains when compared with a reference population with no chronic illness.

CONCLUSION

Qualitative and quantitative data highlight the positive effect that LRLD can have on pediatric patients as they transition from childhood to adolescence to young adulthood.

PRACTICE IMPLICATIONS

As pediatric transplant centers in the United States soon mark 30 years of performing live-liver donation, recipients are becoming adults and understanding more clearly that the long-term effects of such donations will lead to improvements in future care.

Health-related quality of life changes following renal transplantation in children

BACKGROUND

Studies of HRQoL after kidney transplant have yielded conflicting results. We sought to assess the impact of kidney transplant on HRQoL.

METHODS

We performed a retrospective study using the PedsQL3.0ESRD module during dialysis and at 3 and 12 months following kidney transplant in 56 recipients. For the entire cohort, we described HRQoL scores at each time point and used ANOVA models to test for associations between demographic and transplant-related factors and post-transplant scores. We used linear mixed models to investigate interactions between transplant and demographic and transplant-related factors and to estimate differences between mean pre- and post-transplant scores. Longitudinal changes in HRQoL were assessed by t test.

RESULTS

We found increases in all mean total scores, including subscales, at each assessed time period from dialysis to 3 months post-transplant to 12 months post-transplant. Post-transplant total scores did not differ by gender, race, proximity to hospital, allograft source, or dialysis modality, but did differ by recipient age. Among participants with both pre- and post-transplant observations, total scores increased for both recipients and parent-proxies.

CONCLUSIONS

This study affirms the association between kidney transplant and improvement in HRQoL in the first year following transplant. Future research should further explore outcomes over the longer-term and factors contributing to HRQoL among this population.

In their own words: the value of qualitative research to improve the care of children with chronic kidney disease

Patient- and family-centered care is hailed as a hallmark of high-quality pediatric care. This partnership between patients, families and their healthcare providers is central to caring for children with chronic kidney disease (CKD), given the long-term and profound impact of the disease and its treatment on the development and quality of life of these children. This paradigm hinges on a comprehensive and detailed understanding of the needs, beliefs and values of children with CKD and their families. However, their perspectives may remain undisclosed during time-limited clinical consultations and because of beliefs that if they did disclose their concerns, their care would be jeopardized. Qualitative research provides an avenue for children and families to articulate their perspectives and experiences and thereby to generate relevant, in-depth and often compelling insights to inform care. Yet, qualitative studies remain sparse in biomedical journals. Increasing both our awareness of the role of qualitative research in improving care and outcomes for children and adolescents with CKD and our understanding of the conduct and rigor of qualitative studies is required. This article will outline how qualitative research can generate relevant evidence to inform practice and policy in children with CKD, provide an overview of qualitative methods and introduce a framework to appraise qualitative research. More evidence derived from qualitative research is needed to inform shared decision-making and the development of interventions and policies that address the preferences and priorities of children with CKD and their families. Ultimately, this strategy may help to improve the outcomes that they regard as critical to their care.

Experiences of adolescent lung transplant recipients: A qualitative study

Many young transplant recipients experience psychological distress and adjustment difficulties, yet there is little research investigating lung transplantation from the recipients' perspective. This qualitative study aimed to explore experiences of young people who underwent lung transplantation. Semi-structured interviews were conducted with six lung transplant recipients (aged 15-18). Interviews were analysed using IPA, a qualitative research approach examining how people make sense of their major life experiences. The analysis revealed three master themes: "Living with Dodgy Lungs" outlined how participants dealt with their experiences, managing through accepting or discussing their feelings with others, although talking was often difficult. "The Big Deal" reflected participants' experiences of the process, their expectations, and the contrast of their lives pre- and post-transplant. Inherent in their accounts was the profound meaning ascribed to transplantation, the emotional turmoil, and impact on their lives. "A Sense of Self" illustrated participants' developing identities within their social contexts and at times isolating experiences. The results highlight key areas where adolescent lung transplant recipients could be supported by clinicians, enabling the promotion of psychological well-being. Examples include supporting identity integration post-transplant, facilitating social inclusion, considering alternative means of support, and involving adolescents in healthcare decisions.

Experiences of Korean adolescent renal transplant recipients

PURPOSE

To understand the experiences of Korean adolescents who have undergone a renal transplant.

DESIGN AND METHODS

Nine adolescents aged 12-18 who received a renal transplant participated in this qualitative descriptive study. Using content analysis, we analyzed in-depth interview data from individual adolescents.

RESULTS

The main themes extracted were "being different from others," "not being invited as a decision maker," "becoming one of them," "still being different from others," "having mixed feeling toward mothers," and "coping with new circumstances."

PRACTICE IMPLICATIONS

Interventions designed to improve adolescent renal transplant recipients' sense of autonomy and belongingness are needed.

In My Shoes: Children's Quality of Life after Heart Transplantation

Background

Although heart transplantation has been offered for 2 decades to prolong the lives of children with end-stage heart disease, we know little about how these children view their lives, how they deal with their complicated medical regimen, and how the transplantation affects their quality of life.

Objectives

To examine the quality of life of school-aged heart transplant recipients and to identify the key factors they believe affect their quality of life.

Design

Focused ethnography.

Participants and Setting

Eleven children (7 girls, 4 boys) between the ages of 6 and 12 years (mean 9.1 years) who had received a transplant at least 6 months earlier were recruited from a large children's hospital.

Data Collection and Analysis

Semistructured interviews were conducted in private locations. Data were analyzed using content analysis and constant comparison.

Results

The children described their quality of life as “mostly good,” yet reported that life was “easy and not easy.” Ten factors that affected the children's quality of life were Doing Things/Going Places, Favorite School Activities, Hard Things About School, Being With Friends and Family, Doing Things/Going Places With Friends and Family, Interactions With Friends and Family, Taking Care of My Heart, My Body, The Transplant Team, and Other Health Problems. Based on similarities in meaning, these factors were combined into 3 themes: Doing What Kids Do, Being With Friends and Family, and Being a Heart Transplant Kid. The themes and factors can provide useful direction for interventions aimed at improving the quality of life for children after heart transplantation.

A struggle to survive: the experience of awaiting pediatric heart transplantation

Despite the establishment of heart transplantation as a life-saving therapy for children and adolescents, little research has focused on the biopsychosocial impact of the transplant process. Few studies have captured the subjective experiences of young heart transplant recipients. This study examined the experiences and perspectives of children and adolescents during the pretransplant phase of waiting for a donor organ. Grounded theory methods guided data collection and analysis. A total of 27 adolescents participated in semistructured qualitative interviews. Findings illuminate the waiting period for pediatric heart transplantation to be a pervasive experience, with consequent impact on physical, psychological, and social well-being. Participants described various biopsychosocial processes and experiences that occurred during this time, with data analysis yielding themes reflecting notions of "struggling to survive," including physical limitations, lethargy, social isolation, discomfort with physical appearance, and academic issues. This research identifies the pretransplant experience as a period framed within a text of debilitation and negative self-perceptions related to health and well-being. Supporting children and their families as they navigate this complex and uncertain journey is merited, and results invite further interventional development and research.

Living with a heart transplant: a phenomenological study

BACKGROUND

Heart transplantation is a relatively new medical treatment for end-stage heart failure. Many studies have addressed the outcomes and the complications and technical problems associated with heart transplants, but few have explored the whole clinical experience of being a heart transplant recipient.

PURPOSE

To understand and gain deeper insight into the lived experience of Iranian heart transplant recipients.

METHODS

Interviews of 11 heart transplant recipients were analyzed according to phenomenological guidelines set forth by Diekelmann.

RESULTS

Six major themes emerged from 29 subthemes, depicting the meaning of living with a transplanted heart. These themes include having a new life, living with new concerns, living with vigilance, paradoxical emotions, bearing others' behaviors, and the prominent role of God in life.

CONCLUSION

Heart transplant recipients in Iran experience a new life in which their faith in God helps them go through hardships and difficulties.

Child and family adjustment following pediatric solid organ transplantation: factors to consider during the early years post-transplant

Adjusting to life after transplant can be challenging to pediatric solid organ transplant recipients and their families. In this review, we discuss a number of important factors to consider during the first 2-3 yr after transplant (defined as the "early years"), including transitioning from hospital to home, returning to physical activity, feeding and nutrition, school reentry, potential cognitive effects of transplant, family functioning, and QOL. We highlight steps that providers can take to optimize child and family adjustment during this period.

Restriction and dependence to autonomy and freedom: transformation in adolescent heart transplant recipients

The process of heart transplantation poses numerous challenges and adaptive tasks for paediatric patients and their families. Few studies have examined how the experience of transplant interacts with developmental transitions such as adolescence, a period of significant change, and adjustment in itself. We explored adolescent heart transplant recipients' and their parents' experience of transplant from the point at which their heart condition was diagnosed to several months after transplantation. We adopted a developmental focus, to consider how participants negotiated the tasks of adolescence in the context of their transplant experiences. A qualitative approach was used to interview five adolescent-parent dyads, who reported few post-transplant complications, and the data were analysed according to the principles of IPA. Our findings revealed transplant to be a transformative experience, with two themes marking a contrast between pre- and post-transplant states: "Restriction and Dependence" and "Autonomy and Freedom." The themes are considered in relation to adolescent development. We propose that clinicians working with paediatric heart transplant recipients and their families need to consider the particular developmental challenges faced by adolescent patients and view the attainment of developmental milestones alongside physical and psychological markers of successful adjustment.

Impact of age at onset for children with renal failure on education and employment transitions

Previous medical research has shown that children with end-stage renal failure experience delay or underachievement of key markers of transition to adulthood. This article analyses 35 qualitative interviews with end-stage renal failure patients, aged 20-30 years, first diagnosed at 0-19 years of age, to explore how far delayed or underachievement in education and employment is related to their age at onset of end-stage renal failure. This study shows how unpredictable failures of renal replacement therapies, comorbidities and/or side effects of treatment in the early life course often coincided with critical moments for education and employment. Entering school, college, work-related training or employment, and disclosing health status or educational underachievement to an employer, were particularly critical, and those who were ill before puberty became progressively more disadvantaged in terms of successful transition into full-time employment, compared with those first diagnosed after puberty.

First two decades of paediatric heart transplantation in Sweden - outcome of listing and post-transplant results

AIMS

To evaluate outcome in the first generation of children with end-stage heart disease to whom heart transplantation was available.

METHODS

Retrospective review of all 135 Swedish children <18 years old listed for heart transplantation 1989-2009, followed to December 31, 2009, including 74 (55%) with cardiomyopathy and 61 (45%) with congenital heart disease; 34 (25%) were infants (<1 year). Cumulative risk of requiring heart transplantation was 1:17,300 (11 patients who improved were omitted from outcome analysis).

RESULTS

Waiting-list mortality was 31% (44% in infants). Median waiting time in 82 transplanted patients was 57 days (0-585 days). Post-transplant follow-up time was median 5.9 years (0.03-20.1 years), and actuarial survival was 92% at 1 year, 82% at 5 years, 76% at 10 years and 58% at 15 years. Survival after listing was 64% at 1 year, 58% at 5 years, 52% at 10 years and 40% at 15 years. Post-transplant complications included rejections (34%), malignancies (12%), renal failure (8%), coronary artery vasculopathy (6%) and re-transplantation (5%). Among 64 survivors, 84% were free of complications affecting prognosis.

CONCLUSION

High waiting-list mortality and post-transplant attrition precluded 60% of this pioneer population from reaching adulthood. Functional status in survivors is generally good.

“It Has its Ups and Downs”: Adolescents' Quality of Life after Heart Transplantation

Context

Heart transplantation is not curative and results in a high-morbidity chronic illness. Despite this, little research has focused on adolescents' quality of life after heart transplant. Such research is critically needed because of the complex developmental changes experienced by adolescents and the need for transition to self-management during this vulnerable period.

Objective

To examine adolescents' perceptions of their quality of life and factors affecting it.

Design

Focused ethnography.

Setting and Participants

Fourteen adolescents (mean age, 17 years) who had received a heart transplant at least 6 months earlier were recruited from a large children's hospital. The ethnically diverse sample (7 black, 5 white, 1 Asian, and 1 Hispanic) included 8 females and 6 males.

Data Collection and Analysis

The adolescents participated in audio-taped qualitative interviews, which were transcribed verbatim and entered into Ethnograph to assist with data management. Thematic analysis was used to identify recurrent themes.

Results

Participants described life after transplant by saying, “It has its ups and downs.” Major themes included these: (1) I am normal and I am not normal, (2) I am grateful and I am resentful, and (3) I am managing and I am not managing. The themes reflect the dichotomous nature of the adolescents' experiences and provide insight into the complex needs of adolescents after heart transplant.

"When I had my transplant, I became normal." Adolescent perspectives on life after kidney transplantation

This study aimed to explore experiences and perspectives of adolescent kidney transplant recipients following kidney transplantation. We conducted 22 in-depth, face-to-face interviews with adolescent kidney transplant recipients (aged 12-19 yr) from five Australian pediatric transplant units. We analyzed the interview transcripts for descriptive and analytical themes. The overarching theme was achieving a sense of normality. Having the same opportunities and potential to achieve as other adolescents facilitated better adjustment, well-being and positive development after transplant. Five facilitators and five barriers to achieving a sense of normality were identified. The facilitators were developing their own identity, peer acceptance, making medications routine, freedom and energy, and support structures. The barriers included identity crisis, peer rejection, aversion to medications, lifestyle limitations, and fear and uncertainty. The adolescents felt more knowledge was needed on the technical, medical, and experiential aspects of transplantation and on pertinent issues such as alcohol, drugs, and substance use. Adolescent kidney transplant recipients value normality and have specific information needs about the effect of kidney transplantation on their physical appearance and the tolerance of drugs and alcohol. Novel approaches are needed to foster self-confidence and sense of normality and to provide comprehensive information on the patient journey following kidney transplantation.

Adolescent experiences following organ transplantation: a systematic review of qualitative studies

OBJECTIVE

To describe the experiences of adolescents who underwent organ transplantation.

STUDY DESIGN

We conducted a systematic review of qualitative studies that explored the experiences of adolescents who underwent organ transplantation. We searched 5 electronic databases (to week 3 of July 2008) and reference lists of relevant articles.

RESULTS

Eighteen articles reporting the experiences of 313 adolescent organ transplant recipients were included. Five major themes were identified: (1) redefining identity (seeking normality, anxiety and disappointment, adopting a positive attitude, desiring independence); (2) family functioning (parental overprotection, sibling support); (3) social adjustment (support networks, peer rejection, maintaining schoolwork, participation in physical activities); (4) managing medical demands (assuming responsibility, dependence on caregivers, disruption to lifestyle, vigilant adherence, pain and discomfort); and (5) attitude toward the donor (obligation of gratitude, strengthened relationship, concerns about risks to donor).

CONCLUSIONS

Although transplantation offers adolescents a better chance of survival and increased freedom and energy, it poses many challenges. A multifaceted response is needed to equip adolescent transplant recipients with skills and capacities to help them achieve a sense of normality, cope with fear of death and organ rejection, gain acceptance among their peers, build confidence in learning, and resolve relationship tensions with the living donor.

Comparing parents' and children's views of children's quality of life after heart transplant

PURPOSE

The purpose of this focused ethnographic study was to explore the quality of life (QOL) of school-age heart-transplant recipients.

DESIGN AND METHODS

Semistructured interviews were conducted with 11 parent-child dyads. Data were analyzed using content analysis and constant comparison.

RESULTS

Participants identified key factors impacting the children's QOL including: participation in normal activities, normalcy, staying healthy, sources of strength and support, and struggles (parents' perspectives) and doing what kids do, being with family and friends, and being a heart transplant kid (children's perspectives).

PRACTICE IMPLICATIONS

Interventions focusing on the key factors identified by participants may impact the QOL of school-age heart-transplant recipients.