The experience of kidney graft failure: patients' perspectives

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.

Post-Traumatic Stress Disorder and Post-Traumatic Growth following Kidney Transplantation

Background

Kidney transplantation (KT) is a life-saving therapy for kidney failure. However, KT recipients can suffer from debilitating depression, post-traumatic stress disorder (PTSD), and suicide. In contrast to PTSD, post-traumatic growth (PTG) is a positive psychologic change in response to a challenging situation. PTG has been studied in other chronic diseases, but less is known about its role in the setting of KT. We sought to elucidate the prevalence, predictors, and the effect of PTSD and PTG on post-KT outcomes. We also considered the roles of benefit finding and resilience.

Methods

In a literature review, we identified publications that examined PTSD, PTG, benefit finding, and/or resilience in KT recipients. We excluded case reports and first-person narratives. Publications meeting the specified criteria after full text review underwent data abstraction and descriptive analysis.

Results

Of the 1013 unique citations identified, 39 publications met our criteria. PTSD was the most common construct evaluated (16 publications). Resilience was studied in 11 publications, PTG in nine, and benefit finding in five. Up to 21% of adult and 42% of pediatric KT recipients may experience PTSD, which is associated with lower quality of life (QOL), impaired sleep, and other psychiatric comorbidity. PTG was associated with improved QOL, kidney function, and reduced risk of organ rejection. Although benefit finding tended to increase post KT, resilience remained stable post KT. Like PTG, resilience was associated with lower psychologic distress and increased treatment adherence and confidence in the health care team.

Conclusions

PTG, resilience, and benefit finding appear to reduce the risk of PTSD, promote well-being, and reduce risk of graft failure in KT recipients. Future research to understand these relationships better will allow clinicians and researchers to develop interventions to promote PTG, resilience, and benefit finding, and potentially improve post-transplant outcomes such as adherence and reducing risk of organ rejection.

Organ Transplant Recipients' Experiences of Physical Activity: Health, Self-Care, and Transliminality

Physical activity (PA) is an important lifestyle component of long-term health management for organ transplant recipients, yet little is known about recipients' experiences of PA. The purpose of this study was to shed light on this experience and to investigate the possible implications of PA in the context of what is a complex patient journey. Phenomenological analysis was used to examine interviews with 13 organ transplant recipients who had taken part in sporting opportunities posttransplantation. Findings illuminate how participants' experiences of PA were commonly shaped by the transliminal nature of being an organ transplant recipient as well as a sense of duty to enact health, self-care, and donor-directed gratitude. This analysis underlines the potential role of PA in supporting organ transplant recipients' attempts to live well following transplantation and makes novel connections between PA and our existing knowledge about challenges related to identity, survivorship, obligation, and patient empowerment.

The economic burden of kidney graft failure in the United States

Despite improvements in outcomes for kidney transplant recipients in the past decade, graft failure continues to impose substantial burden on patients. However, the population-wide economic burden of graft failure has not been quantified. This study aims to fill that gap by comparing outcomes from a simulation model of kidney transplant patients in which patients are at risk for graft failure with an alternative simulation in which the risk of graft failure is assumed to be zero. Transitions through the model were estimated using Scientific Registry of Transplant Recipients data from 1987 to 2017. We estimated lifetime costs, overall survival, and quality-adjusted life-years (QALYs) for both scenarios and calculated the difference between them to obtain the burden of graft failure. We find that for the average patient, graft failure will impose additional medical costs of $78 079 (95% confidence interval [CI] $41 074, $112 409) and a loss of 1.66 QALYs (95% CI 1.15, 2.18). Given 17 644 kidney transplants in 2017, the total incremental lifetime medical costs associated with graft failure is $1.38B (95% CI $725M, $1.98B) and the total QALY loss is 29 289 (95% CI 20 291, 38 464). Efforts to reduce the incidence of graft failure or to mitigate its impact are urgently needed.

Everybody needs a cheerleader to get a kidney transplant: a qualitative study of the patient barriers and facilitators to kidney transplantation in the Southeastern United States

BACKGROUND

Kidney transplantation (KTx) disparity is a significant problem in the United States, particularly in the Southeastern region. In response to this phenomenon, the Southeastern Kidney Transplant Coalition was created in 2011 to increase the KTx rate, and to reduce disparities in access to transplantation in the Southeast, by identifying and reducing barriers in the transplant process.

METHODS

To determine perceived barriers and facilitators to KTx that dialysis patients in this region experience, we conducted three focus groups with 40 total patients in Georgia, North Carolina, and South Carolina.

RESULTS

We identified two novel themes specific to Southeastern dialysis patients that describe the major barriers and facilitators to kidney transplantation: dialysis center approaches to patient education about KTx, and dialysis center advocacy and encouragement for KTx. In addition, themes related to barriers and facilitators of KTx were evident that were previously mentioned in the literature such as age, fear, knowing other patients with good or bad experiences with KTx, distrust of the KTx process equity, financial concerns and medical barriers.

CONCLUSIONS

Dialysis providers are encouraged to enhance their delivery of information and active assistance to underserved patients related to KTx.

Transplant Trajectory and Relational Experience Within Living Kidney Dyads

Living kidney donation is considered common practice across most Westernized countries. While extensive research has documented the experience of living donors, few studies have addressed the perspective of recipients, and even fewer have examined the experience of donor and recipient as an interactive dyad. In this study, our aim was to examine the reciprocal influence between donors and recipients across the transplantation process. We recruited a homogeneous sample of 10 donors and recipients, who were interviewed individually. Data were analyzed using interpretative phenomenological analysis. The presentation of results follows the stages of the transplantation process: the disease experience, the experience of offering and accepting a kidney, the screening period, the surgery, and the post-transplantation period. Results are discussed within the framework of Mauss's gift exchange theory, social roles, and altruism. This comprehensive description of the dyadic experience provides a way to frame and understand psychosocial aspects and relational implications of living renal transplantation.

Common experiences of patients following suboptimal treatment outcomes: implications for epilepsy surgery

Few studies have investigated the patient experience of unsuccessful medical interventions, particularly in the epilepsy surgery field. The present review aimed to gain insight into the patient experience of seizure recurrence after epilepsy surgery by examining the broader literature dealing with suboptimal results after medical interventions (including epilepsy surgery). To capture the patient experience, the literature search focused on qualitative research of patients who had undergone medically unsuccessful interventions, published in English in scholarly journals. Twenty-two studies were found of patients experiencing a range of suboptimal outcomes, including seizure recurrence, cancer recurrence and progression, unsuccessful joint replacement, unsuccessful infertility treatment, organ transplant rejection, coronary bypass graft surgery, and unsuccessful weight-loss surgery. In order of frequency, the most common patient experiences included the following: altered social dynamics and stigma, unmet expectations, negative emotions, use of coping strategies, hope and optimism, perceived failure of the treating team, psychiatric symptoms, and control issues. There is support in the epilepsy surgery literature that unmet expectations and psychiatric symptoms are key issues for patients with seizure recurrence, while other common patient experiences have been implied but not systematically examined. Several epilepsy surgery specific factors influence patient perceptions of seizure recurrence, including the nature of postoperative seizures, the presence of postoperative complications, and the need for increased postoperative medications. Knowledge of common patient experiences can assist in the delivery of patient follow-up and rehabilitation services tailored to differing outcomes after epilepsy surgery.

Renal transplant failure and disenfranchised grief: participants' experiences in the first year post-graft failure--a qualitative longitudinal study

BACKGROUND

Renal transplant failure has a devastating impact on patients and their families. However, little research has been conducted in this area, which limits insight and understanding of the transplant failure experience that could subsequently inform clinical practice.

OBJECTIVES

To explore participants' experiences of renal transplant failure in the first year post-graft failure.

DESIGN

A qualitative, longitudinal study informed by Heideggerian hermeneutics.

PARTICIPANTS AND SETTINGS

A purposive sample of 16 participants (8 recipients, 8 'significant others') from a regional renal transplant unit and 3 District General Hospitals in South-West England.

METHODS

Data were collected through a series of three recorded, semi-structured interviews in the first year post-renal transplant failure. Data analysis was informed by a three-step analytical process.

RESULTS

Renal transplantation was the treatment of choice and had a transformative effect on the lives of all participants. Graft failure has 2 distinct phases; failing and failed and the transition from one phase to the other is unpredictable, uncertain and stressful. Transplant failure had a devastating impact on all participants, regardless of time since transplantation and resulted in feelings of shock, grief, loss, anger, guilt and depression. Dialysis was disruptive and demanding and served as a constant reminder of transplant failure and lost freedom. Participants grieved the loss of their 'previous life' and 'imagined future' but, beyond the understanding of close family members, these losses appeared unrecognised, particularly by health professionals. Participants used various coping mechanisms to deal with stressors associated with transplant failure. Factors affecting coping and adjusting included improved physical health and social support, which was especially important within the marital dyad. Healthcare services were positively evaluated, although information concerning the prospect of transplant failure and support post-graft failure could be improved.

CONCLUSION

Renal transplant failure has a profound impact on recipients, spouses and other close family members and appears to resemble a form of disenfranchised grief. The theory of disenfranchised grief provides a coherent explication of participants' experiences in this study, which should help inform clinical practice, particularly in relation to the provision of information and emotional support post-graft failure.

Sweet and sour after renal transplantation: a qualitative study about the positive and negative consequences of renal transplantation

OBJECTIVES

This qualitative study investigated the renal patients' experience of positive and negative consequences of transplantation, as well as the strategies they use to adapt to the transplantation.

DESIGN AND METHODS

A qualitative design (30 participants in total), using individual interviews (18 participants) and two focus groups (12 participants in total), was used.

RESULTS

The results showed that patients experienced a wide range of positive and negative emotions, in particular, guilt, gratefulness, and fear, partly as a result of their normative persuasions. Normative persuasions may transform inherent positive emotions into negative emotions and subsequent maladaptive behaviour. Not only physical limitations but also physical improvements were found to be related to the experience of negative emotions. Finally, the results indicated that patients mainly used adaptive coping strategies to adjust to life after transplantation, such as looking for opportunities, setting different priorities, making own choices, trying to maintain control, taking good care of oneself, and appreciating other things in life.

CONCLUSIONS

This study offers several new insights regarding the range of experiences of renal patients after transplantation. Health professionals are invited to pay more attention to the full range of positive and negative experiences following transplantation, including the existence of normative persuasions. Health professionals may assist renal patients by helping them to recognize and acknowledge both positive and negative emotions and to encourage the use of more beneficial coping strategies.

STATEMENT OF CONTRIBUTION

What is already known on this subject? The quality of life (QoL) of renal patients significantly improves after transplantation but the post-transplant QoL is lower compared with the QoL in healthy populations. Patients on dialysis and those who have received a donor kidney tend to use mainly emotion-focused coping strategies. What does this study add? This study offers several new insights regarding experiences of renal patients after transplantation: Patients experience a range of positive and negative emotions like guilt, gratefulness, and fear. Emotions are partly a result of normative persuasions. Persuasions may transform positive emotions into negative emotions and maladaptive behaviour. Physical limitations and improvements can due to the persuasions lead to negative emotions. Patients mainly use adaptive coping strategies.

"Her energy kind of went into a different place": a qualitative study examining supervisors' experience of promoting reflexive learning in students

For family therapists in training, a key learning outcome is the development of reflexive abilities. This study explores the experience of three experienced training supervisors as they address this learning outcome with students. Transcripts of semi-structured interviews were analyzed using interpretative phenomenological analysis. The Supervisory Relationship emerged as a single overarching theme that contained and contextualized three further themes: Promoting Learning, Dimensions of Power, and The Self of the Supervisor. One theme is reported here, Promoting Learning, with an illustrative example of experiential learning in a student that demonstrates the overriding significance of The Supervisory Relationship. The findings are discussed in the context of current literature and research regarding supervision and training. This study adds richness and detail to material published on supervisory experience, and documents supervisory "micro-skills" relevant to the development of reflexive abilities in students.

The lived experiences of children and adolescents with end-stage renal disease

Relatively little is known about how children perceive and manage end-stage renal disease (ESRD) in daily life. To address this gap in the literature, the experiences and perceptions of children with ESRD were examined in this study. Study design comprised ethnographic interviews with 25 children and adolescents ages 7 to 18 years. Semistructured interviews were audiotaped, transcribed verbatim, and subjected to content analysis. Participants received a range of ESRD treatments including transplantation and dialysis. Findings indicate that ESRD has a profound impact on children. They described a range of challenges and experiences including not feeling "normal"; developing ESRD knowledge; frequent absence from school; gaining responsibility for ESRD care; relying on family, friends, and health care providers; and adjusting despite adversity. These findings depict a multifaceted, dynamic perspective engendered in tensions as children and adolescents grapple with adversity yet experience personal growth and resiliency. Implications and recommendations for clinical practice and research are discussed.

Reflexivity and minimization of the impact of age-cohort differences between researcher and research participants

Reflexivity in research can be defined as (a) the acknowledgment and identification of one's place and presence in the research, and (b) the process of using these insights to critically examine the entire research process. Many authors implore qualitative researchers to be reflexive. Very few, however, specify how to do this in practice. Furthermore, in discussions of the presence and place of the researcher, the tendency has been to focus on such factors as gender and race or ethnicity with very little attention being given to age or cohort. In this article we seek to redress this deficiency by examining how reflexivity was practiced in a context in which there was a marked difference in age and cohort membership between researcher and research participants. Specifically, we describe the methodological challenges faced by a younger researcher conducting research with older study participants on the lived experience of the body, and how reflexivity was used to adapt the methodology employed so it became more appropriate and productive within this context.

Medical, personal, and social forms of uncertainty across the transplantation trajectory

We designed this study to identify sources of uncertainty across the transplantation trajectory. We interviewed 38 transplant patients, who reported medical, personal, and social forms of uncertainty. Prior to transplantation, they reported uncertainty related to insufficient information about diagnosis, complex decisions about transplantation, unknown/unknowable organ availability, unclear expectations about medical procedures/outcomes, ambiguity in meaning of life, complex role and identity challenges, unclear financial consequences, questioning from others, and unclear relational implications. They reported that uncertainty experienced after transplantation was related to complex medication regimens, unpredictable future health/prognosis, complex role and identity challenges, unclear financial consequences, possible stigmatizing reactions, unclear relational implications, and complex interactions with the deceased donor's family. These findings lay the groundwork for additional research on uncertainty management for transplant patients, and suggest that health care professionals and supportive others cannot apply a one-size-fits-all solution when aiding in uncertainty management.