Employment 12 months after kidney transplantation: An in-depth bio-psycho-social analysis of the Swiss Transplant Cohort

Approaches to the identification and management of depression in people living with chronic kidney disease: A scoping review of 860 papers

BACKGROUND

Depression is prevalent across the spectrum of Chronic Kidney Disease and associated with poorer outcomes. There is limited evidence regarding the most effective interventions and care pathways for depression in Chronic Kidney Disease.

OBJECTIVES

To investigate how depression is identified and managed in adults with Chronic Kidney Disease.

DESIGN

Scoping review.

METHODS

Systematic search of eight databases with pre-defined inclusion criteria. Data relevant to the identification and/or management of depression in adults with Chronic Kidney Disease were extracted.

RESULTS

Of 2147 articles identified, 860 were included. Depression was most identified using self-report screening tools (n = 716 studies, 85.3%), with versions of the Beck Depression Inventory (n = 283, 33.7%) being the most common. A total of 123 studies included data on the management of depression, with nonpharmacological interventions being more frequently studied (n = 55, 45%). Cognitive Behavioural Therapy (n = 15) was the most common nonpharmacological intervention, which was found to have a significant effect on depressive symptoms compared to controls (n = 10). However, how such approaches could be implemented as part of routine care was not clear. There was limited evidence for antidepressants use in people with Chronic Kidney Disease albeit in a limited number of studies.

CONCLUSIONS

Depression is commonly identified using validated screening tools albeit differences exist in reporting practices. Evidence regarding the management of depression is mixed and requires better-quality trials of both pharmacological and nonpharmacological approaches. Understanding which clinical care pathways are used and their evidence, may help facilitate the development of kidney care specific guidelines for the identification and management of depression.

Development and implementation of work-oriented clinical care to empower patients with kidney disease: an adapted intervention mapping approach

BACKGROUND

Many people with chronic kidney disease (CKD) have problems to stay at work. Patients and health care professionals (HCPs) see the potential benefit of work-oriented clinical care, yet this care is not manifested in current practice. The aim of this study was to develop and implement a program called work-oriented clinical care for kidney patients (WORK) to support sustainable work participation.

METHODS

An adapted version of Intervention Mapping (AIM) was used for the systematic development of work-oriented care in a hospital. Based on the needs of patients and (occupational) health professionals, and in close cooperation with both, a theoretical and empirically based program was developed. Feasibility and clinical utility were assessed among patients with CKD, HCPs and hospital managers. To increase the chances of successful implementation we focused on determinants related to the innovation, the users, the organization (hospital), and socio-political context.

RESULTS

We developed, implemented, and pilot-tested WORK, an innovative program consisting of a care pathway in the hospital that targets patients with work-related questions and tailors the support they receive to their needs. Several practical tools were developed and an internal and external referral structure with a focus on work was implemented. A labor expert was deployed to the hospital to support patients and HCPs with simple work-related questions. The feasibility and clinical utility of WORK were rated positively.

CONCLUSIONS

This work-oriented clinical care program provides HCPs in the hospital with the necessary tools to support patients with CKD in dealing with work challenges. HCPs can discuss work with patients at an early stage and support them in anticipating work-related challenges. HCPs can also bridge the gap to more specialized help if necessary. WORK has the potential for wider application in other departments and hospitals. So far, the implementation of the WORK program was successful, though structural implementation may be challenging.

Employment and ability to work after kidney transplantation in the Netherlands: The impact of preemptive versus non-preemptive kidney transplantation

BACKGROUND

Work can have a major positive impact on health and wellbeing. Employment of kidney transplant recipients (KTR) of working age is much lower than in the general population. The first aim of this study was to examine the impact of a preemptive kidney transplantation (PKT) on employment, in addition to other possible influencing factors. The second aim was to explore differences in work ability, absenteeism and work performance among employed KTR with different types of transplantations.

METHODS

A cross-sectional survey study was conducted between 2018 and 2019 in nine Dutch hospitals. PKT as potential predictor of employment was examined. Furthermore, work ability, absenteeism and loss of work performance were compared between employed preemptive recipients with a living donor (L-PKT) and non-preemptive recipients with a living donor (L-nPKT) and with a deceased donor (D-nPKT).

RESULTS

Two hundred and twenty four KTR participated; 71% reported having paid work. Paid work was more common among PKT recipients (82% vs. 65% in L-nPKT and 55% in D-nPKT) and recipients who were younger (OR .950, 95%CI .913-.989), had no comorbidities (1 comorbidity: OR .397, 95%CI .167-.942; 2 comorbidities: OR .347, 95%CI .142-.844), had less fatigue (OR .974, 95%CI .962-.987) and had mentally demanding work tasks (only in comparison with physically demanding tasks, OR .342, 95%CI .145-.806). If recipients were employed, D-nPKT recipients worked fewer hours (mean 24.6±11.3 vs. PKT 31.1±9.6, L-nPKT 30.1±9.5) and D-nPKT and L-nPKT recipients received more often supplemental disability benefits (32 and 33.3%, respectively) compared to PKT recipients (9.9%). No differences were found for self-reported ability to work, sick leave (absenteeism) and loss of work performance with the exception of limitations in functioning at work.

CONCLUSIONS

Preemptive kidney transplantation recipients with a kidney from a living donor are employed more often, work more hours per week (only in comparison with D-nPKT) and have a partial disability benefit less often than nPKT recipients. More knowledge regarding treatments supporting sustainable participation in the labor force is needed as work has a positive impact on recipients' health and wellbeing and is also beneficial for society as a whole.

The Relationship Between Change in Employment Status, Insurance Coverage, and Graft Failure or Death After Kidney Transplant

Introduction: Early change of insurance coverage after kidney transplantation may be associated with worse graft outcomes. We examine how return to employment moderates the hazard of graft failure associated with exit from Medicare within 36 months after transplantation. Design: Patients undergoing kidney transplantation covered by Medicare between January 2005 and December 2016 were identified in the United Network for Organ Sharing (UNOS) database. A composite outcome of graft failure or death was analyzed across four groups: (1) no change in coverage within the first 3 years post-transplant, and no return to work (2) no change in coverage, return to work (3) change in coverage, no return to work (4) change in coverage, return to work. Results: The sample included 46 120 patients; 28% changed insurance coverage from Medicare posttransplant. Among patients who returned to work (36%), change in coverage from Medicare to other insurance was associated with lower hazard of death or graft failure (hazard ratio: 0.93; 95% confidence interval: 0.87, 0.99; P = 0.030). Conclusions: Exit from Medicare was associated with patient and graft survival greater than 3 years after transplant, depending on return to work. Among patients returning to work, changes in insurance from Medicare to private coverage were associated with favorable outcomes.

Cohort profile: The Swiss Transplant Cohort Study (STCS): A nationwide longitudinal cohort study of all solid organ recipients in Switzerland

PURPOSE

The Swiss Transplant Cohort Study (STCS) is a prospective multicentre cohort study which started to actively enrol study participants in May 2008. It takes advantage of combining data from all transplant programmes in one unique system to perform comprehensive nationwide reporting and to promote translational and clinical post-transplant outcome research in the framework of Swiss transplantation medicine.

PARTICIPANTS

Over 5500 solid organ transplant recipients have been enrolled in all six Swiss transplant centres by end of 2019, around three-quarter of them for kidney and liver transplants. Ninety-three per cent of all transplanted recipients have consented to study participation, almost all of them (99%) contributed to bio-sampling. The STCS genomic data set includes around 3000 patients.

FINDINGS TO DATE

Detailed clinical and laboratory data in high granularity as well as patient-reported outcomes from transplant recipients and activities in Switzerland are available in the last decade. Interdisciplinary contributions in diverse fields of transplantation medicine such as infectious diseases, genomics, oncology, immunology and psychosocial science have resulted in approximately 70 scientific papers getting published in peer-review journals so far.

FUTURE PLANS

The STCS will deepen its efforts in personalised medicine and digital epidemiology, and will also focus on allocation research and the use of causal inference methods to make complex matters in transplant medicine more understandable and transparent.

Employment of patients with kidney failure treated with dialysis or kidney transplantation-a systematic review and meta-analysis

BACKGROUND

Patients with kidney failure treated with dialysis or kidney transplantation experience difficulties maintaining employment due to the condition itself and the treatment. We aimed to establish the rate of employment before and after initiation of dialysis and kidney transplantation and to identify predictors of employment during dialysis and posttransplant.

METHODS

This systematic review and meta-analysis were carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for studies that included employment rate in adults receiving dialysis or a kidney transplant. The literature search included cross-sectional or cohort studies published in English between January 1966 and August 2020 in the PubMed, Embase, and Cochrane Library databases. Data on employment rate, study population, age, gender, educational level, dialysis duration, kidney donor, ethnicity, dialysis modality, waiting time for transplantation, diabetes, and depression were extracted. Quality assessment was performed using the Newcastle-Ottawa Scale. Meta-analysis for predictors for employment, with odds ratios and confidence intervals, and tests for heterogeneity, using chi-square and I2 statistics, were calculated. PROSPERO registration number: CRD42020188853.

RESULTS

Thirty-three studies included 162,059 participants receiving dialysis, and 31 studies included 137,742 participants who received kidney transplantation. Dialysis patients were on average 52.6 years old (range: 16-79; 60.3% male), and kidney transplant patients were 46.7 years old (range: 18-78; 59.8% male). The employment rate (weighted mean) for dialysis patients was 26.3% (range: 10.5-59.7%); the employment rate was 36.9% pretransplant (range: 25-86%) and 38.2% posttransplant (range: 14.2-85%). Predictors for employment during dialysis and posttransplant were male, gender, age, being without diabetes, peritoneal dialysis, and higher educational level, and predictors of posttransplant: pretransplant employment included transplantation with a living donor kidney, and being without depression.

CONCLUSIONS

Patients with kidney failure had a low employment rate during dialysis and pre- and posttransplant. Kidney failure patients should be supported through a combination of clinical and social measures to ensure that they remain working.

Work status and work ability of patients receiving kidney replacement therapy: Results from a European survey

BACKGROUND

Employment is important for the quality of life and financial security of patients of working age receiving kidney replacement therapy (KRT). We aimed to examine self-reported work status and general, physical and mental work ability, and to determine associations between demographic, disease-related, work-related, and macro-economic factors and employment. .

METHODS

Europeans from 37 countries, aged 19-65 years, treated with dialysis or kidney transplantation, filled out the web-based or paper-based cross-sectional EDITH kidney patient survey between November 2017 and January 2019. We performed descriptive analyses and multivariable generalized logistic mixed models.

RESULTS

Of the 3 544 patients, 36.5% were employed and working (25.8% of dialysis patients, 53.9% of kidney transplant recipients [KTRs]). Mean general work ability was 5.5 out of 10 (dialysis: 4.8, KTRs: 6.5). Non-working patients (all: 4.1, dialysis: 3.9, KTRs: 4.7) scored lower than working patients (all: 7.7, dialysis 7.3, KTRs: 8.0). Working dialysis patients scored lower on physical and mental work ability (7.1 and 8.1) than working KTRs (8.0 and 8.4, p < 0.001). Impaired physical work ability (42.7%) was more prevalent than impaired mental work ability (26.7%). Male sex, age 40-49 years, higher education, home dialysis or kidney transplantation as current treatment, treatment history including kidney transplantation, absence of diabetes mellitus, better general work ability, and higher country GDP were positively associated with employment (p < 0.05).

CONCLUSIONS

Low employment rates and impaired work ability were prevalent among European patients receiving KRT. Demographic, disease-related, work-related, and macro-economic factors were associated with employment.

Analysis of Factors Affecting Employment Status of Kidney Transplant Recipients in Selected European Union Member States

Despite an increasing quality of life after renal transplantation, the number of recipients undertaking paid professional work remains relatively low. Employment after kidney transplantation became a new important marker of clinically significant health recovery. Furthermore, for social and economic reasons, returning to work and participation in social life may be considered as an objective parameter that demonstrate the effectiveness of transplantation. The objectives of the following study were to evaluate the factors that determine resuming paid work after renal transplantation, to assess a patient’s decision about returning to professional activity by comparative analysis of renal transplant recipients from Poland, Czech Republic and Germany, and to identify groups of patients exposed to professional exclusion in those EU countries. Five hundred renal transplant recipients from three EU countries were included into the study. The two main research methods used in the study were the SF-36 questionnaire, constructed and validated to assess the quality of life after kidney transplantation and a questionnaire constructed for the purposes of this study. Multifactorial analysis identified several risk factors associated with professional exclusions after kidney transplantation, namely young or advanced age, female gender, lack of education, place of residence in rural areas, long period of illness, and lack of occupational activity before transplantation. Despite the high standards of social care and rehabilitation support, patients in Germany failed to take up professional activity after kidney transplantation in more cases than those in Poland and Czech Republic. Surprisingly, the objective function of the kidney (creatinine level) and the multidimensional assessment of quality of life (SF-36 survey) did not have a significant association with the employment status after renal transplantation.

Mapping Health-Related Quality Of Life After Kidney Transplantation By Group Comparisons: A Systematic Review

Background

Health-related quality of life (HRQOL) is becoming an increasingly important outcome in kidney transplantation (KT). To describe HRQOL in kidney transplant recipients (KTRs), this systematic review summarizes literature that compared HRQOL among KTRs and other relevant populations [i.e. patients receiving dialysis, patients on the waiting list (WL) for KT, patients with chronic kidney disease (CKD) not receiving renal replacement therapy (RRT), the general population (GP) and healthy controls (HCs)] and themselves before KT.

Methods

The literature search was conducted in PubMed, Embase, Web of Science and the Cochrane Library. Eligible studies published between January 2000 and October 2020 were included.

Results

Forty-four studies comprising 6929 KTRs were included in this systematic review. Despite the study heterogeneity, KTRs reported a higher HRQOL after KT compared with pre-transplantation and compared with patients receiving dialysis with or without being on the WL, especially in disease-specific domains (i.e. burden and effects of kidney disease). Additionally, KTRs had similar to marginally higher HRQOL compared with patients with CKD Stages 3–5 not receiving RRT. When compared with HCs or the GP, KTRs reported similar HRQOL in the first 1 or 2 years after KT and lower physical HRQOL and lower to comparable mental HRQOL in studies with longer post-transplant time.

Conclusions

The available evidence suggests that HRQOL improves after KT and can be restored to but not always maintained at pre-CKD HRQOL levels. Future studies investigating intervention targets to improve or maintain post-transplant HRQOL are needed.

Clinical factors and comorbidities affecting health-related quality of life in postrenal transplant patients

Background:

Health-related quality of life is different among different transplant cohorts with respect to different variables which predict mortality and graft survival. The aim of this study was to identify the effects of clinical factors on the health-related quality of life in postrenal transplant patients.

Methods:

This census study was conducted at the Institute of Kidney Diseases Peshawar, Pakistan. Data were collected on a questionnaire “ Kidney Diseases Quality of Life-Short Form-1.3 Urdu version” and were analyzed in the 3 main domains, for example, physical component summary (PCS), mental component summary, and kidney disease component summary using SPSS version 21. Mean scores for patients with diabetes mellitus (DM), hypertension, levels of hemoglobin, and serum creatinine were compared by unpaired t-test.

Results:

A total of 277 men (87.9%) and 38 (12.1%) women participated in the study. Mean age was 37.26 (±10.14) years (range 18–65 years). Hypertension was reported in 72.2% and DM in 10.8%. Hemoglobin was <12.5g% in 26.0% patients. Patients with DM had significant lower PCS (P = .001) and mental component summary (MCS; P = .001) scores. Patients with hypertension had significant lower MCS score (P = .01). Patients with hemoglobin <12.5g% had significantly lower PCS (P = .001) score than those with hemoglobin >12.5 g%. The PCS score in patients with serum creatinine level >2 mg% was significantly lower (P = .02) than those with serum creatinine <2 mg%.

Conclusion:

Lower graft function and DM were associated with lower PCS and MCS scores. Hypertension was associated with lower MCS score and anemia with lower PCS score.

Fighting the unbearable lightness of neglecting kidney health: the decade of the kidney

A brief comprehensive overview is provided of the elements constituting the burden of kidney disease [chronic kidney disease (CKD) and acute kidney injury]. This publication can be used for advocacy, emphasizing the importance and urgency of reducing this heavy and rapidly growing burden. Kidney diseases contribute to significant physical limitations, loss of quality of life, emotional and cognitive disorders, social isolation and premature death. CKD affects close to 100 million Europeans, with 300 million being at risk, and is projected to become the fifth cause of worldwide death by 2040. Kidney disease also imposes financial burdens, given the costs of accessing healthcare and inability to work. The extrapolated annual cost of all CKD is at least as high as that for cancer or diabetes. In addition, dialysis treatment of kidney diseases imposes environmental burdens by necessitating high energy and water consumption and producing plastic waste. Acute kidney injury is associated with further increases in global morbidity, mortality and economic burden. Yet investment in research for treatment of kidney disease lags behind that of other diseases. This publication is a call for European investment in research for kidney health. The innovations generated should mirror the successful European Union actions against cancer over the last 30 years. It is also a plea to nephrology professionals, patients and their families, caregivers and kidney health advocacy organizations to draw, during the Decade of the Kidney (2020–30), the attention of authorities to realize changes in understanding, research and treatment of kidney disease.

Personalized physical rehabilitation program and employment in kidney transplant recipients: a randomized trial

Kidney transplantation is the preferred treatment for kidney failure; however after transplant, reduced physical function, poor self-perceptions, and unemployment are common concerns that remain. This randomized controlled trial compared the effects of a 12-month exercise rehabilitation program (intervention) to standard care alone (control) in kidney transplant recipients. The exercise intervention consisted of a 2 day/week, 60-minute personalized, one-on-one, resistance-based exercise trainings. Eighty participants completed the study (52 intervention vs. 28 control). For individuals unemployed at baseline, there was a 52.3% increase in employment compared to 13.3 % increase in the control group after 12 months (P = <0.0001). For those already employed at baseline, 100% of individuals maintained employment in both groups after 12 months (P = 0.4742). For all comers, there was a positive trend for Global Physical Health (P = 0.0034), Global Mental Health (P = 0.0064), and Physical Function (P = 0.0075), with the intervention group showing greater improvements. These findings suggest the implementation of an exercise rehabilitation program postkidney transplant can be beneficial to increase employment for individuals previously unemployed, improve self-perceived health, physical function, and mental health, overall contributing to better health outcomes in kidney transplant recipients. (Clinicaltrials.gov number: NCT02409901).

The Preventable Productivity Burden of Kidney Disease in Australia

BACKGROUND

Kidney disease is associated with impaired work productivity. However, the collective effect of missed work days, reduced output at work, and early withdrawal from the workforce is rarely considered in health-economic evaluations.

METHODS

To determine the effect on work productivity of preventing incident cases of kidney disease, using the novel measure "productivity-adjusted life year" (PALY), we constructed a dynamic life table model for the Australian working-age population (aged 15-69 years) over 10 years (2020-2029), stratified by kidney-disease status. Input data, including productivity estimates, were sourced from the literature. We ascribed a financial value to the PALY metric in terms of gross domestic product (GDP) per equivalent full-time worker and assessed the total number of years lived, total PALYs, and broader economic costs (GDP per PALY). We repeated the model simulation, assuming a reduced kidney-disease incidence; the differences reflected the effects of preventing new kidney-disease cases. Outcomes were discounted by 5% annually.

RESULTS

Our projections indicate that, from 2020 to 2029, the estimated number of new kidney-disease cases will exceed 161,000. Preventing 10% of new cases of kidney disease during this period would result in >300 premature deaths averted and approximately 550 years of life and 7600 PALYs saved-equivalent to a savings of US$1.1 billion in GDP or US$67,000 per new case avoided.

CONCLUSIONS

Pursuing a relatively modest target for preventing kidney disease in Australia may prolong years of life lived and increase productive life years, resulting in substantial economic benefit. Our findings highlight the need for investment in preventive measures to reduce future cases of kidney disease.

Factors associated with health-related quality of life in kidney transplant recipients in Korea

Health-related quality of life (HRQOL) of kidney transplant recipients is an outcome evaluation after kidney transplants. Therefore, we investigated the associations among perceived health status, social support, self-determination, post-traumatic growth, and kidney transplant recipients' HRQOL. This study involved a descriptive, self-report survey of 163 kidney transplant recipients visiting an outpatient solid organ transplant center in South Korea. Participants' general and transplant characteristics, perceived health status, post-traumatic growth, social support, self-determination, and HRQOL were collected. Data were statistically analyzed using the software SPSS version 25.0. HRQOL showed statistically significant positive correlation with perceived health status (r = .56, p < .001), post-traumatic growth (r = .18, p = .022), social support (r = .25, p = .002), and self-determination (r = .36, p < .001). The factors affecting HRQOL were perceived health status (β = 0.47, p < 0.001), post-transplant occupation (β = 0.17, p = 0.009), and income source (β = -0.13, p = 0.046). The explanatory power of these variables was 34.8% (F = 28.81, p < 0.001). In the subdomains of HRQOL, the factors influencing HRQOL of mental component summary were perceived health status (β = 0.45, p < 0.001), self-determination (β = 0.27, p < 0.001), and education level (β = 0.18, p = 0.006). The explanatory power of these variables was 34.8% (F = 28.81, p < 0.001). To promote the HRQOL of kidney transplant recipients, an institutional system to assist kidney transplant recipients in returning to work needs to be developed. Additionally, creating an environment that allows kidney transplant recipients to act with self-determination, and developing intervention programs that can enhance self-determination will contribute to enhancing the HRQOL of kidney transplant recipients.

Pre-transplant Social Adaptability Index and clinical outcomes in renal transplantation: The Swiss Transplant Cohort study

BACKGROUND

The impact of pre-transplant social determinants of health on post-transplant outcomes remains understudied. In the United States, poor clinical outcomes are associated with underprivileged status, as assessed by the Social Adaptability Index (SAI), a composite score of education, employment status, marital status, household income, and substance abuse. Using data from the Swiss Transplant Cohort Study (STCS), we determined the SAI's predictive value regarding two post-transplant outcomes: all-cause mortality and return to dialysis.

METHODS

Between 2012 and 2018, we included adult renal transplant patients (aged ≥ 18 years) with pre-transplant assessment SAI scores, calculated from a STCS Psychosocial Questionnaire. Time to all-cause mortality and return to dialysis were predicted using Cox regression.

RESULTS

Of 1238 included patients (mean age: 53.8 ± 13.2 years; 37.9% female; median follow-up time: 4.4 years [IQR: 2.7]), 93 (7.5%) died and 57 (4.6%) returned to dialysis. The SAI's hazard ratio was 0.94 (95%CI: 0.88-1.01; p = .09) for mortality and 0.93 (95%CI: 0.85-1.02; p = .15) for return to dialysis.

CONCLUSIONS

In contrast to most published studies on social deprivation, analysis of this Swiss sample detected no significant association between SAI score and mortality or return to dialysis.

Long-term psychosocial outcomes of adults transplanted in childhood: A social work perspective

While much research exists regarding medical outcomes for pediatric end stage renal disease (ESRD) populations and for adults receiving dialysis or kidney transplant, the understanding of long-term psychosocial outcomes for individuals diagnosed with ESRD or transplanted in childhood remains limited. A literature review was undertaken by two social work researchers to identify relationship, education, employment, and quality of life (QOL) outcomes for this population utilizing PUBMED and PsycInfo databases. Inconsistencies in the MeSH terms and keywords used across the relevant articles were noted. The impact of transplantation in childhood is significant across multiple facets of social development including but not limited to peer/intimate relationships, education and employment and QOL, and overall well-being. When compared to healthy peers, those with ESRD were delayed in all areas of social development. While improvements in psychosocial outcomes have occurred alongside improved graft and patient survival, more focused longitudinal and qualitative inquiry is needed. Partnerships are needed across disciplines and across those caring for different age cohorts in pediatric, adult nephrology, and transplant practices.

Organ donation and transplantation: a multi-stakeholder call to action

Although overall donation and transplantation activity is higher in Europe than on other continents, differences between European countries in almost every aspect of transplantation activity (for example, in the number of transplantations, the number of people with a functioning graft, in rates of living versus deceased donation, and in the use of expanded criteria donors) suggest that there is ample room for improvement. Herein we review the policy and clinical measures that should be considered to increase access to transplantation and improve post-transplantation outcomes. This Roadmap, generated by a group of major European stakeholders collaborating within a Thematic Network, presents an outline of the challenges to increasing transplantation rates and proposes 12 key areas along with specific measures that should be considered to promote transplantation. This framework can be adopted by countries and institutions that are interested in advancing transplantation, both within and outside the European Union. Within this framework, a priority ranking of initiatives is suggested that could serve as the basis for a new European Union Action Plan on Organ Donation and Transplantation.

Employment and Patient Satisfaction after Liver Transplantation

Background and Aims: This study serves to revisit the effects of liver transplantation (LT) on employment in an era of improving survival outcomes post-transplant, and to identify areas of improvement in the transplant process to better optimize post-LT employment and patient satisfaction. Methods: Prospectively, patients who had undergone LT at a single tertiary LT center were surveyed in person and by e-mail. Primary outcomes included employment rate pre- and post-LT, annual salary, weekly hours worked, barriers to re-employment, and patient satisfaction. Results: Responses were collected and analyzed from 121 patients who underwent LT. Pre-LT, 68 (56.1%) reported full-time employment, 13 (10.7%) part-time employment, and 40 (33.1%) unemployment. Post-LT, 26 (21.4%) reported continued full-time employment, 18 (14.9%) part-time employment, and 77 (63.6%) unemployment. Average weekly work hours decreased post-LT (16.1 h/week vs. 39.9 h/week). Mean annual salaries decreased post-LT (17 earning salary ≥$40,000 vs. 56 earning salary ≥$40,000). These outcomes differed from patient pre-LT expectations, with 81.0% of previously employed patients believing they would return to employment, resulting in decreased patient satisfaction. Patients working physically demanding jobs pre-LT were less likely to return to work. Reasons cited for lack of return to full employment included early fatigue and difficulty regaining physical strength. Conclusions: Re-employment rates remain low post-LT, which is particularly true for patients working physically active jobs. Fatigue is a significant barrier to re-employment and increased physical rehabilitation post-LT may prove to be beneficial. Patients should be given realistic expectations about return to employment prior to their LT.

Changes in employment status prior to initiation of maintenance hemodialysis in the USA from 2006 to 2015

BACKGROUND

Hemodialysis (HD) patients have high unemployment rates associated with higher mortality and poor quality of life. Changes in employment status prior to dialysis initiation may predict subsequent patient outcomes. We sought to examine US national trends in employment status prior to and at HD initiation, risk factors for job loss and their association with transplantation and mortality.

METHODS

Employment was defined as working full-time or part-time for 496 989 patients initiating maintenance HD from 2006 to 2015. Associations between patient and dialysis facility characteristics and employment change were analyzed using multivariable logistic regression. Cox regression was used to assess job loss with mortality and transplantation.

RESULTS

About 26% (n = 129 622) of patients were employed 6 months prior compared with 15% (n = 75 719) at HD initiation. Employment rates 6 months prior to HD initiation decreased from 29% in 2006 to 23% in 2014. Employed patients who maintained employment increased from 57% in 2006 to 64% in 2015. Patients who were older, female, Hispanic, Black, with more comorbidities or living in low-income zip codes were less likely to maintain employment. Facility characteristics associated with employment maintenance included nonprofit status, more stations, dialysis availability after 5 p.m. and home dialysis training. Patients maintaining employment during the 6 months prior to HD had lower mortality and higher transplantation rates than patients who became unemployed.

CONCLUSIONS

Employment rates among HD patients are low and employment changes common during the 6 months prior to HD. Maintaining employment status was associated with key patient and facility characteristics, kidney transplantation and survival.

The correlation of patients' anxiety after a liver or kidney transplantation with functional and self-reported work ability

Organ transplantation has become the treatment of choice for end-stage organ failure, including renal and liver failure. The benefits of patient employment after transplantation are numerous, but factors determining the ability to work among these patients are not clearly defined. The growing interest in these factors has strong practical implications for organizations creating vocational rehabilitation programs. Given the interconnection between psychological and physical functioning in patients after transplantation, the present study examined the impact of anxiety on vocational rehabilitation and its relationship with functional tests. A total of 100 patients after liver or kidney transplantation underwent functional tests, including the 6-minute walking test and 30-second chair stand test (30"CST), and psychological tests, specifically the Inventory of Physical Activity Objectives, Work Ability Index, and State-Train Anxiety Inventory. Working ability was affected by psychological factors. State and trait anxiety exhibited inverse relationships with subjective readiness to occupational activity (P < .001, r = -.59 and P < .001, r = -.56, respectively). The level of anxiety was negatively related to the results of the 30"CST. State-Train Anxiety Inventory, State Anxiety subscale and State-Train Anxiety Inventory, State-Trait Anxiety subscale vs 30"CST: P < .001, r = -.43 P < .001, r = -.44). Thus, state and trait anxiety influence perceived work ability and partially functional status. These observations may indicate the potential benefits of including psychologists in interdisciplinary teams for physical and especially vocational rehabilitation of patients after liver or kidney transplantation.

Return to work after kidney transplant: a systematic review

BACKGROUND

Renal transplant is the gold standard treatment for patients with end-stage renal disease. Employment after transplant is an important marker of recovery and a key component of general well-being with important social implications.

AIMS

To evaluate employment status after renal transplant and to investigate facilitators of and barriers to return to work for renal transplant patients.

METHODS

We searched PubMed, Scopus and the Cochrane Library in March 2019 using the following algorithms: 'return to work' AND kidney AND transplant. Eligible studies were selected by two independent researchers. Quality assessment was performed using the following tools: International Narrative Systematic Assessment (INSA) and Newcastle-Ottawa Scale (NOS) for cross-sectional and cohort studies.

RESULTS

The review included 18 papers: 10 cross-sectional studies, 6 cohort studies and 2 narrative reviews. The weighted mean percentage for return to work within 1 year was 39.4% (95% CI 39.3-39.6%). Employment status was influenced by modifiable and non-modifiable factors, such as pre-transplant employment, sociodemographic characteristics, clinical conditions and comorbidities, operative technique (invasive or not), type of transplants (living donor or cadaver), pre-transplant dialysis, psychosocial support, educational level and participation in education programmes.

CONCLUSION

Return to work after kidney transplant is a dynamic process influenced by numerous factors. It is vital to implement multidimensional interventions focused on rehabilitation and influencing modifiable factors to improve return to work after kidney transplant. This systematic review updates knowledge in the field of transplant and of disability management.

Employment Status and Associations with Workability, Quality of Life and Mental Health after Kidney Transplantation in Austria

Kidney transplantation (KTx) in end-stage renal disease is associated with a significant increase in quality of life (QoL) and self-perceived health, optimally leading to the maintenance of employment or return to work (RTW) in working-age patients. The aim of this study was to assess individual factors including the QoL and mental health of kidney transplant recipients (KTRs) associated with employment after transplantation. A cross-sectional study including working-age patients with a history of KTx after 2012 was conducted at two Austrian study centers (Vienna and Graz). Brief Symptom Inventory (BSI-18), World Health Organization Quality of Life (WHOQOL-Bref) and Workability Index (WAI) were assessed along with detailed questionnaires on employment status. Out of n = 139 KTRs (43.2 ± 9.07 years; 57.6% male), 72 (51.8%) were employed. Employed patients were more frequently in a partnership (p = 0.018) and had higher education levels (p = 0.01) and QoL scores (<0.001). Unemployed KTRs reported fatigue and mental health issues more often (p < 0.001), and had significantly higher anxiety, depression and somatization scores (BSI-18). In unadjusted logistical regression, workability score (WAS; odds ratio (OR) = 3.39; 95% confidence interval (CI) = 1.97–5.82; p < 0.001), partnership (OR = 5.47; 95% CI 1.43–20.91; p = 0.013) and no psychological counseling after KTx (OR = 0.06; 95% CI = 0.003–0.969; p = 0.048) were independently associated with employment. Self-assessed mental health, workability and QoL were significantly associated with employment status after KTx. Thus, in order to facilitate RTW after KTx in Austria, vocational rehabilitation and RTW programs addressing KTRs should focus on increasing social support and care for their mental health.

Predictors of return to work after kidney transplantation: a 12-month cohort of the Japan Academic Consortium of Kidney Transplantation study

OBJECTIVES

To investigate the cumulative return-to-work (RTW) rate and to identify predictors of employment after kidney transplantation (KT).

DESIGN

Retrospective, outpatient-based cohort study.

SETTING

This was a single-centre study of the largest Japanese kidney transplant centre.

PARTICIPANTS

We selected Japanese kidney transplant recipients aged 20-64 years who were employed in paid jobs at the time of transplantation and who visited an outpatient clinic from December 2017 to March 2018. From 797 patients, we evaluated 515 in this study.

INTERVENTIONS

We interviewed patients at an outpatient clinic and investigated the timing and predictors of RTW using logistic regression models.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the cumulative RTW rate, and the secondary outcome was to investigate the predictors of RTW after KT.

RESULTS

Among the 515 included recipients, the cumulative overall partial/full RTW rates at 2, 4, 6 and 12 months were 22.3%, 59.0%, 77.1% and 85.0%, respectively. The median duration from transplantation to RTW was 4 months. Regarding partial/full RTW, according to the multivariable analysis including all variables, male sex was a greater predictor for RTW than female sex (OR 2.05, 95% CI 1.32 to 3.20), and a managerial position was a greater predictor than a non-managerial position (OR 2.23, 95% CI 1.42 to 3.52). Regarding full RTW, male sex (OR 1.95, 95% CI 1.25 to 3.06) and managerial position (OR 1.95, 95% CI 1.25 to 3.06) were also good predictors.

CONCLUSIONS

The cumulative RTW rate was 85.0% 1-year post-transplantation. Given that cumulative RTW rates varied by sex and position, transplant and occupational physicians should support kidney transplant recipients in the aspect of returning to work.

TRIAL REGISTRATION NUMBER

UMIN000033449.

Multivariate analysis of biopsychosocial determinants of professional activity among patients after kidney or liver transplantation in Poland

OBJECTIVE

The aim of the present study was to assess the employment rate among kidney and liver transplant recipients in Poland and identify the predictors of employment.

SETTINGS

The study was based on a self-prepared questionnaire containing five parts: demographic data and professional, medical, physical and psychological factors. This is a multicentre study involving four hospitals in Poland.

PARTICIPANTS

The investigated group consisted of 285 individuals (92 women and 185 men; 8 no sex given) aged between 18 and 45 years who underwent kidney or liver transplantation 1-5 years prior. Because of missing data, 279 questionnaires were considered regarding employment status after transplantation and 277 when sex differences were considered.

RESULTS

A total of 120 patients (43%) worked full-time, 42 (15%) part-time and 117 (42%) remained unemployed, with a higher employment rate post-transplantation among men than women (60% vs 55%, p=0.04). More women performed white collar work (74% vs 41%, p=0.0003) and had to modify their working position than men (22% vs 7%, p=0.0118). Factors determining employment after transplantation included higher level of education (OR=27.08; p=0.0096), employment 1 year prior to transplantation (OR=11.05; p<0.001) and good psychological adaptation (OR=4.23; p<0.001). Men working the year before transplantation had higher education (OR=9.66; p=0.0356). Among men, more kidney recipients worked compared with liver recipients (OR=3.567; p=0.0417). Among women, age determined employment status (OR=0.89; p=0.0234).

CONCLUSION

Higher education is the most important predictor of employment after transplantation. Therefore, rehabilitation programmes including vocational activity should be directed to increase the level of education, both pretransplantation and post-transplantation if possible.

Predictors of Return to Work 12 Months After Solid Organ Transplantation: Results from the Swiss Transplant Cohort Study

Background Return to work with or after a chronic disease is not a very well understood process, influenced by a variety of personal, professional, societal and medical factors. The aim of this study is to identify predictors for return to work 12 months after a solid organ transplant applying a bio-psycho-social model. Methods This study is based on patients included in the Swiss Transplant Cohort Study, a national prospective multicentre cohort, who underwent a first solid organ transplant (kidney, liver, heart, lung). Bio-psycho-social factors were tested and predictors of return to work identified using logistic regression models. Results Among the 636 patients included in the study, 49.8% (317) were employed 12 months post-transplant. The major predictor for returning to work 12 months posttransplant was pre-transplant employment status (OR 10.8). Accordingly, the population was stratified in employed and not employed pre-transplant groups. Age, self-perceived health (6 months post-transplant) and the transplanted organ were significantly associated with post-transplant employment status in both groups. Return to work was influenced by education, depression (6 month post-transplant) and waiting time in the employed pre-transplant group and by invalidity pension in the not employed pre-transplant group. Conclusion Employment status pre-transplant being highly associated with employment status post-transplant, the process promoting return to work should be started well before surgery. Biomedical, psychological and social factors must be taken into account to promote return to work in transplanted patients.

Determinants of Professional Activity After Kidney and Liver Transplantation: Questionnaire Development and Validation

BACKGROUND

Organ transplantation is currently the treatment of choice in end-stage organ failure. Organ replacement therapy compensates for most of organ function loss and offers recipients the potential for an independent life; nevertheless, the employment rate after kidney or liver transplant is low vs the general population. The purpose of this study was to create a questionnaire for kidney and liver transplant patients that comprehensively assesses factors affecting employment among these people including demographic, physical, and psychosocial variables.

MATERIAL AND METHODS

The study was based on a self-prepared questionnaire developed by a team of specialists in the field of medicine, rehabilitation, psychology, and employment. The questionnaire contained 5 parts: demographic data, professional factors, medical factors, physical factors, and psychological factors. The normalization sample consisted of 64 individuals (women and men) aged between 18 to 45 years 1 to 5 years after kidney or liver transplant. The Determinants of Professional Activity after Kidney and Liver Transplantation Questionnaire (DPATQ) was developed based on descriptive statistics, Spearman ρ coefficient, principal component analysis, Cronbach α, and item response theory analysis.

RESULTS

The Cronbach α reliability coefficient for the psychological part reached 0.88.

CONCLUSION

The DPATQ is a new method for measuring post-transplant adaptation and other factors influencing employment status. It offers good psychometric reliability. The DPATQ may be useful in the preparation process of vocational rehabilitation programs or in research studying problems with employment after solid organ transplant.

Education and Employment After Lung Transplantation in Adolescents and Young Adults

Pediatric transplant recipients experience barriers to social functioning, including participation in school and work, but our understanding of barriers to these activities is limited by insufficient data collection and standardization. Existing studies rely on cross-sectional surveys of transplant survivors that are subject to survivorship and nonresponse bias, or analyses of large registry data that lack detail on educational progress and work participation. We report our experience using the electronic medical record to retrospectively review work and educational attainment in this population, and identify specific barriers that were encountered and how they were addressed by the patient and care team. We reviewed current literature on post-transplant survey participation and compared questionnaires to our current documentation practice for tracking education and employment progress in the transplant recipient population. Based on this review, we discuss the possibility, barriers, and implications of conducting a standardized assessment to track social participation outcomes of transplantation.

Couples' employment after spousal kidney donation

We used data from the United Network for Organ Sharing registry of living kidney donors and recipients to identify correlates of paid employment among couples following spousal living donation. Among such couples, post-transplant employment of both spouses (41%) was as common as employment of the donor only (41%). However, when the recipient was female, donor-only employment after transplant was more than twice as likely as compared to employment of both spouses (relative risk ratio = 2.57; p < .001). We conclude that traditional gender roles regarding paid workforce participation may be associated with the likelihood of employment after spousal kidney donation.