Completeness and satisfaction with the education and information received by patients immediately after kidney transplant: a mixed-models study

Losing Much More Than a Transplant: A Qualitative Study of Kidney Transplant Recipients' Experiences of Graft Failure

Introduction

Kidney transplant recipients with graft failure are a growing cohort of patients who experience high morbidity and mortality. Limited evidence guides their care delivery and patient perspective to improve care processes is lacking. We conducted an in-depth exploration of how individuals experience graft failure, and the specific research question was: "What impact does the loss of an allograft have on their lives?"

Methods

We adopted an interpretive descriptive methodological design. Semistructured in-depth narrative interviews were conducted with adult recipients who had a history of ≥1 graft failure. Data were collected until data saturation was achieved and analyzed using an inductive and thematic approach.

Results

Our study included 23 participants from 6 provinces of Canada. The majority were on dialysis and not waitlisted for retransplantation (60.9%). Our thematic analysis identified that the lives of participants were impacted by a range of tangible and experiential losses that go beyond the loss of the transplant itself. The themes identified include loss of control, loss of coherence, loss of certainty, loss of hope, loss of quality of life, and loss of the transplant team. Although many perceived that graft failure was inevitable, the majority were unprepared. The confusion about eligibility for retransplantation appears to contribute to these experiences.

Conclusion

Individuals with graft failure experience complex mental and emotional challenges which may contribute to poor outcomes. The number of patients with graft failure globally is increasing and our findings can help guide practices aimed at supporting and guiding them toward self-management and adaptive coping.

Lessons learned: Development of an organ transplant caregiver educational resource

BACKGROUND

Organ transplant lay caregivers perform an essential and complex role, but there is a paucity of comprehensive, accessible education regarding transplant caregiving. We sought to create a broad, multifaceted educational toolkit for transplant caregivers. Given the complexities of this population, we report on lessons learned by organising diverse stakeholder engagement to develop an educational resource covering the breadth and depth of organ transplantation.

APPROACH

Following a call from organ transplant patients and caregivers, the American Society of Transplantation (AST) formed an Organ Transplant Caregiver Initiative with the aim to develop a comprehensive educational toolkit for transplant caregivers. The AST Organ Transplant Caregiver Toolkit was created through a shared, multi-step process involving transplant professionals and caregivers, who formed an education subcommittee to develop and refine content domains. The caregiver toolkit was reviewed with relevant external stakeholders and through an internal organisational review process.

EVALUATION

Lessons learned included seeking guidance from others with experience creating similar resources, flexibility in project development, creativity in engaging stakeholders and routine communication between all entities involved. Insights gained contributed to the caregiver toolkit completion despite project challenges.

IMPLICATIONS

The AST Organ Transplant Caregiver Toolkit can be utilised by health care professionals to educate and counsel transplant patients and caregivers. Lessons learned from the development of the caregiver toolkit can provide guidance to health care professionals and clinical teachers for the development of future education resources.

Pretransplant Patient Education in Solid-organ Transplant: A Narrative Review

Education for pretransplant, solid-organ recipient candidates aims to improve knowledge and understanding about the transplant process, outcomes, and potential complications to support informed, shared decision-making to reduce fears and anxieties about transplant, inform expectations, and facilitate adjustment to posttransplant life. In this review, we summarize novel pretransplant initiatives and approaches to educate solid-organ transplant recipient candidates. First, we review approaches that may be common to all solid-organ transplants, then we summarize interventions specific to kidney, liver, lung, and heart transplant. We describe evidence that emphasizes the need for multidisciplinary approaches to transplant education. We also summarize initiatives that consider online (eHealth) and mobile (mHealth) solutions. Finally, we highlight education initiatives that support racialized or otherwise marginalized communities to improve equitable access to solid-organ transplant. A considerable amount of work has been done in solid-organ transplant since the early 2000s with promising results. However, many studies on education for pretransplant recipient candidates involve relatively small samples and nonrandomized designs and focus on short-term surrogate outcomes. Overall, many of these studies have a high risk of bias. Frequently, interventions assessed are not well characterized or they are combined with administrative and data-driven initiatives into multifaceted interventions, which makes it difficult to assess the impact of the education component on outcomes. In the future, well-designed studies rigorously assessing well-defined surrogate and clinical outcomes will be needed to evaluate the impact of many promising initiatives.

Non-pharmacological interventions engaging organ transplant caregivers: A systematic review

Lay-caregivers in organ transplantation (to candidates, recipients, and donors) are essential to pre- and post-operative care, but report significant caregiving-related stressors. This review aims to summarize studies testing non-pharmacological interventions aimed at improving organ transplant caregiver-reported outcomes.

METHODS

In accordance with PRISMA, we conducted a systematic review (searched PubMed, Embase, Cochrane Central, PsycInfo, and CINAHL, no start-date restriction through 7/1/2021). Quality of comparative studies assessed by ROBS-2 or ROBINS.

RESULTS

Twelve studies met inclusion. Study designs, interventions, and outcomes varied. Sample sizes were small across caregivers to adult (nine studies, five with caregiver samples ns≤50) and pediatric patients (three studies, caregiver samples ns≤16). Study designs included seven single-arm interventions, two pre-post with comparison cohorts, and three randomized-controlled trials. Eight studies included transplant-specific education as the intervention, an interventional component, or as the comparison group. Outcomes included transplant specific knowledge, mental health, and intervention acceptability. Of the nine pre-post caregiver assessments and/or comparison groups, four studies demonstrated no statistically significant intervention effects.

CONCLUSION

Few interventions addressing the needs of organ transplant caregivers have been empirically evaluated. Existing interventions were well-received by caregivers. Given complexities of care in transplantation, research is needed evaluating interventions using rigorous trial methodology with adequate samples. This article is protected by copyright. All rights reserved.

Perspectives of solid organ transplant recipients on medicine-taking: Systematic review of qualitative studies

Medicine-taking among transplant recipients is a complex and ubiquitous task with significant impacts on outcomes. This study aimed to describe the perspectives and experiences of medicine-taking in adult solid organ transplant recipients. Electronic databases were searched to July 2020, and thematic synthesis was used to analyze the data. From 119 studies (n = 2901), we identified six themes: threats to identity and ambitions (impaired self-image, restricting goals and roles, loss of financial independence); navigating through uncertainty and distrust (lacking tangible/perceptible benefits, unprepared for side effects, isolation in decision-making); alleviating treatment burdens (establishing and mastering routines, counteracting side effects, preparing for the unexpected); gaining and seeking confidence (clarity with knowledge, reassurance through collective experiences, focusing on the future outlook); recalibrating to a new normal posttransplant (adjusting to ongoing dependence on medications, in both states of illness and health, unfulfilled expectations); and preserving graft survival (maintaining the ability to participate in life, avoiding rejection, enacting a social responsibility of giving back). Transplant recipients take medications to preserve graft function, but dependence on medications jeopardizes their sense of normality. Interventions supporting the adaptation to medicine-taking and addressing treatment burdens may improve patient satisfaction and capacities to take medications for improved outcomes.

A Randomized Controlled Trial of a Pretransplant Educational Intervention in Kidney Patients

Supplemental Digital Content is available in the text.

Poor patient knowledge about transplantation is a significant problem following kidney transplant. A video-based educational intervention was developed to supplement standard education provided by transplant teams.

Feasibility and preliminary effects of a theory-based self-management program for kidney transplant recipients: A pilot study

Self-care activities are important to prevent transplant-related side effects and complications among kidney transplant recipients. Therefore, we developed a theory-based self-management program for kidney transplant recipients hospitalized after surgery. This study aimed to examine the feasibility of the program and to identify its preliminary effects on autonomy, competence, and self-care agency. We assessed feasibility using quantitative data collected based on a single group repeated-measures design, along with qualitative data such as patients' feedback on satisfaction during patient counseling. The program comprised video education and individual counseling by nurses. Thirty patients completed this program. Outcome variables were measured thrice: before education, immediately following the first week of video education, and after two consecutive weeks of counseling. A repeated measures ANOVA showed a statistically significant increase in autonomy (F = 5.03, p = .038), competence (F = 17.59, p < .001), and self-care agency (F = 24.19, p < .001). Our pilot study provided preliminary evidence supporting the feasibility for implementation of the theory-based self-management program, and suggesting its preliminary effects in improving autonomy, competence, and self-care agency among kidney transplant recipients. Further research is needed to examine the short- and long-term effects of this program in a longitudinal, randomized control study with a larger sample.

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).

Life experiences of adult heart transplant recipients: a new life, challenges, and coping

PURPOSE

The process during and after heart transplantation is quite complicated, and studies addressing patient experiences are needed. Heart transplantation particularly affects the recipients' activities of daily living and exposes them to various complications. The aim of this study is to explore the experiences of heart transplant recipients during and after heart transplantation.

METHODS

This qualitative, phenomenological research was conducted with 11 heart transplant recipients in the university hospital, which is one of the 14 heart transplantation centers in Turkey. The data were collected through in-depth semi-structured interviews in a private room that ensured both the comfort of the participants and the necessary conditions for safe data collection. The interviews were recorded using an audio recorder, transcribed, and then analyzed using inductive content analysis. Data collection was terminated after the 11th interview when the data reached the saturation point.

RESULTS

The study data were categorized into the following three main themes and subthemes: (1) a new life with a new heart; an opportunity arising at an unexpected time, heart donation, and transplantation as a value, (2) challenges; management of medication therapy and side effects, emotion management, maintaining social relations, and social stigma, and (3) coping; faith in God and praying, responsibility of living with a blessing (donated heart), health professional support, family support, and peer counseling. In line with these themes, expressions of value given to new life and gratitude to heart transplantation were important. The availability and diversity of support sources came to the fore in coping. Social stigma expressions of especially male patients were remarkable in challenges.

CONCLUSION

At the end of the study, the experiences of heart transplant recipients were obtained regarding a new life with a new heart, challenges, and coping. The study results provide an insight into the challenges that the heart transplant recipients face and their coping strategies, guiding the healthcare professionals. The challenges and relevant coping strategies of heart transplant recipients may be integrated into clinical practice and may help plan patient's care. The results may also be used to design and implement an intervention program to improve care for these patients.

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.

An Exploratory Correlational Study in the Use of Mobile Technology Among Adult Kidney Transplant Recipients

INTRODUCTION

Rapidly growing use of mobile technology provides a platform for self-management of care support for those with chronic conditions. Few studies have explored the characteristics or access patterns of kidney transplant recipients who use mHealth applications (apps) for self-management of care.

RESEARCH QUESTIONS

The primary aim of this study was to describe demographics, use, barriers, and perceptions of mobile apps for self-management of care among adult kidney transplants recipients. The secondary aim was to compare blood urea nitrogen, glomerular filtration rate, and number of hospitalizations among mHealth app users, other app users, and non-app users.

METHODS

A cross-sectional design was used to administer the Mobile Application Use among Kidney Transplant Recipients Questionnaire. Descriptive statistics, χ² statistics, and analysis of variance were used for the primary aim and linear regression was used for the secondary aim.

RESULTS

The sample included mostly African American males (n = 123, 75.5%) with a mean age of 50 (13.2) years. Knowledge was the greatest barrier reported by the non-app users (mHealth app users 9%, other app users 12%, non-app users, 49%, P < .001). Significantly fewer hospitalizations were found in the mHealth app users compared to other app users (regression coefficient b = -1.2, standard error [SE] = 0.5) and non-app users ( b = -0.9, SE = 0.6), adjusting for patient demographic and clinical characteristics.

DISCUSSION

Findings suggest a relationship may exist between mHealth app use and a decrease in the number of hospitalizations following kidney transplantation.

Work of being an adult patient with chronic kidney disease: a systematic review of qualitative studies

INTRODUCTION

Chronic kidney disease (CKD) requires patients and caregivers to invest in self-care and self-management of their disease. We aimed to describe the work for adult patients that follows from these investments and develop an understanding of burden of treatment (BoT).

METHODS

Systematic review of qualitative primary studies that builds on EXPERTS1 Protocol, PROSPERO registration number: CRD42014014547. We included research published in English, Spanish and Portuguese, from 2000 to present, describing experience of illness and healthcare of people with CKD and caregivers. Searches were conducted in MEDLINE, Embase, CINAHL Plus, PsycINFO, Scopus, Scientific Electronic Library Online and Red de Revistas Científicas de América Latina y el Caribe, España y Portugal. Content was analysed with theoretical framework using middle-range theories.

RESULTS

Searches resulted in 260 studies from 30 countries (5115 patients and 1071 carers). Socioeconomic status was central to the experience of CKD, especially in its advanced stages when renal replacement treatment is necessary. Unfunded healthcare was fragmented and of indeterminate duration, with patients often depending on emergency care. Treatment could lead to unemployment, and in turn, to uninsurance or underinsurance. Patients feared catastrophic events because of diminished financial capacity and made strenuous efforts to prevent them. Transportation to and from haemodialysis centre, with variable availability and cost, was a common problem, aggravated for patients in non-urban areas, or with young children, and low resources. Additional work for those uninsured or underinsured included fund-raising. Transplanted patients needed to manage finances and responsibilities in an uncertain context. Information on the disease, treatment options and immunosuppressants side effects was a widespread problem.

CONCLUSIONS

Being a person with end-stage kidney disease always implied high burden, time-consuming, invasive and exhausting tasks, impacting on all aspects of patients' and caregivers' lives. Further research on BoT could inform healthcare professionals and policy makers about factors that shape patients' trajectories and contribute towards a better illness experience for those living with CKD.

PROSPERO REGISTRATION NUMBER

CRD42014014547.

Development of a patient-centered video series to improve education before kidney transplantation

BACKGROUND

Inadequate patient knowledge about transplantation can result in low patient satisfaction and contribute to poor clinical outcomes. The purpose of this patient-oriented research project was to develop an educational intervention for patients awaiting kidney transplantation.

METHODS

An educational intervention was developed by patients and health care providers, experts in medication adherence, video education, motivational psychology, and cultural education. Project objectives were defined and content was guided by a series of studies conducted with stakeholders. A review process was undertaken with additional patients, external health care providers and ninth grade high school students and edits were applied accordingly.

RESULTS

A set of six educational videos, ranging in length from 3 to 24 min, was created to describe the transplant process. The videos are patient friendly in design, and incorporate animations to explain complex information to accommodate low health literacy, and patient testimonials align the content with principles of adult learning theory. Feedback from external patient reviews [n = 8], external care providers [n = 13] and students [n = 26], indicate that the mini-series is informative and useful.

CONCLUSION

Patient involvement significantly influenced the development of a video series about kidney transplantation.

PRACTICE IMPLICATIONS

Patient engagement is integral for developing high quality and relevant educational interventions.

Education Before Kidney Transplantation

Context:

Poor knowledge about immunosuppressive (IS) medications remains a major problem for patients in the posttransplant setting. Therefore, more effective educational strategies in the pretransplant setting are being considered as a possible method to improve knowledge and readiness for the challenges of posttransplant care. However, the most effective/relevant content of a pretransplant educational program is yet to be determined.

Objective:

To identify pretransplant education topics from the posttransplant patient perspective.

Design:

A focus group meeting was conducted among 7 high-functioning, stable adult kidney transplant recipients recruited from the Saskatchewan Transplant Program. Demographic information including age, gender, occupation, background/ethnicity, and time since transplant were recorded. A moderator, assistant moderator, and research assistant facilitated the 90-minute focus group meeting using a predetermined semistructured interview guide. The session was audio recorded and transcribed verbatim. Nvivo software was used to code the data and identify emerging themes exploring views of participants relating to the educational information required for pretransplant patients.

Results:

Patients were satisfied with the education they had received. Ideas were classified into the following major themes—patient satisfaction, transplant waitlist, surgery, medications, posttransplant complications, lifestyle and monitoring, knowledge acquisition, illusion of control, and life changes posttransplant. Knowledge gaps were identified in all areas of the transplantation process and were not exclusive to IS medications.

Conclusion:

Misconceptions regarding transplantation were identified by a group of high-functioning, stable adult recipients who were satisfied with their clinical care. Future educational strategies should aim to address the entire transplantation process and not be limited to medications.

Lifestyle and Self-Management by Those Who Live It: Patients Engaging Patients in a Chronic Disease Model

BACKGROUND

Patients pursuing organ transplantation have complex medical needs, undergo comprehensive evaluation for possible listing, and require extensive education. However, transplant patients and their supports frequently report the need for more lifestyle and self-management strategies for living with organ transplantation.

OBJECTIVES

First, to explore feasibility of a successful, patient-run transplant lifestyle educational group (Transplant Living Community), designed to complement medical care and integrated into the clinical setting; and second, to report the major themes of patients' and supports' qualitative and quantitative feedback regarding the group.

METHODS

Informal programmatic review and patient satisfaction surveys.

RESULTS

A total of 1862 patient satisfaction surveys were disseminated and 823 were returned (response rate, 44.2%). Patients and their supports reported positive feedback regarding the group, including appreciation that the volunteer was a transplant recipient and gratitude for the lifestyle information. Five areas were associated with the success of Transplant Living Community: 1) a "champion" dedicated to the program and its successful integration into a multidisciplinary team; 2) a health care environment receptive to integration of a patient-led group with ongoing community development; 3) a high level of visibility to physicians and staff, patients, and supports; 4) a clearly presented and manageable lifestyle plan ("Play Your ACES"(a) [Attitude, Compliance, Exercise, and Support]), and 5) a strong volunteer structure with thoughtful training with the ultimate objective of volunteers taking ownership of the program.

CONCLUSION

It is feasible to integrate a sustainable patient-led lifestyle and self-management educational group into a busy tertiary care clinic for patients with complex chronic illnesses.

Understanding Patient Barriers to Kidney Transplant Evaluation

BACKGROUND

Some patients referred for kidney transplant evaluation fail to attend the visit. Our goal was to compare demographic, socioeconomic, and psychologic factors between evaluation visit attendees and absentees.

METHODS

A convenience sample of patients referred and scheduled for kidney transplant evaluation at a single center from November 2012 to December 2013 participated in a phone survey reporting socioeconomic, demographic, and clinical characteristics; health literacy; and perceived knowledge and concerns about transplantation. Absentees were matched by race with attendees. Analyses of differences between groups were performed with chi-square test, Fisher exact test, and t tests. Multivariable logistic regression was adjusted for relevant demographic characteristics.

RESULTS

One hundred four adults participated (61% men, 46% white, 52 ± 12 years). Financial concerns were the most prevalent (67.3% affording medication, 64.1% affording operation). Previous evaluation at a different transplant center (P = 0.029) and being on dialysis (P = 0.008) were significantly associated with absence. Attendance was associated with concerns about finding a living donor (P = 0.038) and higher perceived general knowledge about transplantation (P ≤ 0.001). No differences were appreciated in demographic, socioeconomic, or health literacy factors between groups.

CONCLUSION

Both attendee and absentee patients were most concerned with the financial burden of kidney transplantation. Although concerns and perceived knowledge are important correlates of behavior, other considerations such as psychologic factors and prior medical experiences may influence patients' ability to complete the kidney transplant evaluation process. Although this pilot study was conducted in a small sample and has limited generalizability, our findings can guide future research.

What are Patients Saying about Sex after a Kidney or Simultaneous Kidney/Pancreas Transplant?

Context—

Chronic illnesses such as kidney failure and diabetes and their treatments can affect people's identity, including their sexual identity. Little is known about patients' perspective on the effect of transplant on their sexual identity.

Objective—

To explore the sexual concerns of kidney and simultaneous pancreas/kidney transplant recipients.

Design—

Descriptive, qualitative.

Setting—

Major Midwestern university hospital.

Patients—

143 kidney and 70 pancreas/kidney transplant recipients; most were male (63.0%), married (64.7%), and white (83.7%), and the mean age was 49 years.

Intervention—

The qualitative data reported in this manuscript are derived from 2 larger quantitative studies of sexuality and quality of life in kidney and pancreas/kidney transplant recipients. The questionnaire in those studies included 2 open-ended questions that allowed participants to share their experiences as transplant recipients.

Main Outcome Measure—

Two faculty and 3 students did a conventional content analysis on patients' responses to the open-ended questions. Codes were extracted from the responses and then themes were created that best represented the codes.

Results—

Participants shared how sexual concerns affected their identity as sexual beings after transplant. Based on the responses to these open-ended questions, 4 themes were identified: sexual functioning, health care concerns, relationship with partner, and appearance changes. The study results indicate the need for improved education and provider-initiated dialogue related to sexuality after transplant.