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

Life experiences after kidney transplantation in adolescents: A qualitative meta-synthesis

PURPOSE

To systematically evaluate the life experience of adolescents after kidney transplantation.

METHODS

We use computer search Web of Science, PubMed, Cochrane Library, Embase, EBSCO, CNKI, Wanfang, VIP database, search database to October 2024, screening after kidney transplant adolescents life experience of qualitative study. We used the Australian Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research to quality evaluation, and using the thematic analysis method to integrate the results.

RESULTS

7 articles were included, and 31 research results were integrated into 8 new categories and combined results are 3 integration results: complex emotional experience; eager for multifaceted support; self-adjustment.

CONCLUSION

Nursing staff should pay attention to the psychological experience and needs of adolescents, to eliminate their stigma, to promote positive cognition, and to improve their quality of life.

Quality of Life in Pediatric CKD Patients on Dialysis vs Renal Transplantation: A Comparative Study of the Perspectives of Parents and Children

BACKGROUND

Chronic kidney disease (CKD) is a burden on children and their caregivers, especially in advanced stages requiring different renal replacement modalities (peritoneal/hemodialysis and renal transplant). The aim of the study is to measure the health-related quality of life (HRQOL) of children and their caregivers for each renal replacement modality, specifically dialysis and transplant.

METHODS

This study is a single-center cross-sectional study that was carried out at King Fahad Specialist Hospital in Dammam (KFSH-D). A total of 57 participants ranging from 5 to 18 years of age were included in the study, comprised of 42 patients and their parents in the transplant arm and 15 patients and their parents in the end-stage renal disease (ESRD) arm. The HRQOL was measured using the Pediatric Quality of Life Inventory (PedsQL) version 3.0 ESRD and transplant modules, respectively.

RESULTS

The mean scores for HRQOL for children receiving dialysis were found to be 60.2 ± 22.6, which was significantly lower than the scores for children who had undergone transplantation (84.1 ± 14.7, P = .001). Additionally, the scores for the parents providing proxy reports for children on dialysis (52.5 ± 25.7) were also significantly lower compared with those for parents of children who had undergone transplantation (83.8 ± 13.9, P ≤ .001).

CONCLUSIONS

This research demonstrated that HRQOL of both children who had undergone transplants and their caregivers was notably superior to that of individuals with ESRD. Which reinforces the importance of timely kidney transplantation in children and its positive impact on both physical and psychosocial well-being.

'You Can't Muck Around With Transplant': Young People's Experiences of Clinical Care Following Lung Transplant

BACKGROUND

Lung transplantation improves survival and quality of life in young people with end-stage lung disease. Few studies have investigated the clinical care experiences of young people after lung transplantation.

DESIGN

This qualitative study aimed to explore the experiences of young people who underwent lung transplantation. Semi-structured interviews were conducted with 16 lung transplant recipients (< 25 years at transplant). Interviews were analysed to identify themes and categorize and describe the experience of young lung transplant recipients.

RESULTS

The themes that emerged were (1) Hope and spectre: The transplant dilemma; (2) Information delivery and comprehension; (3) Independence and navigating care; and (4) Continuity and youth-appropriate care. Findings suggest that young people have distinct care needs that consider the many parallel life transitions that occur in addition to transplantation. They value consistent and familiar teams, which nurture autonomy and independence in the context of post-transplant survivorship and highlight the importance of feeling that they can relate to the healthcare process.

CONCLUSION

The results highlight key areas where adolescent lung transplant recipients can be supported by clinicians, enabling the development of youth-friendly services that cater to this group's healthcare and psychosocial needs.

PATIENT OR PUBLIC CONTRIBUTION

Sixteen lung transplant recipients participated in the study by completing a semi-structured interview. Two additional lung transplant recipients who received lung transplants as adolescents and one parent of an adolescent lung transplant recipient participated in a Project Advisory Group (PAG) with six clinicians representing paediatric, adolescent, and adult healthcare experience. They provided advice on research design including the development and revision of the interview guide and recruitment methods. They additionally provided feedback on the preliminary findings and outline of the manuscript. A summary of results was presented to the PAG who in conjunction with the writing group developed a list of recommendations based on the themes identified and the tenets of youth-appropriate care as set out by the World Health Organization. One lung transplant recipient was an author on the manuscript contributing to its writing and review before submission. The clinicians who participated in the PAG did not have direct healthcare relationships with the study participants.

The Evaluation of Change in Psychosocial Risk With Caregivers of Children With Chronic Kidney Disease: A Short-term Longitudinal Mixed-Methods Study

Background

The COVID-19 pandemic and its accompanying safeguards intensified many of the ongoing daily challenges faced by caregivers of young people with chronic kidney disease (CKD) both pre-transplant and post-transplant, and also created a variety of new and pressing concerns. Little is known about how these families managed this unexpected adversity in their lives.

Objective

To evaluate change in psychosocial risk for families of young people with CKD during the COVID-19 pandemic health emergency from the perspective of caregivers.

Design

A short-term longitudinal mixed-methods study with a convergent parallel design.

Setting

Manitoba, Canada.

Participants

Thirty-six caregivers of young people with CKD participated in a quantitative assessment prior to the pandemic; approximately half were transplant recipients. Thirteen were re-assessed during the pandemic (62% were caregivers of transplant recipients) using both qualitative and quantitative assessments.

Methods

First, caregivers completed the Psychosocial Assessment Tool (PAT) prior to the pandemic. Second, caregivers were re-assessed using the PAT during the pandemic. They were also interviewed about their experiences. Changes in PAT scores over time were evaluated, including an investigation of whether psychosocial risk was related to transplant status. Interviews were coded using thematic analysis. In the interpretation stage, the qualitative findings were combined with the quantitative results to help explain the latter and reach a more fulsome understanding of caregivers' experience.

Results

Quantitatively, overall family psychosocial risk scores increased significantly during the pandemic health emergency, as did the domain of Caregiver Problems. Families of transplant recipients were found to be at significantly lower psychosocial risk pre-pandemic than families of transplant candidates. Coding identified Negative Pandemic Experiences, Positive Pandemic Experiences, and Coping Mechanisms. Mixed-methods analyses revealed several areas of convergence and divergence between the quantitative and qualitative findings.

Limitations

Limitations included a small sample size that limited generalizability, single site data collection, and single caregiver report.

Conclusions

Although overall family psychosocial risk increased during the pandemic, caregivers described several resilience processes and characteristics. A mixed-method approach provided a unique perspective that highlighted the value of integrating quantitative and qualitative findings. Results were discussed within the pediatric psychosocial preventive health model framework.

Adolescent and Young Adult Development in Transplant Recipients

Solid organ transplantation (SOT) is the gold standard of therapy for individuals with end-organ dysfunction. Improved survival outcomes after SOT can help adolescent and young adult (AYA) recipients lead long and healthy life. However, successful SOT during adolescence and young adulthood is often complicated by the innate developmental challenges of this age group. The psychosocial tasks of adolescence include identity development, autonomous decision-making, establishing social networks, educational and vocational preparation, and navigating romantic relationships. These goals may be amplified or delayed for pediatric SOT recipients. Adolescence is also marked by rapid physical changes in linear growth and the development of secondary sexual characteristics. Yet AYA may experience physical and pubertal delays related to transplantation, as well as exaggerated body image dissatisfaction due to medication side effects. Strict adherence to medication and post-transplant regimens may interfere with adolescents' desire for normalcy and fitting in with peers. Healthcare providers should be aware that AYA value education and self-empowerment in transplant care. Transplant success needs to be defined by both medical and psychosocial outcomes, particularly when it relates to the vulnerable AYA population. Fortunately, investment from the patient, family, and care team can aid in transplant recovery and success. This article will identify the developmental challenges faced by AYA undergoing solid organ transplantation as well as strategies to engage positive outcomes.

Identifying experiences of supportive care of children and young people affected by kidney failure: A qualitative systematic review

BACKGROUND

Children and young people affected by kidney failure experience complexities in their care. Little is known about the unique needs of this young patient population group living with a long-term condition.

OBJECTIVE

A meta-aggregation of all qualitative studies was conducted to identify experiences of supportive care among children and young people living with kidney failure.

METHODS

A systematic review of qualitative studies was conducted following the Joanna Briggs Institute meta-aggregation method. This review has been reported according to the PRISMA statement guidelines. Six electronic databases (CINAHL, Cochrane Library, MEDLINE, Proquest, PsycINFO, and Scopus) were comprehensively searched by an expert systematic review librarian using keywords and subject headings, from inception to September 2022. All studies were accessed using a predetermined inclusion and exclusion criteria. Methodological quality assessment and data extraction performed. Qualitative findings accompanied by illustrative quotes from included studies were extracted and grouped into categories which created the overall synthesised findings.

RESULTS

A total of 34 studies were included in this review representing a total of 613 children and young people affected by kidney failure. There was a total of 190 findings which created 13 categories representing experiences of supportive care. The meta-aggregation developed five synthesised findings namely: 'physical needs', 'information and technology', 'treatment and healthcare', 'social needs' and 'psychological impacts'.

CONCLUSION

This systematic review identified that children and young people affected by kidney failure can experience a range of unmet supportive care needs in routine clinical services. Kidney failure impacted children and young people's self-identify, social and peer networks, introduced daily practical needs because of inherent physical and psychological burden due to the failure and associated treatments. Despite improvements in the medical management of kidney failure in children and young people, further attention is needed to optimise supported self-management in this young patient group.

Mental health and social-emotional functioning in children and adolescents with chronic kidney disease

For children and young adults, living with chronic kidney disease (CKD) poses physical, mental, and social challenges. The mental health functioning of children and adolescents with CKD plays an important role in the medical, educational, vocational, and quality of life outcomes, yet receives little systematic attention in the busy pediatric nephrology clinic. This article will provide an overview of the prevalence of mental illness and symptoms in children and young adults with CKD, strategies to assess for dysfunction, and the long-term outcomes associated with impaired functioning. While there is a relative dearth of literature regarding evidence-based interventions in this population to improve mental health functioning, we provide "best practice" strategies based on the available literature to address emotional and/or behavioral challenges once they are identified. More research is needed to define appropriate interventions to alleviate mental health issues and social-emotional distress, and this review of the literature will serve to provide directions for future research.

Risk assessment of organ transplant operation: A fuzzy hybrid MCDM approach based on fuzzy FMEA

Nowadays, most fatal diseases are attributed to the malfunction of bodily. Sometimes organ transplantation is the only possible therapy, for instance for patients with end-stage liver diseases, and the preferred treatment, for instance for patients with end-stage renal diseases. However, this surgical procedure comes with inherent risks and effectively managing these risks to minimize the likelihood of complications arising from organ transplantation (maximizing life years from transplant and quality-adjusted life years) is crucial. To facilitate this process, risk ranking is used to identify and promptly address potential risks. Over recent years, considerable efforts have been made, and various approaches have been proposed to enhance Failure Modes and Effects Analysis (FMEA). In this study, taking into account the uncertainty in linguistic variables (F-FMEA), we introduce an approach based on Fuzzy Multi Criteria Decision Making (F-MCDM) for effectively evaluating scenarios and initial failure hazards. Nevertheless, the results of ranking failure modes generated by different MCDM methods may vary. This study is a retrospective study that suggests a comprehensive unified risk assessment model, integrating multiple techniques to produce a more inclusive ranking of failure modes. Exploring a broad spectrum of risks associated with organ transplant operations, we identified 20 principal hazards with the assistance of literature and experts. We developed a questionnaire to examine the impact of various critical factors on the survival of transplanted organs, such as irregularities in immunosuppressive drug consumption, inappropriate dietary habits, psychological disorders, engaging in strenuous activities post-transplant, neglecting quarantine regulations, and other design-related factors. Subsequently, we analyzed the severity of their effects on the durability of transplanted organs. Utilizing the Mamdani algorithm as a fuzzy inference engine and the Center of Gravity algorithm for tooling, we expressed the probability and severity of each risk. Finally, the failure mode ranking obtained from the F-FMEA method, three fuzzy MCDM methods, and the proposed combined method were identified. Additionally, the results obtained from various methods were evaluated by an expert team, demonstrating that the highest consistency and effectiveness among different methods are attributed to the proposed method, as it achieved a 91.67% agreement with expert opinions.

It's About the Journey - Capturing Stories of the Fluctuating Experiences of Youth Kidney Transplant Patients

Youth who undergo a kidney transplant can experience a fluctuation of successes and challenges throughout their chronic illness journey. Designing to capture their journey could help youth to reflect on their experiences, collaborate on their care, and be empowered to live their lives to the fullest. We interviewed 11 youth kidney transplant patients and 12 caregivers to elicit their transplant journey experiences. We found that probing participants about specific parts of their transplant journey gave them structure to tell us rich stories about their experiences. Based on our findings, we discuss informing the design of a tool to support the capturing of stories for youth with chronic illnesses. Designing such tool could help youth and their caregivers to identify barriers, support reflection, and promote self-efficacy. Youth with chronic illnesses already have to change so many aspects of their lives to accommodate their illness, however, by giving them a platform to capture their chronic illness journey, it could encourage them to take more control of their lives and better collaborate with others.

Timing of Kidney Replacement Therapy among Children and Young Adults

BACKGROUND

No randomized trials exist to guide the timing of the initiation of KRT in children. We sought to define trends and predictors of the eGFR at initiation of KRT, center-related clinical practice variation, and any association with patient survival.

METHODS

Children and young adults (1-25 years) commencing KRT (dialysis or kidney transplantation) between 1995 and 2018 were included using data from the Australia and New Zealand Dialysis and Transplant Registry. The associations between eGFR on commencing KRT and covariates were estimated using quantile regression. Cox regression was used to estimate the association between eGFR and patient survival. Logistic regression, categorizing eGFR about a value of 10 ml/min per 1.73 m 2 , was used in conjunction with a random effect by center to quantify clinical practice variation.

RESULTS

Overall, 2274 participants were included. The median eGFR at KRT initiation increased from 7 to 9 ml/min per 1.73 m 2 over the study period and the 90th centile from 11 to 17 ml/min per 1.73 m 2 . The effect of era on median eGFR was modified by modality, with a greater increase among those receiving a preemptive kidney transplant (1.0 ml/min per 1.73 m 2 per 5 years; 95% confidence interval [CI], 0.6 to 1.5) or peritoneal dialysis (0.7 ml/min per 1.73 m 2 per 5 years; 95% CI, 0.4 to 0.9) compared with hemodialysis (0.1 ml/min per 1.73 m 2 per 5 years; 95% CI, -0.1 to 0.3). There were 252 deaths (median follow-up 8.5 years, interquartile range 3.7-14.2) and no association between eGFR and survival (hazard ratio, 1.01 per ml/min per 1.73 m 2 ; 95% CI, 0.98 to 1.04). Center variation explained 6% of the total variance in the odds of initiating KRT earlier. This rose to over 10% when comparing pediatric centers alone.

CONCLUSIONS

Children and young adults progressively commenced KRT earlier. This change was more pronounced for children starting peritoneal dialysis or receiving a preemptive kidney transplant. Earlier initiation of KRT was not associated with any difference in patient survival. A substantial proportion of clinical practice variation was due to center variation alone.

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_08_08_CJN0000000000000204.mp3.

The Educational Needs of Adolescent and Young Adult Renal Transplant Recipients-A Scoping Review

Renal transplantation is the gold-standard treatment for adolescents and young adults with end-stage renal disease. Despite enjoying excellent short-term outcomes, they suffer the worst rates of premature transplant function loss. Health behaviors: such as lack of adherence to immunosuppressive medications, are felt to be the major contributory factor. Understanding the educational needs of young renal transplant recipients allows healthcare practitioners to better support patients in managing their chronic disease. The aim of this scoping review was to understand what is known about their educational needs. A scoping review methodology was followed. Following an online search, study titles, and abstracts were screened for eligibility, followed by full-text assessment and data extraction. Data were qualitatively analyzed using thematic analysis. A total of 29 studies were included in the scoping review. In young people who struggled with self-management, three themes were identified (1) the Needs of the disrupted youth, (2) the Needs of the disorganized youth (3) the Needs of the distressed youth. There was a paucity of research to identify the protective factors that enable young recipients to successfully manage their health. This review outlines current knowledge of the patient education needs of young transplant recipients. It also highlights remaining research gaps that will need to be addressed with future research.

My Kidney Identity: Contextualizing pediatric patients and their families kidney transplant journeys

BACKGROUND

Even though having a kidney transplant is the treatment of choice for children with kidney failure, it can cause anxiety for patients and their families resulting in decreased psychosocial functioning, adherence, and self-management. We set out to identify the information needs required to help pediatric patients and their families contextualize their posttransplant experiences as they recalibrate their understanding of normalcy throughout their transplant journey.

METHODS

Participants submitted photographs related to feeling: (1) worried, (2) confident, (3) similar to peers without kidney disease, and (4) different from these peers. The photographs served as a foundation for an in-depth interview.

RESULTS

Nineteen individuals (10 pediatric transplant recipients and 9 caregivers) were interviewed at a mean of 8 years posttransplant. We identified five specific themes and tensions our participants associated with recalibrating their version of "normal" throughout the transplant journey: (1) exchanging information (information consumers vs. information contributors, (2) transitional management (family management vs. self-management), (3) building confidence (worry vs. confidence), (4) telling one's story (hiding vs. self-expression), and (5) normalizing kidney transplantation (feeling different vs. feeling similar). These five themes/tensions form one's Kidney Identity, shift from negative to positive throughout the transplant journey, illustrating a more abstract and complex account of kidney transplantation over time.

CONCLUSIONS

Having a patient view their Kidney Identity over time may support self-reflection of one's progress posttransplant and potentially help clinicians, patients, and their caregivers identify barriers and areas where they may need more support to ensure their successful engagement in their care.

The psychosocial needs of adolescent and young adult kidney transplant recipients, and associated interventions: a scoping review

BACKGROUND

Renal transplantation is considered the gold standard treatment for end-stage kidney disease. Adolescent and young adult kidney transplant recipients have the highest rate of graft loss amongst transplanted patients. It is largely accepted this is due to psychosocial and behavioural difficulties, which impact adherence to prescribed therapies. This phenomenon is not isolated to a particular healthcare system having been observed in multiple countries across different continents. It is a global issue of concern. We sought to review the psychosocial needs of these patients, and the interventions designed to meet these needs.

METHODS

A scoping review was conducted based on Arksey and O'Malley's six-stage framework. Eligibility criteria included primary studies of any type that investigated the psychosocial needs of adolescent and/or young adult renal transplant recipients or studies which examined interventions designed to address these needs. Search strategies were developed and conducted on PsycINFO, PubMed, Embase, and CINAHL. Articles meeting the inclusion criteria were critically reviewed using a descriptive-analytical narrative method.

RESULTS

Thirty-nine studies met our inclusion criteria, 30 of which related to psychosocial needs, and the remainder examined psychosocial interventions. Four main themes were derived from our analysis of psychosocial needs literature, as follows: the need for (1) emotional support, (2) acceptance, (3) direction, (4) equality in healthcare. 2 main themes emerged from analysis of psychosocial intervention literature, namely: psychosocial (1) capability, (2) assessment. Despite the evidence that graft health is strongly associated with psychosocial wellbeing, findings revealed a significant lack of literature investigating how best to meet psychosocial needs. Trends were observed amongst intervention studies, namely interventions of novel and non-evidenced based design, with the aim of improving medication adherence through organisational strategies and education. However, literature regarding psychosocial needs showed non-adherence to therapies was not simply a result of disorganisation or lack of understanding, but rather, was founded on a recipient's idiosyncratic relationship with their prescribed therapies e.g., psychological, social or financial reasons for non-adherence.

CONCLUSIONS

Future research should be directed at investigating the efficacy of evidence-based interventions that empower the individual patient to overcome their specific barrier to an optimal relationship with their therapies.

A qualitative exploration of the facilitators and barriers to self-management in kidney transplant recipients

Background

Understanding the behaviours that facilitate or impede one’s ability to self-manage is important to improve health-related outcomes in kidney transplant recipients (KTRs). Previous studies exploring the self-management experiences of KTRs have focused on specific tasks (e.g., medication adherence), age groups (e.g., adolescent or older recipients), or have been conducted outside of the UK where transferability of findings is unknown. Our study aimed to explore the perceptions and experiences of self-management in UK KTRs to identify facilitators and barriers associated with self-management tasks.

Methods

Semi-structured interviews were conducted with eleven KTRs. Topics explored included experiences of self-management tasks (diet, exercise, medications, stress management), perceived healthcare role, and future interventional approaches. Thematic analysis was used to identify and report themes.

Results

Eight themes were identified which were mapped onto the three self-management tasks described by Corbin and Strauss: medical, role and emotional management. Perceived facilitators to self-management were: gathering health-related knowledge, building relationships with healthcare professionals, creating routines within daily life, setting goals and identifying motivators, establishing support networks, and support from family and friends. Complexity of required treatment and adjusting to a new health status were perceived barriers to self-management.

Conclusions

Participants described the importance of collaborative consultations and continuity of care. Tailored interventions should identify individualised goals and motivators for participating in self-management. Education on effective strategies to manage symptoms and comorbidities could help alleviate KTRs’ perceived treatment burden. Family and peer support could emotionally support KTRs; however, managing the emotional burden of transplantation warrants more attention.

Graphic abstract

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

An explorative study using a qualitative method.

PARTICIPANTS

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

APPROACH

A qualitative exploratory study taking a phenomenological-hermeneutic approach.

METHOD

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

FINDINGS

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

CONCLUSION

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

Considering a COVID-19 vaccine mandate for pediatric kidney transplant candidates

The world continues to face the effects of the SARS-CoV-2 pandemic. COVID-19 vaccines are safe and effective in protecting recipients, decreasing the risk of COVID-19 acquisition, transmission, hospitalization, and death. Transplant recipients may be at greater risk for severe SARS-CoV-2 infection. As a result, transplant programs have begun instituting mandates for COVID-19 vaccine for transplant candidacy. While the question of mandating COVID-19 vaccine for adult transplant candidates has garnered attention in the lay and academic press, these discussions have not explicitly addressed children who may be otherwise eligible for kidney transplants. In this paper we seek to examine the potential ethical justifications of a COVID-19 vaccine mandate for pediatric kidney transplant candidacy through an examination of relevant ethical principles, analogous cases of the use of mandates, differences between adult and pediatric kidney transplant candidates, and the role of gatekeeping in transplant vaccine mandates. At present, it does not appear that pediatric kidney transplant centers are justified to institute a COVID-19 vaccine mandate for candidates. Finally, we will offer suggestions to be considered prior to the implementation of a COVID-19 vaccine mandate.

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

PURPOSE

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

DESIGN AND METHODS

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

RESULTS

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

CONCLUSION

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

PRACTICE IMPLICATIONS

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

Describing barriers and facilitators for medication adherence and self-management among kidney transplant recipients using the information-motivation-behavioral skills model

BACKGROUND

We aimed to develop an adapted information-motivation-behavioral skills (IMB) model to describe barriers and facilitators for adherence and self-management among kidney transplant recipients.

METHODS

We conducted a review of literature about kidney transplant recipients' knowledge, perceptions, and experiences and organized our results using the IMB framework. We then conducted interviews with transplant recipients and transplant providers to supplement our literature search.

RESULTS

Our proposed adaption of the IMB model describes informational, motivational, and behavioral skills barriers and facilitators for medication adherence and self-management among kidney transplant recipients. Moderating factors influence not only behavioral skills, but also recipients' understanding of information and motivation to adhere and practice self-management.

CONCLUSION

By using the IMB model to organize current research and interviews with recipients and providers, we developed an adapted model for medication adherence and self-management. Results are promising to impact future educational and behavioral interventions for kidney transplant recipients.

Becoming unique: A qualitative study of identity development of adolescent kidney recipients

Teenagers who receive a renal organ transplant have to take up the double challenge of identity development, the primary task of adolescence, and of overcoming the complexities of their illness. Previous qualitative studies found that adolescents felt that the organ transplant and its treatments mainly defined who they are. The relationship to the donor can be a source of concern for some of them, especially for those who received from a parent and feel an obligation to be obedient and grateful. While donor parents are known to interpret their gesture as giving life for a second time, no research to date has described how this particular gesture may influence adolescent development. The present article aims to examine and describe identity development of teenage kidney recipients in a context of parental or deceased donation. We used a qualitative design involving individual interviews with 10 adolescents. Five of them received from a donor parent, five from a deceased donor. Data were analyzed using IPA. Results suggest that identity development is influenced by similar concerns for all adolescents regardless of donor source: body image, social relationships, and anxiety about the future. One aspect that stood out from the discourse of those who received from a parent was feelings of guilt towards the donor when engaging in behaviors that could comprise graft survival, which was a challenge for identity development. Receiving the transplant freed teens from the struggle of just managing their illness and was a catalyst for exploration and engagement, which are crucial for identity development.

Children's experiences and expectations of kidney transplantation: A qualitative interview study

AIM

Kidney transplantation offers improved quality of life and life expectancy compared with dialysis for children. This study aims to understand the experiences and expectations of children during the kidney transplantation process to inform clinical care.

METHODS

Face-to-face, semi-structured interviews were conducted with 13 children and adolescents aged between 7 and 17 years in New Zealand who had received a kidney transplantation. Findings were conceptualized using thematic analysis with inductive coding.

RESULTS

Three major themes were identified: transplant as the goal (the only real treatment and escaping dialysis); dealing with negative emotions (coping with anxiety and fear, guilt for siblings and burden of parent as donor); and enhancing understanding and knowledge (individualised education and reassurance from peer support).

CONCLUSION

Children and adolescents view transplantation as freedom from dialysis and return to a more normal life. Children focus on the positive aspects of transplantation to reduce anxiety and be reassured in the face of uncertainty. Complex emotions arise when thinking about their donor. Children recognize transplantation is not a return to full health and actively seek out ways to self-manage their care, while remaining anxious about their future.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Obstáculos y estrategias de afrontamiento en la atención renal: estudio cualitativo en jóvenes con enfermedad renal crónica en diálisis peritoneal

Resumen Este trabajo se propone identificar los obstáculos que enfrentan individuos jóvenes en tratamiento de diálisis peritoneal, así como examinar las estrategias de afrontamiento que utilizan en la atención renal. Para ello, se llevó a cabo un estudio cualitativo desde una perspectiva crítico-interpretativa. Participaron 12 jóvenes con insuficiencia renal y en tratamiento de diálisis peritoneal, viviendo en Guadalajara, México. Mediante un muestreo por bola de nieve, se seleccionaron siete hombres y cinco mujeres. La información se obtuvo mediante entrevistas narrativas y observación participante, además de conversaciones en WhatsApp y Facebook. Se hizo análisis de contenido. Además del consentimiento informado, se aseguró el anonimato y la confidencialidad de la información. Los resultados desvelan cuatro ejes temáticos que emergen del análisis de la información: Enfrentando dificultades económicas, Viviendo las deficiencias de los servicios de salud, Interferencias en la comunicación con los profesionales sanitarios y En búsqueda permanente de estrategias. Múltiples estrategias se emplean para enfrentar los problemas económicos, la falta de información y el control emocional. Se observó que la falta de recursos económicos es el principal obstáculo que enfrentan los jóvenes en diálisis. Estos jóvenes impulsan estrategias, junto con familiares y sus pares, para afrontar las dificultades.

Why is transition between child and adult services a dangerous time for young people with chronic kidney disease? A mixed-method systematic review

Young people age 14-25 years with chronic kidney disease have been identified as generally having poor health outcomes and are a high-risk group for kidney transplant loss due in part to poor self-management. This raises a key question as to what happens during transition from child to adult services? This paper presents a mixed-method systematic review of health and social care evidence concerning young people with chronic kidney disease transitioning from child to adult health and social care services. Quantitative and qualitative evidence were synthesised in streams followed by an overarching synthesis. Literature searches (2000 to March 2017) were conducted using Pubmed, BioMed Central and Cochrane Library, grey literature sources ZETOC, .gov.uk, third sector organisations, NHS Evidence, SCIE, TRIP, Opengrey. Snowball searching was conducted in the databases Ovid, CINAHL, ISI Web of Science, Scopus and Google Scholar. Of 3,125 records screened, 60 texts were included. We found that while strategies to support transition contained consistent messages, they supported the principle of a health-dominated pathway. Well-being is mainly defined and measured in clinical terms and the transition process is often presented as a linear, one-dimensional conduit. Individual characteristics, along with social, familial and societal relationships are rarely considered. Evidence from young people and their families highlights transition as a zone of conflict between independence and dependency with young people feeling powerless on one hand and overwhelmed on the other. We found few novel interventions and fewer that had been evaluated. Studies were rarely conducted by allied health and social care professionals (e.g. renal social workers and psychologists) as part of multi-disciplinary renal teams. We conclude that there is a lack of good evidence to inform providers of health and social care services about how best to meet the needs of this small but vulnerable cohort.

Did parents have it right all along? Parents, risk, and living kidney donation: Revisiting the arguments for and against parental living donation of kidneys

Historically, living kidney donation has been justified in part by our belief that living donors face minimal risks of subsequent disease. Recent research has brought that presumption into question, particularly for younger donors including parents. In light of this finding, we re-examine many of the traditional arguments both for and against the practice of parental living kidney donation. We then propose an alternative framework in which the burden of having a child with end-stage kidney disease can be considered as an illness experienced by the potential donor parent. We believe this allows a more straightforward, as well as more accurate, assessment of the risks and benefits of donation for the potential parental donor. This assessment might then be used to best inform the decision whether or not to proceed with kidney donation using a shared decision-making model, while reflecting the appropriate ethical roles of both the potential donor and the transplantation program.

Pediatric Renal Transplantation: Focus on Current Transition Care and Proposal of the "RISE to Transition" Protocol

The transition from pediatric to adult medical services is an important time in the life of an adolescent or young adult with a renal transplant. Failure of proper transition can lead to medical non-adherence and subsequent loss of graft and/or return to dialysis. The aim of this study was to conduct a systematic review and survey to assess the challenges and existing practices in transition of renal transplant recipient children to adult services, and to develop a transition protocol.

We conducted a literature review and performed a survey of pediatric nephrologists across the United States to examine the current state of transition care. A structured transition protocol was developed based on these results.

Our literature review revealed that a transition program has a positive impact on decline in renal function and acute rejection episodes, and may improve long-term graft outcomes in pediatric kidney transplant patients. With a response rate of 40% (60/150) from nephrologists in 56% (49/87) of centers, our survey shows inconsistent use of validated tools despite their availability, inefficient communication between teams, and lack of use of dedicated clinics. To address these issues, we developed the “RISE to Transition” protocol, which relies on 4 competency areas: Recognition, Insight, Self-reliance, and Establishment of healthy habits.

The transition program decreases acute graft rejection episodes, and the main challenges in transition care are the communication gap between health care providers and inconsistent use of transition tools. Our RISE to transition protocol incorporates transition tools, defines personnel, and aims to improve communication between teams.

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

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

Experiences of adolescent lung transplant recipients: A qualitative study

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

Health-related quality of life in patients with pediatric onset of end-stage renal disease: state of the art and recommendations for clinical practice

Health-related quality of life (HRQoL) is increasingly recognized as a key outcome in both clinical and research settings in the pediatric population with end-stage renal disease (ESRD). This review aims to: (1) summarize the current knowledge on HRQoL and socioprofessional outcomes and (2) provide strategies for incorporation of HRQoL assessment into clinical practice. Studies report that pediatric patients with ESRD have significantly lower HRQoL scores compared with children with other chronic diseases. Patients treated by dialysis are at particularly high risk for impaired HRQoL. Furthermore, patients more often have impaired neurocognitive functioning and lower academic achievement. Important determinants of impaired HRQoL include medical factors (i.e., receiving dialysis, disabling comorbidities, cosmetic side effects, stunted growth), sociodemographic factors (i.e., female gender, non-Western background) and psychosocial factors (i.e., noneffective coping strategies). Contrary to the situation in childhood, adult survivors of pediatric ESRD report a normal mental HRQoL. Despite this subjective feeling of well-being, these patients have on average experienced significantly more difficulties in completing their education, developing intimate relationships, and securing employment. Several medical and psychosocial strategies may potentially improve HRQoL in children with ESRD. Regular assessment of HRQoL and neurocognitive functioning in order to identify areas in which therapies and interventions may be required should be part of standard clinical care.

Experiences of Korean adolescent renal transplant recipients

PURPOSE

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

DESIGN AND METHODS

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

RESULTS

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

PRACTICE IMPLICATIONS

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

The role of the body in end-stage kidney disease in young adults: Gender, peer and intimate relationships

OBJECTIVES

To understand how the physical body, and changes in the physical body, influence peer and intimate relationships and parenting in young adults on renal replacement therapies (RRT).

METHODS

Qualitative interview data from 40 young adults aged 16-30 years with end-stage kidney disease (ESKD), first diagnosed aged 0-19 years, were analysed using modified grounded theory.

FINDINGS

Alternating modalities of RRT had a 'yo-yo' effect on the bodies of interviewees, repeatedly reconstructing them as either 'transplanted' bodies, often initially obese, or as 'dialysis' bodies', often underweight. Invisible somatic changes had a major impact on gendered social identity, making intimate social relationships and parenthood problematic. Prepubertal onset interviewees were generally less successful in forming partnerships than those with postpubertal onset; and interviewees on dialysis were likely to postpone partnering until they were transplanted. Social networks were essential for finding a partner, but male interviewees had fewer networks than females. Parenthood was particularly challenging for female interviewees.

CONCLUSIONS

In ESKD, life-saving RRT brings major changes to the body. These adversely affect social relationships and family formation during the crucial period of early adulthood. Effects vary according to age of onset, RRT modality, and gender, with those who were ill before puberty and those on dialysis worst affected.

Differences between paediatric and adult presentation of ESKD in attainment of adult social goals

BACKGROUND

Living with end-stage kidney disease (ESKD) is complex for young adults who experience difficulties with adherence to medications and attainment of social markers of adulthood.

METHODS

We studied adult outcomes (education, employment and accommodation) and evaluated adherence in young adults (age 16-30 years) according to paediatric (<16 years) and adult presentation (16-30 years) of ESKD. Initial questionnaire surveys were undertaken with patients (n = 931) identified from the databases of 12 adult and two paediatric nephrology programmes in England.

RESULTS

Young adults (n = 296, 52 % male, 79 % Caucasian and 73 % with functioning renal allograft) with a mean age at first presentation of ESKD and current age of 17 and 25 years, respectively, were surveyed, of whom 5 % still attended paediatric services. Outcomes of patients aged >23 years and in stable health (n = 146) were compared between paediatric and adult presentation, with 30 and 20 % of patients, respectively, registered as disabled (p = 0.02). Educational attainment, based on percentage of those not achieving the General Certificate of Secondary Education (GCSE) level for England, was lower in the paediatric presentation group than in the adult one (7 vs. 18 %, respectively; p = 0.04). Compared to adult presentation patients, paediatric presentation patients were less likely to have full or part time paid work (57 vs. 76 %; p = 0.2). They also tended to be less likely to be living independently, less likely to be living with a partner, and, if living with their parents, more likely to be living in rented accommodation. Only 10 % patients missed taking medication weekly or more often. A higher frequency of missing medication was related to dialysis patients (p = 0.05), who assigned lower importance to taking medication (p < 0.001). However, patients aged <23 years attached less importance to complying with advice about treatment and health (p = 0.02), especially those who presented with ESKD during childhood (p = 0.01).

CONCLUSIONS

Among our study cohort, young adults who presented with ESKD during childhood have poorer social and educational attainment compared to their counterparts who presented in adulthood. Adherence to medications remains important to ESKD patients. However, young adults wish to have personal control over their own life and health and need additional support and healthcare advice from the multi-disciplinary team. Qualitative work is required to understand the meaning of these outcomes on the quality of life for each individual patient.

Post-transplant adjustment--the later years

As survival rates for pediatric solid organ transplantation have continued to improve, researchers and healthcare providers have increasingly focused on understanding and enhancing the HRQOL and psychosocial functioning of their patients. This manuscript reviews the psychosocial functioning of pediatric transplant recipients during the "later years," defined as more than three yr post-transplant, and focuses on the day-to-day impact of living with a transplant after the immediate period of adjustment and early years after surgery. Key topics reviewed include HRQOL, cognitive functioning, impact on the family, regimen adherence, and transition of responsibility for self-management tasks. Overall, pediatric transplant recipients evidence impairment in HRQOL, neuropsychological outcomes, and family functioning as compared to non-transplant recipients. However, the degree of impairment is influenced by a variety of factors including, disease severity, age, solid organ type, and study methodologies. Studies are limited by small samples, cross-sectional design, and the lack of universal assessment battery to allow for comparisons across solid organ populations. Areas for future research are discussed.

Health-related quality of life of children and adolescents with CKD stages 4-5 and their caregivers

BACKGROUND

Renal replacement therapies may affect the quality of life of patients and their primary caregivers (PC).

METHODS

This study describes the perception of health-related quality of life (HRQoL) of children/adolescents with CKD stages 4-5, as well as of their PC (n = 64), in comparison to healthy peers and their PC (n = 129), respectively, based on the Peds QL™ 4.0 and Short Form-36 (SF-36) questionnaires and selected biomarkers.

RESULTS

Patients reported a deleterious impact on physical capacity and on social and school activities. A negative influence on emotional aspects was reported by older patients, but not by their PC. Hemodialysis, followed by peritoneal dialysis, had a more negative impact on patients' physical functioning domain. PC HRQol proxy reports differed from those of their children, especially in older patients. PC of both groups presented similar SF-36 scores. An association was demonstrated between the magnitude of treatment target inadequacies, lower specific dominion scores in the patients/PC proxy reports and PC SF-36 general health scores.

CONCLUSION

The HRQoL of patients with CKD stages 4-5 is negatively affected to different degrees depending on age and treatment modality. The results suggest an association between worsening HRQoL parameters and inadequate control of recognized therapeutic CKD treatment targets.

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

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

Quality of life of adolescent kidney transplant recipients

OBJECTIVE

To elicit utility-based quality of life (QOL) of adolescent kidney transplant recipients.

STUDY DESIGN

We measured QOL in adolescent transplant recipients by using a visual analog scale (VAS), and 2 utility-based QOL measures, the Health Utilities Index (HUI) Mark 2/3 (HUI2/3), and the time trade-off. Participants aged 11-19 years old were recruited from 5 transplantation centers in Australia. Mean scores were compared by using paired t tests, and linear multiple regression was used to define predictors for time trade-off QOL weights.

RESULTS

Twenty-six adolescents participated in the study. On a scale with extremes of 0 (death) and 1 (full health), the participants had a mean (SD) time trade-off QOL weight of 0.99 ± 0.01 and HUI2/3 utility scores of 0.86 ± 0.16 and 0.85 ± 0.21, respectively. Time trade-off values were significantly higher than HUI Mark 2 values (P = .01) and HUI Mark 3 values (P = .02). From the HUI measure, decrements were observed in specific QOL domains, including vision, emotion (depression and anxiety), cognition, and pain.

CONCLUSION

Adolescent kidney transplant recipients had consistent and high values for their current QOL, which suggests that they perceive themselves to be close to full health. However, adequate emotional and cognitive support may improve their overall QOL.