Quality of life outcomes associated with variable posttransplant prednisone dosing regimens

Contribution of post-transplant social support to the quality of life of transplant recipients

With advances in medicine and pharmacology, post-transplant quality of life (QoL) has become a major concern of researchers. In social work transplant practice, provision of social support towards QoL warrants attention. The purposes of this study were (1) to describe the social support networks of kidney, liver, and pancreas transplant recipients during the post-transplant phase of their recovery, and (2) to examine the correlations between the types and nature of social support networks and the QoL of these transplant recipients. We conducted an exploratory-descriptive study in a US university's transplant clinic. Instruments were the Social Network Map, Adult Self-Image Scale, Sickness Impact Profile, and Quality of Life Index. Descriptive statistics, and correlation analyses were used with a significance level of .05. We observed correlations between concrete and emotional support, and direction, closeness and duration of support, and QoL. Based on our findings, we discussed implications for research and practice.

Health-related quality of life in two hundred-eighty lung transplant recipients

BACKGROUND

Health-related quality of life (HRQoL) has increasingly been accepted as a supplementary outcome measure for patients after lung transplantation (LTx).

METHODS

Using a retrospective cross-sectional study design, 280 LTx recipients (3 months to 14 years after LTx) were asked to assess their HRQoL using a generic (Quality of Life Profile for Chronic Diseases) questionnaire, which was previously validated for this specific population. In addition, the questionnaire was also performed by 155 healthy participants.

RESULTS

All sub-scale findings ranged from 2.40 to 3.08 (0 to 4) for all patients after LTx. A significantly reduced HRQoL was reported by the sub-cohort of patients living 5 to 6 years with the allograft for all sub-scales (p < 0.006), except for Social Functioning, and was associated with the incidence of bronchiolitis obliterans syndrome (BOS; p < 0.05). Cystic fibrosis patients (p < 0.05), single-lung transplant recipients (p < 0.05) and patients of older age (p < 0.05) showed significantly decreased physical ability ratings. Patients who remained free of infection and late acute rejection episodes scored themselves significantly higher with regard to their Relaxation Capabilities (p < 0.05 for rejection; p < 0.05 for infection) and Social Functioning (p < 0.01 for rejection; p < 0.05 for infection) vs patients who experienced infection or rejection episodes. Comparisons with a normative cohort showed similar HRQoL scales for LTx patients and the healthy population, except with regard to Social Functioning (p < 0.01).

CONCLUSIONS

Self-ratings for HRQoL were high for all dimensions for the entire sample, and remained relatively similar even for medium- and long-term survivors. HRQoL was dependent on incidence of infections, rejections and the onset of BOS. Despite differences in life expectancy of LTx patients compared with the healthy population, HRQoL self-ratings were within similar ranges.

Assessing Health Status and Health Care Utilization in Adolescents with Chronic Kidney Disease

Few validated health status measures have been assessed in children with chronic kidney disease (CKD). The objective was to assess the validity of a generic health status measure, the Child Health and Illness Profile-Adolescent Edition (CHIP-AE), in adolescents with CKD. A case-control study was performed (1) to assess scores on the CHIP-AE in adolescents with CKD compared with two control groups of age-, socioeconomic-, and gender-matched peers and (2) to compare health of patients who had chronic renal insufficiency (CRI), were on dialysis, and were posttransplantation. Seven pediatric nephrology centers recruited 113 patients (mean age, 14 yr; 39 CRI, 21 dialysis, 53 posttransplantation). Compared with 226 control subjects, patients with CKD had lower overall satisfaction with health and more restriction in activity. Positively, patients with CKD had more family involvement, better home safety and health practices, and better social problem-solving skills and were less likely to participate in risky social behaviors or socialize with peers who engaged in risky behavior. Patients who received dialysis were less physically active and experienced more physical discomfort and limitations in activities than did transplant or CRI patients. It is concluded that patients with CKD have poorer functional health status than age-matched peers. Among CKD patients, dialysis patients have the poorest functional health status. These results suggest that the CHIP-AE can be used to measure functional health status in adolescent patients with CKD.

The HRQoL of renal transplant patients

BACKGROUND

After undergoing kidney transplant surgery, patients face many new challenges. For example, they face new pathologies associated with the complex medical regimens that they will need to follow rigorously for the rest of their lives. They live with the uncertainty and fear of organ rejection. They will also need to acquire new skills to take care of themselves, such as recognizing the signs and symptoms of impending infection and rejection. This suggests that once a transplant has been performed and the patient has been discharged with a functioning graft, the patient must continue to deal with a life of chronic illness.

AIM

The aim of this study was to explore health-related quality of life of Chinese kidney transplant patients in Hong Kong.

METHODS

Non-structured interviews were conducted. The transcripts were analysed by qualitative content analysis. Codes were used to identify a passage of text that the researcher interprets as having a particular meaning. Data analysis is an iterative process. The codes emerging from each new interview were analysed together with the codes which had previously emerged. Across the dataset, codes were compared for similarities and differences, both within and across interviews. Codes of common property were clustered into categories. The transcripts were re-read and checked against the categories until there was no more to be gleaned, and the titles of the categories reflected the totality of that experience. Interviews were conducted until unique categories were no longer identified. There were 31 participants.

RESULTS

The participants are complying with medication regimens and nursing recommendations. Although new symptoms related to the medication regime surfaced, participants commented that they improved markedly in physical and social functioning, and have a better quality of life as a whole. Participants expressed their needs regarding information on the side effects of medications, proper exercise and diet.

CONCLUSIONS

To optimize post-transplant quality of life, a follow-up rehabilitation programme is recommended.

RELEVANCE TO CLINICAL PRACTICE

Rich and meaningful insights about the perceptions and experiences of renal patients after transplantion can be obtained in this study. Having known the real needs of patients, nurses can develop strategies to help patients to cope with the demands of life with a renal graft, from the early days of convalescence to re-integration into work, family responsibilities and life beyond.

Quality of life after kidney and pancreas transplantation: a review

There is an increasing amount of data on quality of life (QOL) in most chronic illnesses; some of the instruments used are generic, but recently, there is a tendency to use disease-specific instruments. We propose that recipients of organ transplants be assessed routinely for QOL by means of the 36-Item Short-Form Health Survey or a disease-specific instrument; for compliance, by means of the Long-Term Medication Behavior Self-Efficacy Scale; and for psychological status, by means of the Beck Depression Inventory Brief Symptom Inventory or the Symptom Checklist. The widespread use of QOL data in recipients of organ transplants will increase accountability of service providers and eventually increase patient satisfaction because these instruments are patient reported.

The first report from the patient outcomes registry for transplant effects on life (PORTEL): differences in side-effects and quality of life by organ type, time since transplant and immunosuppressive regimens

BACKGROUND

Post-transplant patient quality of life (QOL) is affected by a number of different factors. A nationwide patient registry has been established to evaluate QOL and determine the effects of transplant and immunosuppressive regimens on patient outcomes.

METHODS

Patients were contacted directly at national meetings, through transplant centers, and patient support groups and invited to participate in the registry. All transplant patients aged 16 and over were eligible to enroll. Patients completed a 100-item self-administered questionnaire consisting of questions about patient demographics, organ functioning, and other post-transplant outcomes. General QOL was measured by the Short form - 12 (SF-12). The Memphis Survey, an instrument developed and psychometrically validated at the University of Tennessee, was administered to patients to evaluate side-effects associated with immunosuppression. Data were analyzed from the first 722 patients who entered the registry. Side-effect profile and QOL outcomes were evaluated by organ type, time since transplant and immunosuppressive regimen. Multiple regression analyses were conducted to determine predictors of post-transplant QOL.

RESULTS

When outcomes were analyzed by organ type, there were no differences in SF-12 or total weighted Memphis scores. Analysis by time since transplant demonstrated that side-effects in the mobility domain increased with patient age and time since transplant. Analysis by immunosuppressive regimen focused on cyclosporine and tacrolimus-based regimens congruent with similar classifications reported in previous studies (Pirsch JD et al. Transplantation 1997: 63: 977, Shield CF III et al. Transplantation 1997: 64: 1738). When analyzed by regimen, there were no differences between the groups in terms of patients reporting good to excellent organ function, treatment for rejection, infection, and over-immunosuppression. Statistically significant differences were observed when side-effect profile was analyzed by immunosuppressive regimen. Patients on cyclosporine-based regimens reported greater overall side-effect severity and more problems with mobility and life roles. Cyclosporine patients also reported more problems in the miscellaneous subscale, including high blood pressure, enlarged gums and hair growth, but less trouble with trembling hands. Multiple stepwise regression models identified several side-effect subscales as having profound effects on mental and physical QOL.

CONCLUSION

Transplant recipients report good to excellent levels of QOL, however, side-effects associated with immunosuppressive regimens impair post-transplant QOL. Problems in certain domains, such as mobility, are found to increase with time since transplant. Tacrolimus-based regimens are associated with fewer and less severe side-effects than cyclosporine-based regimens in key domains that affect post-transplant QOL.

Renal transplant recipient attitudes toward steroid use and steroid withdrawal

Although steroid avoidance and withdrawal in renal transplant recipients (RTR) are actively being evaluated by physicians, the attitudes of recipients toward steroid use have not been systematically studied in the modern era. We conducted a confidential written survey of single-organ adult RTR pertaining to prednisone-related side-effects. Recipients were asked which drug they felt maximized graft life, which drug they wished to avoid if graft life was unaffected, and which drug they had most compliant with. They also rated 16 common immunosuppressive-related side-effects on a Likert scale with 1 meaning complete disagreement and 10 complete agreement with their own prednisone-attributed experience. A comparison of responses based on RTR demographic characteristics was made by ANOVA or chi-square analysis with Bonferroni correction. The questionnaire was completed by 223 recipients, of whom 93% were primary recipients, 57% were cadaveric organ recipients, and 69% were white people, 7% black people, and 23% Asian people. Age at transplant, age at survey and time since transplant were 41.5 +/- 11, 47.5 +/- 11 and 6.0 +/- 5 yr, respectively. For the entire group, overall side-effect profile for prednisone was rated as 6.1 +/- 3 on the Likert scale, while efficacy was rated as 7.3 +/- 3. If offered monotherapy, 67% preferred a calcineurin-inhibitor (CI), 23% mycophenolate mofetil (MMF)/azathioprine (AZA), and 10% prednisone. When asked which drug they would like to discontinue, 19% chose CI, 16% MMF/AZA, and 65% prednisone. Most recipients felt that CI was the most efficacious drug (80%), followed by MMF/AZA (12%), and prednisone (8%). The side-effects reported as most common were unacceptable weight gain (5.8 +/- 3) and bone/joint disease (5.3 +/- 3). The least common side-effects were blood disorders (2.2 +/- 2) and cancer (2.3 +/- 2). Black people were more likely than non-black people to report developing diabetes (p = 0.02), blood disorders (p = 0.003) and headaches (p = 0.003) as a result of prednisone use. Males reported more liver damage (p = 0.01) while females reported more body fat (p = 0.01) and fluid retention (p = 0.006). RTR >5 yr post-transplant reported more infections (p = 0.008), skin/hair problems (p = 0.02), gastrointestinal irritation (p = 0.02), and bone disease (p = 0.02) compared with RTR <1 yr. Donor source and recipient age did not determine any responses. If given a 'risk-free' choice, the majority of recipients prefer withdrawal of steroids over other agents. Demographic data may be used to predict prednisone-related side-effects and guide steroid use in this population. Study designs related to steroid withdrawal should account for patient preferences in this context.

Tacrolimus: the good, the bad, and the ugly

The aim of this study was to evaluate the efficacy and side-effects of tacrolimus in pediatric transplant patients previously receiving cyclosporin A (CsA). This study was a retrospective chart review strengthened by a concomitant patient interview. Eleven pediatric cardiac or renal transplant patients, who had been converted from CsA to tacrolimus from October 1995 to January 1999 at The Cleveland Clinic Foundation, were included; there were six renal and five cardiac transplant patients. Each chart was reviewed to assess transplanted organ function pre- and post-conversion. For the six renal transplant patients, creatinine levels and biopsy findings were evaluated. For the five cardiac transplant patients, cardiac catheterization and routine biopsy data were analyzed likewise. Epstein Barr virus (EBV) status was also evaluated in each patient. In addition, each parent or patient was interviewed to ascertain dates of transplant, current medications, and side-effects. The patients' ages ranged from 6 to 20 yr (mean age 14.6 yr). All patients had been converted to tacrolimus. Eight patients were converted for treatment of refractory rejection, two were converted because of CsA-associated side-effects, and one patient was converted empirically for a history of multiple previous transplant rejections. Seven out of eight patients who received tacrolimus for rejection therapy improved. One patient had complete resolution of gingival hyperplasia. Another patient who previously developed hemolytic uremic syndrome on CsA had no further evidence of hemolysis. Four patients were weaned off steroid therapy. Despite conversion, two renal transplant patients progressed to chronic rejection. Five patients exhibited no side-effects. Side-effects experienced included transient hyperglycemia in conjunction with steroid use, headaches, and tremors that subsided rapidly. Four of 11 patients developed post-transplant lymphoproliferative disease (PTLD). Fortunately, reducing the dose of tacrolimus and/or surgical resection of the mass (if present), eradicated the disease. In conclusion, conversion therapy successfully provides an alternate treatment for acute rejection. It also enabled some patients to discontinue steroid therapy, maximizing growth potential. PTLD is a severe, potentially life-threatening complication that needs to be recognized and monitored closely. In conclusion, tacrolimus has been shown to be a very effective agent for the treatment of refractory organ rejection, but must be used cautiously.

Stabilisation of diabetic retinopathy following simultaneous pancreas and kidney transplant

BACKGROUND/AIMS

Simultaneous pancreas and kidney transplantation (SPK) has become an important option in selected IDDM patients with end stage renal disease (ESRD). Successful SPK transplants are associated with long term normoglycaemic control and improved quality of life. However, debate still continues on the benefit to patients in terms of stabilisation or amelioration of diabetic retinopathy. The progression of diabetic retinopathy (DR) in a cohort of 20 SPK transplant patients is reported.

METHODS

All patients were reviewed postoperatively with corrected visual acuity, slit lamp examination, and fundal biomicroscopy. Preoperative data were collected retrospectively and DR was considered unstable if there had been a drop in Snellen acuity greater than three lines or a need for laser photocoagulation or vitrectomy in the 2 years preoperatively.

RESULTS

20 patients who received SPK transplants between March 1983 and April 1994 were reviewed (mean age 35.1 years; mean duration of IDDM = 24.6 years). 17 patients still had functioning grafts at a mean follow up of 5.1 years. Nine of these patients had unstable DR before transplantation. Of these, 89% (8/9) had stabilised DR following transplantation with only a single case requiring laser photocoagulation. Of the eight patients that had stable DR before transplantation all had stable DR following transplantation. 41% of cases (7/17) required cataract surgery during the follow up period.

CONCLUSIONS

Advanced diabetic retinopathy is present in a high proportion of cases managed with SPK transplant as a consequence of the duration of IDDM and the presence of ESRD. More than 90% of cases have stable DR following transplant.

Azathioprine monotherapy in HLA-identical live donor kidney transplant recipients

The high success rate of HLA-identical sibling transplants and our previous experience with steroid-free immunosuppressive regimens and cyclosporine withdrawal prompted us to evaluate the safety and efficacy of monotherapy with azathioprine in 12 HLA-identical kidney transplant recipients with a serum creatinine concentration less than 176.8 mumol/L, a 1-way stimulatory index less than 2.0 in a post-transplant mixed lymphocyte culture, and a demonstrated tolerance of a minimum azathioprine dose of 1.0 mg/kg per day without leukopenia. Eleven of 12 patients were successfully converted to azathioprine monotherapy without a significant change in serum creatinine concentration for as long as 76 months. Benefits of steroid and cyclosporine withdrawal included a significant reduction in mean systolic and diastolic blood pressure, number of blood pressure medications, total serum cholesterol, and glycohemoglobin in diabetic subjects. Our results suggest that azathioprine monotherapy is safe and effective in a select group of HLA-identical sibling transplants, but these benefits must be carefully balanced against an associated risk of precipitating acute allograft rejection.

Posttransplant quality of life: a decade of descriptive studies leading to practice interventions. Posttransplant Quality of Life Intervention Study Group

Following 10 years of descriptive quality-of-life studies, an innovative approach to outpatient care has been developed to decrease adverse events, increase employment, and enhance social support among renal transplant recipients. These 3 variables were found in the authors' previous studies to be predictive of increased quality of life following transplantation. With funding from the National Institute of Nursing Research, a multidisciplinary team has been assembled to implement the interventions identified. This article reviews the previous work that led to the development of the intervention study and demonstrates how research can guide practice.