The Effect of Pre-Transplant Psychosocial Problems on Kidney Transplantation Outcomes

Document Type : Original Article

Authors

1 Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran

2 Urology Research Center, Tehran University of Medical Sciences, Tehran, Iran

3 Student Research Committee, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran

4 Organ Procurement Unit, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran

Abstract

Introduction: The present study aimed to evaluate the association between the pre-transplant psychosocial profile and kidney transplant candidates' clinical outcomes.
Methods: The present study population included all patients assessed for kidney transplant candidacy in Sina Hospital, Tehran University of Medical Sciences. The 42 patients who were candidates for kidney transplantation were enrolled in the present study. The mental health was measured by psychosocial assessment of candidates for transplantation (PACT) questionnaire. A global score of equal or lower than 2 was categorized as a low PACT score and equal and higher than 3 was defined as a high score. PACT questionnaire was completed before the kidney transplantation for each patient. The outcomes of our study were post-transplant dialysis, time of dialysis, hospital stay after transplant, rejection after transplant, time of rejection after transplant, delayed graft function, re-hospitalization after transplant, and time of re-hospitalization that were followed after transplantation.
Results: A total of 42 patients underwent kidney transplantation; 15 ( 35.7%) patients had a poor PACT score while 27 (64.3%) patients had a high PACT score. There were no significant differences in age, sex, marital status, literacy, insurance, supplementary insurance, smoking, being head of household between the two groups. There were no significant differences between the two groups in clinical characteristics after kidney transplantation (P-value > 0.05).
Conclusions: In our study, there was no significant association between psychosocial status and clinical outcomes and it has been suggested that more studies are needed in this field

Graphical Abstract

The Effect of Pre-Transplant Psychosocial Problems on Kidney Transplantation Outcomes

Highlights

  • Psychosocial factors that could negatively affect post-transplant care and clinical outcomes.
  • In the present study, 7% of patients had a poor PACT score.
  • In our study, there was no significant association between psychosocial status and clinical outcomes.

Keywords

Main Subjects


Introduction

Chronic kidney disease (CKD) is one of the main health problems in the world. Significantly, CKD is associated with important clinical, social, and mental problems, particularly in patients with end-stage renal disease (ESRD), and ESRD is mostly established as an obvious reduction in kidney function (1). The frequency rate of ESRD rises every year. Even with the improvement of therapeutic principles and standards, the death rate remains great (2). In patients with ESRD, the reduction in renal function has been observed that the patients require receiving kidney replacement therapies including per­­itoneal dialysis, hemodialysis, as well as kidney transplantation.

It was observed that among patients with ESRD, long-lasting dialysis disturbs the quality of life, and manifested as the growth of depression rate, reduction of physical functioning, social communication, and aggravation of clinical symptoms such as muscle weakness, leg restlessness, and fatigue (3). The previous documents showed the patients with ESRD had poorer quality of life than the general population (4, 5).

The effective treatment choice for patients with ESRD is kidney transplantation that makes corrects the hematological and metabolic profile, endocrine abnormalities and causes the quality of life to get better in most of the patients with ESRD (6-9). kidney transplantation includes many psychosocial, emotional, and social changes both for the patient and for the patient’s family (9, 10). In this context, it is essential to assess the mental condition and the character of the patient who is a candidate for a kidney transplantation to prevent factors that could affect the outcome of transplantation or clinical outcomes after surgery (11-14).

It is important to identify the psychosocial factors that could negatively affect post-transplant care and clinical outcomes such as patient and allograft survival, rejection rate, hospitalization rate, and adherence to medications. So present study aimed to evaluate the pre-transplant psychosocial profile and assess the association between pre-transplant psychosocial profile with the clinical outcomes.

 

Methods

The present study population included all patients assessed for kidney transplant candidacy in Sina Hospital, Tehran University of Medical Sciences. The 42 patients who were a candidate for kidney transplantation were enrolled in the present study. The inclusion criteria of the present study were the patient had to be satisfied with participating in the study. So, verbal consent and written informed consent were obtained from all participants after explaining the study aim to all the patients. The Ethics Committee of Tehran University of Medical Sciences approved the study (IR.TUMS.VCR.REC.1398.363).

Demographic data were collected such as gender, age, marital status, literacy status, insurance, supplementary insurance, smoking, as well as being head of household. The questionnaires were completed through a face-to-face interview with each patient. The mental health was measured by psychosocial assessment of candidates for transplantation (PACT) questionnaire. This questionnaire is a valid instrument to assess mental health. PACT is a 10-item clinician tool, was developed for the screening of transplant psychosocial evaluation. The overall final score from 0 (contraindication to kidney transplantation) to 4 (perfect candidate) was assigned by the psychiatrist. A global score of equal or lower than 2 was categorized as a low PACT score and equal and higher than 3 was defined as a high score (15). It has been shown that PACT has an excellent interrater consistency (83.7%). PACT questionnaire was completed before the kidney transplantation for each patient. The outcomes of our study were post-transplant dialysis, time of dialysis, hospital stay after transplant, rejection after transplant, time of rejection after transplant, delayed graft function, re-hospitalization after transplant, and time of re-hospitalization that were followed after transplantation.

Statistical Analysis

The continuous and discrete variables are reported as mean (standard deviation (SD)) and number (percent), respectively. The paired t-test was the tool for comparing variables between the low and high groups. The statistical software Stata (ver. 12) was used to perform the analyses. The significant level was set at 0.05.

 

Results

A total of 42 patients underwent kidney transplantation; 15 ( 35.7%) patients had a poor PACT score while 27 (64.3%) patients had a high PACT score. The demographic variables are shown between the two groups in Table 1. There were no significant differences in age, sex, marital status, literacy, insurance, supplementary insurance, smoking, being head of household between the two groups.

The clinical outcomes between patients with poor and high PACT scores are displayed in Table 2. There were no significant differences between the two groups in clinical characteristics after kidney transplantation (P-value > 0.05).

 

Table 1. Demographic characteristics by PACT score

Variables

Final PACT score

 

Poor

High

P-value

Age, mean(SD)

36.6 (11.4)

39.8 (13.2)

0.452

Sex, n (%)

 

 

 

Female

7 (38.9 %)

11 (61.1 %)

0.710

Male

8 (33.3 %)

16 (66.7 %)

Marital status, n (%)

 

 

 

Single

3 (27.3 %)

8 (72.7 %)

0.717

Married

12 (38.7 %)

19 (61.3 %)

Literacy, n (%)

 

 

 

Illiterate

2 (40.0 %)

3 (60.0 %)

 

0.120

Middle school

0

7 (100 %)

Diploma

9 (50 %)

9 (50 %)

Graduate

4 (36.4 %)

7 (63.6 %)

Insurance, n (%)

 

 

 

Yes

15 (33.3 %)

27 (66.7 %)

-

No

0

0

Supplementary insurance, n (%)

 

 

 

Yes

6 (30 %)

14 (70 %)

0.393

No

7 (43.8 %)

9 (56.2 %)

Smoking, n (%)

 

 

 

Yes

3 (50 %)

3 (50 %)

0.649

No

12 (33.3 %)

24 (66.7 %)

Being head of household, n (%)

 

 

 

Yes

5 (26.3 %)

14 (73.7 %)

0.311

No

7 (43.8 %)

9 (56.2 %)

 

Table 2. clinical characteristics by PACT score

Variables

PACT score

 

Poor

High

P-value

Post-transplant dialysis, n (%)

5 (33.3 %)

9 (36.0 %)

0.864

Time of dialysis (Days), median (IQR)

2 (1-2)

1 (1-2)

0.577

The hospital stay after transplant (Day), median (IQR)

15 (12-18)

14 (12-17)

0.934

Rejection after transplant, n (%)

0

1 (4.2 %)

0.423

Delayed graft function, n (%)

2 (15.4 %)

1 (4.2 %)

0.278

Re-hospitalization after transplant, n (%)

2 (13.3 %)

8 (33.3 %)

0.263

Time of re-hospitalization (Day)

8 (7-9)

11 (6-16)

0.429

 

Discussion

In the present study, the impact of pre-transplant psychosocial status on the clinical outcomes after kidney transplantation was assessed. The results of the present study did not show any significant association between pre-transplant psychosocial profile the clinical outcomes such as post-transplant dialysis, hospitalization time, transplant rejection, delayed graft function. PACT questionnaire was developed as a standard pre-transplant psychosocial assessment tool, and a helpful tool to recognize high-risk patients with mental and psychosocial problems that required more regular post-transplant follow-up and monitoring (16), and patients with low PACT scores need to monitor more carefully after transplant.

In the present study, according to PACT, 36% of patients were considered as poor candidates and 64% were good candidates. The previous document showed that 11% of liver transplantation candidates were considered poor candidates and had a minimum of one main psychosocial risk factor. Also, a low PACT score was associated with anxiety, depression, and impaired health-related quality of life (17).

Prior studies have indicated the PACT score to be associated with a lower mortality rate, shorter hospitalization, and readmission period (18-20). Freischlag et al., investigated the clinical efficacy of PACT in pediatric kidney transplantation and presented no significant differences between post-transplant dialysis, graft failure, hospitalization time, and delayed graft function between the low and high PACT groups (21). Our results are consistent with Freischlag’s study. But, in Hong et al’s study, the association between PACT score with hematopoietic cell transplantation (HCT) outcomes was assessed and indicated the high PACT score was significantly associated with race and higher quality of life in HCT recipients. Also, the authors mentioned the PACT could be considered as a psychosocial tool for recognizing the patients who need more attention and monitoring (22). The document indicated that support of family, adherence, and personality factors are the cause of the difference between low and high PACT groups (21). A current review document indicates the relationship between pre-transplant depression and a higher risk of post-transplant mortality in different solid organ transplants (23, 24).

 

Conclusion

Kidney transplantation is a process that requires attention and monitoring to pre-transplant psychosocial status for increasing the success rate and better clinical outcomes. In our study, there was no significant association between psychosocial status and clinical outcomes and it was suggested that more studies be needed in this field.  

 

Authors’ contributions

All authors contributed equally.

 

Acknowledgments

We would like to thank the Tehran University of Medical Sciences. 

 

Conflict of interest

There was not any conflict of interest.

 

Funding

There was no funding.

 

Ethics statement

The Ethics Committee of Tehran University of Medical Sciences approved the study (IR.TUMS.VCR.REC.1398.363).

 

Data availability

All data and information will be provided on request.

 

Abbreviations

CKD   Chronic kidney disease

ESRD   End-stage renal disease

HCT     Hematopoietic cell transplantation

PACT    Psychosocial assessment of candidates for transplantation

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