Quality of Life After Kidney Transplantation: A Prospective Study


J.Z. Kostroa,*, A. Hellmanna, J. Kobielaa, I. Skórab, M. Lichodziejewska-Niemierkoc, A. Dębska-Slizie  d,
n
 
and Z. Sledzinski a

a
sk, Poland; bRegional Transplant Coordination
Department of General, Endocrine, and Transplant Surgery, Medical University of Gdan
Centre, UCK Gdan sk, Poland; cDepartment of Palliative Medicine, Medical University of Gdan
 sk, Poland; and dDepartment of

Nephrology, Transplantology, and Internal Medicine, Medical University of Gdansk, Poland

ABSTRACT
Background. The purpose of renal transplantation is to achieve a maximal improvement
in quality of life (QoL) and life expectancy in patients with end-stage renal disease (ESRD)
while minimizing the potential side effects of this procedure. It is important to achieve an
optimal balance between graft function and the patient’s QoL. This study was designed to
assess the changes in the QoL after kidney transplantation (KTx) in patients with ESRD
previously treated with hemodialysis (HD) or peritoneal dialysis (PD).
Methods. QoL was prospectively analyzed in 69 patients after kidney transplantation in a
single-center study. Patients with ESRD were divided into 2 groups: those previously
treated with HD (n ¼ 44 patients; group 1) or PD (n ¼ 25 patients; group 2). Both
groups were asked to complete the KDQOL-SFtm questionnaire before and 12 months
after kidney transplantation.
Results. We observed significant differences in many parameters of QoL in both groups
after KTx but more positive changes of most parameters in question exhibited by patients
previously treated by means of HD than PD. Patients treated with HD and PD demon-
strated improvement after KTx in 74% of dimensions. There were no statistical differences
in the QoL between group 1 and group 2 before or after KTx.
Conclusions. The study demonstrated post- to pre-transplant improvements of QoL
independently of previous treatment.

A S DEFINED by the World Health Organization model

of health, quality of life (QoL) is a multidimensional
concept that concerns an individual’s usual or expected
physical, emotional, and social well-being [1,2]. The
perception of QoL is, to a large extent, individual and may
be particularly affected by chronic disease. In the case of
patients with end-stage renal disease (ESRD), living with
the consequences of a chronic disease, various types of
medical treatment, as well as personal feeling and experi-
ences can have a significant impact on QoL. The choice to
initiate a new therapy usually involves hope for a relatively
normal life, free from the limitations associated with chronic
disease. Patients with ESRD waiting for kidney trans-
plantation (KTx) expect an improvement in their QoL in all
aspects of their life. Not only is the presence on the waiting
list for transplantation important, but also the length of
waiting time for a transplant [3]. Patients should assess their
own QoL during different types of treatment. Comparison
of these results appears to be the best method of assessing
which form of therapy provides the greatest QoL [4].
Assessment of QoL only in patients who have undergone
different types of therapy does not provide answers as to
which method of treatment improves a patient’s life.
Several different generic and disease-specific questionnaires
have been developed for assessing the QoL of patients
with ESRD. Not only the questionnaire, but also the
This work was supported by Medical University of Gdan  sk,
Poland.
*Address correspondence to Justyna Z. Kostro, Gdan ski Uni-
wersytet Medyczny, Klinika Chirurgii Ogólnej, Endokrynolo-
gicznej i Transplantacyjnej, Centrum Medycyny Inwazyjnej, Ul.
Smoluchowskiego 17, 80-214 Gdan sk, Poland. E-mail: kostro@
gumed.edu.pl

0041-1345/16 ª 2016 by Elsevier Inc. All rights reserved.

http://dx.doi.org/10.1016/j.transproceed.2015.10.058 360 Park Avenue South, New York, NY 10010-1710

50 Transplantation Proceedings, 48, 50e54 (2016)

QUALITY OF LIFE AFTER KIDNEY TRANSPLANT 51

circumstances of QoL assessment can affect patient (2 items), sleep (4 items), social support (2 items), dialysis staff
outcome. Results were not always consistent because encouragement (2 items), patient satisfaction (1 item), and 36-item
different QoL questionnaires were used at different stages health survey (8 dimensions/36 items): physical functioning
of the disease and in different settings [1,4]. In general, (10 items), role limitations caused by physical health problems
(4 items), role limitations caused by emotional health problems
generic QoL measurements can be used to assess overall
(3 items), social functioning (2 items), emotional well-being
health and functioning of patients. Targeted instruments (5 items), pain (2 items), energy/fatigue (4 items), and general
may be used to focus on individual symptoms specific for a health perceptions (5 items).
disease or on its treatment methods. The use of both generic
and targeted QoL instruments is a frequently implemented Statistical Analysis
strategy used in an effort to maximize the utility of assess-
The scoring procedure for the KDQOL-SFtm first transformed the
ment [1,5]. However, there is still no consensus regarding a
raw pre-coded numeric values of times to a 0- to 100-point scale.
gold-standard instrument to use in measuring QoL. The
Each item is converted into 0 to 100 so that the lowest and highest
objective of future studies could be the evaluation of the possible scores are 0 and 100, respectively, with higher scores
changes in QoL in patients with ESRD after KTx who were reflecting a better QoL [6]. Statistical analyses were performed with
previously studied while undergoing dialysis [4]. The Kidney the use of Statistical Package for the Social Sciences, version 7.1 PL
Disease Quality of Life (KDQOL) questionnaire was orig- (software licensed to the Medical University of Gda nsk). Results
inally developed to assess QoL in patients with chronic were presented as an average value and standard deviation. For all
kidney disease. The KDQOL questionnaire includes 36 comparisons, the Kolmogorov-Smirnov test for normality was used,
general items of the SF-36 as well as 98 additional items followed by the t test. Statistical significance was considered for a
which target kidney diseaseerelevant issues. The short form value of P < .05.
of the KDQOL (KDQOL-SFtm) includes 43 kidney
diseaseespecific items. Believable QoL variability can be RESULTS
obtained by comparing the opinion of the same patient by
We analyzed QoL in 69 patients from a single transplant
use of a variety of variables such as time of assessment, the
center. Patients were divided into 2 groups. Group 1
use of different type of treatment, and so forth. The aim of
(n ¼ 44) comprised ESRD patients who received trans-
this study was to evaluate the quality of life in patients with
plants after HD treatment. There were 14 women (31.8%)
ESRD who were previously treated with hemodialysis (HD)
and 30 men (68.2%) in the group. Patient age ranged from
or peritoneal dialysis (PD) before KTx and then after kidney
18 to 76 years (mean, 49 years). Patients were previously
transplantation both transversely and longitudinally.
treated with HD for a mean of 23 months (range, 12e159
months). All patients had a functioning graft 1 year after
KTx (Table 1). Group 2 (n ¼ 25) comprised ESRD patients
METHODS
who received a transplant after PD. There were 11 women
Quality of life was measured in a prospective, single-center, 2-year (44%) and 14 men (56%) in the group. Age ranged from 18
study in which KDQOL-SFtm was used. We utilized the following to 70 years (mean, 42 years). Patients were previously
inclusion criteria: male or female kidney transplant recipients at treated with PD for a mean of 26 months (range, 12e180
least 18 years of age who had their first KTx with graft survival
months). All patients had a functioning graft 1 year after
longer than 12 months and had also been treated by either HD or
PD for longer than 1 year before transplantation. The inclusion
KTx (Table 1). The groups were compared longitudinally
criteria also required that the graft function well without any (group 1 before and after KTx, group 2 before and after
complications during the observation period and that the patient KTx) as well as vertically (both groups before and after
had the ability to understand and give informed consent to partic- KTx). The populations of groups 1 and 2 did not demon-
ipate in the study. A total of 162 patients operated during these 2 strate a statistically significant difference relative to age, sex,
years were screened, yielding an enrollment of 69 KTx patients. body mass index, length of time on dialysis, graft function,
Ninety-three patients were excluded from the study on the grounds or comorbidities (Table 1).
of the following criteria: no dialysis before KTx (n ¼ 17 patients),
second or third KTx (n ¼ 16 patients), dialysis shorter than 1 year
Table 1. Patient Characteristics
(n ¼ 33 cases), and return to dialysis treatment within 1 year of KTx
(n ¼ 7 patients); 20 patients did not complete the questionnaire. Group 1 Group 2
(HD ¼ 44) (PD ¼ 25) P Value
All patients who agreed to participate in the study were also
asked to complete the KDQOL-SFtm questionnaires. Patients Age (years), mean 49 42 NS
assessed their QoL before KTx, and, 1 year after transplantation, Sex (M/F) 30/14 14/11 NS
the questionnaires were sent by post. The responders were con- BMI 23  4 20  6 NS
tacted by the research team by phone or met in the outpatient clinic Dialysis (months), mean 23 26 NS
during follow-up visits. Serum creatinine (mg/dL) 1.6  0.4 1.5  0.6 NS
The KDQOL-SFtm questionnaire consists of 80 items divided eGFR (mL/min), mean 60  18 58  22 NS
into kidney diseaseetargeted items (11 dimensions/43 items): Diabetes 4 3 NS
symptom list (12 items), effects of kidney disease (8 items), burden Cardiovascular morbidity 24 14 NS
of kidney disease (4 items), work status (2 items), cognitive function Abbreviations: BMI, body mass index; eGFR, estimated glomerular filtration
(3 items), quality of social interaction (3 items), sexual function rate; NS, no statistical differences.
52 KOSTRO, HELLMANN, KOBIELA ET AL

Comparison of QoL in Group 1 (HD) Before and After Kidney
Transplantation
In all dimensions, the assessment of QoL was better after
KTx. There were significant differences in 14 of the 19
dimensions (74%): symptom list, effects of kidney disease,
cognitive function, quality of social interaction, sexual
function, sleep, social support, patient satisfaction, physical
functioning, physical role, pain, emotional well-being,
emotional role, and energy/fatigue (Table 2). Patients
demonstrated improved QoL with no significant differences
1 year after KTx in the remaining dimensions: burden of
kidney disease, work status, staff encouragement, general
health status, and social function (Table 2).
Comparison of QoL in Group 2 (PD) Before and After KTx
Improvement in most of the parameters was observed in
patients with primary peritoneal dialysis. The patients
treated with PD (group 2) demonstrated significant differ-
ences after KTx in the assessment of 14 of 19 dimensions
(74%): symptom list, effects of kidney disease, cognitive
function, quality of social interaction, sexual function,
sleep, social support, patient satisfaction, physical func-
tioning, physical role, pain, general health status, emotional
well-being, emotional role, and energy/fatigue (Table 2).
Transplant recipients in group 2 demonstrated better QoL
after KTx with no significant differences in 3 assessment
dimensions: burden of kidney disease, social support, and
social function. In the assessment of patients, 2 parameters
deteriorated after KTx: work status and staff encourage-
ment (Table 2). QoL in groups 1 and 2 before and after
KTx were similar. We observed differences only in the
assessment of social support, which presented more posi-
tively in patients from group 1, and general health, which
was better in group 2.
Comparison of QoL Between Groups 1 and 2 Before and
After KTx
The study showed no statistically significant differences in
QoL measured by use of the KDQOL-SFtm questionnaire
between patients from groups 1 and 2 before KTx (Table 3).
Similarly, no statistically significant differences were
observed after KTx (Table 3). Although we did not observe
statistically significant differences in QoL between both
groups before KTx, there were more dimensions (15/19 ¼
79%) identified as improved by the patients from group 2.
Only cognitive function, quality of social interaction, phys-
ical functioning, general health, and emotional well-being
were assessed as improved by patients from group 1
(Table 3). This situation was changed 1 year after KTx.
Patients from group 1 had more positive feelings and
perceived benefits (improvement was observed in 11 of 19
dimensions ¼ 58%) of the KDQOL-SFtm in comparison
with group 2. Symptom list, burden of kidney disease, work
status, cognitive function, quality of social interaction,
staff encouragement, physical functioning, physical role,
emotional well-being, social function, and energy/fatigue
were better in group 1 as compared with group 2 (Table 3).
DISCUSSION
In this study, we compared the QoL of patients originally
treated with PD or HD both before and after KTx. In the
analysis of QoL, the patient’s subjective assessment is a very

Table 2. Comparison of QoL in Group 1 (HD) and Group 2 (PD) Before and After KTx
Group 1 (HD/KTx) Group 2 (PD/KTx)
Before (SD) After (SD) P Value Before (SD) After (SD) P Value

Kidney diseaseetargeted domains

Symptom list 61 (18) 85 (14) <.001* 65 (20) 81 (20) <.001*
Effects of kidney disease 52 (16) 78 (20) <.001* 56 (21) 81 (16) <.001*
Burden of kidney disease 35 (20) 39 (19) .36 38 (27) 38 (23) .99
Work status 27 (40) 33 (41) .47 34 (45) 30 (43) .57
Cognitive function 67 (24) 77 (23) .006* 59 (25) 74 (17) .007*
Quality of social interaction 72 (20) 79 (19) .04* 69 (23) 78 (16) .005*
Sexual function 54 (31) 72 (32) .003* 61 (30) 77 (35) .005*
Sleep 51 (22) 69 (22) <.001* 51 (27) 70 (23) .002*
Social support 69 (18) 83 (17) <.001* 75 (25) 83 (19) .24
Staff encouragement 79 (22) 83 (19) .32 84 (23) 83 (25) .86
Patient satisfaction 41 (19) 57 (22) <.001* 46 (24) 60 (22) .002*
Generic (SF-36) domains
Physical functioning 58 (25) 74 (25) .002* 55 (25) 68 (27) .01*
Role-physical 15 (31) 52 (44) <.001* 23 (35) 46 (41) .005*
Pain 52 (27) 67 (29) .01* 56 (28) 70 (29) .046*
General health 34 (19) 40 (14) .07 32 (15) 40 (18) .045*
Emotional well-being 45 (18) 63 (19) <.001* 44 (22) 63 (17) <.001*
Role-emotional 30 (39) 65 (41) <.001* 45 (46) 68 (39) .009*
Social function 49 (21) 54 (17) .22 52 (30) 54 (18) .80
Energy/fatigue 41 (18) 60 (17) <.001* 43 (23) 58 (19) .005*
*Significant values.
QUALITY OF LIFE AFTER KIDNEY TRANSPLANT 53

Table 3. Comparison of QoL Between Group 1 (HD) and Group 2 (PD) Before and After KTx
Before KTx Mean (SD) After KTx Mean (SD)
Group 1 Group 2 P Value Group 1 Group 2 P Value

Kidney diseaseetargeted domains

Symptom list 61 (18) 65 (19) .45 85 (14) 81 (20) .42
Effects of kidney disease 52 (16) 56 (21) .48 78 (20) 81 (16) .57
Burden of kidney disease 35 (20) 38 (27) .62 39 (19) 38 (23) .93
Work status 27 (40) 34 (45) .52 33 (41) 30 (43) .76
Cognitive function 67 (24) 59 (25) .24 77 (23) 74 (17) .58
Quality of social interaction 72 (20) 69 (23) .56 79 (19) 78 (16) .88
Sexual function 54 (31) 61 (30) .36 72 (32) 77 (35) .52
Sleep 51 (22) 51 (27) .99 69 (22) 70 (23) .89
Social support 69 (18) 75 (25) .26 83 (17) 83 (19) .99
Staff encouragement 79 (22) 84 (23) .47 83 (19) 83 (25) .95
Patient satisfaction 41 (19) 46 (24) .38 57 (22) 60 (22) .69
Generic (SF-36) domains
Physical functioning 58 (25) 55 (25) .60 74 (25) 68 (27) .35
Role functioningephysical 15 (31) 23 (35) .36 52 (44) 46 (41) .55
Pain 52 (27) 56 (28) .55 67 (29) 69 (29) .75
General health 34 (19) 32 (15) .57 40 (14) 40 (18) .99
Emotional well-being 45 (18) 44 (22) .92 63 (19) 63 (17) .96
Role-emotional 30 (39) 45 (46) .16 65 (41) 68 (39) .80
Social function 49 (21) 52 (30) .66 54 (17) 54 (18) .91
Energy/fatigue 41 (18) 43 (22) .58 60 (17) 58 (19) .63

important topic. To confirm the benefits from treatment, it
is believed that assessment of different therapies be given by
a single patient to draw clear contrasts and comparisons.
Such an approach to the subject is shown in only a few
publications in which the authors demonstrated improve-
ment in the QoL of patients with chronic renal failure after
KTx [4,7]. In our analysis, patients also confirmed this
hypothesis; they identified an improvement in their QoL
after KTx. The major goal of transplantation is to improve
the QoL and life expectancy of ESRD patients. The ques-
tion is not only whether and how long a patient will survive,
but also how the treatment will affect the patient’s QoL [8].
Many factors can affect QoL assessment. Good communi-
cation between patients with chronic disease and their
healthcare providers is necessary for successful disease
management. Effective healthcare guides and supports
patients throughout their treatment [9]. In our study,
patients evaluated the cooperation of health workers as
good, rating it at 80%. The results were comparable before
and after KTx. Another object of transplantation is to offer
patients a state of health similar to what they had before the
onset of the disease, achieving a balance between the
functional efficacy of the graft and the patient’s psycholog-
ical and physical integrity [9,10]. However, any treatment of
ESRD causes significant lifestyle changes. We observed that
patients after KTx, regardless of the type of previous dial-
ysis, demonstrated statistically significant improvements in
domains such as cognitive function, sexual function, physical
function, physical role, emotional well-being, and emotional
role. The majority of studies demonstrated statistically sig-
nificant pre- to post-transplant improvements in physical
function, mental health, cognitive status, social functioning,
and overall QoL perceptions [11]. Individuals with chronic
kidney disease must adapt their lives to a number of new
conditions. Chronic illness can have a significant impact on
a person’s life. Although none of the treatments provides a
complete cure, transplant patients appear to function more
normally. Our patients also presented fewer symptoms and
signs of kidney disease after transplantation. Among the
different types of replacement therapy for chronic renal
failure, a review of a few studies shows a general consensus
that KTx improves QoL [1,4,12,13]. The QoL depends on
the patient’s life from the moment in which it is evaluated.
Better QoL may also be related to any treatment regimen
that a patient can self-administer at home. It has been
confirmed in several reports that PD is associated with a
higher QoL than those treated by means of HD [14e17];
however, other reports have shown no difference in the
general health status and QoL between the 2 groups [5,18].
In our study, patients achieved no statistical differences in
QoL before and after KTx between groups. A lack of sta-
tistical differences before transplantation may be due to the
fact that our patients answered the questionnaire after
having been informed about the possibility of KTx. They
could be more emotionally invested in transplantation than
to the previous dialysis treatment. Despite this, our study
demonstrated better results before KTx in group 2, whereas
improvements in group 1 were seen after KTx, though they
lack statistical significance. Sayin et al [19] reported that the
3 forms of renal replacement therapy did not differ in
regard to QoL and that the underlying mechanisms of
such findings must be clarified in further studies. These
54
inconsistencies may have been caused by the usage of
different QoL scales or different timing. The differences in
QoL may also occur among patients who are on the waiting
list for transplantation and those who remain only on renal
replacement therapy (HD or PD) [20]. Our patients were
all awaiting transplantation. It was reported that it is
possible to improve the QoL of patients while they await
transplantation [3]. The prospect of relatively normal
functioning can have a positive impact on the assessment
of QoL. A person usually tries to maintain their QoL level
by striving to achieve the highest level of any kind of
functioning. Improved QoL involves the patients assuming
more proactive roles in their own lives. In our study,
patients significantly improved QoL scores after KTx
regardless of the type of dialysis treatment they were
receiving. Only 2 parameters in group 1 showed a lower
score after KTx: work status and staff encouragement. Any
type of treatment may affect the possibility to perform
varying kinds of work. KTx can also cause certain limita-
tions in the choice of a patient’s profession. At the same
time, it opens up the possibility for the patients to live a life
less dependent on medical staff than other forms of
treatment. We have also compared the answers between
both groups 1 and 2. We did not prove any statistical
differences in QoL between PD and HD patients before
and after KTx. Some papers assess the QoL as better in PD
patients in comparison to HD patients [15,17], whereas
others find no difference between the two [3,18].
Furthermore, no articles were found stating that QoL was
higher in patients treated with HD than in those treated
with PD. QoL covers many aspects of life. For analysis,
many instruments of research are available that can care-
fully analyze particular problems or approach the topic
more generally. For a more complete analysis of our
patients’ QoL, we chose the KDQOL-SFtm questionnaire;
it is a multidimensional, reliable, and validated instrument
designed for kidney disease and dialysis patients that
utilizes a generic coredthe 36-item Short Form Health
Survey (SF-36) [5,9,16]. The KDQOL-SFtm questionnaire
is a reproducible questionnaire that was validated by
the KDQOL Working Group studies [10]; it was used
in several recent studies on QoL assessment in the eval-
uation of transplant patients and in comparisons of
transplant recipients and patients on peritoneal and
hemodialysis [1,9,16]. Unfortunately there is no ideal
questionnaire that can measure all possible variables. It
is possible that substantially different Health-Related
Quality of Life (HRQL) results can be obtained in the
same population if different tools are applied [13]. Tar-
geted instruments offer fine-tuned assessment of narrow
aspects and symptoms. The advantages of targeted in-
struments include the focus on relevant areas, sensitivity
to change in clinical status over time, and perceived
relevance and practicality by clinicians and patients [1].
Although there are a number of reliable and valid QoL
instruments, none can be considered the gold standard for
assessment in all situations [1].
KOSTRO, HELLMANN, KOBIELA ET AL
CONCLUSIONS
The study demonstrated post- to pre-transplant improve-
ments of QoL. Despite this, we did not prove any statistical
differences in QoL between PD and HD patients before and
after kidney transplantation.
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