|Year : 2020 | Volume
| Issue : 3 | Page : 219-223
Employment and quality of life postkidney transplant: Are we justifying the choice of RRT - A cross sectional study
Shikha Khandelwal, Vinay Malhotra, Dhananjay Agarwal, Pankaj Beniwal, Sanjeev Sharma, Rajesh Jorawat, Vartul Gupta, Shiv Chada
Department of Nephrology, S M S Medical College, Jaipur, Rajasthan, India
|Date of Submission||21-May-2020|
|Date of Acceptance||15-Jul-2020|
|Date of Web Publication||30-Sep-2020|
Dr. Pankaj Beniwal
6, New Hera Bagh, Near Kalyan Dharmshala, Jaipur - 302 004, Rajasthan
Source of Support: None, Conflict of Interest: None
Introduction: For kidney, patients' socioeconomic status (SES) and employment significantly contribute to their general well-being, mental health (MH), and quality of life (QoL). Due to the scarcity of the literature, the present study was conducted to analyze the interrelationship between QoL, employment, and sociodemographic factors postkidney transplant and to identify the possible predictors of employment. Materials and Methods: This cross-sectional study was conducted on 90 kidney transplant patients during follow-up visits from July 2018 to June 2019 in the tertiary care government institute in North India. Employment before and after transplant was evaluated using a sociodemographic schedule. Short-form health survey 36 was used for the QoL. Results: Lower SES was not found in any of the subject's prekidney transplants, whereas it was revealed in 27.8% of the subject's postkidney transplant with a statistically significant difference. Unemployed status was also increased from 23.3% to 47.8% postkidney transplant. Employment posttransplant (EPT) is not associated with a good perception of psychophysical well-being: EPT/general health, r = −01.6; EPT/MH, r=-0.08, and EPT/ Mental component summary score (MCS), r = −0.34. It emerged that job return depends on the highest education, exercise, and insurance, while it is inversely proportional to the residence in a rural area and lower SES. Conclusion: Maintaining employment pretransplant and posttransplant should be actively supported and in case employment is lost, return to work should be integrated into the transplant planning. It may be useful to organize psychological support for these patients and to cure any psychological fragility in the posttransplant condition.
Keywords: Employment, quality of life, renal transplantation
|How to cite this article:|
Khandelwal S, Malhotra V, Agarwal D, Beniwal P, Sharma S, Jorawat R, Gupta V, Chada S. Employment and quality of life postkidney transplant: Are we justifying the choice of RRT - A cross sectional study. Indian J Transplant 2020;14:219-23
|How to cite this URL:|
Khandelwal S, Malhotra V, Agarwal D, Beniwal P, Sharma S, Jorawat R, Gupta V, Chada S. Employment and quality of life postkidney transplant: Are we justifying the choice of RRT - A cross sectional study. Indian J Transplant [serial online] 2020 [cited 2022 Oct 5];14:219-23. Available from: https://www.ijtonline.in/text.asp?2020/14/3/219/296896
| Introduction|| |
In India, the incidence of end-stage renal disease (ESRD) is around 232 per million population. Kidney transplantation (Tx) is currently the treatment of choice for ESRD. For kidney patients, employment significantly contributes to their general well-being, mental health (MH), and quality of life (QoL). Employment rates after kidney Tx vary widely from as low as 28% to as high as 58%.,, To support Tx patients in returning to work, a deeper understanding of the predictors of this process is crucial.
Health-related QoL (HRQoL) contains multiple aspects of health-related issues from the patients' perspective including physical, psychological, social functioning (SF), and overall well-being. HRQoL is also recognized as an important measure of outcome following solid-organ transplantation.
The cost of treatment in Indian ESRD participants has been associated with the financial burden to the recipients and their families. Therefore, socioeconomic status (SES) is an important determinant of health, nutritional status, mortality, and morbidity of an individual as well as family. SES also influences the accessibility, affordability, acceptability, and actual utilization of available health facilities. Thus, assessing SES, which includes various domains, including education, occupation, monthly income, and social participation, can evaluate the socioeconomic impact of kidney transplantation and subsequent socioeconomic rehabilitation of transplant patients in a broader aspect.
Due to the scarcity of the literature, the present study was conducted to analyze the interrelationship between QoL, employment, and sociodemographic factors postkidney transplant and to assess the predictors for employment after renal transplantation.
| Materials and Methods|| |
This cross-sectional study was conducted on 90 kidney transplant patients during follow-up visits from July 2018 to June 2019 at tertiary care government institute in North India. We selected patients' age between 21 and 65 years and completed 1 year after a kidney transplant. Kidney transplant recipients who were considered at or past retirement age (i.e., 65 year or older) and previous transplants excluded from this study.
The data were collected in a pro forma by eliciting the information from patients. Written consent was obtained from the patient before collecting the data. The data collected included age, sex, literacy, etiology of ESRD, the modality of dialysis, time on dialysis (TD) (waiting period), year after transplant, the presence of comorbid conditions, the effect of Internet and exercise on HRQoL, SES, and the employment before and after transplantation, Health survey scoring system (SF-36V2) for QoL. SES was assessed using a modified Kuppuswamy SES scale. This scale consists of educational, occupational, and economic criteria.
Subjective HRQoL instruments were hand delivered at OPD visits for self-administration. Strict confidentiality was ensured. The health survey scoring system (SF-36V2) was used to assess the physical, functional, emotional, and social dimensions of QoL after renal transplantation. Patients took the SF-36 V2 at one point in time in their course, providing a cross-sectional sample. The responses were summarized and transformed into the following eight summary scales to give HRQoL: Physical functioning (PF), role limitation attributable to role limitation attributable to physical problems (RP), bodily pain (BP), general health perception (GH), vitality (VT), SF, role limitation attributable to emotional problems (RE), and MH. Physical component summary score included PF, RP, and BP, whereas the mental component summary (MCS) score included SF, RE, and MH. GH and VT were considered as the members of both dimensions.
Data so collected were tabulated and analyzed using the SPSS software version 22.00 for Windows; SPSS Inc., Chicago, IL, USA. The difference between the two groups was determined using the Chi-square test, and the level of significance was set at P < 0.05. Pearson correlation coefficient ® was used to analyze the association between the variables of the SF-36 and employment posttransplant (EPT) with demographic characteristics of the sample: Age, sex, education, TD and years after transplant (YT), and insurance. We applied a multivariate linear regression analysis to predict the values of the outcome variable (EPT) from predictor variables (demographic characteristics).
Declaration of patient consent
The patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names, initials would not be published, and all standard protocols will be followed to conceal their identity.
The study was approved by Ethics committee of Sawai Mansingh medical college(No 43/EC/SMS/2020 dated 23/1/20). The study was carried out in accordance with principles of Declaration of Helsinki.
| Results|| |
The present study comprised 90 participants, of which 87 were male and 3 were female, with a mean age of 34.51 years. The majority of participants in the study had undergone live-related kidney transplantation (84) as compared to cadaver transplantation (6). More than 2/3rd of the participants had insurance coverage. Hypertension and new-onset diabetes after transplant were reported in 27.78% and 8.89% of the participants, respectively, postkidney transplant [Table 1].
|Table 1: Demographic and clinical characteristics of the study population|
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Lower SES was not found in any of the subject's prekidney transplant, while it was found in 27.8% of the participants' postkidney transplant. Participants having upper-lower SES were 41.1% prekidney transplant which was reduced to 25.6% postkidney transplant. When SES was compared statistically according to prekidney and post-kidney transplant, it was found to be statistically significant. Unemployed status was also increased from 23.3% to 47.8% postkidney transplant with a statistically significant difference [Table 2].
|Table 2: Socioeconomic status and employment prekidney and postkidney transplant|
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Age, dialysis time, and years since transplant correlate negatively with a good GH perception: Age/GH, r = −0.22 (age/physical health index, r = 0.16); dialysis time/GH, r = −0.15; years since transplant/GH, r = −0.13. Conversely, return to work is not associated with a good perception of psychophysical well-being: EPT/GH, r = −01.6; EPT/MH, r = −0.08, and EPT/MCS, r = −0.34 [Table 3].
|Table 3: Correlation between SF-36 test and characteristics of the study population|
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The analysis of the correlations by Pearson r coefficient between posttransplant employment and characteristics of the study population is shown in [Table 4]. It emerged that job return depends on highest education (EPT/highest education, r = 0.41), exercise (EPT/exercise, r = 0.20), and insurance (EPT/insurance, r = 0.22), while it is inversely proportional to the residence in the rural area (EPT/residence, r = −0.19), lower SES (EPT/lower SES, r = −0.24), and occupation such as farmer and laborer (EPT/farmer, r = −0.39, EPT/laborer, r = −0.51).
|Table 4: Correlation between employment postransplant and characteristics of the study population|
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The main cause of unemployment postkidney transplant was fear of graft loss due to heavy physical work (26.7%) followed by illness (20%).
| Discussion|| |
In developed and developing countries, successful kidney transplantation is associated with considerable improvements in survival and QoL, the positive psychosocial outcome as well as significant cost-savings when compared with dialysis. ESRD has a serious effect on the patient's QoL, negatively affecting their social, financial, and psychological well-being. Transplant recipient's return to work posttransplant is an important indicator of functional benefit to the recipient and social benefit to the community as it has been widely documented that employment is an important component in the reestablishment of a transplant recipient's identity, self-esteem, and QoL. Limited literature is available in India regarding the impact of a postkidney transplant on employment and relationship with QoL. Hence, this study conducted to assess the interrelationship between QoL, employment, and sociodemographic factors postkidney transplant.
The present study showed male dominance, which is in accordance with the study done by C. De Pasquale et al. The mean age of study participants was 34.51 years in the present study showing the predominance of young adult patients. Similar results were reported by Callahan who also showed a predominance of young adult patients aged up to 35 years (50.8%), and the mean age was 38.9 years (standard deviation = 12.9). These results revealed a worrying statistic because of the early development of kidney disease and its rapid progression in economically active young individuals.
In the present study, lower SES was not found in any of the participants' prekidney transplant, whereas it was reported in 27.8% of the participants' postkidney transplant. Participants having upper lower SES were 41.1% prekidney transplants which were reduced to 25.6% postkidney transplant with a statistically significant difference. Unemployed status was also increased from 23.3% to 47.8% postkidney transplant with statistically significant difference. Postkidney transplant, farmers, and laborer occupation reduced from 22.2% to 4.4% and 17.8% to 1.1%. Kapoor et al. in their study stated that 41 (22%) patients have lost their job after transplantation as compared to 56% patients as found by Ramachandran and Jha. These are the very alarming reality that should be kept in mind before offering transplant to underprivileged population, where decision of transplantation is often taken on an emotional basis and many patients are uninformed regarding the number of expenses and the need for continuous funding sources.
Similar results were revealed by De Pasquale et al. BIAS-Bigger sample size may further validate the results. They found that the unemployment rate after kidney transplant increased from 32.10% to 61.7% (P = 0.005): Only 3.7% of factory workers, 21% of office workers, and 13.6% of self-employed workers retained their pretransplant job. In our view, this difficulty depends on the type of pretransplant work. Some professions that require greater physical effort are no longer adopted after transplant. Potential adverse effects of immunosuppressive therapy and focus on the new perception of health also influence return to work. Specifically, it appeared that the return to work has dropped considerably in jobs such as farmer and factory worker, but remained unchanged in professions such as office worker.
In the present study, age, dialysis time, and YT correlate negatively with a good GH perception: Age/GH, r = −0.22 (age/physical health index, r = 0.16); dialysis time/GH, r = −0.15; years since transplant/GH, r = −0.13. Conversely, return to work is not associated with a good perception of psychophysical well-being: EPT/GH, r = −01.6; EPT/MH, r = −0.08, and EPT/MCI, r = −0.34. These results were in accordance with the study done by De Pasquale et al. They revealed that age, TD, and YT correlate negatively with a good GH perception. Conversely, return to work is not associated with a good perception of psychophysical well-being: EPT/GH, r = −0.207; EPT/VT, r = −0.154; EPT/SF, r = −0.132; EPT/MH, r = −0.111; and EPT/ISF, r = −0.141.
It emerged that work return depends on highest education (EPT/highest education, r = 0.41), exercise (EPT/exercise, r = 0.20) and insurance (EPT/insurance, r = 0.22), while it is inversely proportional to the residence (EPT/residence, r = −0.19), lower SES (EPT/lower SES, r = −0.24) and occupation like a farmer as well as laborer (EPT/farmer, r = −0.39, EPT/laborer, r = −0.51). Patients with higher levels of education return to their pretransplant occupational status more willingly, probably because it is more necessary to meet their self-realization and self-expression needs. Another reason for unemployment is the financial support from disability pension that provides transplant recipients an economic remuneration for the management of daily life. In line with this, Sangalli et al. and Tzvetanov et al. reported lower employment rates post-Tx in persons insured by public insurances and Nour et al. reported an increase in retirement rates from pre-Tx (8.3%) to post-Tx (18.3%). Another explanation may be that transplanted persons still feel handicapped and perceive their work-ability as insufficient despite the increase in health perception such as described by Slakey and Rosner. These authors reported a striking contrast between the percentage of transplanted patients who were working (28%) and the percentage of those who were feeling able to work (60%).
This study has several strengths: To our knowledge, this is one of the few studies assessing the QoL factors and analyzing their influence on employment in the Indian population. The present study was conducted among tertiary care government institute in India catering to patients from multiple states, which leads to minimal selection bias.
The limitation of the study is that it was a single centre study and similar studies from across states and across government and private institutes are required to further validate the findings.
| Conclusion|| |
Based on the results of our study, we tried to identify potentially modifiable factors that could be acted upon to improve work participation in kidney recipients. First, maintaining pretransplant and posttransplant employment should be actively supported and in case employment is lost, return to work should be integrated into the transplant planning and indulge them in some skill development program. Second, emphasis should be given to health perception. It may be useful to organize psychological support and to cure any psychological fragility in the posttransplant condition.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Modi GK, Jha V. The incidence of end-stage renal disease in India: A population-based study. Kidney Int 2006;70:2131-3.
Raiz L, Monroe J. Employment post-transplant: A biopsychosocial analysis. Soc Work Health Care 2007;45:19-37.
Bohlke M, Marini SS, Gomes RH, Terhorst L, Rocha M, Poli de Figueiredo CE, et al
. Predictors of employment after successful kidney transplantation-A population-based study. Clin Transplant 2008;22:405-10.
Eng M, Zhang J, Cambon A, Marvin MR, Gleason J. Employment outcomes following successful renal transplantation. Clin Transplant 2012;26:242-6.
Revicki DA, Osoba D, Fairclough D, Barofsky I, Berzon R, Leidy NK, et al
. Recommendations on health-related quality of life research to support labeling and promotional claims in the United States. Qual Life Res 2000;9:887-900.
Ramachandran R, Jha V. Kidney transplantation is associated with catastrophic out of pocket expenditure in India. PLoS One 2013;8:e67812.
Aggarwal SK, Bhasin AK, Sharma P, Chhabra K, Aggarwal OP, Rajoura. A new instrument (Scale) for measuring the socioeconomic status of a family: Preliminary study. Indian J Community Med 2005;30:10-12.
Fujisawa M, Ichikawa Y, Yoshiya K, Isotani S, Higuchi A, Nagano S, et al
. Assessment of health-related quality of life in renal transplant and hemodialysis patients using the SF-36 health survey. Urology 2000;56:201-6.
Saleem SM. Modified Kuppuswamy scale updated for year 2018. Paripex Indian J Res 2018;7:435-6.
Callahan MB. Dollars and sense of successful rehabilitation. Prog Transplant 2005;15:331-7.
De Pasquale C, Veroux M, Pistorio ML, Papotto A, Basile G, Patanè M, et al
. Return to work and quality of life: A psychosocial survey after kidney transplant. Transplant Proc 2019;51:153-6.
Kapoor R, Sharma RK, Srivastava A, Kapoor R, Arora S, Sureka SK. Socioeconomic rehabilitation of successful renal transplant patients and impact of funding source: Indian scenario. Indian J Urol 2015;31:234-9.
] [Full text]
Eppenberger L, Hirt-Minkowski P, Dickenmann M. Back to work? Socioeconomic status after kidney transplantation. Swiss Med Wkly 2015;145:w14169.
Sangalli V, Dukes J, Doppalapudi SB, Costa G, Neri L. Work ability and labor supply after kidney transplantation. Am J Nephrol 2014;40:353-61.
Tzvetanov I, D'Amico G, Walczak D, Jeon H, Garcia-Roca R, Oberholzer J, et al
. High rate of unemployment after kidney transplantation: Analysis of the United network for organ sharing database. Transplant Proc 2014;46:1290-4.
Nour N, Heck CS, Ross H. Factors related to participation in paid work after organ transplantation: Perceptions of kidney transplant recipients. J Occup Rehabil 2015;25:38-51.
Slakey DP, Rosner M. Disability following kidney transplantation: The link to medication coverage. Clin Transplant 2007;21:224-8.
[Table 1], [Table 2], [Table 3], [Table 4]