Quality of life assessments may inform kidney transplant waitlist practices
For patients with advanced chronic kidney disease, differences in health-related quality of life — including depressive symptoms and physical function — were associated with variations in time to wait-list for kidney transplantation.
This finding led Meera Nair Harhay, MD, MSCE, associate professor of medicine at Drexel University College of Medicine, to suggest that assessing HRQoL in late-stage CKD might provide insight into the motivations and barriers to kidney transplantation, while also helping to guide patient-physician discussions on renal replacement therapy options.
“People with late-stage kidney disease can derive benefits from being wait-listed for transplant before requiring maintenance dialysis (ie, preemptive wait-listing), but the majority of people with end-stage kidney disease who initiate dialysis in the United States are not wait-listed preemptively,” Harhay told Healio Nephrology. “We wanted to understand whether differences in patient experiences with CKD, specifically related to self-reported quality of life and depressive symptoms, might explain why some patients are not wait-listed as rapidly as others.”
Including 1,676 patients from the Chronic Renal Insufficiency Cohort Study, the researchers determined HRQoL for each patient utilizing five scales of the Kidney Disease Quality of Life-36 Survey (physical component summary [PCS], mental component summary, symptoms, burdens and effects). Researchers noted higher scores indicated better HRQoL. Depressive symptoms were ascertained by the Beck Depression Inventory.
Patients were followed for a median of 5.1 years, during which time 652 patients (39%) were wait-listed (304 patients were preemptively wait-listed).
After adjusting for demographics, comorbidities, eGFR slope and cognitive function, researchers found patients who reported the most burdens and effects from kidney disease, as well as more depressive symptoms, were wait-listed more quickly than those who reported the fewest burdens and effects.
More specifically, patients with the highest scores on the burden and effects scales (ie, those with higher reported QoL) had lower rates of being wait-listed than those with the lowest scores (waitlists were adjusted hazard ratios [aHRs] for burden and effect scale, 0.70 and 0.74, respectively).
Regarding depressive symptoms, patients with fewer depressive symptoms (BDI <14) had lower waitlist rates than those with more depressive symptoms (aHR = 0.81).
On the other hand, patients with better physical function had more rapid preemptive waiting lists than those with worse physical function (aHR in highest tertile of physical component score relative to lowest tertile = 1.58).
Harhay said it is interesting to note that the mean self-reported physical and mental health scores in this cohort were similar to published data regarding patients on dialysis. This, she contended, highlights the substantial burden of functional impairments in nondialysis- dependent patients with CKD.
As for future research, Harhay suggested examinations be conducted to determine whether interventions aimed at improving physical function might also improve rates of preemptive waiting lists.
“Research is [also] needed to understand which interventions might hold the most promise to improve health-related quality of life during late-stage CKD, and whether assessments of quality of life can help to improve transitions to end-stage kidney disease for patients,” she said.