Most symptoms improve within 3 months of kidney transplantation
Research from Johns Hopkins showed that although high symptom burden was linked to mortality for those awaiting kidney transplantation, survivors experienced improvement in nine of 11 symptoms within 3 months following the procedure.
“Among patients undergoing dialysis, symptom burden is associated with lower quality of life, depression, early termination of dialysis/under-dialysis and greater risk of both hospitalization and mortality,” Mara A. McAdams-DeMarco, PhD, of the department of epidemiology at Johns Hopkins University Bloomberg School of Public Health, and colleagues wrote. “While undergoing dialysis and waiting for transplantation, these symptoms likely persist or worsen, putting candidates at risk for these adverse outcomes. However, cross-sectional studies suggest that restoration of kidney function after kidney transplantation improves symptoms and overall health-related quality of life.”
According to McAdams-DeMarco and colleagues, this study is the first to evaluate specific symptoms — and how these might change before and after transplantation — in those involved in the transplant process (ie, kidney transplant candidates and recipients rather than patients receiving maintenance dialysis).
“Our findings on the post-transplantation change in symptoms can help inform the important discussion surrounding post-transplant care, clarify the timeline for improvement, identify populations who are most likely to benefit, and promote patient-centered care,” McAdams-DeMarco said in a related press release.
For the study, researchers evaluated symptom burden in 1,298 kidney transplant candidates (42% of whom were preemptive candidates and not on dialysis) and 521 recipients. Utilizing the kidney disease quality of life-short form, symptom burden was initially attained at the time of evaluation for candidates and at the time of transplant admission for recipients. Researchers continued monitoring symptom status in candidates throughout the waitlist period, with recipients reporting symptoms at routine clinical follow-up visits after transplantation (at 1, 3, 6 months and yearly). Special focus was placed on the association between symptom burden and mortality for candidates awaiting transplant.
“For candidates who received kidney transplant (n=190), we calculated the difference in overall symptom scores between evaluation and transplantation,” the researchers wrote. “Among recipients, we described the post-transplantation trajectories of the 11 individual symptom scores (excluding dialysis site-related symptoms) and the overall symptom score using mixed-effects models (adjusted for age, sex, race, diabetes, and time on dialysis) with random slope and random intercept for person and time.”
Symptom burden and mortality
Researchers found fatigue, xeroderma, muscle soreness and pruritus were the most commonly reported symptoms at the time of transplant evaluation, with 16% and 21% of candidates reporting “high” and “very high” symptom burden, respectively.
During a median follow-up of 1.9 years, 12% of those awaiting transplant died, and findings indicated candidates with very high symptom burden were at greatest risk for waitlist mortality (adjusted subdistribution hazard ratio = 1.67). Additional observations suggested a 10-point reduction (ie, worsening) in individual symptom scores for muscle soreness, chest pain, cramps, dyspnea anorexia and fatigue were independently associated with a greater risk of waitlist mortality.
Symptom improvement after transplant
For individuals who did receive a kidney transplant, a 10% improvement in symptom burden was seen at 3 months (estimated overall symptom score was 82.3 points at transplantation vs. 90.6 at 3 months), with nine of 11 symptoms improving; the greatest improvements occurred for pruritus and fatigue, which improved by 23% and 21%, respectively.
Researchers observed a plateau in symptom scores after 3 months, which they hypothesize may be due to “a lack of precision in the data during follow-up or ... to other transplant-related factors such as choice of immunosuppression,” but noted this remains an area that requires further investigation.
“These findings highlight the importance of restoration of kidney function on changes in symptoms, provide estimates of percent reduction for each individual symptom, and clarify the timeframe for these reductions in symptoms,” McAdams-DeMarco and colleagues concluded.
“Discussion of expected reductions in symptoms should be a part of the shared decision-making for future care post-transplantation,” they wrote.