Kidney Disease Symptoms before and after Kidney Transplantation

Abstract

Background and objectives: Patients with kidney failure report a high symptom burden, which likely increases while on dialysis due to physical and mental stressors and decreases after kidney transplantation due to restoration of kidney function.

Design, setting, participants, & measurements: We leveraged a two-center prospective study of 1298 kidney transplant candidates and 521 recipients (May 2014 to March 2020). Symptom scores (0-100) at evaluation and admission for transplantation were calculated using the Kidney Disease Quality of Life Short-Form Survey, where lower scores represent greater burden, and burden was categorized as very high: 0.0-71.0; high: 71.1-81.0; medium: 81.1-91.0; and low: 91.1-100.0. We estimated adjusted waitlist mortality risk (competing risks regression), change in symptoms between evaluation and transplantation (n=190), and post-transplantation symptom score trajectories (mixed effects models).

Results: At evaluation, candidates reported being moderately to extremely bothered by fatigue (32%), xeroderma (27%), muscle soreness (26%), and pruritus (25%); 16% reported high and 21% reported very high symptom burden. Candidates with very high symptom burden were at greater waitlist mortality risk (adjusted subdistribution hazard ratio, 1.67; 95% confidence interval, 1.06 to 2.62). By transplantation, 34% experienced an increased symptom burden, whereas 42% remained unchanged. The estimated overall symptom score was 82.3 points at transplantation and 90.6 points at 3 months (10% improvement); the score increased 2.75 points per month (95% confidence interval, 2.38 to 3.13) from 0 to 3 months, and plateaued (-0.06 points per month; 95% confidence interval, -0.30 to 0.18) from 3 to 12 months post-transplantation. There were early (first 3 months) improvements in nine of 11 symptoms; pruritus (23% improvement) and fatigue (21% improvement) had the greatest improvements.

Conclusions: Among candidates, very high symptom burden was associated with waitlist mortality, but for those surviving and undergoing kidney transplantation, symptoms improved.

Keywords: kidney transplantation.

Copyright © 2021 by the American Society of Nephrology.

Figures

Graphical abstract

Figure 1.

Comparison of individual symptom burdens at evaluation (n=1298), admission for kidney transplantation (n=521), and 3 months post-transplantation (n=452). Burden at evaluation was examined among candidates who were enrolled at evaluation for kidney transplant, and burden at admission for transplantation and 3 months post-transplantation was examined among recipients who were enrolled at admission for kidney transplantation and followed up approximately 1, 3, and 6 months and yearly post-transplantation. Participants reported burdens of individual symptoms with five response options ranging from “not at all bothered” to “extremely bothered.” The prevalence of each individual symptom was defined as participants reported being moderately to extremely bothered by the symptom. Dialysis site–related symptom was not assessed after transplantation.

Figure 2.

Change in symptom burden at evaluation and admission for kidney transplantation among the combined kidney transplant candidate and recipient cohorts (n=190). Transplant candidates were enrolled at evaluation; recipients were enrolled at admission for transplantation. The overall symptoms score ranged from zero to 100 points and was on the basis of self-reported burden of individual symptom/problem of kidney disease with five response options ranging from “not at all bothered” to “extremely bothered.” Symptom burden was defined as very high: 0.0–71.0; high: 71.1–81.0; medium: 81.1–91.0, and low: 91.1–100.0.

Figure 3.

Symptom scores at evaluation and at kidney transplantation among the combined candidate and recipient cohorts (n=190). Candidates were enrolled at evaluation for transplant; recipients were enrolled at admission for transplantation.

Figure 4.

Estimated postkidney transplantation change in overall symptom score by months since transplantation among recipients (n=521). Recipients were enrolled at admission for kidney transplantation. The overall symptom score ranged from zero to 100 points and was on the basis of self-reported burden of individual symptom/problem of kidney disease with five response options ranging from “not at all bothered” to “extremely bothered.” A higher symptom score represents a lower burden. Symptom burden was defined as very high: 0.0–71.0; high: 71.1–81.0; medium: 81.1–91.0; and low: 91.1–100.0. A knot was fit at 3 months post-transplantation on the basis of exploratory data analysis using lowess plots. The score was calculated from adjusted mixed effects models and was estimated for the “reference population” in which age is set to 65, sex is set to men, race is set to non-Black, diabetes status is set to nondiabetic, and time on dialysis is set to zero.