A Systematic Review of The Best Approaches to Improve Quality of Life and Longevity Post Kidney Transplant
Introduction
Chronic kidney disease is an ever-growing pathology worldwide, with the treatment of choice being dialysis or kidney transplant. The world health organization in 2007 has cited that in 2005, there had been 66,000 kidney transplants reported by 98 countries, but this only represented an estimated 10% of the required amount. In the USA, Medicare reported an annual expense of US$28 billion for haemodialysis and US$3.4 billion on transplant, (The Kidney Project, 2019), similarly NHS expends £1.5 billion a year on British adults with chronic kidney disease representing 10% of its adult population (Trueland, 2020).
The global prevalence of CKD in the year 2020 is estimated to be approximately 13.4%, referring to 850 million persons and a whooping 4,902 to 7,083 million patients requiring renal replacement therapy (Ji-Cheng et al., 2019).
According to the American heart association, there has been an increase of 41.5% in mortality for CKD over the past thirty years. This represents an annual death toll of more than two million persons. In 2019, there were 2.4 million deaths, qualifying CKD as the sixth deadliest infirmity in the world (American Heart Association, 2019).
One in every ten persons have been estimated to have CKD in India in the year 2019, with a staggering figure of 1,75,000 new cases being diagnosed annually and requires renal replacement therapy (Narayana Health, 2019).
A rate of increase in CKD of 5-7% annually has been reported and with the highest prevalence in Taiwan, Japan, Mexico, the United States of America and Belgium. The United States of America had a higher mortality risk of 15% than that of Europe and 33% than that of Japan in the year 2007 (The Kidney Project, 2019).
Regarding race, black people are more likely to have kidney failure, to be exact, they are 3.5 times more likely to develop this disease when compared to whites, moreover, the Kidney Project, 2019 went unto to mention that statistics also support those low-income persons are mostly affected as a result of higher prevalence of Diabetes and Hypertension in this class.
Worldwide, the most common risk factors for progressing to CKD are type 1 diabetes (30%), type 2 diabetes (10-40%) and hypertension. Severely obese patients are at risk for kidney disease due to the increase risk of hypertension by 65-75%. Moreover, persons who consume alcohol and use tobacco are five times more likely to develop CKD (National Kidney Foundation, 2021).
The Centre for Disease Control in 2021 stated that men are less likely to develop CKD than women, representing a percentage of 12% to 15% respectively. Furthermore, there is a higher percentage of persons over the age of 65 who presents with CKD at a rate of 38% in comparison ages 45-64 has a percentage of 13% and ages 18-44 a percent of 7%. A higher death rate is present in patients with chronic kidney disease when compared with persons who do not present with this disease, more so that it outranks breast cancer and prostate cancer annually.
Sars COV 2 has been shown to have an effect on the kidney, with data from China and New York demonstrating that 30% of hospitalised patients had some form of moderate to severe kidney affectation. (Sperati, 2020).
Patients who are diagnosed with CKD are often challenged with numerous comorbidities, accompanied with polypharmacy, social issues, poor mental health, increased hospitalizations, even ICU admissions and ultimately a high mortality and as such the complexity of this illness surpasses all other conditions (Stenvinkel et al., 2020).
Medical or conservative management, dialysis and kidney transplant are the options of treatment for kidney failure, with the best being transplant. BIDMC of Boston, 2021, related that dialysis patients have an approximate life expectancy of 5 years whereas live kidney recipients have an estimated lifespan of 12 to 20 years in comparison to 8 to 12 years with deceased donor kidney recipients. Kidney transplant requires the recipient, the donor (deceased or live), major preparations, major surgery and a lifetime of medications to prevent rejection of the kidney with a multifaceted guideline to ensure longevity. It is extremely important for kidney transplant recipients to ensure full compliance since there has always been a shortage of donors. The Kidney Project, 2019 listed that there are over 100,000 kidney failure patients in the USA waiting list and in 2016 only 20,161 kidney transplant was accomplished. 22,393 kidney transplants occurred in 2018 for a combined total amount of 229,887 patients living with a transplant. In 2020 22,817 patients were transplanted a kidney with a third being from living donors.
There is also an increase by 8% annually for this organ. Each month there is an addition of 3000 patients to the waiting list with a median of 3.6 years wait for the first surgery/transplant. However, some patients are on the list for more than 5 years due to certain factors such as compatibility, blood group, or sensitization from previous transplant, blood products transfusion, or pregnancy and of course the availability of donors. It is estimated that 12 people die daily waiting on a kidney transplant in the US (National Kidney Foundation, 2021).
Kidney transplantation has evolved into an established treatment option for end-stage kidney failure. The graft and patient outcomes post-transplantation continue to improve, and 1-year survival currently exceeds 80%. (Neuberger et al., 2017). However, the long-term survival rates gradually decline, with reported 5- and 10-year kidney transplant survival rates in Europe at 77% and 56%, respectively (Neuberger et al., 2017). Once the transplant is successful, the new organ is regarded by the body as a foreign object, and as such immunosuppressive medications are required throughout the life span of the new kidney. This class of drug is known to have multiple side effects as it blocks the body’s immune system from full functionality, thereby exposing the recipient to an increased risk of infections and malignancies. The recipient’s immune system is the biggest threat to the new organ once donor and recipient are not genetically identical (The Kidney Project, 2019).
Post-graft care requires the involvement of multidisciplinary healthcare teams, working collaboratively with the healthcare provider, patient, their family (Rangaswami et al., 2019). Many factors are taken into consideration to maintain viable transplants, including managing immunosuppression with the associated risks (Kazory et al., 2018). Furthermore, there are many other risk factors that affect the survival of the patient and the graft (Rangaswami et al., 2019). Research has demonstrated that some of the risk factors such as donor age and cardiovascular disease that cannot be modified exist pre-transplantation (Veroux et al., 2012). However, some risk factors, such as behavioural and cardiovascular risk factors, can be modified or mitigated after the transplantation to improve the patient and graft outcomes (Rangaswami et al., 2019).
Although kidney transplantation improves both the recipient’s quality of life, the survival rates are lower than the general population (El-Agroudy et al., 2003; Shimmura et al., 2004; Rangaswami et al., 2019). Chronic rejection and recurrent disease are the main causes of graft failure (El-Agroudy et al., 2003; Shimmura et al., 2004). El-Agroudy et al. (2003) reported infections, cardiovascular disease, malignancy, and liver disease as the leading causes of death in recipients of kidney allograft. A study in Japan found that infection, stroke, cardiovascular disease, liver failure, and malignancy were the most significant causes of death in kidney allograft recipients (Shimmura et al., 2004).
Factors such as donor factors, organ factors, and logistic factors before, during, and after solid organ transplantation may impact long-term outcomes (Neuberger et al., 2017). Delayed graft function, acute graft rejection, and ischemic injury are the most likely factors to impact the long-term outcomes of kidney transplantation (Pascual et al., 2002). Furthermore, the modifiable risk factors in kidney transplant recipients over the longer term involve problems associated with adverse and toxicity effects related to immunosuppression, immunosuppression, underimmunosuppression, non-adherence, and high intrapatient variability (IPV) in immunosuppressive exposure (Borra et al., 2010; Irish et al., 2010). Sellarés et al. (2012) established the effects of non-adherence on de novo donor-specific antibody development and its consequences on immunosuppression in recipients of a kidney transplant.
Studies show that the allograft recipient survival can be improved significantly by addressing the risk factors for cardiovascular disease, some infections, cerebrovascular disease, and some malignancies (Pascual et al., 2002). Furthermore, paying attention to the new-onset diabetes posttransplant development is critical to reducing the survival of the patient and graft survival (Chakkera & Mandarino, 2013). Pascual et al. (2002) also observed that recurrence of initial disease could have a major impact on the patient and graft outcomes. Although little can be done as far as nonmodifiable risk factors of graft failure are concerned, the long-term survival rates can be improved through better screening and management of modifiable factors.
The attention of previous studies on the risk factors that influence the patient and graft outcomes of allograft recipients implies that the best management strategies to improve the quality of life in these patients are those that address the risk factors (Allen et al., 2017; Hamed et al., 2015; Nankivell et al., 2018; Sprangers et al., 2018). However, there is a gap in the extant literature concerning the specific approaches to improve the quality of life and longevity following a kidney transplant.
The increased number of people who require kidney transplants for survival is increasing worldwide. Although many people have benefited from kidney allografts due to the improving treatment options, their survival rates decline in the long term (Neuberger et al., 2017). This study reviews the impact of current post-transplant management practices on the quality of life for living kidney donor transplant recipients. It also reviews the latest literature related to best practices that can improve the quality of life of allograft recipients. Specifically, the study seeks to answer the following research question: “What are the best approaches to improve quality of life and longevity post kidney transplant? Addressing this question will help improve understanding of the latest best practices in post-operative kidney transplantation to improve the quality of life and longevity. The research to be undertaken as a component of the master’s program is therefore intended to ascertain information on all measures being employed under the present guidelines for a kidney transplant from living donors and to interpret if they are optimal to ensure maximal life expectancy, taking into consideration all the challenges aforementioned.
Methods
This chapter describes the methodology for finding evidence for the best approaches to improve the quality of life and longevity in kidney allograft recipients. First, it defines the eligibility criteria for selecting the relevant articles for this qualitative study. The second step describes the search strategy and studies selecting, including how the search terms were developed to search the databases. The third step describes the data collection, including the screening process of the articles retrieved from the databases. This step also details the data extraction method, including the type of data extracted and the characteristics of the included studies. The last step explains the data analysis methods used. The study uses the constructivist/interpretive research approach to explain the best practices for improved quality of life and longevity in kidney allograft recipients (Wiltshire, 2018).
Eligibility criteria
The eligibility criteria played an integral role in narrowing the search for evidence and guarding against potential bias to allow only relevant articles to be selected for the review (Akhter et al., 2019). The inclusion or exclusion of articles was influenced by the research question. As such, any type of study qualified for selection for this review provided it addressed quality of life, longevity, and post-kidney transplant. All articles, including studies with adult individuals (18 years and above) who would have received a living kidney donor transplant and are on the recommended treatment and lifestyle guidelines pre and post kidney transplant, are included. However, the study must have been published between 2000 and 2021, peer-reviewed, and published in English.
On the other hand, the sources eligible for exclusion include commentaries, non-peer-reviewed articles, seminar papers, and opinions. Furthermore, studies with individuals who would have been non-compliant pre or post kidney transplant according to guidelines for management, recipients of deceased kidney donors, articles not published in English text, and multiorgan transplant studies will be excluded.
Search strategy and Study selection
The evidence was searched in various databases, including PubMed (Medline), Google Scholar, The Wiley online library, University of South Wales library services, BMC public health, sciencedirect.com, OpenGrey online library, Library Hub, and Dynamed. The research question played an important role in developing the keywords. They include “quality of life,” “longevity,” and “kidney transplant.” The truncation sign (*) was to help identify studies containing different forms or spellings of the keyword, such as improved quality of life* for “quality of life and long-term survival* for “longevity.” Furthermore, synonyms were used for the search terms to increase the search sensitivity by increasing the number of relevant studies (Eriksen & Frandsen, 2018). The final search terms comprising keywords and phrases, shown in Table 1, were combined using the Boolean operator “OR” to ensure the precision of the search.
Table .1: Search terms
| Component | Keywords |
| Population | “Kidney transplant patients” OR “kidney allograft recipients” |
| Exposure | “Management strategies” OR “support mechanisms” |
| Outcome | “Quality of life” OR “longevity.” |
The screening process was carried out using language and time limiters. The identified studies were screened for eligibility in four key steps using the PRISMA framework (McInnes et al., 2018). First, the identified articles were checked for duplicates, and if found, they were removed. Secondly, the titles of the remaining articles were checked for their relevance to the research question, and those found to have irrelevant titles dropped. Of the remaining articles, the abstracts were screened to determine if they met the inclusion criteria in the third step. Full texts of the eligible articles identified from the abstracts screening were then be retrieved for final screening. A PRISMA flow diagram, shown in Figure 1, was used to narrow down the search results and present the included studies (Page et al., 2021). Specifically, the PRISMA flow includes the number of identified articles from the unlimited and limited search, following removal of duplicates, and exclusion at the title, abstract and full-text screening stages, as well as the reasons for inclusion.
