記住我
Kidney (KTx), liver (LTx), and heart transplantation (HTx) improve survival in patients with corresponding terminal organ failure and have become more and more standardized. Psychosocial variables influence the outcome of transplantation and predict complications as well as the quality of life (1–3). Consequently, psychosomatic or psychiatric evaluation before wait-listing is widely recommended and established (4–6). Because there are many differences to the situations of patients evaluated for KTx, LTx, and HTx, providing care for the respective group might require distinct care structures: Patients with chronic kidney failure undergo recurrent dialysis, causing additional restriction of social life. Patients suffering from liver disease endure icterus, ascites, or hepatic encephalopathy. Heart failure patients may suffer from chest pain, shortness of breath, palpitations, syncope, and, ultimately, cardiogenic shock.
Recurrent exacerbation of chronic illness often leads to hospitalization. Wait-listing implies additional burden because patients are subjected to additional regular extensive diagnostics, including invasive procedures like heart catheterization in the setting of HTx. Moreover, wait-listed patients must remain within reach of the transplant center and be available permanently, further burdening their psychosocial wellbeing. During the evaluation phase before organ transplantation, patients report the highest need for counseling (e.g., about 50% in patients awaiting LTx) (7). Research is often driven by experts of a single discipline and therefore often focuses on one organ system in terminal failure. However, differences between divergent organ recipients and its implications for further care are highly relevant, and the knowledge of organ-system specific psychosocial characteristics may prevent assessment pitfalls and beneficially shape the subsequent treatment. In this study, we compared the psychosocial characteristics of patients evaluated for KTx, LTx, and HTx.
Across different organ recipients and across different stages of the transplantation process, the association between depression and various transplantation outcomes has been replicated many times: in a review and meta-analysis including 27 studies with different organ types by Dew et al. (8), depression increased the relative risk for mortality by 65%, including three studies that identified an association between depression and graft loss. The type of transplant did not impact the association of depression with mortality. Conversely, anxiety was not significantly associated with increased mortality or morbidity upon organ transplantation.
Two correlates of depression in transplantation patients are sense of coherence (SoC) and self-efficacy (9). SoC refers to a mental disposition, described in Antonovsky’s model of salutogenesis on stress processing (10), comprising comprehensibility of the current events, the belief in one’s ability to manage those challenges, and meaningfulness of the desired aim. Goetzmann et al. (11) observed significant positive correlations between SoC, optimism, and social support, and significant negative correlations with depression and anxiety in a pretransplant sample. The same study found SoC as a significant predictor of posttransplant mental health. Self-efficacy is a related but not identical construct; it refers to the belief in one’s own ability to manage situations. It has been shown to be a protective factor for depression and anxiety (12,13). In the transplantation context, self-efficacy has been found to be a significant predictor for the prevalence of both depression and stress after HTx and was negatively associated with depression in KTx patients, while beneficially impacting self-care behavior and mental health–related quality of life (14). Pre-Tx lower received social support has been shown to be a predictor of post-Tx medication nonadherence (1). Insufficient social support can be a contraindication for organ transplantation (4). Therefore, it is evaluated in the psychosocial evaluation process. Body Image has been linked to psychological organ integration after transplant, and organ-specific discrepancies have been reported (15). Changes in body image have mostly been measured after transplantation, so the question of pretransplantation differences is still not sufficiently answered.
We evaluated the inclination of patients regarding several forms of available additional therapy. Although self-reported preferences do not imply an indication for the respective treatment, the willingness to undergo a respective treatment is a mandatory prerequisite. Patients with physical illnesses may be hesitant toward psychosocial interventions because of false assumptions and fear of stigmatization. In the German health care system, psychological treatments are well integrated and covered by insurance. It is possible to conduct psychological counseling as a short-term intervention to overcome specific challenges, or evidence-based psychotherapy (e.g., psychodynamic psychotherapy, cognitive behavioral therapy), which is indicated for psychological disorders. Other available treatments comprise medication, physiotherapy, treatment by a specialist or by a family doctor, different inpatient and outpatient settings, and several naturopathic approaches. As a result, the theoretical options for patients are manyfold. The question of which treatments the patient is open for is therefore quite relevant.
Here, we investigated the research questions a) whether there are organ-specific differences in the psychosocial characteristics of patients evaluated for transplantation regarding depression and anxiety symptoms, mental and physical quality of life, perceived social support, SoC, self-efficacy, vital body dynamics, and rejecting body evaluation, and b) whether there are organ-specific differences in the preferences for additional supportive therapy for patients evaluated for transplantation.
METHODS Design and Study SampleThe study was conducted as a single-center survey from November 2013 to February 2020. The data presented in this study were generated as part of the standard clinical routine for psychosomatic evaluation before wait-listing for transplantation in the Department of General, Internal Medicine and Psychosomatics at Heidelberg University Hospital. This evaluation routine comprises a set of standardized questionnaires and a consultation. Patients could consent or decline the use of their data for scientific purposes without impact on their medical treatment. Data were collected with a final sample size of 1110 (n = 544 for LTx, n = 330 for KTx, and n = 236 for HTx). Of 1178 patients, n = 68 declined to participate. No study dropouts were documented. Because of the regular treatment strategy in our hospital, patients evaluated for LTx and HTx were awaiting deceased donor transplantation, whereas KTx patients were awaiting living donor transplantation. The study was approved by the Ethical Commission of Heidelberg University Hospital (S-066/2014). Inclusion criteria were a) at least 18 years of age, b) sufficient knowledge of the German language, and c) written consent for participation. Excluded were a) minors, b) patients with insufficient skills of the German language, and c) patients with impaired capacity to conduct business or give consent.
QuestionnairesBefore their assessment, patients were handed a set of questionnaires that included questions on sociodemographic data (age, sex, occupational status, marital status). Occupational status addressed the question of whether patients were currently able to work (employed or unemployed) or not (sick note or disability pension). For the assessment of the psychosocial variables used in this study, we used validated instruments to measure depressive and anxiety symptoms, quality of life, SoC, self-efficacy, and body image. Depressive symptoms were measured with the German version of the Patient Health Questionnaire Depression Scale (PHQ-9), comprising all diagnostic A-criteria of major depressive disorder according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) within the last 2 weeks, whereby higher scores indicate more depressive symptoms. The PHQ-9 is an established instrument for the assessment of primary care patients for psychological symptoms (16,17). It has been shown to have excellent reliability and validity (18). Items are answered on a scale from 0 (“not at all”) to 3 (“nearly every day”). The scores can range from 0 to 27 and can be interpreted dimensionally as well as categorically. Established cutoffs are no depression (<5), mild depression (5–9), moderate (10–14), moderately severe (15–19), and severe (20–27) (17). In our sample, the PHQ-9 showed good reliability with Cronbach α = .87. Generalized anxiety symptoms were measured using the seven-item Generalized Anxiety Disorder Screener (GAD-7), the validity of which has been thoroughly established (19). Items are answered on a scale from 0 (“not at all”) to 3 (“nearly every day”). The scores can range from 0 to 21 and can be interpreted dimensionally as well as categorically. Established cutoffs are minimal (<5), mild (5–9), moderate (10–14), and severe (15–21). In our sample, the reliability was Cronbach α = .88. Health-related quality of life was assessed using the German version of the 36-Item Short Form Health Survey, which has been proven to be reliable and valid (20). The questionnaire measures eight subscales: physical functioning (Cronbach α = .95), bodily pain (Cronbach α = .90), general health perception (Cronbach α = .62), vitality (Cronbach α = .90), social functioning (Cronbach α = .80), role functioning emotional (Cronbach α = .92), and mental health (Cronbach α = .85). Those subscales are summarized into two main component scores representing a physical and a mental component of quality of life on a T-scale and interpreted in comparison to the national norm (German) (21).
Perceived social support was measured with the German short form of the Perceived Social Support Questionnaire (22,23). This unidimensional questionnaire shows high reliability and validity. It measures perceived social support with 14 items on a 5-point Likert scale, with higher scores indicating more perceived support. The reliability in our sample was Cronbach α = .94. SoC was measured with the German version of the Sense of Coherence Scale by Antonovsky in its short-form SOC-L9. The questionnaire is unidimensional and consists of nine items that are rated on a 7-point Likert scale (24,25). Its reliability and validity have been proven (26). In our sample, α was Cronbach α = .89. Self-efficacy was measured with the German version of the General Self-Efficacy Short Scale. The questionnaire is unidimensional and consists of three items rated on a 5-point Likert scale. It has been shown to have good reliability and validity (27). In our sample, α was Cronbach α = .86. For the assessment of body image, we used the German Body Image Questionnaire-20 (28). The German Body Image Questionnaire has two subscales: rejecting body evaluation, which refers to a generally negative evaluation of one’s body, and vital body dynamics, which refers to the perception of the own body regarding movement and physical activity. Both scales are measured with 10 items on a 5-point Likert scale. Results are expressed as sum scores between 10 and 50 points, with higher scores indicating more rejecting body evaluation and more vital body dynamics, respectively. The reliability for the subscales was Cronbach α = .87 for vital body dynamics and Cronbach α = .76 for rejecting body evaluation.
For evaluation of preferences for additional therapy, we used a 16-item binary scale with a multiple-choice format. There, patients could indicate by ticking check boxes if they were interested in a variety of 16 optional treatments, including medication, psychological counseling, psychotherapy, relaxation techniques, couple/family counseling, support for relatives, pastoral care, naturopathic treatment, help and advice on social issues, health and nutrition advice, physiotherapy/massage, self-help group participation, rehabilitation, treatment by the family physician (to indicate concomitant treatment by the family’s general practitioner), treatment by a medical specialist (to indicate concomitant treatment by a specialist in nephrology, cardiology [HTx], or gastroenterology [LTx] in an ambulant setting), and inpatient admission (to indicate the wish admission and treatment in the ward). The patients could indicate for each treatment option whether they wish for it or not. There was no limit to the number of additional supportive treatments, so patients could check none or up to all 16 options.
Statistical AnalysisPsychosocial variables were compared among the different organ recipients using multivariate analysis of covariance (MANCOVA), followed by univariate analyses of covariance to determine the respective effect of each variable. Sociodemographic variables (sex, marital status, and occupational status) were entered as factors into the model. Age was added as a covariate. Organ-specific differences regarding the psychosocial variables were analyzed by post hoc Šidák tests. Preferences for complementary therapy were analyzed using a χ2 test because the respective data are nominally scaled. A missing value analyses was performed and found that 13.99% of values were missing across all relevant outcome variables. There was no variable without missing values, and 37.48% of the cases contained incomplete data. These data were missing completely at random (Little’s missing completely at random test = 1.000). Because there is no established procedure to pool p values of multiply imputed data for the results of a MANCOVA, we decided to use maximum likelihood estimation with an expectation maximization procedure to impute missing values. Regarding the necessary assumptions for the use of MANCOVA, we found independence of the measures, a sufficiently large sample size, metric dependent variables, nominally scaled independent variables, and absence of multi-colinearity to be fulfilled. The assumptions of multinomial normal distribution, homogeneity of variance, and independence of the variance-covariance matrices were violated. However, those violations were likely to cause a loss of power but not a change in error rates. Because we have a sufficiently large sample size to afford a loss of power, we continued the analyses (29,30). We identified 35 multivariate outliers and performed the analysis with and without them. Because the results were not affected, we did not exclude the outliers. Preferences for additional supportive therapy were analyzed using a χ2 test. Analyses were performed using SPSS 26 (31) and JASP 0.14.1.0 (32).
RESULTS Sociodemographic and Descriptive DataIn total, 1110 patients gave informed consent and participated in the study. Of those, n = 544 were evaluated for LTx, n = 330 for KTx, and n = 236 for HTx. In line with disease prevalence of corresponding organ failure, most patients were male (63.9%) with the highest predominance in the HTx group (72.5%). Patients awaiting KTx were younger (mean [standard deviation] = 43.12 [13.73] years), and according to overall impairment in the setting of respective organ failure, most KTx patients were able to work (72.4%) as opposed to their LTx (50%) and HTx (46.6%) counterparts. Between 55.5% and 60.6% of the patients were married at the time of assessment. Table 1 summarizes the sociodemographic data of the sample. Table 2 shows the descriptives for the dependent variables by organ type. Table 3 shows the correlations between the dependent variables.
TABLE 1 - Sociodemographic Description of the Sample LTx KTx HTx F/χ 2 df p N 544 330 236 Age, M (SD), y 51.95 (9.84) 43.12 (13.73) 51.93 (9.92) F = 72.457 2 <.001** Female 201 (36.9%) 135 (40.9%) 65 (27.5%) χ 2 = 10.967 2 .004* Married 302 (55.5%) 186 (56.4%) 143 (60.6%) χ 2 = 41.729 10 <.001** Unable to work 272 (50%) 91 (27.6%) 126 (53.4%) χ 2 = 53.031 2 <.001**LTx = liver transplantation; KTx = kidney transplantation; HTx = heart transplantation; F/χ2 = respective test-statistic; df = degrees of freedom; M (SD) = mean (standard deviation).
* p < .05 (two-sided).
** p < .01 (two-sided).
LTx = liver transplantation; KTx = kidney transplantation; HTx = heart transplantation; M (SD) = mean (standard deviation).
Depressive symptoms: Patient Health Questionnaire Depression Scale; anxiety symptoms: seven-item Generalized Anxiety Disorder Screener; Quality of life physical: 36-Item Short Form Health Survey physical component score; Quality of life mental: 36-Item Short Form Health Survey mental component score; Social support: Perceived Social Support Questionnaire; Sense of coherence: short form of the Sense of Coherence Scale; Self-efficacy: General Self-Efficacy Short Scale; Rejecting body evaluation: German Body Image Questionnaire-20 subscale rejecting body evaluation; vital body dynamics: German Body Image Questionnaire-20 subscale vital body dynamics.
The psychosocial variables of the participants were compared between HTx, KTx, and LTx candidates using MANCOVA. There were significant main effects of organ (Pillai-Spur = 0.135, F(18,2084) = 8.371, p < .001, partial η2 = 0.07), sex (Pillai-Spur = 0.032, F(9,1041) = 3.774, p < .001, partial η2 = 0.03), marital status (Pillai-Spur = 0.035, F(9,1041) = 4.164, p < .001, partial η2 = 0.04), ability to work (Pillai-Spur = 0.051, F(9,1041) = 6.276, p < .001, partial η2 = 0.05), and age (Pillai-Spur = 0.065, F(9,1041) = 8.008, p < .001, partial η2 = 0.07). There was a significant interaction between sex and marital status (Pillai-Spur = 0.025, F(9,1041) = 2.914, p = .002, partial η2 = 0.03). After the main effects and the interaction were established, we continued the analyses using univariate analyses of covariance, which revealed significant group differences for all psychosocial variables (Table 4). Pairwise multiple comparisons (Šidák procedure) revealed significant differences between all three organ types for depressive symptoms, anxiety symptoms, mental and physical quality of life, and vital body dynamics. For social support, self-efficacy, SoC, and rejecting body evaluation, the effects were more heterogeneous (Table 5).
TABLE 4 - Between-Subject Effects (ANCOVA) Sum of Squares df Mean Square F p η p2 Depressive symptoms 1289.33 2 644.66 25.059 <.001 0.05 Anxiety symptoms 549.84 2 274.92 17.794 <.001 0.03 Quality of life physical 10,243.46 2 5121.73 48.019 <.001 0.08 Quality of life mental 2950.94 2 1475.47 12.645 <.001 0.02 Social support 9.69 2 4.84 10.951 <.001 0.02 Sense of coherence 20.23 2 10.11 8.709 <.001 0.02 Self-efficacy 9.02 2 4.51 8.538 <.001 0.02 Rejecting body evaluation 280.87 2 140.44 3.565 .029 0.01 Vital body dynamics 2045.87 2 1022.94 17.815 <.001 0.03ANCOVA = univariate analyses of covariance; df = degrees of freedom.
留言 (0)