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Showcasing Our Research at the 5th ELPAT Congress

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The Kidney Health Education & Research Group had the pleasure of presenting our research at the Ethical, Legal And Psychosocial Aspects of Transplantation Congress 2019 in Krakow, Poland. The congress is the fifth hosted by the European Society for Organ Transplantation (ESOT) and centred around developing dialogue and pioneering practice in organ transplantation.

In keeping with this theme, Sumaya Dano and Evan Tang, along with their respective co-authors and working groups, submitted two abstracts studying the psychosocial aspects of kidney transplant recipients.

Fatigue in Kidney Transplant Recipients and patients on Maintenance Dialysis – using the PROMIS-57 questionnaire

Sumaya Dano1, Marta Novak2 and Istvan Mucsi1

1Multi-Organ Transplant Program and Division of Nephrology, University Health Network, Toronto, Canada
2Centre for Mental Health, University Health Network, Toronto, Canada

Background

Fatigue is a debilitating symptom experienced by many patients with chronic kidney disease (CKD) and has been associated with decreased quality of life. The Patient Reported Outcomes Measurement Information System (PROMIS) item banks assess domains of illness experience and quality of life, such as fatigue, that are relevant for individuals with chronic illness. Here we compare the prevalence of fatigue in kidney transplant recipients (KTRs) and patients on maintenance dialysis using PROMIS-57 Fatigue domain.

Methods

A cross-sectional, convenience sample of adult KTRs and patients on maintenance dialysis were recruited from several clinics across the Greater Toronto Area. Patients completed the PROMIS-57 questionnaire on an electronic data capture system. Clinical characteristics were collected from medical records. Multiple imputation by chained equations was used to handle missing data and multivariable adjusted linear regression and logistic regression models were used to assess the associations between fatigue and treatment modality (transplant or dialysis). Clinically potentially significant fatigue was defined as PROMIS-57 Fatigue score of ≥ 55.

Results

A total of 321 participants were enrolled, 163 (51%) on dialysis and 158 (49%) KTRs. The mean (SD) PROMIS Fatigue score was higher in patients on dialysis compared to KTRs: 54 (12) vs 49 (11); p<0.001. Using half a standard deviation above the mean to indicate potentially significant fatigue, 79(48%) of the patients on dialysis were classified as experiencing potentially significant fatigue compared to 47(30%) of KTRs (p <0.001). After adjusting for clinical variables (serum albumin and hemoglobin levels, comorbidity), socio-economic variables (age, sex, ethnicity, education, marital status, income), and psychological factors (anxiety and depression), patients on dialysis had significantly higher fatigue score compared to KTRs (coeff=3.30; CI:0.22, 6.37). Accounting for the same confounders in multivariable adjusted logistic regression, dialysis patients were more likely to have significant fatigue compared to KTRs, although association did not show statistical significance (OR 1.98; CI:0.76–5.17; P=0.16)

Conclusion

The results confirm that patients on dialysis experience significantly higher levels of fatigue compared to KTRs, although nearly 1 in 3 KTRs did experience potentially significant fatigue. Future research should assess correlates of fatigue to help improve assessment and management of fatigue in patients with chronic kidney disease.

Clinical Utility of the Edmonton Symptom Assessment System to Screen for Depression and Anxiety in Kidney Transplant Recipients

E.Tang1, S. Dano1, N.Edwards1, Mohammed Saqib, Ali Ayub, Vernon Li, Ivan Escudero, Noshin Ullah, M.Novak2, I.Mucsi1

1Multi-Organ Transplant Program, Toronto General Hospital, Toronto, Canada
2Centre for Mental Health, University Health Network, Toronto, Canada

Anxiety and depression are frequent concerns in kidney transplant recipients and are associated with non-adherence and worse clinical outcomes. However, they are often underrecognized due to lack of inquiry. We have recently validated the Edmonton Symptom Assessment System-revised (ESASr) in kidney transplant recipients for symptoms assessment. Here we asses the measurement characteristics of ESASr to screen for anxiety and depression.

A cross-sectional sample of stable kidney transplant recipients completed legacy instruments (patient health questionnaire (PHQ-9) and generalized anxiety disorder (GAD-7)) and the ESASr. In this analysis we focused on the ESASr-A (anxiety) and ESASr-D (depression) items. The correlation between the legacy and ESASr scores was compared using spearman’s rho. Discrimination was assessed using receiver operating characteristic (ROC) analysis. We determined the cut-off to identify potential “cases” that require further assessment using Youden’s J. We also constructed a Bayesian conditional probability plot integrating pre-test probability and likelihood ratios.

Mean(±SD) age of the 270 participants was 51 (±16), 61% were male and 55% Caucasian. Spearman’s correlation between ESASr and the legacy questionnaires was moderately strong (ESASr-A/GAD-7: 0.64; ESASr-D/PHQ-9: 0.61). Good discrimination was found on ROC analysis (area under the curve ESASr-A 0.95; ESASr-D 0.82). From the ROC, the optimal cut off was ≥4 for ESASr-A (Sensitivity = 0.75; Specificity = 0.86) and ≥2 for ESASr-D (Sensitivity = 0.75; Specificity = 0.77).


ESAS-A and ESAS-D show good correlation with the respective legacy questionnaires. The identified cut-offs show good discrimination for moderate anxiety/depression (NPV and sensitivity). The findings may support the potential for ESASr use as an initial screening tool, with the ability to identify cases with only a few false negatives. Positive results can be paired with a second screening tool to identify true cases.

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