You are on page 1of 5

Quality of Life After Kidney Transplantation: A Prospective Study


J.Z. Kostroa,*, A. Hellmanna, J. Kobielaa, I. Skórab, M. Lichodziejewska-Niemierkoc, A. Dębska-Slizie  d,
n
 
and Z. Sledzinski a

a
sk, Poland; bRegional Transplant Coordination
Department of General, Endocrine, and Transplant Surgery, Medical University of Gdan
Centre, UCK Gdan sk, Poland; cDepartment of Palliative Medicine, Medical University of Gdan
 sk, Poland; and dDepartment of

Nephrology, Transplantology, and Internal Medicine, Medical University of Gdansk, Poland

ABSTRACT
Background. The purpose of renal transplantation is to achieve a maximal improvement
in quality of life (QoL) and life expectancy in patients with end-stage renal disease (ESRD)
while minimizing the potential side effects of this procedure. It is important to achieve an
optimal balance between graft function and the patient’s QoL. This study was designed to
assess the changes in the QoL after kidney transplantation (KTx) in patients with ESRD
previously treated with hemodialysis (HD) or peritoneal dialysis (PD).
Methods. QoL was prospectively analyzed in 69 patients after kidney transplantation in a
single-center study. Patients with ESRD were divided into 2 groups: those previously
treated with HD (n ¼ 44 patients; group 1) or PD (n ¼ 25 patients; group 2). Both
groups were asked to complete the KDQOL-SFtm questionnaire before and 12 months
after kidney transplantation.
Results. We observed significant differences in many parameters of QoL in both groups
after KTx but more positive changes of most parameters in question exhibited by patients
previously treated by means of HD than PD. Patients treated with HD and PD demon-
strated improvement after KTx in 74% of dimensions. There were no statistical differences
in the QoL between group 1 and group 2 before or after KTx.
Conclusions. The study demonstrated post- to pre-transplant improvements of QoL
independently of previous treatment.

A S DEFINED by the World Health Organization model


of health, quality of life (QoL) is a multidimensional
concept that concerns an individual’s usual or expected
own QoL during different types of treatment. Comparison
of these results appears to be the best method of assessing
which form of therapy provides the greatest QoL [4].
physical, emotional, and social well-being [1,2]. The Assessment of QoL only in patients who have undergone
perception of QoL is, to a large extent, individual and may different types of therapy does not provide answers as to
be particularly affected by chronic disease. In the case of which method of treatment improves a patient’s life.
patients with end-stage renal disease (ESRD), living with Several different generic and disease-specific questionnaires
the consequences of a chronic disease, various types of have been developed for assessing the QoL of patients
medical treatment, as well as personal feeling and experi- with ESRD. Not only the questionnaire, but also the
ences can have a significant impact on QoL. The choice to
initiate a new therapy usually involves hope for a relatively
This work was supported by Medical University of Gdan  sk,
normal life, free from the limitations associated with chronic
Poland.
disease. Patients with ESRD waiting for kidney trans- *Address correspondence to Justyna Z. Kostro, Gdan ski Uni-
plantation (KTx) expect an improvement in their QoL in all wersytet Medyczny, Klinika Chirurgii Ogólnej, Endokrynolo-
aspects of their life. Not only is the presence on the waiting gicznej i Transplantacyjnej, Centrum Medycyny Inwazyjnej, Ul.
list for transplantation important, but also the length of Smoluchowskiego 17, 80-214 Gdan sk, Poland. E-mail: kostro@
waiting time for a transplant [3]. Patients should assess their gumed.edu.pl

0041-1345/16 ª 2016 by Elsevier Inc. All rights reserved.


http://dx.doi.org/10.1016/j.transproceed.2015.10.058 360 Park Avenue South, New York, NY 10010-1710

50 Transplantation Proceedings, 48, 50e54 (2016)


QUALITY OF LIFE AFTER KIDNEY TRANSPLANT 51

circumstances of QoL assessment can affect patient (2 items), sleep (4 items), social support (2 items), dialysis staff
outcome. Results were not always consistent because encouragement (2 items), patient satisfaction (1 item), and 36-item
different QoL questionnaires were used at different stages health survey (8 dimensions/36 items): physical functioning
of the disease and in different settings [1,4]. In general, (10 items), role limitations caused by physical health problems
(4 items), role limitations caused by emotional health problems
generic QoL measurements can be used to assess overall
(3 items), social functioning (2 items), emotional well-being
health and functioning of patients. Targeted instruments (5 items), pain (2 items), energy/fatigue (4 items), and general
may be used to focus on individual symptoms specific for a health perceptions (5 items).
disease or on its treatment methods. The use of both generic
and targeted QoL instruments is a frequently implemented Statistical Analysis
strategy used in an effort to maximize the utility of assess-
The scoring procedure for the KDQOL-SFtm first transformed the
ment [1,5]. However, there is still no consensus regarding a
raw pre-coded numeric values of times to a 0- to 100-point scale.
gold-standard instrument to use in measuring QoL. The
Each item is converted into 0 to 100 so that the lowest and highest
objective of future studies could be the evaluation of the possible scores are 0 and 100, respectively, with higher scores
changes in QoL in patients with ESRD after KTx who were reflecting a better QoL [6]. Statistical analyses were performed with
previously studied while undergoing dialysis [4]. The Kidney the use of Statistical Package for the Social Sciences, version 7.1 PL
Disease Quality of Life (KDQOL) questionnaire was orig- (software licensed to the Medical University of Gda nsk). Results
inally developed to assess QoL in patients with chronic were presented as an average value and standard deviation. For all
kidney disease. The KDQOL questionnaire includes 36 comparisons, the Kolmogorov-Smirnov test for normality was used,
general items of the SF-36 as well as 98 additional items followed by the t test. Statistical significance was considered for a
which target kidney diseaseerelevant issues. The short form value of P < .05.
of the KDQOL (KDQOL-SFtm) includes 43 kidney
diseaseespecific items. Believable QoL variability can be RESULTS
obtained by comparing the opinion of the same patient by
We analyzed QoL in 69 patients from a single transplant
use of a variety of variables such as time of assessment, the
center. Patients were divided into 2 groups. Group 1
use of different type of treatment, and so forth. The aim of
(n ¼ 44) comprised ESRD patients who received trans-
this study was to evaluate the quality of life in patients with
plants after HD treatment. There were 14 women (31.8%)
ESRD who were previously treated with hemodialysis (HD)
and 30 men (68.2%) in the group. Patient age ranged from
or peritoneal dialysis (PD) before KTx and then after kidney
18 to 76 years (mean, 49 years). Patients were previously
transplantation both transversely and longitudinally.
treated with HD for a mean of 23 months (range, 12e159
months). All patients had a functioning graft 1 year after
KTx (Table 1). Group 2 (n ¼ 25) comprised ESRD patients
METHODS
who received a transplant after PD. There were 11 women
Quality of life was measured in a prospective, single-center, 2-year (44%) and 14 men (56%) in the group. Age ranged from 18
study in which KDQOL-SFtm was used. We utilized the following to 70 years (mean, 42 years). Patients were previously
inclusion criteria: male or female kidney transplant recipients at treated with PD for a mean of 26 months (range, 12e180
least 18 years of age who had their first KTx with graft survival
months). All patients had a functioning graft 1 year after
longer than 12 months and had also been treated by either HD or
PD for longer than 1 year before transplantation. The inclusion
KTx (Table 1). The groups were compared longitudinally
criteria also required that the graft function well without any (group 1 before and after KTx, group 2 before and after
complications during the observation period and that the patient KTx) as well as vertically (both groups before and after
had the ability to understand and give informed consent to partic- KTx). The populations of groups 1 and 2 did not demon-
ipate in the study. A total of 162 patients operated during these 2 strate a statistically significant difference relative to age, sex,
years were screened, yielding an enrollment of 69 KTx patients. body mass index, length of time on dialysis, graft function,
Ninety-three patients were excluded from the study on the grounds or comorbidities (Table 1).
of the following criteria: no dialysis before KTx (n ¼ 17 patients),
second or third KTx (n ¼ 16 patients), dialysis shorter than 1 year
Table 1. Patient Characteristics
(n ¼ 33 cases), and return to dialysis treatment within 1 year of KTx
(n ¼ 7 patients); 20 patients did not complete the questionnaire. Group 1 Group 2
(HD ¼ 44) (PD ¼ 25) P Value
All patients who agreed to participate in the study were also
asked to complete the KDQOL-SFtm questionnaires. Patients Age (years), mean 49 42 NS
assessed their QoL before KTx, and, 1 year after transplantation, Sex (M/F) 30/14 14/11 NS
the questionnaires were sent by post. The responders were con- BMI 23  4 20  6 NS
tacted by the research team by phone or met in the outpatient clinic Dialysis (months), mean 23 26 NS
during follow-up visits. Serum creatinine (mg/dL) 1.6  0.4 1.5  0.6 NS
The KDQOL-SFtm questionnaire consists of 80 items divided eGFR (mL/min), mean 60  18 58  22 NS
into kidney diseaseetargeted items (11 dimensions/43 items): Diabetes 4 3 NS
symptom list (12 items), effects of kidney disease (8 items), burden Cardiovascular morbidity 24 14 NS
of kidney disease (4 items), work status (2 items), cognitive function Abbreviations: BMI, body mass index; eGFR, estimated glomerular filtration
(3 items), quality of social interaction (3 items), sexual function rate; NS, no statistical differences.
52 KOSTRO, HELLMANN, KOBIELA ET AL

Comparison of QoL in Group 1 (HD) Before and After Kidney assessment of social support, which presented more posi-
Transplantation tively in patients from group 1, and general health, which
In all dimensions, the assessment of QoL was better after was better in group 2.
KTx. There were significant differences in 14 of the 19
Comparison of QoL Between Groups 1 and 2 Before and
dimensions (74%): symptom list, effects of kidney disease,
After KTx
cognitive function, quality of social interaction, sexual
function, sleep, social support, patient satisfaction, physical The study showed no statistically significant differences in
functioning, physical role, pain, emotional well-being, QoL measured by use of the KDQOL-SFtm questionnaire
emotional role, and energy/fatigue (Table 2). Patients between patients from groups 1 and 2 before KTx (Table 3).
demonstrated improved QoL with no significant differences Similarly, no statistically significant differences were
1 year after KTx in the remaining dimensions: burden of observed after KTx (Table 3). Although we did not observe
kidney disease, work status, staff encouragement, general statistically significant differences in QoL between both
health status, and social function (Table 2). groups before KTx, there were more dimensions (15/19 ¼
79%) identified as improved by the patients from group 2.
Comparison of QoL in Group 2 (PD) Before and After KTx Only cognitive function, quality of social interaction, phys-
ical functioning, general health, and emotional well-being
Improvement in most of the parameters was observed in were assessed as improved by patients from group 1
patients with primary peritoneal dialysis. The patients (Table 3). This situation was changed 1 year after KTx.
treated with PD (group 2) demonstrated significant differ- Patients from group 1 had more positive feelings and
ences after KTx in the assessment of 14 of 19 dimensions perceived benefits (improvement was observed in 11 of 19
(74%): symptom list, effects of kidney disease, cognitive dimensions ¼ 58%) of the KDQOL-SFtm in comparison
function, quality of social interaction, sexual function, with group 2. Symptom list, burden of kidney disease, work
sleep, social support, patient satisfaction, physical func- status, cognitive function, quality of social interaction,
tioning, physical role, pain, general health status, emotional staff encouragement, physical functioning, physical role,
well-being, emotional role, and energy/fatigue (Table 2). emotional well-being, social function, and energy/fatigue
Transplant recipients in group 2 demonstrated better QoL were better in group 1 as compared with group 2 (Table 3).
after KTx with no significant differences in 3 assessment
dimensions: burden of kidney disease, social support, and
social function. In the assessment of patients, 2 parameters DISCUSSION
deteriorated after KTx: work status and staff encourage- In this study, we compared the QoL of patients originally
ment (Table 2). QoL in groups 1 and 2 before and after treated with PD or HD both before and after KTx. In the
KTx were similar. We observed differences only in the analysis of QoL, the patient’s subjective assessment is a very

Table 2. Comparison of QoL in Group 1 (HD) and Group 2 (PD) Before and After KTx
Group 1 (HD/KTx) Group 2 (PD/KTx)
Before (SD) After (SD) P Value Before (SD) After (SD) P Value

Kidney diseaseetargeted domains


Symptom list 61 (18) 85 (14) <.001* 65 (20) 81 (20) <.001*
Effects of kidney disease 52 (16) 78 (20) <.001* 56 (21) 81 (16) <.001*
Burden of kidney disease 35 (20) 39 (19) .36 38 (27) 38 (23) .99
Work status 27 (40) 33 (41) .47 34 (45) 30 (43) .57
Cognitive function 67 (24) 77 (23) .006* 59 (25) 74 (17) .007*
Quality of social interaction 72 (20) 79 (19) .04* 69 (23) 78 (16) .005*
Sexual function 54 (31) 72 (32) .003* 61 (30) 77 (35) .005*
Sleep 51 (22) 69 (22) <.001* 51 (27) 70 (23) .002*
Social support 69 (18) 83 (17) <.001* 75 (25) 83 (19) .24
Staff encouragement 79 (22) 83 (19) .32 84 (23) 83 (25) .86
Patient satisfaction 41 (19) 57 (22) <.001* 46 (24) 60 (22) .002*
Generic (SF-36) domains
Physical functioning 58 (25) 74 (25) .002* 55 (25) 68 (27) .01*
Role-physical 15 (31) 52 (44) <.001* 23 (35) 46 (41) .005*
Pain 52 (27) 67 (29) .01* 56 (28) 70 (29) .046*
General health 34 (19) 40 (14) .07 32 (15) 40 (18) .045*
Emotional well-being 45 (18) 63 (19) <.001* 44 (22) 63 (17) <.001*
Role-emotional 30 (39) 65 (41) <.001* 45 (46) 68 (39) .009*
Social function 49 (21) 54 (17) .22 52 (30) 54 (18) .80
Energy/fatigue 41 (18) 60 (17) <.001* 43 (23) 58 (19) .005*
*Significant values.
QUALITY OF LIFE AFTER KIDNEY TRANSPLANT 53

Table 3. Comparison of QoL Between Group 1 (HD) and Group 2 (PD) Before and After KTx
Before KTx Mean (SD) After KTx Mean (SD)
Group 1 Group 2 P Value Group 1 Group 2 P Value

Kidney diseaseetargeted domains


Symptom list 61 (18) 65 (19) .45 85 (14) 81 (20) .42
Effects of kidney disease 52 (16) 56 (21) .48 78 (20) 81 (16) .57
Burden of kidney disease 35 (20) 38 (27) .62 39 (19) 38 (23) .93
Work status 27 (40) 34 (45) .52 33 (41) 30 (43) .76
Cognitive function 67 (24) 59 (25) .24 77 (23) 74 (17) .58
Quality of social interaction 72 (20) 69 (23) .56 79 (19) 78 (16) .88
Sexual function 54 (31) 61 (30) .36 72 (32) 77 (35) .52
Sleep 51 (22) 51 (27) .99 69 (22) 70 (23) .89
Social support 69 (18) 75 (25) .26 83 (17) 83 (19) .99
Staff encouragement 79 (22) 84 (23) .47 83 (19) 83 (25) .95
Patient satisfaction 41 (19) 46 (24) .38 57 (22) 60 (22) .69
Generic (SF-36) domains
Physical functioning 58 (25) 55 (25) .60 74 (25) 68 (27) .35
Role functioningephysical 15 (31) 23 (35) .36 52 (44) 46 (41) .55
Pain 52 (27) 56 (28) .55 67 (29) 69 (29) .75
General health 34 (19) 32 (15) .57 40 (14) 40 (18) .99
Emotional well-being 45 (18) 44 (22) .92 63 (19) 63 (17) .96
Role-emotional 30 (39) 45 (46) .16 65 (41) 68 (39) .80
Social function 49 (21) 52 (30) .66 54 (17) 54 (18) .91
Energy/fatigue 41 (18) 43 (22) .58 60 (17) 58 (19) .63

important topic. To confirm the benefits from treatment, it function, mental health, cognitive status, social functioning,
is believed that assessment of different therapies be given by and overall QoL perceptions [11]. Individuals with chronic
a single patient to draw clear contrasts and comparisons. kidney disease must adapt their lives to a number of new
Such an approach to the subject is shown in only a few conditions. Chronic illness can have a significant impact on
publications in which the authors demonstrated improve- a person’s life. Although none of the treatments provides a
ment in the QoL of patients with chronic renal failure after complete cure, transplant patients appear to function more
KTx [4,7]. In our analysis, patients also confirmed this normally. Our patients also presented fewer symptoms and
hypothesis; they identified an improvement in their QoL signs of kidney disease after transplantation. Among the
after KTx. The major goal of transplantation is to improve different types of replacement therapy for chronic renal
the QoL and life expectancy of ESRD patients. The ques- failure, a review of a few studies shows a general consensus
tion is not only whether and how long a patient will survive, that KTx improves QoL [1,4,12,13]. The QoL depends on
but also how the treatment will affect the patient’s QoL [8]. the patient’s life from the moment in which it is evaluated.
Many factors can affect QoL assessment. Good communi- Better QoL may also be related to any treatment regimen
cation between patients with chronic disease and their that a patient can self-administer at home. It has been
healthcare providers is necessary for successful disease confirmed in several reports that PD is associated with a
management. Effective healthcare guides and supports higher QoL than those treated by means of HD [14e17];
patients throughout their treatment [9]. In our study, however, other reports have shown no difference in the
patients evaluated the cooperation of health workers as general health status and QoL between the 2 groups [5,18].
good, rating it at 80%. The results were comparable before In our study, patients achieved no statistical differences in
and after KTx. Another object of transplantation is to offer QoL before and after KTx between groups. A lack of sta-
patients a state of health similar to what they had before the tistical differences before transplantation may be due to the
onset of the disease, achieving a balance between the fact that our patients answered the questionnaire after
functional efficacy of the graft and the patient’s psycholog- having been informed about the possibility of KTx. They
ical and physical integrity [9,10]. However, any treatment of could be more emotionally invested in transplantation than
ESRD causes significant lifestyle changes. We observed that to the previous dialysis treatment. Despite this, our study
patients after KTx, regardless of the type of previous dial- demonstrated better results before KTx in group 2, whereas
ysis, demonstrated statistically significant improvements in improvements in group 1 were seen after KTx, though they
domains such as cognitive function, sexual function, physical lack statistical significance. Sayin et al [19] reported that the
function, physical role, emotional well-being, and emotional 3 forms of renal replacement therapy did not differ in
role. The majority of studies demonstrated statistically sig- regard to QoL and that the underlying mechanisms of
nificant pre- to post-transplant improvements in physical such findings must be clarified in further studies. These
54 KOSTRO, HELLMANN, KOBIELA ET AL

inconsistencies may have been caused by the usage of CONCLUSIONS


different QoL scales or different timing. The differences in The study demonstrated post- to pre-transplant improve-
QoL may also occur among patients who are on the waiting ments of QoL. Despite this, we did not prove any statistical
list for transplantation and those who remain only on renal differences in QoL between PD and HD patients before and
replacement therapy (HD or PD) [20]. Our patients were after kidney transplantation.
all awaiting transplantation. It was reported that it is
possible to improve the QoL of patients while they await
transplantation [3]. The prospect of relatively normal REFERENCES
functioning can have a positive impact on the assessment
[1] Butt Z, Yount SE, Caicedo JC, et al. Quality of life assess-
of QoL. A person usually tries to maintain their QoL level ment in renal transplant review and future directions. Clin Trans-
by striving to achieve the highest level of any kind of plant 2008;22:292e303.
functioning. Improved QoL involves the patients assuming [2] World Health Organization. Quality of Life in Health Care,
more proactive roles in their own lives. In our study, Workshop, Geneva, Switzerland, February 11-16, 1991.
patients significantly improved QoL scores after KTx [3] Rodrigue JR, Mandelbrot DA, Pavlakis M. A psychological
intervention to improve quality of life and reduce psychological
regardless of the type of dialysis treatment they were distress in adults awaiting kidney transplantation. Nephrol Dial
receiving. Only 2 parameters in group 1 showed a lower Transplant 2011;26:709e15.
score after KTx: work status and staff encouragement. Any [4] Jofre R, Lopez-Gomez JM, Moreno F, et al. Changes in quality
type of treatment may affect the possibility to perform of life after renal transplantation. Am J Kidney Dis 1998;32:93e100.
[5] Wu AW, Fink NE, Marsh-Manzi JV, et al. Changes in quality
varying kinds of work. KTx can also cause certain limita- of life during hemodialysis and peritoneal dialysis treatment: generic
tions in the choice of a patient’s profession. At the same and disease specific measures. J Am Soc Nephrol 2004;15:743e53.
time, it opens up the possibility for the patients to live a life [6] Hays RD, Kallich JD, Mapes DL, et al. Kidney disease
less dependent on medical staff than other forms of quality of life short form (KDQOL-SFTM), Version 1.3: a manual
treatment. We have also compared the answers between for use and scoring. Santa Monica, Calif: RAND; 1997.
[7] Griva K, Thompson D, Jayasena D, et al. Cognitive func-
both groups 1 and 2. We did not prove any statistical tioning pre- to post-kidney transplantation: a prospective study.
differences in QoL between PD and HD patients before Nephrol Dial Transplant 2006;21:3275e82.
and after KTx. Some papers assess the QoL as better in PD [8] Burra P, De Bona M. Quality of life following organ trans-
patients in comparison to HD patients [15,17], whereas plantation. Transpl Int 2007;20:397e409.
[9] Barotfi S, Molnar MZ, Almasi C, et al. Validation of the
others find no difference between the two [3,18]. kidney disease quality of life-short form questionnaire in kidney
Furthermore, no articles were found stating that QoL was transplant patients. J Psychosom Res 2006;60:495e504.
higher in patients treated with HD than in those treated [10] Hays RD, Kallich JD, Mapes DL, et al. Development of the
with PD. QoL covers many aspects of life. For analysis, kidney disease quality of life (KDQOL) instrument. Qual Life Res
many instruments of research are available that can care- 1994;3:329e38.
[11] Dew MA, Switzer GE, Goycoolea JM, et al. Does trans-
fully analyze particular problems or approach the topic plantation produce quality of life benefits? A quantitative analysis
more generally. For a more complete analysis of our of the literature. Clin Transplant 1997;64:1261e73.
patients’ QoL, we chose the KDQOL-SFtm questionnaire; [12] Rowi nski W, Wesołowski T, Szyber P. A trial of objective
it is a multidimensional, reliable, and validated instrument comparison of quality of life between chronic renal failure patients
treated with hemodialysis and renal transplantation. Ann Trans-
designed for kidney disease and dialysis patients that plant 2003;8:48e54.
utilizes a generic coredthe 36-item Short Form Health [13] Fiebiger W, Mitterbauer C, Oberbauer R. Health-related
Survey (SF-36) [5,9,16]. The KDQOL-SFtm questionnaire quality of life outcomes after kidney transplantation. Health Qual
is a reproducible questionnaire that was validated by Life Outcomes 2004;2:1e6.
the KDQOL Working Group studies [10]; it was used [14] Frimat L, Durand PY, Loos-Ayav C, et al. Impact of first
dialysis modality on outcome of patients contraindicated for kidney
in several recent studies on QoL assessment in the eval- transplant. Perit Dial Int 2006;26:231e9.
uation of transplant patients and in comparisons of [15] Majkowicz M, Afeltowicz Z, Lichodziejewska-Niemierko M,
transplant recipients and patients on peritoneal and et al. Comparison of the quality of life in hemodialised (HD) and
hemodialysis [1,9,16]. Unfortunately there is no ideal peritoneally dialised (CAPD) patients using the EORTC QLQ C30
questionnaire. Int J Artif Organs 2000;23:423e8.
questionnaire that can measure all possible variables. It [16] Carmichael P, Popoola J, John I, et al. Assessment of QOL
is possible that substantially different Health-Related in a single dialysis center dialysis population using the KDQOL-SF
Quality of Life (HRQL) results can be obtained in the questionnaire. Qual Life Res 2000;9:195e205.
same population if different tools are applied [13]. Tar- [17] Fructuoso MR, Castro R, Oliveira I, et al. Quality of life in
geted instruments offer fine-tuned assessment of narrow chronic kidney disease. Nefrologia 2011;31:91e6.
[18] Wasserfallen JB, Halabi G, Saudan P, et al. QOL on chronic
aspects and symptoms. The advantages of targeted in- dialysis: comparison between haemodialysis and peritoneal dialysis.
struments include the focus on relevant areas, sensitivity Nephrol Dial Transplant 2004;19:1594e9.
to change in clinical status over time, and perceived [19] Sayin A, Mutluay R, Sindel S. Quality of life in hemodial-
relevance and practicality by clinicians and patients [1]. ysis, peritoneal dialysis and transplantation patients. Transplant
Proc 2007;39:3047e53.
Although there are a number of reliable and valid QoL [20] Akman B, Uyar M, Afsar B, et al. Adherence, depression
instruments, none can be considered the gold standard for and quality of life in patients on a renal transplantation waiting list.
assessment in all situations [1]. Transpl Int 2007;20:682e7.