Health-Related Quality of Life After Kidney Transplantation

in Comparison Intermittent Hemodialysis, Peritoneal Dialysis,

and Normal Controls
B. Ogutmen, A. Yildirim, M.S. Sever, S. Bozfakioglu, R. Ataman, E. Erek, O. Cetin, and A. Emel

ABSTRACT
The purpose of this study was to compare the quality of life (QOL) in renal transplantation
patients. QOL is one of the important indicators of the effects of medical treatment. In this
cross-sectional study, QOL was analyzed in 302 renal transplant recipients compared with
64 hemodialysis (HD) patients, 207 (PD) peritoneal dialysis patients, and 278 normal
controls (NC) matched as closely as possible to the grafted patients regarding age, gender,
education, and occupation. All groups were asked to estimate their subjective QOL by
responding to sociodemographic data, Turkish adapted instruments of the Nottingham
Health profile (NHP), and the Short-form 36 (SF-36). Transplant recipients were
significantly younger than the HD and PD patients (P ⬍ .0001). There was no statistically
significant differences between normal controls and transplant patients ages. Among the
three renal replacement methods, QOL in transplants was clearly better than that in HD
or PD patients (P ⬍ .0001). The QOL measured by the NHP and SF-36 scale showed that
the normal population was statistically significantly better than the transplant recipients
(P ⬍ .0001). Transplant renal replacement therapy provides a better QOL compared with
other replacement methods.

Q UALITY OF LIFE (QOL), which is an indicator of

therapeutic efficacy in the outcome of patient care
usually reflects a patient’s subjective perception of current
health function.1 As defined by the World Health Organi-
zation, QOL is an individual’s perception of their position
in life in the context of the culture and value systems in
which they live with the relation to their goals, expectations,
standards, and concerns. Health care providers need to
interpret QOL results cautiously for patient care, in order
to prevent aggravations of disease and policy making.2,3 The
purpose of this study was to first examine differences between
aspects of life quality among patients receiving renal trans-
plant compared with hemodialysis (HD) patients, peritoneal
dialysis (PD) patients and normal controls. Second, we sought
agreements of the two instruments Nottingham Health Profile
[NHP] and Short-Form 36 [SF-36]) as effectiveness estimates.
Generic instruments were preferred because of their allow-
ance for comparisons across different treatment modalities
(HD, PD, and transplantation).
PARTICIPANTS AND METHODS
This cross-sectional study was conducted from April 2003 to April
2004. All public tertiary care hospitals that have active kidney
transplantation units, dialysis centers, and nephrology residency
training program were included in the sampling frame. We ran-
domly chose 64 conventional HD thrice-weekly patients, 207 PD,
and 302 transplant recipients each for more than 3 months. Two
hundred seventy eight controls were selected randomly from the
Istanbul Municipality Population Register Center to represent the
general population. The age and gender of controls matched were as
closely as possible to transplanted subjects. Patients and controls were
evaluated using both Turkish adapted instruments4,5 NHP and SF-36.
Each scale of NHP had a range from 0 to 100, with higher scores
reflecting a better quality of life. Dimension scores of SF-36 ranged
from 0 to 100, with higher scores indicating greater health problems.
Informed consent was obtained from all people who accepted to
participate in the study. The University Hospital Ethics Committee
approved the study protocol.
From the Department of Nephrology (B.O., O.C., A.E.) and
Health Education Faculty (A.Y.), Marmara University, Istanbul,
Turkey, and Department of Nephrology (M.S.S., S.B.) and De-
partment of Nephrology (R.A., E.E.), Istanbul University, Cerrah-
pasa, Istanbul, Turkey.
Address reprint requests to Dr. Betül Öğütmen, Gardenya 4/1
D 3 62 Ada Ataşehir Istanbul, Turkey. E-mail: betulogutmen@
yahoo.com

© 2006 by Elsevier Inc. All rights reserved. 0041-1345/06/$–see front matter

360 Park Avenue South, New York, NY 10010-1710 doi:10.1016/j.transproceed.2006.01.016

Transplantation Proceedings, 38, 419 – 421 (2006) 419

420 OGUTMEN, YILDIRIM, SEVER ET AL

The overall response rate was 99%, a high degree of interest that
probably represented their wish to demonstrate collaboration with
their physicians. The healthy person responses rate in the normal
group was 50.18%. Patients were evaluated by a face-to-face
questionnaire, including sociodemographic, familial characteristics,
staff behaviors, education provided by health professionals.
Biochemical data records were also collected. Controls only an-
swered questions about age, sex, educational level, marital status,
profession and occupation, social insurance, living status, smoking
habits, drinking habits.
The data analyzed using SPSS 11.0 are given as mean values ⫾
standard deviations. Data analysis was performed using one-way
variance, Tukey multiple comparison tests, and chi-square tests.
Results were significant at P ⬍ .05 level in the 95% confidence
interval.
RESULTS
The sample included 851 individuals: 53.24% men and
46.76% women. HD patient mean age was 48.14 ⫾ 15.5
years; transplant recipients was 38.22 ⫾ 11.52 years, PD
subjects was 46 ⫾ 13.88 years, and controls was 39.20 ⫾ 9.87
years. The sociodemographic characteristics of the partici-
pants are shown in Table 1.
The apparently best possible QOL mean scores, were
observed among male patients and normal males controls,
aged above 40 years, married, and having an occupation
compared with females patients or normal females controls,
aged above 40, not married, and not having an occupation.
Measured QOL was not influenced by educational level,
social insurance, living status, smoking habits, drinking
habits, familial characteristics, staff behaviors, education
provided by health professionals.
Biochemical data were statistically significant among
transplant recipients. Hemoglobin level was 13.13 ⫾ 2.81
(F: 12.52, P ⬍ .0001); hematocrit, 42.34 ⫾ 29.67 (F: 9.78,
P ⬍ .0001); serum creatinine level 1.66 ⫾ 1.10 (F: 28.34,
P ⬍ .0001); cholesterol level was 168.93 ⫾ 39.14. All
biochemical levels were statistically lower in the HD group
when compared other renal replacement groups (F: 7.92,
P ⬍ .0001). Transplant recipients who had good biochem-
ical data reported significantly better total QOL scores than
chronic HD and PD patients (P ⬍ .0001). Mean QOL
scores of the controls were significantly better compared
with the transplant, HD or PD patients (P ⬍ .0001).
Significant differences were observed in the other compa-
rable quality of life domains of SF-36 and NHP (Table 2).
All dimensions of the NHP and SF-36 significantly corre-
lated with renal transplant recipients, HD, PD and control
groups (F: 16.11, P ⬍ 0.001).
A logistical regression was performed with the purpose of
determining the predictive capacity of the variables studied
through the NHP and SF-36 scale and the sociodemo-
graphic and clinical data. QOL measured by the NHP and
SF-36 scale was permitted correct classification of the
patient in 84.78% of cases.

Table 1. The Sociodemographic Characteristics of Participants

Hemodialysis Group Transplantation Group Peritoneal Dialysis Group Normal Group
(n ⫽ 64) (n ⫽ 309) (n ⫽ 207) (n ⫽ 278) P

Age, mean (SD) 48.14 (15.5) 38.22 (11.52) 46 (13.88) 39.20 (9.87) ⬍.0001
Gender ␹2: 6.43; ⬎.05
Men 32 (50%) 187 (61.9%) 109 (52.7%) 125 (44.96%)
Women 32 (50%) 115 (38.1%) 98 (47.3%) 153 (55.04%)
Educational level ␹2: 16.25; ⬍.05
Illiterate 5 (7.8%) 3 (1.1%) 10 (4.9%) 8 (2.78%)
Literate 2 (3.1%) 8 (2.8%) 13 (6.4%) 9 (3.13%)
Middle and high school level 45 (70.3%) 204 (72.3%) 131 (64.2%) 210 (73.17%)
College, university, and upper 12 (18.8%) 67 (23.7%) 50 (24.5%) 60 (20.59%)
Marital status ␹2: 11.91; ⬍.05
Married 41 (65.1%) 217 (74.8%) 147 (72.8%) 197 (71.94%)
Single 20 (31.7%) 71 (24.5%) 46 (22.8%) 64 (23.02%)
Widowed 2 (3.2%) 2 (0.7%) 9 (4.5%) 17 (6.11%)
Profession and occupation ␹2: 44.73; ⬍.0001
Civil servant 23 (38.3%) 38 (12.3%) 29 (14.1%) 34 (12.23%)
Employer 2 (3.3%) 22 (7.1%) 5 (2.4%) 20 (7.19%)
Home duties 14 (23.3%) 68 (22.1%) 64 (31.1%) 56 (20.14%)
Retired 8 (13.3%) 35 (11.4%) 31 (15%) 31 (11.15%)
Unemployed 1 (1.7%) 10 (3.2%) 7 (3.4%) 12 (4.31%)
Student 2 (3.3%) 19 (6%) 6 (2.9%) 21 (7.55%)
Trade 12 (20%) 117 (37.9%) 64 (31%) 104 (37.41%)
Social insurance
Yes 64 (100%) 309 (100%) 207 (100%) 250 (90%)
No 0 0 0 28 (10.07%)
Living status ␹2: 8.14; ⬍.05
Alone 5 (8.2%) 4 (1.3%) 8 (3.9%) 3 (1.07%)
With family 56 (91.8%) 297 (98.7%) 195 (96.1%) 275 (98.92)
HEALTH-RELATED QUALITY OF LIFE 421

Table 2. Differences in Comparable Domains in the NHP and the SF-36 Between Transplant Recipients and Normal Control Groups
Quality of Life Hemodialysis Peritoneal Dialysis Transplantation Normal Controls
Instrument Dimensions (n ⫽ 64) (n ⫽ 207) (n ⫽ 302) (n ⫽ 278) F P

SF-36* Physical functioning 56.99 ⫾ 24.97 57.06 ⫾ 18.62 59.92 ⫾ 27.41 61.82 ⫾ 18.61 0.52 ⬍.05
Social functioning 66.11 ⫾ 24.84 71.93 ⫾ 20.77 75.61 ⫾ 19.26 78.31 ⫾ 22.54 7.11 ⬍.01
Role physical 35.71 ⫾ 41.57 55.10 ⫾ 46.11 71.09 ⫾ 43.08 82.84 ⫾ 30.67 21.27 ⬍.0001
Role emotional 48.44 ⫾ 41.54 62.96 ⫾ 44.58 77.96 ⫾ 39.09 79.44 ⫾ 36.74 18.26 ⬍.0001
Mental health 64.71 ⫾ 14.00 66.55 ⫾ 12.12 68.55 ⫾ 13.31 69.71 ⫾ 15.00 1.38 ⬎.05
Energy/fatigue 55.79 ⫾ 22.09 55.51 ⫾ 11.14 57.27 ⫾ 17.49 58.79 ⫾ 22.09 0.6 ⬍.05
Bodily pain 70.02 ⫾ 30.04 74.34 ⫾ 26.71 75.80 ⫾ 22.68 77.02 ⫾ 26.01 1.41 ⬎.05
General health 50.08 ⫾ 10.68 50.66 ⫾ 8.04 51.50 ⫾ 8.21 52.08 ⫾ 9.58 0.93 ⬎.05
NHP** Pain 20.09 ⫾ 17.17 19.21 ⫾ 16.75 17.97 ⫾ 11.97 16.51 ⫾ 14.65 0.24 ⬎.05
Physical mobility 25.39 ⫾ 21.67 29.72 ⫾ 24.60 17.40 ⫾ 12.11 16.40 ⫾ 14.13 23.61 ⬍.0001
Energy level 43.23 ⫾ 36.46 40.59 ⫾ 36.30 30.80 ⫾ 27.16 27.80 ⫾ 28.14 6.18 ⬍.001
Sleep 32.50 ⫾ 30.34 26.70 ⫾ 21.71 20.99 ⫾ 18.14 17.99 ⫾ 19.12 9.02 ⬍.0001
Social isolation 17.81 ⫾ 12.21 16.56 ⫾ 12.05 15.30 ⫾ 12.96 14.56 ⫾ 18.04 0.14 ⬎.05
Emotional reaction 25.00 ⫾ 18.72 18.66 ⫾ 13.95 13.40 ⫾ 10.04 12.40 ⫾ 16.05 9.82 ⬍.0001
NHP total scores 24.92 ⫾ 22.26 23.02 ⫾ 18.21 17.07 ⫾ 14.61 16.07 ⫾ 12.50 10.04 ⬍.0001
*A higher score (100) indicates more perceived problems.
**A higher score (100) indicates fewer perceived problems.

DISCUSSION factors (sex, age, education, sociodemographics) play im-

Renal failure is a chronic disorder that not only affects the
patient but also gives rise to health service costs. The
recognition of the predictors of patient subjective general
state and reported QOL may have clear repercussions for
approaches to this disorder. Life quality detected between
men and women favored men, which we believe to mainly
reflect differences in men’s perceptions of life. Men are
socialized differently from women, being taught to be more
independent and self-controled especially in Middle East
cultures.6 Women are taught to be more emotionally ex-
pressive, dependent, and concerned with their physical
appearance in order to be accepted by society. The majority
of the renal failure patients live with their family, because
most patients experience good support by family ties in the
traditional Turkish culture. Social support has beneficial
effects on the domains of QOL. Family support helps
coping, managing severity of illness, and stressful situa-
tions.7 Married patients showed significantly better QOL
than single patients, indicating that most patients experi-
ence good support from their spouses and children. The
QOL of transplant patients, who had good biochemical
control, was clearly better than that of chronic HD and PD
patients but worse than the healthy population.8 It is also
important to consider that the disease alone does not
determine one’s view of life quality, but many nondisease
portant additive role in the perception of QOL.9,10
REFERENCES
1. Yildirim A: Health related quality of social life. Gulhane
Medical Journal 44:480, 2002
2. Akinci F, Yildirim A, Ogutmen B, et al: Translation, cultural
adaptation, initial reliability and validation of Turkish 15D’s ver-
sion: a generic health-related quality of life (HRQoL) Instrument.
Eval Health Prof 28:53, 2005
3. Eser E, Fidaner H, Eser S, et al: Derivation of Response
Scales for WHOQOL TR. European Psychologist 5:278, 2000
4. Koçyigit H, Aydemir Ö, Fişek G, et al: Kisa form 36(KF36)’nın
Türkçe versionunun güvenilirligi ve geçerliligi [Validation and reli-
ability of SH-36]. Ilac ve Tedavi Dergisi 12:102, 1999
5. Kucukdeveci AA, McKenna SP, Kutlay S, et al: The develop-
ment and psychometric assessment of the Turkish version of the
Nottingham Health Profile. Int J Rehabil Res 23:31, 2000
6. Kongar E: 21. yüzyılda Türkiye. 5th ed. Istanbul: Remzi
Kitapevi; 1998, p 581
7. Overbeck I, Bartels M, Decker O, et al: Changes in quality of
life after renal transplantation. Transplant Proc 37:1618, 2005
8. Rebollo P, Bobes J, Gonzalez MP, et al: Factors associated
with health related quality of life in patients undergoing renal
replacement therapy. Nefrologia 20:171, 2000
9. Rebollo P, Ortega F, Baltar JM, et al: Health related quality
of life (HRQOL) of kidney transplanted patients: variables that
influence it. Clin Transplant 14:199, 2000
10. Aikawa A, Arai K, Kawamura T, et al: First living related
kidney transplantation results in execellent outcomes for small
children. Transplant Proc 37:2947, 2005