ADULT UROLOGY

ASSESSMENT OF HEALTH-RELATED QUALITY OF LIFE IN

RENAL TRANSPLANT AND HEMODIALYSIS PATIENTS USING
THE SF-36 HEALTH SURVEY
MASATO FUJISAWA, YASUJI ICHIKAWA, KUNIHIKO YOSHIYA, SHUJI ISOTANI,
AKIHIRO HIGUCHI, SHUNSUKE NAGANO, SOICHI ARAKAWA, GAKU HAMAMI,
OSAMU MATSUMOTO, AND SADAO KAMIDONO

ABSTRACT
Objectives. To determine whether the health-related quality of life (HQOL) for renal transplant patients
improved using SF-36 survey scores and to examine which clinical measures after renal transplantation are
connected to aspects of their HQOL.
Methods. A total of 117 renal transplant patients and 114 hemodialysis patients, including 49 awaiting
transplantation and 65 not awaiting transplantation, were included in this study. The scale scores of the
SF-36 survey concerning HQOL were compared between the two groups of patients. The relationships of the
clinical episode and complications with the scale scores were examined.
Results. The renal transplant patients had significantly higher scores in the physical functioning, bodily pain,
general health, and social functioning scales than did the hemodialysis patients. The role-physical function-
ing, bodily pain, and social functioning scales of the transplant patients were significantly higher than those
of the hemodialysis patients not awaiting transplantation. In contrast, the scores, except for that of general
health, of the transplant patients were not significantly different from those of the hemodialysis patients
awaiting transplantation. Multiple regression analysis demonstrated that the scale scores of physical func-
tioning, general health, and vitality were significantly dependent on the serum level of creatinine in the renal
transplant patients (P ⬍0.05). The scores of physical functioning and general health of the patients with a
creatinine level ⬎2 mg/dL were significantly lower than those of the patients with 1 mg/dL ⬍ creatinine level
ⱕ1.5 mg/dL or a creatinine level ⱕ1 mg/dL (P ⬍0.05). An episode of hospitalization was not related to the
scale scores, but an instance of rejection had an effect on the scores of social functioning and role-emotional
functioning.
Conclusions. The SF-36 health survey is a short but comprehensive scale for evaluating a patient’s HQOL.
The renal transplant patients’ HQOL improved compared with that of the hemodialysis patients. The most
important factor affecting HQOL was the serum creatinine level at the time of testing with the SF-36
survey. UROLOGY 56: 201–206, 2000. © 2000, Elsevier Science Inc.

G raft survival after renal transplantation has

improved remarkably after the introduction
of cyclosporine and tacrolimus. Although clini-
cians have relied on the graft survival to determine
From the Department of Urology, Kobe University School of Med-
icine, Kobe; Department of Urology, Miki Municipal Hospital,
Miki; Department of Urology, Hyogo Prefectural Nishinomiya
Hospital, Nishinomiya; Department of Urology, Hara Genitouri-
nary Hospital, Kobe; and Department of Urology, Hyogo Prefec-
tural Amagasaki Hospital, Amagasaki , Japan
Reprint requests: Masato Fujisawa, M.D., 7-5-2 Kusunoki-cho,
Chuo-ku, Kobe 650-0017, Japan
Submitted: December 20, 1999, accepted (with revisions):
March 27, 2000
the efficacy of the transplantation, such measures
do not fully address the patient’s general or dis-
ease-specific health status. It should be realized
that renal transplantation is likely to affect not only
patients’ physical well-being but also their social
and psychological well-being. A patient’s health-
related quality of life (HQOL) has increasingly
been recognized as an outcome that can and
should be measured in studies of the effects of dis-
ease and treatments on patients. The SF-36 survey
(SF-36) has become an extensively used generic
measure throughout the world.1 It is considered
valid, reliable, comprehensive, brief, and poten-
tially useful for individual patient applications.

© 2000, ELSEVIER SCIENCE INC. 0090-4295/00/$20.00

ALL RIGHTS RESERVED PII S0090-4295(00)00623-3 201
 TABLE I. Patient characteristics
Tx (n ⴝ 117) HD Awaiting Tx (n ⴝ 49) HD Not Awaiting Tx (n ⴝ 65)
Duration of dialysis (yr) 3.1 ⫾ 3.8 10.0 ⫾ 6.8 7.7 ⫾ 5.0
Sex (M/F) 50/67 37/12 45/20
Cause of ESRD CGN and some unknown CGN, IgA, NS, DM, DPK, CGN, DM, DPK, RR ⫽ 58, 3, 3, 1
cases Hypo, T, HS ⫽ 36, 4,
2, 2, 2, 1, 1, 1
Age at Tx (yr) 33 ⫾ 9.5 — —
CD 31 — —
LD 86 — —
Prior transplant None — —
Term of transplantation 10.5 ⫾ 6.9 — —
(yr)
Patients with rejection 40 — —
episode (n)
Creatinine (mg/dL) 1.2 ⫾ 0.53 — —
Patients with
complications after Tx
or with HD (n)
Diabetes 5 2 3
Hypertension 35 46 44
Liver dysfunction 19 5 5
Age at SF-36 survey (yr) 43.9 ⫾ 9.1 45.8 ⫾ 11.9 45.7 ⫾ 6.8
KEY: HD ⫽ hemodialysis; ESRD ⫽ end-stage renal disease; Tx ⫽ transplantation; CD ⫽ cadaveric donor; LD ⫽ living-related donor; CGN ⫽ chronic glomerular nephritis;
IgA ⫽ IgA nephropathy; NS ⫽ nephrotic syndrome; DM ⫽ diabetic nephropathy; DPK ⫽ polycystic kidney disease; Hypo ⫽ hypoplastic kidney; T ⫽ toxicemia; HS ⫽
Henöch-Schonlein purpura; RR ⫽ reflux nephropathy.
Values presented as mean ⫾ SD.

Numerous international cross-cultural adaptations
of the original instrument, as well as the results of
its validation for normal subjects and different
chronic conditions, are already available.2– 6 Some
reports suggest that the SF-36 can be useful in as-
sessing the HQOL of renal transplant recipients.2
Therefore, we administered the SF-36 to patients
who underwent renal transplantation and exam-
ined which items affected their HQOL after renal
transplantation. We also compared the HQOL of
the renal transplant patients with that of hemodi-
alysis patients.
MATERIAL AND METHODS
A total of 126 renal transplant patients who underwent 33
cadaveric and 93 living-related transplantations were enrolled
in this study. Patients were recruited from the outpatient clin-
ics of the Departments of Urology in Kobe University School of
Medicine and Nishinomiya Hospital and were informed of the
study during routine follow-up visits to the hospital. The pa-
tients who answered fewer than one half of the items on at
least one scale were excluded from the psychometric analyses.
The remaining 117 renal transplant patients (50 men and 67
women) and 114 hemodialysis patients, including 65 hemo-
dialysis patients not awaiting renal transplantation and 49 pa-
tients awaiting transplantation, were analyzed in this study.
The patient profiles are presented in Table I. All renal trans-
plant patients received immunosuppressive therapy with aza-
thioprine and a steroid; azathioprine, a steroid, and tacroli-
mus; or azathioprine, a steroid, and cyclosporine. In some
cases, azathioprine was substituted with mizoribine. The
SF-36 contains 36 questions that assess eight aspects of
HQOL: physical functioning (PF), role-physical functioning
(RP), bodily pain (BP), general health (GH), vitality (VT),
social functioning (SF), role-emotional functioning (RE), and
mental health (MH). The number of questions directed to each
health concept range from two (for SF and BP) to 10 (for PF),
and the number of response options per question range from
two (no, yes) to six (none, very mild, mild, moderate, severe,
and very severe).1 Each question is given a score from 0 to 100.
A mean score is produced for each health concept, ranging
from 0 to 100, with higher scores indicative of a better out-
come. Information on the patient’s age, sex, medical history,
duration of the transplantation and hemodialysis before trans-
plantation, instances of rejection, complications such as he-
patic dysfunction and hypertension, hospitalization during
the past year, interventions occurring after the transplanta-
tion, and the findings from the most recent laboratory data
were abstracted from the patients’ medical records.
All descriptive data are reported as the mean ⫾ SD. Multiple
regression analysis was used to quantify and assess the rela-
tionship between the results of the quality-of-life (QOL) in-
strument and a number of independent variables such as clin-
ical conditions. In the multiple regression analysis, each
parameter of medical history and complications was given a
score of 0 or 1. Differences in the mean value between the
transplant and hemodialysis patients were analyzed by a two-
tailed, unpaired t test. Significance was present at the 5% level.
RESULTS
The scale score of PF, RP, BP, GH, VT, SF, RE,
and MH in the renal transplant patients was 86.2,
77.6, 80.2, 56.4, 63.3, 82.1, 78.0, and 70.0, respec-
tively. In contrast, the scale score of PF, RP, BP,
GH, VT, SF, RE, and MH in the hemodialysis pa-
tients was 81.6, 68.0, 70.2, 51.0, 59.2, 74.5, 74.6,
and 68.5, respectively. In the hemodialysis patients

202 UROLOGY 56 (2), 2000

awaiting transplantation, the scale score of PF, RP,
BP, GH, VT, SF, RE, and MH was 81.7, 73.5, 74.1,
49.6, 61.2, 74.9, 80.3, and 67.8, respectively. The
scale score of PF, RP, BP, GH, VT, SF, RE, and MH
in the hemodialysis patients not awaiting trans-
plantation was 81.5, 63.8, 67.2, 52.0, 57.6, 74.2,
70.3, and 69.0, respectively. The renal transplant
patients gave significantly higher scores in the
scale scores of PF, BP, GH, and SF than all patients
receiving hemodialysis (Table II). The RP, BP, and
SF scores of the transplant patients were signifi-
cantly higher than those of the hemodialysis pa-
tients not awaiting transplantation. In contrast, the
scores, except GH of the transplant patients, were
not statistically different from those of hemodialy-
sis patients awaiting transplantation. Regarding
the sex of the transplant patients, no differences
were found in any scale score between the men and
women. With respect to age, the transplant pa-
tients were divided into four groups: younger than
30 years, 30 to 39 years, 40 to 49 years, and 50
years old or older. The younger the patients, the
higher the scale scores tended to be. In particular,
the scale of GH was significantly higher in patients
who were younger than 30 years old than in the
patients who were older than 40 (P ⬍0.05) (Table
II).
Using the clinical data and scale scores, multiple
regression analysis demonstrated that the scale
scores of PF, GH, and VT were significantly depen-
dent on the serum level of creatinine in the renal
transplant patients (P ⬍0.05) (Table III). Separat-
ing the transplant patients into four groups accord-
ing to the serum level of creatinine (creatinine ⬎2,
1.5 ⬍ creatinine ⱕ2, 1 ⬍ creatinine ⱕ1.5, creati-
nine ⱕ 1 mg/dL; normal range 0.5 to 1.3 mg/dL),
we compared the scale scores of the transplant pa-
tients. The scale scores of PF and GH of the pa-
tients with a creatinine level ⬎2 mg/dL were sig-
nificantly lower than those of the patients with 1 ⬍
creatinine level ⱕ1.5 mg/dL or a level ⱕ1 mg/dL (P
⬍0.05) (Table II).
Forty (34.2%) of 117 transplant patients had an
occurrence of clinically defined acute rejection af-
ter transplantation. In comparing the patients who
had an occurrence of rejection with those who did
not, we found that the scale scores of SF and RE
were significantly higher in the former group (P
⬍0.05). All other scale scores were similar in both
groups (Table II). When comparing patients who
had had a period of hospitalization with those who
had not, no significant difference was observed be-
tween the two groups. The scores of the patients
with cadaveric transplantation were similar to
those who received a living-related transplanta-
tion. Patients were divided into three groups ac-
cording to the immunosuppressive agents (aza-
thioprine and a steroid; azathioprine, a steroid, and
UROLOGY 56 (2), 2000
tacrolimus; or azathioprine, a steroid, and cyclo-
sporine). However, no significant differences were
found among these three groups.
COMMENT
Ideally, a QOL measure should show little
change in score over time in stable patients, yet be
sensitive to clinically relevant changes in patient
well-being after the introduction of new therapy.
Many reports are available concerning the im-
provement of QOL in transplant patients.7–15
Cross-sectional and prospective studies comparing
dialysis and transplantation commonly report sta-
tistically significant improvements in the QOL in
the transplant recipients. Eighty-six percent of pa-
tients have been able to undertake normal or near
normal activity for most of the period after trans-
plantation.13
Several methods for scoring the HQOL have been
reported. Russell et al.5 reported that the mean
time trade-off score rose from 0.41 to 0.74 after
renal transplantation. The Sickness Impact Profile
was also used to assess actual health status of trans-
plant patients.6 However, it takes the patients con-
siderable time to answer the many questions in-
volved. In contrast, the SF-36 survey used in the
present study consists of only 36 questions. There-
fore, it is easier for outpatients to respond to the
questions. The SF-36 has been extensively studied,
and its reliability and validity have been reported
for normal populations.1– 4 Use of the SF-36 mea-
sure allowed us to assess the extent to which renal
transplantation, as assessed clinically, influenced
the patients’ physical, social, and psychological
sense of well-being. Painter et al.15 demonstrated
by means of the SF-36 survey that organ, including
kidney, transplant recipients have the potential to
achieve levels of HQOL similar to those of the gen-
eral population. Our study found that all scale
scores of transplant patients in Japan seem to be
similar to those reported by Ware16 in the United
States. Therefore, we confirmed that, as was re-
ported for their American counterparts, most Jap-
anese transplant patients improved their QOL. Do
the scale scores in the SF-36-survey we observed
represent a real benefit for patients? We demon-
strated that the RP, SF, and BP of transplant pa-
tients were significantly higher than those of he-
modialysis patients not awaiting transplantation.
These differences mean that the transplantation re-
duced the limitations in both physical and social
function. In addition, the bodily pain experienced
by patients during hemodialysis was also reduced
after transplantation. The score change most prob-
ably reflects a change in a multitude of factors,
including relief from uremia, renewed indepen-
dence, and freedom from dialysis, that were attrib-
203
 TABLE II. SF-36 scale scores in transplant and hemodialysis patients
PF RP BP GH VT SF RE MH
Patients
Transplant patients (n ⫽ 117) 86.2 ⫾ 14.8* 77.6 ⫾ 35.0* 80.2 ⫾ 21.6† 56.4 ⫾ 19.0* 63.3 ⫾ 20.3 82.1 ⫾ 19.7* 78.0 ⫾ 37.2 70.0 ⫾ 19.7
Hemodialysis patients (n ⫽ 114) 81.6 ⫾ 17.0* 68.0 ⫾ 39.1 70.2 ⫾ 23.6† 51.0 ⫾ 19.2* 59.2 ⫾ 21.4 74.5 ⫾ 26.0* 74.6 ⫾ 38.5 68.5 ⫾ 22.4
Hemodialysis patients awaiting 81.7 ⫾ 16.0 73.5 ⫾ 35.5 74.1 ⫾ 21.9 49.6 ⫾ 18.1* 61.2 ⫾ 19.6 74.9 ⫾ 24.5 80.3 ⫾ 34.6 67.8 ⫾ 22.4
Tx (n ⫽ 49)
Hemodialysis patients not 81.5 ⫾ 17.8 63.8 ⫾ 41.5* 67.2 ⫾ 24.5† 52.0 ⫾ 20.0 57.6 ⫾ 22.7 74.2 ⫾ 27.3* 70.3 ⫾ 40.9 69.0 ⫾ 22.5
awaiting Tx (n ⫽ 65)
Serum creatinine (mg/dL)
Creatinine ⱕ1 (n ⫽ 43) 87.4 ⫾ 1.9* 77.3 ⫾ 5.5 81.5 ⫾ 3.3 59.4 ⫾ 2.8† 63.5 ⫾ 3.3 83.6 ⫾ 2.9 78.3 ⫾ 6.0 71.2 ⫾ 3.0
1 ⬍ creatinine ⱕ1.5 (n ⫽ 50) 87.4 ⫾ 1.8* 82.0 ⫾ 4.2 80.9 ⫾ 2.8 59.5 ⫾ 2.5† 63.8 ⫾ 2.8 81.9 ⫾ 2.7 81.3 ⫾ 4.5 69.1 ⫾ 2.8
1.5 ⬍ creatinine ⱕ2 (n ⫽ 14) 85.4 ⫾ 4.5 67.9 ⫾ 12.1 82.1 ⫾ 5.6 50.2 ⫾ 4.8 62.9 ⫾ 4.1 79.6 ⫾ 4.8 69.1 ⫾ 12.3 73.4 ⫾ 3.7
Creatinine ⬎2 (n ⫽ 10) 76.5 ⫾ 8.2* 70.0 ⫾ 12.8 68.4 ⫾ 8.9 37.0 ⫾ 6.2† 61.0 ⫾ 8.1 80.2 ⫾ 9.3 73.3 ⫾ 13.9 64.4 ⫾ 8.7
Age at survey (yr)
Age ⬍30 (n ⫽ 8) 91.9 ⫾ 7.5 68.8 ⫾ 34.7 81.3 ⫾ 13.5 69.3 ⫾ 20.4* 68.1 ⫾ 12.5 79.8 ⫾ 21.1 79.3 ⫾ 24.8 71.5 ⫾ 8.4
30 ⱕ age ⬍40 (n ⫽ 32) 87.7 ⫾ 13.9 80.5 ⫾ 30.0 77.7 ⫾ 21.5 59.4 ⫾ 16.1 58.4 ⫾ 19.8 82.2 ⫾ 19.3 76.0 ⫾ 39.0 64.9 ⫾ 21.7*
40 ⱕ age ⬍50 (n ⫽ 49) 84.8 ⫾ 18.0 82.7 ⫾ 31.1 83.7 ⫾ 22.6 54.4 ⫾ 17.6* 63.7 ⫾ 19.7 82.1 ⫾ 20.7 83.6 ⫾ 33.5 70.2 ⫾ 20.1
Age ⱖ50 (n ⫽ 28) 85.5 ⫾ 10.9 67.9 ⫾ 41.3 76.6 ⫾ 21.9 53.0 ⫾ 22.6* 67.0 ⫾ 23.2 82.8 ⫾ 19.3 70.3 ⫾ 43.8 75.0 ⫾ 18.5*
Episode of acute rejection
Yes (n ⫽ 40) 88.5 ⫾ 2.0 84.4 ⫾ 4.2 84.8 ⫾ 2.8 59.0 ⫾ 2.5 67.5 ⫾ 2.8 88.9 ⫾ 2.3† 87.4 ⫾ 4.3* 74.3 ⫾ 2.7
No (n ⫽ 77) 85.1 ⫾ 1.8 74.1 ⫾ 4.4 77.8 ⫾ 2.6 55.1 ⫾ 2.3 61.4 ⫾ 2.4 78.6 ⫾ 2.4† 73.2 ⫾ 4.7* 67.7 ⫾ 2.4
KEY: PF ⫽ physical functioning; RP ⫽ role-physical functioning; BP ⫽ bodily pain; GH ⫽ general health; VT ⫽ vitality; SF ⫽ social functioning; RE ⫽ role-emotional functioning; MH ⫽ mental health; Tx ⫽ transplantation.
Values presented as the mean ⫾ SD.
Transplant patients were classified according to serum creatinine level, age at survey, or an episode of acute rejection.
* P ⬍0.05.
†
P ⬍0.01.
 TABLE III. Multiple regression study concerning each scale score
PF RP BP GH VT SF RE MH
Age at transplantation 0.22 0.903 0.723 0.879 0.888 0.199 0.454 0.454
Term of hemodialysis 0.005 0.877 0.322 0.253 0.342 0.328 0.453 0.527
Sex 0.215 0.011 0.083 0.747 0.577 0.251 0.049 0.448
Serum creatinine 0.04 0.189 0.46 0.002 0.022 0.885 0.895 0.428
Hypertension 0.845 0.468 0.998 0.994 0.633 0.4 0.199 0.82
Hepatic dysfunction 0.358 0.978 0.444 0.082 0.23 0.113 0.426 0.182
Acute rejection 0.765 0.365 0.359 0.486 0.291 0.019 0.57 0.24
KEY: Abbreviations as in Table II.

uted to the successful renal transplantation. In
contrast, the scale scores, except for GH, of the
patients awaiting transplantation were not signifi-
cantly different from those of transplant patients,
although no apparent differences in patient char-
acteristics were observed between the hemodialy-
sis patients awaiting and not awaiting transplanta-
tion. These results suggested that the desire to
undergo the transplantation may improve the
scores of HQOL compared with those of hemodi-
alysis patients not awaiting transplantation. The
scale scores of MH in the transplant patients were
the same as those of the hemodialysis patients.
Therefore, mental health care support should be a
consideration, even in the event of a successful
transplantation.
We analyzed which factors have the most effect
on the scale scores of the SF-36. The multiple re-
gression analysis confirmed that creatinine level is
the most important factor for determining the
scores of PF, GH, and VT. The lower the patient’s
level of serum creatinine, the higher the scale
scores. In particular, patients with a relatively high
serum creatinine level reported more problems
with PF and GH (P ⬍0.05). The serum level of
creatinine most likely reflects the HQOL.
In our study, an episode of hospitalization did
not affect the scale score of the SF-36. In contrast,
Shield et al.2 reported that patients with no subse-
quent hospitalizations demonstrated significantly
greater improvement in their BP score of SF-36
compared with patients with one to two hospital-
izations. In addition, they also demonstrated a sig-
nificantly better change in GH, VT, and SF com-
pared with patients with three or more
hospitalizations. On the other hand, our patients
who had an occurrence of rejection reported al-
most the same score as those without an occur-
rence. The SF and RE scores of the rejection group
were higher than those who had not experienced
rejection. Even if they had experienced acute rejec-
tion, their present condition was the factor that
most reflected the functioning of the patients. The
patients were always concerned about their present
creatinine level, but remained unconcerned about
a previous experience such as rejection and hospi-
talization.
In conclusion, SF-36 is a short but comprehen-
sive scale for evaluating HQOL. The transplant pa-
tients’ subjective QOL improved noticeably com-
pared with the hemodialysis patients. The most
important factor affecting HQOL was the present
serum creatinine level.
ACKNOWLEDGMENT. To Dr. Shunichi Fukuhara, a Japanese
member of IQOLA, Kyoto University, for supporting this
study and to the Urology Nursing Team at Kobe University
Hospital, the Transplant Nursing Team at Hyogo Prefectural
Nisinomiya Hospital (E. Hirose, T. Kageyama, and Y. Miy-
amoto), and the Dialysis Nursing Team at Hara Genitourinary
Hospital for their help with this study at the outpatient clinics.
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