It is very important for outpatients who have had a kidney transplant to take care of themselves after discharge. However, outpatients have limited access to medical care by hospital staff after discharge; therefore, medical staff are unaware of the patient’s living conditions, and the uncertainties and problems that they encounter related to self-management. We conducted a questionnaire survey among 161 of 200 outpatients who received kidney transplants to investigate their recognition and actual practice of daily self-management. To determine the characteristics of adherent outpatients, we divided patients into two groups (the adherent and non-adherent group) and compared them. The Chi-squared test was conducted to test the equality of proportions among the groups, and then multiple logistic regression analysis was used to explore the factors significantly associated with regularly taking medicine or failing to take medicine. As a result of the logistic regression model using demographic factors as independent factors, the periods after transplantation (2 - 5 and 5 - 10 years) and living-donor kidney transplantation or cadaveric kidney transplantation were selected as significant factors associated with good self-management. As a whole, 68.3% of the 145 patients were correctly predicted using the model. The results of this study suggest that in the short period after transplantation (2 - 5 years), cadaveric kidney transplantation and that the patient has a job are significant factors associated with good self-management. Behind these results, a unique Japanese concept, “ amae”, could be found. Therefore, medical knowledge and techniques as well as cultural background should be studied.
In 1956 our hospital conducted the first cadaveric kidney transplantation in Japan [
It is very important for outpatients who have had kidney transplantations to take care of themselves after discharge. Inpatients have careful nursing by medical staff. However, outpatients have limited access to medical care by nursing staff after discharge. Moreover, they have to check their blood pressure at home daily. Thus, they need to understand the importance of self-management and have the basic knowledge to practice self- management in their daily life. Additionally, outpatients have to take immunosuppressive drugs because these drugs are necessary for graft survival [
Therefore, we conducted a questionnaire survey among 200 outpatients who had had a kidney transplant to investigate their recognition and actual practice of daily self-management. To determine the characteristics of adherent outpatients, we divided patients into two groups, an adherent and a non-adherent group. We studied whether the following factors were associated with good self-management by multivariate analysis: age, gender, period after transplantation (years), experience of dialysis (before transplantation), period of dialysis (years), type of kidney transplantation (living-donor kidney or cadaveric kidney), and whether or not they were employed.
We studied kidney transplant patients at Niigata University Medical and Dental Hospital who received kidney transplants between March 1997 and June 2004. Of 200 patients who left the hospital after kidney transplantation, 39 patients were excluded since they were under age (<20 years old) or they had communication problems. The remaining 161 patients agreed to take part in the study, but 16 cases were omitted for factors such as incomplete forms, a missing signature or excess answers; therefore, 145 patients(male = 91 and female = 54) were included in the study. Patients were divided into two groups, an adherent (n = 68) and a non-adherent group (n = 77). Patients in the former group regularly took medicine, while those in the latter group sometimes forgot to take medicine, even though regularly taking medicine is one of the minimum requirements of self-management. In Short, the former answered “No” while the latter selected “Yes” in Q8 of our questionnaire (Appendix). Details of participants were shown in
The demographic factors and the corresponding categories used in this study are shown in
Adherent group (n = 68) | Non-adherent group (n = 77) | P | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Demographic factors | n | % | n | % | |||||||
Age (years) | 0.776 | ||||||||||
20 - 29 | 7 | 46.7 | 8 | 53.3 | |||||||
30 - 39 | 12 | 40.0 | 18 | 60.0 | |||||||
40 - 49 | 14 | 42.4 | 19 | 57.6 | |||||||
50 - 59 | 19 | 50.0 | 19 | 50.0 | |||||||
≥60 | 16 | 44.8 | 13 | 44.8 | |||||||
Gender | 0.911 | ||||||||||
Male | 43 | 47.3 | 48 | 52.7 | |||||||
Female | 25 | 46.3 | 29 | 53.7 | |||||||
Period after transplantation (years) | <0.001 | ||||||||||
<2 | 22 | 81.5 | 5 | 18.5 | |||||||
2 - 5 | 23 | 62.2 | 14 | 37.8 | |||||||
5 - 10 | 14 | 31.1 | 31 | 68.9 | |||||||
>10 | 9 | 25.0 | 27 | 75.0 | |||||||
Dialysis (before transplantation) | 0.702 | ||||||||||
Yes | 53 | 46.1 | 62 | 53.9 | |||||||
No | 15 | 50.0 | 15 | 50.0 | |||||||
Period of dialysis (years) | 0.097 | ||||||||||
<1 | 28 | 50.0 | 28 | 50.0 | |||||||
1 - 2 | 5 | 33.3 | 10 | 66.7 | |||||||
2 - 5 | 5 | 23.8 | 16 | 76.2 | |||||||
5 - 10 | 7 | 58.3 | 5 | 41.7 | |||||||
>10 | 23 | 56.1 | 18 | 43.9 | |||||||
Living-donor kidney or cadaveric kidney | 0.015 | ||||||||||
Living-donor kidney transplantation | 48 | 41.7 | 67 | 58.3 | |||||||
Cadaveric kidney transplantation | 20 | 66.7 | 10 | 33.3 | |||||||
Job | 0.022 | ||||||||||
Yes | 28 | 60.9 | 18 | 39.1 | |||||||
No | 40 | 40.4 | 59 | 59.6 | |||||||
Pearson’s Chi-squared test. Two-tailed significance with P values < 0.05.
The distributions of factors used in this analysis were described in contingency tables. Pearson’s Chi-squared test was conducted to test the equality of proportions among groups. Multiple logistic regression analysis was used to explore the factors significantly associated with the adherent group. Candidate factors of the multivariate analysis are shown in
Moreover, in the adherent group, 60.9% of patients had a job while 40.4% did not; by contrast, in the non- adherent group, 39.1% of patients had a job and 59.6% did not (P = 0.022). However, neither experience of dialysis (before transplantation) nor period of dialysis differed between the two groups (P = 0.702 and P = 0.097).
Multiple logistic regression analysis was used to explore the characteristics associated with being able to self- manage (
Variables | Coefficients | Std. error | P | Odds ratio | 95% CI | |
---|---|---|---|---|---|---|
Lower | Upper | |||||
Period after transplantation (years) | ||||||
<2** | - | - | - | 1 | ||
2 - 5 | 0.886 | 0.609 | 0.146 | 2.425 | 0.739 | 8.005 |
5 - 10 | 2.306 | 0.604 | <0.001 | 10.035 | 3.072 | 32.784 |
>10 | 2.553 | 0.639 | <0.001 | 12.843 | 3.672 | 44.924 |
Live kidney or cadaveric kidney | ||||||
Cadaveric kidney | - | - | - | 1 | ||
Living-donor kidney | 1.125 | 0.482 | 0.020 | 3.082 | 1.128 | 7.579 |
Constant | -2.353 | 0.645 | 0.580 | 1.356 |
*Factors significantly associated with the non-adherent group were selected by a forward stepwise regression method; **Reference group.
In this study, features of adherent kidney transplant outpatients were studied though analysis of questionnaire responses.
The most interesting result was the different proportion of patients with a living-donor kidney transplantation or a cadaveric kidney transplantation in the adherent and non-adherent groups. This result was also supported by the logistic regression analysis because living-donor kidney or cadaveric kidney was selected as a significant factor associated with drug compliance. In short, it is possible that patients who had a cadaveric kidney transplantation managed themselves better than those who had a living-donor kidney transplantation. To the best of our knowledge, this study is the first to report this interesting and unexpected result.
Living-donor kidneys are usually donated from a blood relative, while cadaveric kidneys are donated by a stranger. Therefore, cadaveric kidney donation cannot meet the needs of all patients who require a kidney transplantation in Japan. In the USA, the waiting time for a deceased kidney donation may be 2 - 5 years [
In Japan, living-donor kidneys are donated from family members (such as brothers, sisters, parents and children). Although fatality resulting from live kidney donation is extremely rare, the risks of donation are considered similar to those involved with any major surgery, such as bleeding and infection. Donors face physical and mental burdens.
We also studied the cultural background of the patients (all subjects were Japanese). Doi advocated a unique Japanese concept, which is called “amae”. It is understood as a unique and comfortable relationship of dependency among Japanese [
In the Chi-square test, the factor “with or without a job” showed a P value of 0.022; however, this finding was not supported by the results of the logistic regression analysis. Patients with jobs lead regular lives and they can routinely take medicine. By contrast, it is not as easy for a patient without a job because their daily routine is not controlled by their work. Therefore, they may forget to take medicine.
The results of this study are important for medical staff in order to improve the quality of medical intervention as well as the quality of life of patients. However, our study has several limitations. First, the number of cases were limited in this study, therefore, further research, such as larger scale studies, are required to support the findings. Second, “amae” is a unique Japanese concept and patients with different cultural backgrounds should be studied for comparison. Third, we did not investigate personality tendencies of each patient, for example, if their attitudes were optimistic or pessimistic. Moreover, we did not inquire about their family relationships, educational background and income. These would be valuable factors to assess in any future study.
The results of this study suggest that the short periods after transplantation (2 - 5 years) and cadaveric kidney transplantation are factors significantly associated with self-management. Additionally, whether patients have a job or not is another significant factor. Behind these results, a Japanese unique concept, “amae”, could also be found. We consider that the cultural background of patients as well as the knowledge and techniques of medical staff must be studied.
The authors wish to thank all medical staff, especially nursing staff, and patients who participated in this study.
Kindly take a few minutes and choose only one best answer to complete the following questionnaire and then hand it back to us.
Q1. Please choose your age group. (Age)
□0: 20 - 29 years old
□1: 30 - 39 years old
□2: 40 - 49 years old
□3: 50 - 59 years old
□4: ≥60 years old
Q2. You are male or female? (Gender)
□0: Male
□1: Female
Q3. Please choose the period after transplantation. (Years) (Period after transplantation)
□0: <2 years
□1: 2 - 5 years
□2: 5 - 10 years
□3: >10 years
Q4. Before kidney transplantation, did you receive dialysis? (Dialysis before transplantation)
□0: No (If No, please skip the next question)
□1: Yes (If Yes, please answer the next question)
Q5. Please choose one group for the period of dialysis before the kidney transplantation. (Period of dialysis)
□0: <1 year
□1: 1 - 2 years
□2: 2 - 5 years
□3: 5 - 10 years
□4: >10 years
Q6. Did you have a living-donor kidney transplantation or a cadaveric kidney transplant? (Living-donor kidney or Cadaveric kidney)
□0: Living-donor kidney transplantation
□1: Cadaveric kidney transplantation
Q7. Do you have a job? (Job)
□0: No
□1: Yes
Q8. Have you forgotten to take medicine prescribed at the hospital? (0 = Adherent; 1 = Non-adherent)
□0: No
□1: Yes
Thank you very much.