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NDT Advance Access originally published online on August 18, 2006
Nephrology Dialysis Transplantation 2006 21(11):3238-3242; doi:10.1093/ndt/gfl433
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© The Author [2006]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Quality of life and surgical complications of kidney donors in the late post-operative period in Brazil

Daniel Xavier Lima, Andy Petroianu and Heather Lynn Hauter

Hospital of Clinics of the Federal University of Minas Gerais, Brazil

Correspondence and offprint requests to: Daniel Xavier Lima, Rua Engenheiro Carlos Antonini, 136 – apto. 201 Belo Horizonte, MG 30240-280, Brazil. Email: limadx{at}hotmail.com



   Abstract
Top
 Abstract
Introduction
 Subjects and methods
 Results
 Discussion
 References
 
Background. Live donor kidney transplantation is a procedure conducted with proven efficacy and safety for its recipients, although the post-operative outcome of the donors has been subjected to little investigation.

Methods. This study assessed 100 donors (34 men and 66 women) for kidney transplants conducted at the Hospital of Clinics of the Federal University of Minas Gerais, Brazil in a post-operative period longer than 2 years. The quality of life evaluation was performed according to the SF-36 health survey.

Results. The quality of life of donors, especially female ones, was equal to or higher than the quality of life of the control group with respect to all the parameters of the short-form health survey. The main complaints were dissatisfaction with the medical service (31%) and with the aspect of the scar (24%). Six percent of the donors regretted the donation and the relationship of 13% of the donors with the recipient of the transplant deteriorated. The rates of overweight and obesity were larger than the Brazilian people averages. The frequency of arterial hypertension did not differ from the average of the Brazilian population, although half of these patients did not previously know their blood pressure levels.

Conclusions. The quality of life of kidney donors was not different than it was for the healthy individuals of the community, although there were variations among donor subgroups. There was dissatisfaction related to the medical service and over the surgical scar, in addition to prevalence of obesity and arterial hypertension above the expectancy.

Keywords: arterial hypertension; kidney transplant; living donors; obesity; quality of life



   Introduction
Top
 Abstract
 Introduction
Subjects and methods
 Results
 Discussion
 References
 
In Brazil, live donor kidney transplantation has become more common in the last few years in comparison with cadaver donor transplantation. According to the Brazilian Association of Organ and Tissue Transplants (ABTO—Associação Brasileira de Transplantes de Órgãos e Tecidos), live donor kidney transplants correspond to ~60% of all cases of kidney transplants in 2002 and 2003 and 48% in 2004. There are 54 000 patients on dialysis, which corresponds to a prevalence of 300 per million population per year (pmp/y) and 17 000 new patients start dialysis each year. Due to complications on dialysis or vascular diseases, the annual mortality of patients is 14.9% [1].

The Brazilian laws that regulate organ donations (Law # 9434, February 1997 and Law # 10211, March 2001) aim to guarantee equal access for the population to transplant procedures. Thanks to the adopted transplant policy, the Brazilian programme is one of the most efficient in the world considering the available financial resources that derive mostly from the public health system [2]. Brain death with heart beating is recognized by law and the donation depends on the authorization of family members. Live donor transplantation is also regulated by laws and judicial authorization is necessary for non-related donors. Donations from cadavers in which brain death was established will possibly increase over the next few years [2].

The lack of cadaver kidneys and the long waiting time on the transplant waiting list play pivotal roles in the high number of live donor kidney transplants when compared with the number of cadaver donor's procedures. Live donor kidney transplantation plays a pivotal role all over the world and the current trend is to increase the number of these procedures [3], which may be the main alternative for reducing the waiting lists for transplants.

According to the Transplantation Society of Latin America and the Caribbean report, approximately 50% of kidney transplants conducted in Latin America and the Caribbean are with live donors [4]. In the United States, the Middle East and in Asia, most of the kidney transplants are also from live donors [5–7]. Otherwise, in European centres living donors are generally less used.

Medical literature indicates that kidney donation is currently a safe procedure with low morbidity and mortality and high rates of satisfaction among the donors [8,9]. Important aspects related to kidney donation that have been subjected to little investigation are quality of life and complications related to the procedure. There are some recent studies concerning living donor transplantation in other countries, most of them using the standardized questionnaire short-form health survey (SF-36) [10].

It is a generic assessment and it has been useful in comparing general and specific populations with various disturbances, as well as and in healthy people. The SF-36 has undergone reliability and validity testing in many countries, including Brazil [11]. The cultural and socio-economic singularities of the Brazilian people and the possible differences in medical treatment indicate the need to better understand the reality of the kidney donors in this country.

The purpose of this study was to evaluate the kidney donors in the late post-operative period, analysing their quality of life, complications related to the surgical procedure and the quality of the medical service.



   Subjects and methods
Top
 Abstract
 Introduction
 Subjects and methods
Results
 Discussion
 References
 
The Ethics Committee for Research of the Federal University of Minas Gerais, Brazil approved the protocol of this investigation. This work assessed 100 donors for kidney transplants conducted at Hospital of Clinics of the Federal of Minas Gerais in a post-operative period longer than 2 years. All patients underwent open retroperitoneal nephrectomies. The control group consisted of 100 healthy persons of the community. The characteristics of donors and individuals of the control group submitted to the SF-36 health survey are listed in Table 1.


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  		Table 1. Kidney donors and control group ages according to the gender

 
The control group, used only to answer the SF-36 questionnaire, consisted of healthy volunteers between the ages of 18 and 60. Controls were matched by sex and age with the donors. Exclusion criteria were chronic disease, with the exception of controlled systemic hypertension and previous surgeries. The subjects answered the SF-36 health survey individually and did not undergo a physical examination or another form of health assessment.

Patients were identified by means of hospital records and those with more than two post-donation years were randomly included. These patients were contacted by telephone, and at this time the objective of the study was outlined. The first 100 donors who accepted to participate in the research were examined and interviewed individually by the physician responsible for this study.

During the interview, after signing the informed consent, patients received the Medical Outcomes Study 36-Item Short-Form Health Survey translated into Portuguese [11]. The patients read and answered the questionnaire in writing with occasional assistance from the examiner in cases of illiteracy. After filling out the SF-36 questionnaire, patients were submitted to an oriented anamnesis that was based on a list of established questions.

Finally, patients underwent a physical examination and were categorized according to their body mass index. When the systolic blood pressure was >140 mmHg or the diastolic blood pressure >90 mmHg, new measurements were taken after 10 min to confirm the results. Patients were considered hypertensive if they maintained high blood pressure levels during the second measurement and were sent to a cardiologist. Incisional hernias were investigated by a thorough examination of the surgical scar.

The chi-square test was applied to verify when the variances were homogenous. In presence of variables with Gaussian distribution, the ANOVA test (analysis of variance) was used. The Kruskal–Wallis test was applied when the variables did not present a Gaussian distribution. After verifying the homogeneity of variances in the multiple groups’ analysis by means of the chi-square test, the Duncan test was applied to compare the averages of different sized groups. A P-value of <0.05 indicated that the groups were statistically different.



   Results
Top
 Abstract
 Introduction
 Subjects and methods
 Results
Discussion
 References
 
According to our purpose of investigating 100 kidney donors, we contacted patients whose donation was more than 2 years prior. Only six of them refused our invitation. Thus, to attain a group of 100 patients, we contacted 106 donors. The complaints and suggestions of these patients are included in Table 2.


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  		Table 2. Complaints and suggestions of 100 living donors for kidney transplantation

 
Clinical examination registered high arterial blood pressure in 31 patients, 14 of them using anti-hypertensive medication. Otherwise 17% of these patients neglected to take anti-hypertensive medication.

Abdominal problems were more frequent in the males. Incisional hernias were three times more frequent in men (9%) when compared with women (3%).

The post-operative recovery was prolonged (5 ± 4 months) and increased rates of overweight and obesity were observed among both men (41% overweight and 18% obese) and women (30% overweight and 21% obese).

The kidney donors presented a quality of life index similar to the control group in five of the eight parameters evaluated according to the SF-36 survey (Table 3). Donors presented better indexes than the control group when vitality (P = 0.002) and general health (P = 0.0004) were evaluated. This difference was due to the higher score of female donors, as observed in Table 4.


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  		Table 3. Quality of life of the kidney donors (SF-36) compared with the control group

 

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  		Table 4. Quality of life of the kidney donors (SF-36), comparing men and women

 
There was a discrepancy among donors according to their relation with the recipient in the following components of the SF-36 quality of life scale (P < 0.05): physical function, bodily pain, vitality and role emotional (Table 5).


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  		Table 5. Quality of life (SF-36) of the kidney donors according to the relationship with the recipient

 


   Discussion
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
References
 
Differences in educational, cultural and socio-economic backgrounds may influence the quality of life in living kidney donors [12]. This study is justified by the paucity of information on the outcome of these patients by Brazilian and South American transplantation centres.

The 94% of donors who accepted to participate in our investigation demonstrates the significant involvement of patients with the kidney transplant. Most of the donors that refused to be included in this research live in other cities, others justified their absence due to their job.

The incidence of regret over the donation in this study cannot be ignored. In most series, a variable number of patients have regretted the donation, ranging from 0.8 to 15% [13]. The main reasons for dissatisfaction are the loss of the graft, the death of the recipient and the lack of explanations provided by the medical team before the transplant [13]. Donors seemed to demand more attention than is usually given before the operation and during the post-operative period. Contrary to the recipients, who receive the kidney and the opportunity of a new life with the transplant, most of the donors are healthy persons who decided to undergo the procedure to improve the health of a loved one.

Weight gain was probably a consequence of the post-operative low physical activity. The frequency of donors above the ideal weight limit was higher than the Brazilian adult average. Nevertheless, these findings are relevant considering the high prevalence of obesity in Brazil [14]. Obese persons have a greater probability of presenting numerous disturbances such as hypertension, diabetes, heart disease and even cancer [15].

Considering the frequency of hypertension in this study, it is worth considering that donors are more vulnerable to the effects of kidney removal. These results are in accordance with literature, which reveals a frequency of arterial hypertension in kidney donors similar to that of the population in general [16].

The predominance of women as donors was a theme that was discussed at the Amsterdam Forum on Living Kidney Donation [17]. It was suggested that this reflects the female psychological submission that occurs in many nations. Thus this fact may have contributed to the higher number of women in this study. In view of the lack of organs for transplantation, spouses have been considered as an alternative among the non-related donors. In this investigation, the spouse subgroup was made up only of female donors, and the results showed low levels of quality of life, according to them. A less favourable outcome of spouses had not been related yet. In certain cultures where the male is a dominant figure in the family, he may coerce the wife into becoming a so-called ‘voluntary’ donor. It is for these reasons that the transplant of spousal organs must be better ruled out. However, there is no ethical objection to using emotionally related donors in addition to genetically related donors, since this policy favours family relationship. In the literature, there are defenders of this type of donation [18], with good results for the recipients. It should be distinguished between donors who are coerced and those who are motivated by love and altruism.

The physical recovery of the parents was worse than that of the children, cousins, nephews, and members of the control group. This result suggests that parents, who are older, have a natural organic debility that interferes in the post-operative recovery for work and other daily activities. Nevertheless, older parents recovered better than the spouses, who are younger. This result supports the need to further investigate the unfavourable outcome of spouse donors.

When living kidney donors are followed prospectively, the SF-36 scores obtained 12 months after donation may show a decrease in vitality, general health and bodily pain parameters, when compared with pre-operative data [19]. Despite the complaints related to medical services and the prolonged post-operative recovery, the quality of life of kidney donors was similar to healthy individuals.

The high proportion of incisional hernias is probably due to a non-perfect closure of the flank, which was performed by the residents, without the direct assistance of a senior surgeon. Recently, the kidney harvesting from living donors started to be performed by laparoscopic means. It is worth considering that laparoscopic procedures would avoid this adverse effect. The comparison of laparoscopic and open nephrectomies did not differ by using SF-36 scores [20]. However, the functional recovery of patients was significantly faster after laparoscopy. Following our line of research, we believe it is worth proposing future prospective studies to evaluate the contribution of medical service improvement in the quality of life of living kidney donors.

Conflict of interest statement. None declared.



   References
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 

  1. Garcia VD, Garcia CD, Keitel CD, et al. (2003) Living kidney transplantation in Brazil: unwanted procedure of choice in view of cadaver organ shortage. Transplant Proc 35:1182–1184.[CrossRef][Web of Science][Medline]
  2. Medina-Pestana JO, Vaz MLS, Park SI. (2002) Organ transplant in Brazil. Transplant Proc 34:441–443.[CrossRef][Web of Science][Medline]
  3. Cohen B and Persijn GG. (1997) Trends in organ donation. Transplant Proc 29:3301–3302.[CrossRef][Web of Science][Medline]
  4. Garcia VD. (2003) Latin America transplantation report—The Transplantation Society of Latin America and the Caribbean.
  5. Ellison MD, McBride MA, Taranto SE, Delmonico FL, Francis L, Kauffman HM. (2002) Living kidney donors in need of kidney transplants: a report from the organ procurement and transplantation network. Transplantation 74:1349–1351.[CrossRef][Web of Science][Medline]
  6. Daar AS. (2001) South Mediterranean, Middle East and subcontinent organ transplantation activity. Transplant Proc 33:1993–1994.[CrossRef][Web of Science][Medline]
  7. Ota K. (2003) Current status of organ transplantation in Asian countries. Transplant Proc 35:8–11.[CrossRef][Web of Science][Medline]
  8. Jordan J, Sann U, Janton A, et al. (2004) Living kidney donor's long-term psychological status and health behaviour after nephrectomy—a retrospective study. J Nephrol 17:728–735.[Web of Science][Medline]
  9. Johnson EM, Remucal MJ, Gillingham KJ, Dahns RA, Najarian JS, Matas AJ. (1997) Complications and risks of living donor nephrectomy. Transplantation 64:1124–1128.[CrossRef][Web of Science][Medline]
  10. Giessing M, Reuter S, Schonberger B, et al. (2004) Quality of life of living kidney donors in Germany: a survey with the validated Short Form-36 and Giessen Subjective Complaints List-24 questionnaires. Transplantation 78:864–872.[CrossRef][Web of Science][Medline]
  11. Cicconelli RM, Ferraz MB, Santos W, Meinão I, Quaresma MR. (1999) Tradução para a língua portuguesa e validação do questionário genérico de avaliação de qualidade de vida SF-36 (Brasil SF-36). Rev Bras Reumatol 39:143–150.
  12. Ku JH. (2005) Health-related quality of life of living kidney donors: review of the short form 36-health questionnaire survey. Transplant Int 18:1309–1317.[CrossRef][Web of Science][Medline]
  13. Schover LR, Streem SB, Boparai N, Duriak K, Novick AC. (1997) The psychosocial impact of donating a kidney: long term follow-up from a urology based center. J Urol 157:1596–1600.[CrossRef][Web of Science][Medline]
  14. Abrantes MM, Lamounier JA, Colosimo EA. (2003) Prevalência de sobrepeso e obesidade nas regiões nordeste e sudeste do Brasil. Rev Assoc Med Bras 49:162–166.[Medline]
  15. Kopelman PG. (2000) Obesity as a medical problem. Nature 404:635–643.[Medline]
  16. Fehrman-Ekholm I, Duner F, Brink B, Tyden G, Elinder CF. (2001) No evidence of accelerated loss of kidney function in living kidney donors: results from a cross-sectional follow-up. Transplantation 72:444–449.[CrossRef][Web of Science][Medline]
  17. The Ethics Committee of the Transplantation Society. Transplantation (2005) 79:S53–S66.[CrossRef][Web of Science][Medline]
  18. Terasaki PI, Cecka JM, Gjertson DW, Takemoto S. (1995) High survival rates of kidney transplants from spousal and living unrelated donors. N Engl J Med 333:333–336.[Abstract/Free Full Text]
  19. Smith GC, Trauer T, Kerr PG, Chadban SJ. (2004) Prospective psychosocial monitoring of living kidney donors using the Short Form-36 Health Survey: results at 12 months. Transplantation 78:1384–1389.[CrossRef][Web of Science][Medline]
  20. Buell JF, Lee L, Martins JE, et al. (2005) Laparoscopic donor nephrectomy vs. open live donor nephrectomy: a quality of life and functional study. Clin Transplant 19:102–109.[CrossRef][Web of Science][Medline]
Received for publication: 13. 2.06
Accepted in revised form: 22. 6.06


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