- Email: [email protected]
Depression and Quality of Life in Living Related Renal Transplantation
Depression and Quality of Life in Living Related Renal Transplantation A. Virzì, M.S. Signorelli, M. Veroux, G. Giammarresi, S. Maugeri, A. Nicoletti, and P. Veroux ABSTRACT Background. More than other operations on the body, organ transplantation has a psychological resonance relating to the self and body image representation, both in donors and in recipients. In the medical literature there are many psychopathological patterns related to ESRD and to the changes in psychologic assessment and lifestyle after transplantation. Similar changes have been found in living donors. Methods. Forty-eight donor-recipient couples were evaluated before and 4 months after transplantation, using clinical interview, according to the DSM IV TR criteria; The structured Interview for renal transplantation, both for recipients and for donors; psychodiagnostic tests: mini-mental state; Hamilton Rating Scale for Depression; Hamilton Anxiety Scale; Self-Rating Anxiety Scale; Short-Form 36 Health Survey Questionnaire. Results. Comparisons by paired Students t tests showed a significant Hamilton depression variation among recipients, with improvement in the gained score and reduction of depressive symptom (Hamilton score ⬎7) frequency from 45.8% to 32%, and a decreased proportion of patients with a score ⬎18 from 16.4% to 0%. There was no significant Hamilton Depression variation among donors, but there was somehow a reduction in depressive symptom frequency (Hamilton score ⬎7) from 37.5% to 33.3% and a decrease among ⬎18 scores from 12.6% to 0% patients. Conclusions. Living donor kidney transplantation did not adversely affect the lives of donors and significantly improved many aspects of the lives of recipients. However, physical and psychological aspects may be impaired by living donation. Careful donor selection, with appropriate pretransplantation psychiatric consulting, allows those with a normal life quality to donate without consequence to their physical or psychological status.
K
IDNEY TRANSPLANTATION is the best renal placement therapy when focusing on survival, since it betters the quality of life in patients who otherwise will be dialysis-dependent. The shortage of cadaveric kidneys for transplantation and the growing time on waiting lists have forced the medical community to look for alternatives, such as living kidney donation. The American Society of Transplantation recommends a formal psychosocial evaluation for transplant candidates.1 The benefits of this assessment are clearly evident in determining factors that may influence a decision to place an individual on the waiting list. More than other surgical interventions, organ transplantation has a psychological resonance relating to the self and body image representation. The growing trend to stimulate living donation to increase organ availability has lead to studies of some psychopathologic patterns that are typical of patients with
end-stage renal disease, and could be found even in living donors. Kidney transplantation is considered not only a surgical intervention but a complex course in which extraordinary physiological and psychological stress sets substantial demand on the patient and his or her family. In every step, from the first surgical evaluation to the subsequent rehabil-
From the Department of Biology, Medicine and Molecular Biology, Psychiatry Unit (A.V., M.S.S., G.G., S.M.); Department of Surgery, Transplantation and Advanced Technologies, Organ Transplant Unit (M.V., P.V.); and Department of Urologic and Neurological Sciences (A.N.), University Hospital of Catania, Catania, Italy. Address reprint requests to Massimiliano Veroux, MD, PhD, Department of Surgical Sciences, Transplantation and Advanced Technologies, Organ Transplant Unit, University Hospital, Via S.Sofia, 78-95123 Catania, Italy. E-mail: [email protected]
© 2007 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/07/$–see front matter doi:10.1016/j.transproceed.2007.05.011
Transplantation Proceedings, 39, 1791–1793 (2007)
1791
1792
VIRZÌ, SIGNORELLI, VEROUX ET AL Table 1. Recipients’ Psychiatric Test Assessment Mean T0
Hamilton anxiety Hamilton depression SAS SF-36 Physical activity Physical role Pain Health Vitality Social activity Mental health
Mean T1
P Value
11.7 ⫾ 7.4 10 ⫾ 7.10 34 ⫾ 7.1
13.3 ⫾ 8 7.6 ⫾ 4.3 32.5 ⫾ 5.5
.17 .009* .27
72 ⫾ 24.3 38 ⫾ 30.7 32.3 ⫾ 15.5 70.3 ⫾ 13.6 56 ⫾ 15.3 49.3 ⫾ 14.8 60.1 ⫾ 13.6
76.7 ⫾ 15.6 58.2 ⫾ 21.7 21 ⫾ 17.2 77.7 ⫾ 12.3 63.4 ⫾ 8.4 61.7 ⫾ 15.9 76.8 ⫾ 8.5
.1 ⬍.0001* .002* .002* .009* .002* ⬍.0001*
*Statistically significant.
itation, many psychological and psychosocial problems can disturb patient’s adaptation and affect therapeutic results. Although the benefits of living donor organs for recipients are well documented, available data examining the quality of life and depression in living donors are currently limited. Some European and US studies have demonstrated that living kidney donors have similar or higher scores in all quality of life domains compared with the healthy US population.2,3 Although such studies are useful, they lack investigation of the relationship dynamics and quality of life of both donor and recipients; moreover, many studies have included only a small sample size. Most studies have investigate the quality of life domains before and after donation; however, there are some psychological aspects, such as depression and anxiety, that affect donor health in the postdonation period, limiting successful living. The present study was designed specifically to evaluate the anxious and depressive symptom frequency and prevalence among recipients and living donors as well as how they may influence postoperative compliance and quality of life.
PATIENTS AND METHODS This prospective, longitudinal study was performed between January 2002 and August 2004. During the course of the study all donor nephrectomies were performed using an open technique without resection of the 12th rib. Only adult subjects (⬎18 years) were included in this study as agreed with the local ethics committee. Both donor and recipient were evaluated 1 month before and 6 months after the living donation using a clinical interview, according to the Diagnostic and Statistical Manual of Mental Disorders Criteria and the structured interview for renal transplantation.4,5 They were also evaluated with psychodiagnostic tests: mini-mental state; Hamilton Rating Scale for Depression, Hamilton Anxiety Scale; Self-Rating Anxiety Scale (SAS); Short-Form 36 Health Survey Questionnaire (SF-36).6,7 The donor and recipient pairs were asked to complete the tests separately, to avoid conflicting responses. The majority were completed during routine clinic visits. All the data were analyzed through EpiInfo and SPSS software.
RESULTS Patient Inclusion and Characteristics
In the study period, 48 donor-recipient pairs consented to participate: 32 pairs were parent to adult child; 12 spousal; and four siblings. The recipient mean age was 41.1 years (range 18 to 63 years), with 20 women (41.7%) and 28 men (58.3%). Concerning their occupational status, there were 11 full-time workers (22.9%), six part-time workers (12.5%), 10 housewives (20.8%), and 21 jobless patients (43.7%), the last ones affirming that they lost their jobs because of physical impairments due to the renal disease. Treatment for renal failure for the 48 recipients included 43 undergoing hemodialysis; one peritoneal dialysis; and four patients transplanted before renal replacement. The mean donor age was 54.2 years (range 33 to 81 years) with 38 women and 10 men. Recipient graft and patient survival in the study period was 100%. No donor suffered a major postoperative complication. They are all alive in good health.
Psychiatric Evaluation
The mean physical scores for recipients are summarized in Table 1. Donor mean physical scores are shown in Table 2. Recipient evaluation by mini-mental state examination gave a mean score of 28.3 ⫾ 3.7, while that of donors was 28.2 ⫾ 2.6. Test comparison preformed through paired Student t test showed a significant Hamilton depression variation in recipients, with an improvement and subsequent reduction of depressive symptoms (Hamilton score ⬎7) frequency from 45.8% to 32%; interestingly, there was a reduction of the proportion of patients with high scores (Hamilton ⬎18) from 16.4% to 0%. There was no significant variation in SAS scores. SF-36 questionnaires showed a significant improvement in all subscales except for physical activities. There was no significant Hamilton depression variation among donors, but there was a reduction of depressive symptom frequency (Hamilton score ⬎7) from 37.5% to 33.3% and in detail a decrease among high score patients (Hamilton score ⬎ 18) from 12.6% to 0%. There was no Table 2. Donors’ Psychiatric Test Assessment Mean T0
Hamilton anxiety Hamilton depression SAS SF-36 Physical activity Physical role Pain Health Vitality Social activity Mental health *Statistically significant.
Mean T1
8.9 ⫾ 5.5 5.8 ⫾ 3.4 28.2 ⫾ 5.2
8.9 ⫾ 5.7 6.5 ⫾ 5.3 28 ⫾ 5.1
98.5 ⫾ 4.5 98.9 ⫾ 5.1 3.7 ⫾ 10.9 54.6 ⫾ 15.9 56.7 ⫾ 14.8 52.7 ⫾ 12.7 64.8 ⫾ 13.4
78.7 ⫾ 9.7 77.9 ⫾ 11 27.7 ⫾ 9.3 56.8 ⫾ 11.7 55.7 ⫾ 16.6 57.7 ⫾ 10.8 66.6 ⫾ 17
P Value
.9 .4 .8 ⬍.0001* ⬍.0001* ⬍.0001* ⬍.0001* .7 .06 .7
DEPRESSION AND QUALITY OF LIFE
significant variation in SAS scores. SF-36 showed significant worsening in physical function and pain subscales. DISCUSSION
The complexity of renal transplantation as a point of arrival to end-stage renal disease is comparable to the beginning of a new life, to which both recipient and donor must adapt. This treatment is not only a reflection but also an intervention topic for liaison psychiatry, because of the psychological implications of somatic disease. The goal of health care today is to improve the quality of life of patients in addition to curing physical illness.7–9 Kidney transplant recipients tend to manifest improvements in perceived quality of life more so than patients treated by dialysis.10 This observation was corroborated by studies that have demonstrated an improvement in overall quality of life rating from pretransplant to posttransplant.11,12 However, while the improvement in recipient quality of life is well established, little is known about the quality of life and the incidence of psychiatric disorders in living donors. The results of methodical studies have shown that donor quality of life is at least comparable with that of general population. Also in donors, and not only in recipients, donation attitude, motivations, and psychological profile are important for posttransplant adaptation and qualityof-life prognostic assessment. This study demonstrated that living donor kidney transplantation affected donor quality of life, which appeared decreased in physical aspects, especially due to pain symptoms and probably to the concern about living with a solitary kidney. However, there was a general improvement in psychological status and a boost in self-esteem. Donor psychological status was related to expectations long-term results of transplantation; in this way, a favorable outcome of the transplant, by seeing their own relatives in a better quality of health, may often give strength to donors. However, expectations may be frustrated. A donor who gave a kidney that doesn’t work often become demoralized. He may feel he gave a part of himself vainly and this may obviously negatively affect his psychological status. Depressive symptoms may be the most common. Significant problems occur among donors after a failed transplantation. This possibility should always be presented to both donor and recipient during the pretransplant interview. The recipient group showed depressive symptoms above all at the pretransplantation assessment, which were related to the end-stage renal disease and to the psychological distress due to dialysis. Freedom from dialysis, even in
1793
preemptive recipients, resulted in a dramatic quality of life improvement, especially in physical functions, social activities, and mental health. Interestingly, there was no significant variation in anxiety tests, probably due to the fear of rejection and to the side effects, of medicines,9,13 whereas there was a significant decrease in Hamilton Depression scores. This study demonstrated that living donor kidney transplantation does not adversely affect the lives of donors and significantly improves many aspects of the lives of recipients. However, some physical and psychological aspects may be impaired by donation. Careful donor selection, with appropriate pretransplantation psychiatric consulting, allows those with a normal quality of life to donate without consequence to their physical and psychological status. REFERENCES 1. Kasiske BL, Cangro GB, Hariharan S, et al: The evaluation of renal transplantation candidates: clinical practice guidelines. Am J Transplant 1(suppl 2):1, 2002 2. Johnson EM, Anderson JK, Jacobs C, et al: Long-term follow up of living kidney donors: quality of life after donation. Transplantation 67:717, 1999 3. Griva K, Ziegelmann JP, Thompson D, et al: Quality of life and emotional responses in cadaver and living related transplant recipients. Nephrol Dial Transplant 17:2204, 2002 4. Mori DL, Gallagher P, Milne J: The Structured Interview for Renal Transplantation—SIRT. Psychosomatics 41:393, 2000 5. Leo RJ, Smith BA, Mori DL: Guidelines for conducting a psychiatric evaluation of the unrelated kidney donor. Psychosomatics 44:452, 2003 6. Ku JH: Health-related quality of life of living kidney donors: review of the short term 36-health questionnaire survey. Transpl Int 18:1309, 2005 7. Smith GC, Trauer T, Kerr P, et al: Prospective psychosocial monitoring of living kidney donors using the SF-36 health survey. Transplantation 76:807, 2003 8. Lumsdaine JA, Wray A, Power MJ, et al: Higher quality of life in living donor kidney transplantation: prospective cohort study. Transpl Int 18:975, 2005 9. Muehrer RJ, Becker BN: Life after transplantation: new transitions in quality of life and psychological distress. Semin Dial 18:124, 2005 10. Evans RW, Manninen DL, Garrison LP Jr, et al: The quality of life of patients with end-stage renal disease. N Engl J Med 312:553, 1985 11. Laupacis A, Keown P, Pus N, et al: A study of the quality of life and cost-utility of renal transplantation. Kidney Int 50:235, 1996 12. Dew MA, Switzer GE, Goycoolea JM, et al: Does transplantation produce quality of life benefits? A quantitative analysis of the literature. Transplantation 64:1261, 1997 13. De Geest S, Moons P: The patient’s appraisal of side-effects: the blind spot in quality-of-life assessments in transplant recipients. Nephrol Dial Transplant 15:457, 2000
K
IDNEY TRANSPLANTATION is the best renal placement therapy when focusing on survival, since it betters the quality of life in patients who otherwise will be dialysis-dependent. The shortage of cadaveric kidneys for transplantation and the growing time on waiting lists have forced the medical community to look for alternatives, such as living kidney donation. The American Society of Transplantation recommends a formal psychosocial evaluation for transplant candidates.1 The benefits of this assessment are clearly evident in determining factors that may influence a decision to place an individual on the waiting list. More than other surgical interventions, organ transplantation has a psychological resonance relating to the self and body image representation. The growing trend to stimulate living donation to increase organ availability has lead to studies of some psychopathologic patterns that are typical of patients with
end-stage renal disease, and could be found even in living donors. Kidney transplantation is considered not only a surgical intervention but a complex course in which extraordinary physiological and psychological stress sets substantial demand on the patient and his or her family. In every step, from the first surgical evaluation to the subsequent rehabil-
From the Department of Biology, Medicine and Molecular Biology, Psychiatry Unit (A.V., M.S.S., G.G., S.M.); Department of Surgery, Transplantation and Advanced Technologies, Organ Transplant Unit (M.V., P.V.); and Department of Urologic and Neurological Sciences (A.N.), University Hospital of Catania, Catania, Italy. Address reprint requests to Massimiliano Veroux, MD, PhD, Department of Surgical Sciences, Transplantation and Advanced Technologies, Organ Transplant Unit, University Hospital, Via S.Sofia, 78-95123 Catania, Italy. E-mail: [email protected]
© 2007 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/07/$–see front matter doi:10.1016/j.transproceed.2007.05.011
Transplantation Proceedings, 39, 1791–1793 (2007)
1791
1792
VIRZÌ, SIGNORELLI, VEROUX ET AL Table 1. Recipients’ Psychiatric Test Assessment Mean T0
Hamilton anxiety Hamilton depression SAS SF-36 Physical activity Physical role Pain Health Vitality Social activity Mental health
Mean T1
P Value
11.7 ⫾ 7.4 10 ⫾ 7.10 34 ⫾ 7.1
13.3 ⫾ 8 7.6 ⫾ 4.3 32.5 ⫾ 5.5
.17 .009* .27
72 ⫾ 24.3 38 ⫾ 30.7 32.3 ⫾ 15.5 70.3 ⫾ 13.6 56 ⫾ 15.3 49.3 ⫾ 14.8 60.1 ⫾ 13.6
76.7 ⫾ 15.6 58.2 ⫾ 21.7 21 ⫾ 17.2 77.7 ⫾ 12.3 63.4 ⫾ 8.4 61.7 ⫾ 15.9 76.8 ⫾ 8.5
.1 ⬍.0001* .002* .002* .009* .002* ⬍.0001*
*Statistically significant.
itation, many psychological and psychosocial problems can disturb patient’s adaptation and affect therapeutic results. Although the benefits of living donor organs for recipients are well documented, available data examining the quality of life and depression in living donors are currently limited. Some European and US studies have demonstrated that living kidney donors have similar or higher scores in all quality of life domains compared with the healthy US population.2,3 Although such studies are useful, they lack investigation of the relationship dynamics and quality of life of both donor and recipients; moreover, many studies have included only a small sample size. Most studies have investigate the quality of life domains before and after donation; however, there are some psychological aspects, such as depression and anxiety, that affect donor health in the postdonation period, limiting successful living. The present study was designed specifically to evaluate the anxious and depressive symptom frequency and prevalence among recipients and living donors as well as how they may influence postoperative compliance and quality of life.
PATIENTS AND METHODS This prospective, longitudinal study was performed between January 2002 and August 2004. During the course of the study all donor nephrectomies were performed using an open technique without resection of the 12th rib. Only adult subjects (⬎18 years) were included in this study as agreed with the local ethics committee. Both donor and recipient were evaluated 1 month before and 6 months after the living donation using a clinical interview, according to the Diagnostic and Statistical Manual of Mental Disorders Criteria and the structured interview for renal transplantation.4,5 They were also evaluated with psychodiagnostic tests: mini-mental state; Hamilton Rating Scale for Depression, Hamilton Anxiety Scale; Self-Rating Anxiety Scale (SAS); Short-Form 36 Health Survey Questionnaire (SF-36).6,7 The donor and recipient pairs were asked to complete the tests separately, to avoid conflicting responses. The majority were completed during routine clinic visits. All the data were analyzed through EpiInfo and SPSS software.
RESULTS Patient Inclusion and Characteristics
In the study period, 48 donor-recipient pairs consented to participate: 32 pairs were parent to adult child; 12 spousal; and four siblings. The recipient mean age was 41.1 years (range 18 to 63 years), with 20 women (41.7%) and 28 men (58.3%). Concerning their occupational status, there were 11 full-time workers (22.9%), six part-time workers (12.5%), 10 housewives (20.8%), and 21 jobless patients (43.7%), the last ones affirming that they lost their jobs because of physical impairments due to the renal disease. Treatment for renal failure for the 48 recipients included 43 undergoing hemodialysis; one peritoneal dialysis; and four patients transplanted before renal replacement. The mean donor age was 54.2 years (range 33 to 81 years) with 38 women and 10 men. Recipient graft and patient survival in the study period was 100%. No donor suffered a major postoperative complication. They are all alive in good health.
Psychiatric Evaluation
The mean physical scores for recipients are summarized in Table 1. Donor mean physical scores are shown in Table 2. Recipient evaluation by mini-mental state examination gave a mean score of 28.3 ⫾ 3.7, while that of donors was 28.2 ⫾ 2.6. Test comparison preformed through paired Student t test showed a significant Hamilton depression variation in recipients, with an improvement and subsequent reduction of depressive symptoms (Hamilton score ⬎7) frequency from 45.8% to 32%; interestingly, there was a reduction of the proportion of patients with high scores (Hamilton ⬎18) from 16.4% to 0%. There was no significant variation in SAS scores. SF-36 questionnaires showed a significant improvement in all subscales except for physical activities. There was no significant Hamilton depression variation among donors, but there was a reduction of depressive symptom frequency (Hamilton score ⬎7) from 37.5% to 33.3% and in detail a decrease among high score patients (Hamilton score ⬎ 18) from 12.6% to 0%. There was no Table 2. Donors’ Psychiatric Test Assessment Mean T0
Hamilton anxiety Hamilton depression SAS SF-36 Physical activity Physical role Pain Health Vitality Social activity Mental health *Statistically significant.
Mean T1
8.9 ⫾ 5.5 5.8 ⫾ 3.4 28.2 ⫾ 5.2
8.9 ⫾ 5.7 6.5 ⫾ 5.3 28 ⫾ 5.1
98.5 ⫾ 4.5 98.9 ⫾ 5.1 3.7 ⫾ 10.9 54.6 ⫾ 15.9 56.7 ⫾ 14.8 52.7 ⫾ 12.7 64.8 ⫾ 13.4
78.7 ⫾ 9.7 77.9 ⫾ 11 27.7 ⫾ 9.3 56.8 ⫾ 11.7 55.7 ⫾ 16.6 57.7 ⫾ 10.8 66.6 ⫾ 17
P Value
.9 .4 .8 ⬍.0001* ⬍.0001* ⬍.0001* ⬍.0001* .7 .06 .7
DEPRESSION AND QUALITY OF LIFE
significant variation in SAS scores. SF-36 showed significant worsening in physical function and pain subscales. DISCUSSION
The complexity of renal transplantation as a point of arrival to end-stage renal disease is comparable to the beginning of a new life, to which both recipient and donor must adapt. This treatment is not only a reflection but also an intervention topic for liaison psychiatry, because of the psychological implications of somatic disease. The goal of health care today is to improve the quality of life of patients in addition to curing physical illness.7–9 Kidney transplant recipients tend to manifest improvements in perceived quality of life more so than patients treated by dialysis.10 This observation was corroborated by studies that have demonstrated an improvement in overall quality of life rating from pretransplant to posttransplant.11,12 However, while the improvement in recipient quality of life is well established, little is known about the quality of life and the incidence of psychiatric disorders in living donors. The results of methodical studies have shown that donor quality of life is at least comparable with that of general population. Also in donors, and not only in recipients, donation attitude, motivations, and psychological profile are important for posttransplant adaptation and qualityof-life prognostic assessment. This study demonstrated that living donor kidney transplantation affected donor quality of life, which appeared decreased in physical aspects, especially due to pain symptoms and probably to the concern about living with a solitary kidney. However, there was a general improvement in psychological status and a boost in self-esteem. Donor psychological status was related to expectations long-term results of transplantation; in this way, a favorable outcome of the transplant, by seeing their own relatives in a better quality of health, may often give strength to donors. However, expectations may be frustrated. A donor who gave a kidney that doesn’t work often become demoralized. He may feel he gave a part of himself vainly and this may obviously negatively affect his psychological status. Depressive symptoms may be the most common. Significant problems occur among donors after a failed transplantation. This possibility should always be presented to both donor and recipient during the pretransplant interview. The recipient group showed depressive symptoms above all at the pretransplantation assessment, which were related to the end-stage renal disease and to the psychological distress due to dialysis. Freedom from dialysis, even in
1793
preemptive recipients, resulted in a dramatic quality of life improvement, especially in physical functions, social activities, and mental health. Interestingly, there was no significant variation in anxiety tests, probably due to the fear of rejection and to the side effects, of medicines,9,13 whereas there was a significant decrease in Hamilton Depression scores. This study demonstrated that living donor kidney transplantation does not adversely affect the lives of donors and significantly improves many aspects of the lives of recipients. However, some physical and psychological aspects may be impaired by donation. Careful donor selection, with appropriate pretransplantation psychiatric consulting, allows those with a normal quality of life to donate without consequence to their physical and psychological status. REFERENCES 1. Kasiske BL, Cangro GB, Hariharan S, et al: The evaluation of renal transplantation candidates: clinical practice guidelines. Am J Transplant 1(suppl 2):1, 2002 2. Johnson EM, Anderson JK, Jacobs C, et al: Long-term follow up of living kidney donors: quality of life after donation. Transplantation 67:717, 1999 3. Griva K, Ziegelmann JP, Thompson D, et al: Quality of life and emotional responses in cadaver and living related transplant recipients. Nephrol Dial Transplant 17:2204, 2002 4. Mori DL, Gallagher P, Milne J: The Structured Interview for Renal Transplantation—SIRT. Psychosomatics 41:393, 2000 5. Leo RJ, Smith BA, Mori DL: Guidelines for conducting a psychiatric evaluation of the unrelated kidney donor. Psychosomatics 44:452, 2003 6. Ku JH: Health-related quality of life of living kidney donors: review of the short term 36-health questionnaire survey. Transpl Int 18:1309, 2005 7. Smith GC, Trauer T, Kerr P, et al: Prospective psychosocial monitoring of living kidney donors using the SF-36 health survey. Transplantation 76:807, 2003 8. Lumsdaine JA, Wray A, Power MJ, et al: Higher quality of life in living donor kidney transplantation: prospective cohort study. Transpl Int 18:975, 2005 9. Muehrer RJ, Becker BN: Life after transplantation: new transitions in quality of life and psychological distress. Semin Dial 18:124, 2005 10. Evans RW, Manninen DL, Garrison LP Jr, et al: The quality of life of patients with end-stage renal disease. N Engl J Med 312:553, 1985 11. Laupacis A, Keown P, Pus N, et al: A study of the quality of life and cost-utility of renal transplantation. Kidney Int 50:235, 1996 12. Dew MA, Switzer GE, Goycoolea JM, et al: Does transplantation produce quality of life benefits? A quantitative analysis of the literature. Transplantation 64:1261, 1997 13. De Geest S, Moons P: The patient’s appraisal of side-effects: the blind spot in quality-of-life assessments in transplant recipients. Nephrol Dial Transplant 15:457, 2000