Social Diagnosis of Chronic Kidney Disease Patients in Preparation for Living Donor Renal Transplantation L.S. Tirapani, C.A. Rodrigues, E.O. Marsicano, L.S.S. Braga, F.R.S. Grincenkov, S.T.C. da Silveira, R.O. Dalamura, M.G. Bastos, and H. Sanders-Pinheiro ABSTRACT Background. The relationship between socioeconomic status and clinical outcome in health and disease is complex and multifactorial. An association between low socioeconomic status and shorter patient survival in renal replacement therapy, dialysis, and transplantation, has been reported, implicating individual and environmental factors. We sought to analyze the socioeconomic and demographic characteristics of chronic kidney disease (CKD) patients in preparation for living kidney transplantation. Methods. We evaluated 60 patients with CKD-V, on hemodialysis or peritoneal dialysis and who were being prepared in our public service between July 2008 and January 2010. Socioeconomic data were collected from the records. Results. The mean age was 44.8 ⫾ 13.3 years and 51% were male. Sixty-three percent were married, most of them with children, with a family size of 3.5 ⫾ 1.45 members. They were taken a mean of 5.8 ⫾ 2.8 drugs; only half of them were dispensed by public health insurance. Almost all—93%— did not work regularly, and the majority reported some limitation in daily activities. The mean monthly income was US$1,535.70 and 76.2% reported a monthly income ⱕ US$1,810.60. The mean of school years was 7.91 ⫾ 4.19. Conclusion. Low-income patients are gaining access to preparing for renal transplantation; we believe that is inherent to the universal structure of Brazil’s public health system. Besides the low income, this population showed a considerable educational level, suggesting this characteristic made the patient more active to search the living transplant as an alternative for their CKD treatment. Knowledge about social status is essential for design strategies in minimizing its potential undesirable effects after transplantation. TUDIES ON the identification of nonbiological risk factors that lead to a faster progression of chronic kidney disease (CKD) have gained prominence in recent publications. It may be related to the difficulty of diagnosis in early stages, limitations of access to renal replacement therapy, since it involves high costs to the health system, whether public or private.1 There is strong evidence of an association between low socioeconomic status and end-stage renal disease and shorter patient survival in renal replacement therapy. Although the relationship between low socioeconomic status and renal disease is evident, the pathways for this association remain unclear. Few studies have investigated the specific ways in which socioeconomic status may affect the development, progression and complications of renal disease.2,3
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Brazil is the second in the number of kidney transplantation worldwide, and our local transplant regulatory law ensure universal access to renal replacement therapy, including all costs related to kidney transplantation.4 How-
From the Renal Transplantation Unit, Division of Nephrology, Federal University of Juiz de Fora, Minas Gerais, Brazil. Núcleo Interdisciplinar de Estudos e Pesquisas em Nefrologia (NIEPEN), Juiz de Fora, Minas Gerais, Brazil. Funded by a grant from the Fundaçao Instituto Mineiro de Estudos e Pesquisas em Nefrologia (IMEPEM), Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil. Address reprint requests to Hélady Sanders-Pinheiro, Rua Benjamin Constant, 1044/1001, Santa Helena, Juiz de Fora-MG, Brazil, 36015-400. E-mail:
[email protected]
© 2012 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/–see front matter http://dx.doi.org/10.1016/j.transproceed.2012.07.012
Transplantation Proceedings, 44, 2341–2343 (2012)
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ever, we suppose the search for a living donor precludes some differential attitude or cultural level. The objective of this study was to analyze the demographic and socioeconomic characteristics of patients with CKD in preparation to living kidney transplant in our center. METHODS Sixty dialysis patients, who were in preparation for renal transplantation at our institution, a public school hospital, from July 2008 to January 2010, were evaluated. The instrument used in data collection was the social history instrument records used by social work, through which it is possible to gather the socioeconomic survey, from questions relating to personal data, health insurance, employment status, and family composition. The study was approved by the local Ethics in Research Committee and is in accordance with the Helsinki Declaration of 1975 (as revised in 1983). We collected data relating to gender, age, marital status, children, number of family members, drugs, health care, employment status, benefits, difficulties in performing daily activities, income, education, and goals after transplantation. A descriptive analysis was performed. Results are presented as percentage or as mean value and standard deviation. All analyses were done using SPSS software 15.0 (SPSS Inc, Chicago, Ill).
RESULTS
The mean age was 44.8 ⫾ 13.3 years and 51% were male. Sixty-thee percent were married; 71% have children, with a family size of 3.5 ⫾ 1.45 members. They attended to a public service, but one third had also private health insurance. The number of drugs taken was 5.8 ⫾ 2.8 and only 3.23 ⫾ 1.78 were dispensed by public health system. CKD impacted patients’ quality of life: 93% were not working, and the majority reported some limitation in daily activities. Family income was US$1,535.70 ⫾ 1,620.20 per month, but half of the families received less than a thousand dollars per month.2 They reported a mean of school years of 7.9 ⫾ 1.2 years. Looking as categories, almost 75% have completed at least the elementary school (8 years) and 13% were illiterate (0 –3 years of schooling). Among the goals of life after the kidney transplant, 26% wanted to return to work, 23% desired to quit the dialysis treatment, and 18% disclosed no identifiable goal (Table 1). DISCUSSION
Access to kidney transplantation involves many factors beyond the traditional clinical factors, but also age, gender, race, socioeconomic status, geographic location, and psychological condition.3 Some of these elements affect strongly people of low socioeconomic status, such as lack of access to health care, lower education, and health behavior. It is well-recognized that people of low socioeconomic status, lower education, and lower family income tend to have a later referral to nephrologists and an increased risk of CKD on renal replacement therapy. Furthermore these social patterns are also associated with greater severity of the disease and worse outcomes.1,5,6
TIRAPANI, RODRIGUES, MARSICANO ET AL Table 1. Socioeconomic Variables From the 60 Patients Preparing for Living Donor Kidney Transplantation Variables
Percent (%)/Mean ⫾ SD
Age (yrs) Male gender Offspring/family members Medications/medications by public system Private health insurance Active work Difficulty in performing daily activities No difficulty Temporary partial difficulty Little permanent difficulty/unable Income (US$/month) Income by categories (US$/month) 452.66–905.30 905.31–1810.60 1810.61–4526.50 ⬎4526.51 Education level (yrs) Education by categories Illiterate Elementary school High school College
44.8 ⫾ 13.3 51 71%/3.5 ⫾ 1.5 5.8 ⫾ 2.8/3.3 ⫾ 1.8 34 7 45 46 9 1535.70 ⫾ 1620.58 59.3 16.9 18.7 5.1 7.9 ⫾ 4.2 15.3 37.3 37.3 10.1
The data was collected from social history instrument. US: American dollars.
Our population is characterized by young adults who are of low income and unemployed, and supported essentially by our public health system. Some studies about the waiting list have shown private health insurance and a higher income are major factors associated with the progress to transplantation.7 The reduction of renal function is associated with lower attainment at work. The presence of physical dysfunction is significantly related to unemployment in those with CKD. Renal replacement therapy has a strong impact on quality of life, because almost all patients analyzed are inactive in the labor market, giving evidence of the impact of CKD on the activity and financial work, many of them draw their income from pensions and social benefits. The majority of patients in our study had some difficulty in performing their usual activities, but believe that this difficulty is temporary, inherent to the disease, and see transplantation a possible return to full capacity.8 The social and psychological impacts become clearly apparent by the percentage of patients whose main goal after transplantation is returning to work. Compared with the Brazilian peritoneal dialysis population, we found candidates for living donor transplantation at our facility have a higher education level.9 This finding confirms what was seen by others, namely that education has been shown to be an independent factor for access to transplantation.3,7 Otherwise, it is worrisome that a significant proportion of these patients illiterate, a factor that deserves attention to nonadherence and allograft failure. This cross-sectional study is descriptive in nature and does not allow any causal association. However, it highlights
SOCIAL DIAGNOSIS OF CKD
the need for further research to estimate the impact of socioeconomic variables in access to renal transplantation. We observed in our study that patients with low income are gaining access to be prepared to renal transplantation. We believe it is inherent to the Brazilian public health system, which grants a universal access. Otherwise, this low-income population has considerable educational level. Information about social status is essential for design intervention strategies in minimizing its potential undesirable effects after transplantation.
REFERRENCES 1. Ward MM: Socioeconomic status and the incidence of ESRD. Am J Kidney Dis 51:563, 2008 2. Norris K, Nissenson AR: Race, gender, and socioeconomic disparities in CKD in the United States. J Am Soc Nephrol 19:1261, 2008
2343 3. Schaeffner ES, Mehta J, Winkelmayer WC: Educational level as a determinant of access to and outcomes after kidney transplantation in the United States. Am J Kidney Dis 51:811, 2008 4. Tedesco-Silva Jr H, Felipe CR, Abbud-Filho M, et al: The emerging role of Brazil in clinical trial conduct for transplantation. Am J Transpl 11:1368, 2011 5. Kee F, Reaney E, Savage G, et al: Are gatekeepers to renal services referring patients equitably? J Health Serv Res Policy 12:36, 2007 6. Bello AK, Peters J, Rigby J, et al: Socioeconomic status and chronic kidney disease at presentation to a renal service in the United Kingdom. Clin J Am Soc Nephrol 3:1316, 2008 7. Schold JD, Gregg JA, Harman JS, et al: Barriers to evaluation and wait listing for kidney transplantation. Clin J Am Soc Nephrol 6:1760, 2011 8. KDOQI clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification. Am J Kidney Dis 39(Suppl 1):111, 2002 9. de Andrade Bastos K, Qureshi AR, Lopes AA, et al: Family income and survival in Brazilian Peritoneal Dialysis Multicenter Study Patients (BRAZPD): time to revisit a myth? Clin J Am Soc Nephrol 6:1676, 2011