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Comparison of the Quality of Life and Emotional Responses in Kidney Transplant Recipients from Living and Deceased Donors in Nephrology Clinics

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Background: Quality of life (QoL) is one of the essential measures in assessing a patient's status after kidney transplant, and emotional response is an important factor in evaluating the patient’s compatibility with the transplant. Also, emotional response affects a patient’s QoL. Objectives: This study aimed to compare the QoL and emotional responses of kidney recipients from deceased and living donors. Methods: This descriptive comparative study randomly selected 118 kidney transplant patients (67 recipients from living donors and 51 recipients from deceased) referred to the Nephrology Clinic of Tehran University of Medical Sciences for a post-surgery follow-up. The QoL questionnaire for patients with renal transplants introduced by Laupacis et al. and the emotional response questionnaire (ERQ) by Ziegelmann et al. were used in this study. For data analysis, Mann-Whitney, independent t-test, and Pearson’s correlation tests were used. All the analyses were performed using SPSS software version 20. Results: The kidney recipients from living donors had significantly higher QoL score (especially emotionally) compared with kidney recipients from deceased donors (P=0.04). The score of emotional response was higher in recipients from a living donor, which is related to feeling guilty, transplant disclosure. Furthermore, recipients from a living donor felt guiltier and were unwilling to disclose their transplant compared with recipients from deceased donors. Conclusions: Feeling of guilt and being anxious about transplant disclosure were higher in recipients from living donors. A significant difference was observed in the QoL and emotional response between the two groups of kidney recipients. Therefore, it is important to involve the transplant team, specifically nurses, in the identification of emotional response and planning accordingly to improve the patients’ QoL, especially in recipients from a living donor.
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Nephro-Urol Mon. In Press(In Press):e100728.
Published online 2021 May 3.
doi: 10.5812/numonthly.100728.
Research Article
Comparison of the Quality of Life and Emotional Responses in Kidney
Transplant Recipients from Living and Deceased Donors in
Nephrology Clinics
Roghayeh Esmaeili 1, * , Ziba Farahani Barziabadi1and Mahdi Khabaz Khoob 2
1Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2Department of Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
*Corresponding author: Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Email:
r_esmaieli@yahoo.com
Received 2020 May 05; Accepted 2020 May 09.
Abstract
Background: Quality of life (QoL) is one of the essential measures in assessing a patient’s status after kidney transplant, and emo-
tional response is an important factor in evaluating the patient’s compatibility with the transplant. Also, emotional response affects
a patient’s QoL.
Objectives: This study aimed to compare the QoL and emotional responses of kidney recipients from deceased and living donors.
Methods: This descriptive comparative study randomly selected 118 kidney transplant patients (67 recipients from living donors and
51 recipients from deceased) referred to the Nephrology Clinic of Tehran University of Medical Sciences for a post-surgery follow-up.
The QoL questionnaire for patients with renal transplants introduced by Laupacis et al. and the emotional response questionnaire
(ERQ) by Ziegelmann et al. were used in this study. For data analysis, Mann-Whitney, independent t-test, and Pearson’s correlation
tests were used. All the analyses were performed using SPSS software version 20.
Results: The kidney recipients from living donors had significantly higher QoL score (especially emotionally) compared with kidney
recipients from deceased donors (P=0.04). The score of emotional response was higher in recipients from a living donor, which
is related to feeling guilty, transplant disclosure. Furthermore, recipients from a living donor felt guiltier and were unwilling to
disclose their transplant compared with recipients from deceased donors.
Conclusions: Feeling of guilt and being anxious about transplant disclosure were higher in recipients from living donors. A sig-
nificant difference was observed in the QoL and emotional response between the two groups of kidney recipients. Therefore, it is
important to involve the transplant team, specifically nurses, in the identification of emotional response and planning accordingly
to improve the patients’ QoL, especially in recipients from a living donor.
Keywords: Quality of Life, Emotional Responses, Kidney Transplant
1. Background
The renal system is the most important regulator of the
body’s internal environment (1). Chronic renal disease is a
burden to society due to its high prevalence and treatment
costs (2). In western societies, the incidence of chronic kid-
ney disease (CKD) is increasing so that approximately 10%
of the population over the age of 20 are involved (3). Di-
abetes is the main cause of CKD. Other causes include hy-
pertension, pyelonephritis, nitrogen and blood urea dis-
orders, glomerulonephritis, renal disease family history,
maternal disorders, and kidney cancers (1). In Iran, there
were approximately 58,000 people with CKD up to the end
of 2016 (4). Depending on the cause of CKD, the available
treatment options are different, including dialysis and kid-
ney transplants (2).
There are some limitations for patients with dialysis
treatment options. They feel that they are dependent
on other individuals and are insecure about their future.
Other stressful factors for these patients are feeling of
powerlessness, lack of control over the disease and its
treatment, limitation imposed by medication, lack of self-
confidence, financial burden, and sexual performance (5).
Another option for these patients is kidney transplan-
tation (2). A kidney transplantation is a surgical proce-
dure to place a healthy kidney from a living or deceased
donor into a person whose kidneys no longer function
properly and is considered as the desired treatment. Pa-
tients with kidney transplantation show higher QoL com-
pared with patients under other treatments. Without the
Copyright © 2021, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License
(http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly
cited.
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Esmaeili R et al.
need for hemodialysis, recipients of a successful kidney
transplant can live a normal life socially and vocation-
ally. Although the cost during the first year after surgery
is higher than the one-year cost of dialysis, the cost for
transplant patients significantly decreases in the follow-
ing years. Finally, the survival of dialysis patients has been
widely improved, but transplantation can help them have
longer lives (6). In Iran, approximately 3,000 patients with
CKD have kidney transplantation annually (5). The three
sources for kidney transplants are a family member as a
living donor, a living donor for financial compensation or
philanthropical reason, and a deceased donor (2,7).
Studies show an increasing trend in kidney transplants
from a living donor in western societies (8). About half of
the kidney transplantations in developed countries (e.g.,
US and UK) are from living donors (9). Since the number of
kidney donations from deceased donors is not sufficient,
and due to the constant increase in the kidney transplant
waiting list, more attention has been paid to living donors
recently (10). Receiving a kidney from a family member
increases the recipient’s life expectancy. The better out-
comes of a transplant from a family member is attributed
to minimum cold ischemia and similar human lympho-
cytes antigens. Moreover, when receiving kidney from a
family member, the necessity for immunosuppressive diet
decreases (11,12). Receiving kidney from a deceased donor
can cause emotional disorder due to the false image of re-
lating the donor’s death to the recipient’s survival. Recip-
ients from deceased donors are usually from low-income
families who cannot afford to receive kidney from a living
donor. Since these patients have been on the waiting list
for a long period of time, they are more prone to emotional
disorders (13).
In recent years, the QoL has been considered as a very
important factor in health. Health and performance im-
provement has been considered as one of the important
factors in patients with renal failure (14). The QoL is a multi-
dimensional concept that includes physical health, disease
prognosis, and treatment, economic and social aspects of
the patient’s life that can be changed with time. (15). In
many studies, the QoL has been identified as a key factor
after transplant (16).
Another factor affected by kidney transplantation in
recipients from living and deceased donors is the emo-
tional response, which refers to a set of behaviors, reac-
tions, and assumptions of the recipient toward the trans-
planted kidney; emotional response may include depres-
sion, anxiety, feeling guilty and responsible after the trans-
plant surgery, anxiety about transplant disclosure, and
medication compliance. Recipients may show different
emotional responses depending on whether the kidney
was received from a deceased, living, or relative donor. The
patients’ response, such as feeling guilty and frustration
can affect their QoL, performance, and behavior (17). Kim et
al. showed that kidney transplant can affect the recipients’
QoL and emotional responses (18). Moreover, de Groot et al.
(2013) showed that recipients who received kidney from a
living donor had a better QoL, less performance degrada-
tion from a physical problem, higher social involvement,
and a better overall health (19). In addition, de Groot et al.
found that kidney recipients from a deceased donor had
a higher sense of responsibility for taking care of them-
selves. In 2016, Zimmerman et al. investigated the emo-
tional response in terms of anxiety, medication compli-
ance, transplant disclosure, and QoL among kidney recip-
ients from deceased or living donors and did not report a
significant difference between the two groups. However,
recipients from a living donor felt guiltier and had a higher
level of anxiety in comparison to kidney recipients from a
deceased donor. Accordingly, this study aimed to identify
the emotional response as an important factor in balanc-
ing emotional reactions after transplant surgery.
Thus, the emotional response of kidney recipients de-
pends on whether they received the kidney from a living or
deceased donor; as a result, this can impact their QoL.
2. Objectives
Therefore, characterizing, managing, and balancing
emotional responses can improve the recipients’ QoL. Due
to the high number of CKD patients and very limited and
controversial studies in this field, this study aimed to com-
pare the QoL and emotional responses of kidney recipients
from deceased and living donors.
3. Methods
This descriptive comparative study randomly selected
118 kidney transplant patients referred to Nephrology Clin-
ics in Medical Sciences University of Tehran city including
Milad, Laleh, Erfan, and Shahid Modares hospital. Out of 118
subjects, 67 patients received a kidney from a living donor
and 51 from a deceased donor.
Inclusion criteria were having passed at least six
months from the transplantation, having no mental disor-
der, over 18 years of age or older, and willingness to partic-
ipate in the study.
We used two questionnaires, including the QoL and
emotional response questionnaire (ERQ). The QoL ques-
tionnaire, specific to patients with kidney transplantation,
includes 25 questions in five different components, includ-
ing physical characteristics, fatigue, fear and uncertainty,
appearance, and emotional components. These compo-
nents are rated based on a Likert scale (from 1 to 7). The
validity of this tool was confirmed by content validity and
face validity. In addition, the reliability of the tool using
Cronbach’s alpha was 0.076 in the study by Tayebi and
0.094 in our study (20).
2 Nephro-Urol Mon. In Press(In Press):e100728.
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Esmaeili R et al.
The ERQ is designed to quantify the emotional re-
sponses in kidney transplant patients. The scores of this 23-
item questionnaire range from ‘totally disagree’ (scale 1) to
‘totally agree’ (scale 5) based on the Likert scale. Also, the
scale evaluates being anxious about the transplant surgery,
feeling guilty toward the donor, disclosure of transplant,
and drug compliance. In the study by Zimmerman (21), the
reliability of the tool based on Cronbach’s alpha was calcu-
lated as 0.84. In this study, we achieved face and content
validity, and Cronbach’s alpha for reliability was achieved
0.85 for questioners.
4. Results
The descriptive statistics are shown in Table 1. Most of
the recipients from the living donors (34.8%) were in the
age range of 31 - 34 years, and most of the recipients from
the deceased donors (33.13%) were in the age range of 59 - 75
years.
Inferential findings, including mean and standard de-
viation, and range for the emotional responses in recip-
ients from a living and deceased donor are presented in
Table 2. The independent t-test results indicated that the
mean of emotional response was higher in recipients from
a living donor due to feeling guilty toward the donor and
transplant disclosure.
The mean, standard deviation, and range of QoL in re-
cipients from a living and deceased donor are presented
in Table 3. The Mann-Whitney test results showed that the
QoL mean is significantly higher in recipients from a living
donor compared with recipients from a deceased donor,
which is attributed to the emotional component. The re-
sults showed a significant difference in QoL between the
two groups (P = 0.04); the mean QoL in recipients from
a living donor was 78.72, and the mean QoL in recipients
from a deceased donor was 66.37. In the emotional compo-
nent of QoL, there was a significant difference between the
two groups (P = 0.02) such that the mean score of the emo-
tional component in recipients from a living donor was
19.21 and that of the recipients from a deceased donor was
15.31.
The analysis of the correlation coefficient and decep-
tive statistics in recipients from a deceased donor showed
that there was a correlation between age and emotional
responses scores in the aspects of feeling responsible to-
ward the donor and transplant disclosure so that as the
recipients’ age increased, the associated scores decreased.
Correlation analysis in QoL components showed that in re-
cipients from a living donor, there was a correlation be-
tween age and income level with the QoL score so that as
the age and income increased, QoL score decreased. More-
over, the results showed a correlation between education
level and QoL, specifically in physical and appearance di-
mensions, so that the associated score in these two dimen-
sions increased as the education level increased. In addi-
tion, there was a correlation between the duration of un-
dergoing dialysis and three aspects of physical, emotional,
and fear in QoL analysis, so that the longer the recipients
received dialysis, the higher their score in these three as-
pects were. Correlation analysis in recipients from a de-
ceased donor showed that there was a negative correlation
between the recipient’s age and fear aspect of QoL, so that
with increase in age, we observed a decrease in fear score.
There was a significant correlation between income level
and the two aspects of fear and emotion in QoL analysis.
Moreover, there was a correlation between age and two as-
pects of fear and appearance, so that as the age increased,
the score in these two aspects increased.
5. Discussion
In this study, we compared the QoL, and emotional re-
sponses in kidney transplant recipients from living and
deceased donors referred to training hospitals in Tehran
for a follow-up. The results showed that there is a signifi-
cant difference in the QoL of kidney recipients from living
donors and recipients from deceased donors, specifically
in the emotional aspect; this is in line with the results of de
Groot et al. (2013). However, a study by Zimmerman (2016)
showed no significant difference in QoL between these two
groups. In order to improve kidney recipients’ QoL, it is im-
portant to recognize the need for emotional and social sup-
port. Ignoring such needs may impact the recipients’ QoL
after the transplant surgery.
While most of the recipients from a living donor had a
high school degree, most of the recipients from a deceased
donor had primary school education. In the study by Kim
et al., college graduates had the highest percentage (52.4%)
of kidney transplants, with most of the recipients receiv-
ing a kidney from a living donor. In western societies, re-
ceiving kidney from a living donor is increasing (8). Most
of the participants received a kidney from a non-relative
living donor. However, receiving a kidney from a family
member of relatives yields and decreases the need for im-
munosuppressive diet (11,12). However, 90% of donors in
Iran are non-relative living donors who have financial mo-
tivation for their donation (21).
Despite the challenges associated with a non-relative
living donor with financial motivations, this kind of do-
nation has received significant attention to fill the gap be-
tween demand and supply and is used in other countries;
however, Iran is the only country in which non-relative liv-
ing donors can donate their kidney for financial compen-
sation. (22,23).
On the other hand, the analysis of the mean of emo-
tional responses showed that the total score of emotional
responses in recipients from a living donor was higher
compared with recipients from a deceased donor. There
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Esmaeili R et al.
Table1. Demographic Information of the Participants
Variable Living, No. (%) Deceased, No. (%)
Gender
Male 34 (54.6) 30 (63.8)
Female 28 (45.4) 18 (36.2)
Age range
17 - 30 11 (16.7) 8 (15.7)
31 - 44 23 (34.8) 13 (25.5)
45 - 58 19 (28.8) 13 (25.5)
59 - 75 12 (18.2) 17 (33.13)
Marital status
Married 52 (43.3) 39 (76.5)
Single 10 (14.9) 10 (19.6)
Divorced 2 (3) 3 (3.9)
Widowed 3 (4.5) 0 (0)
Employment status
Worker 5(7.7) 5(9.8)
Officer 7 (10.8) 5 (9.8)
retired 12 (18.5) 18 (35.3)
Housewife 22 (33.8) 11 (21.6)
Self-employed 8 (12.3) 4 (7.8)
Unemployed 11 (16.9) 8 (15.7)
Income IRR)
Less than one million 21 (41.2) 16 (40)
Between one and two million 24 (47.1) 20 (50)
Between two and three million 4 (7.8) 3 (7.5)
More than three million 2 (3.9) 1 (2.5)
Education
Elementary school 18 (30.5) 16 (35.6)
Middle school 14 (23.7) 2 (4.4)
High school 16 (27.1) 20 (44.4)
College 11 (18.6) 7 (15.6)
was a significant difference in the feeling of guilty to-
ward the donor and transplant disclosure between the two
groups, with the recipients from a living donor having a
higher score as compared with the recipients from a de-
ceased donor. Zimmerman et al. showed that feeling of
guilty is significantly higher in the recipients from a living
donor; however, they reported no significant difference in
transplant disclosure between the two groups. The results
of Gozdwoska et al. in comparison of emotional and social
impacts in the recipients from living and deceased donors
in others study is same as our results (24).
Umel et al., in assessing the experience of kidney recip-
ients and donors, reported depression and anxiety in the
recipients from a living donor as compared with the recip-
ients from a deceased donor. The results of Lim et al. in
comparison of emotional and social impacts in the recip-
ients from living and deceased donors in other studies is
the same as our results. In this study, feeling of guilt, fear of
transplant disclosure, feeling worried, and in general neg-
ative emotional responses were higher in recipients from
a living donor.
In our study, 85% of recipients from a living donor ex-
perienced no to mild depression, while 63% of recipients
from a deceased donor experienced no to mild depression,
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Esmaeili R et al.
Table2. Mean, Standard Deviation, and Range of Emotional Responses Aspects of the Recipients
Emotional Response Aspect Recipients from a Living Donor Recipients from a Deceased Donor t-TestResults
Mean. (SD) Min Max Mean. (SD) Min Max P-Value
Worried about transplant 9 (29) 19.94 6.50 12 (30) 19.71 6.72 0.67
Feeling guilty toward the
donor
5 (20) 12.75 5.31 5 (25) 10.33 4.18 0.009
Transplantdisclosure 3 (15) 6.81 3.45 3 (15) 5.63 3.13 0.04
Feeling responsible 4 (20) 13.43 3.94 4 (20) 13.03 5.04 0.66
Medication compliance 0 (21) 9.43 4.94 5 (17) 8.56 3.86 0.31
Emotional response total
score
33 (89) 62.35 14.03 44 (107) 56.98 14.05 0.045
Table3. Mean, Standard Deviation, and Range of Quality of Life Aspects of the Recipients
Quality of Life
Recipients from a Living Donor Recipients from a Deceased Donor Mann-Whitney Test
Results
Mean. (SD) Min Max Mean. (SD) Min Max P-Value
Physical 6 (42) 19.18 10.7 6 (42) 16.84 10.05 0.17
Appearance 4 (23) 8.88 5.87 4 (22) 7.88 4.90 0.51
Fear/uncertainty 4 (28) 14.32 8.01 4 (38) 11.86 8.37 0.07
Emotional 6 (42) 19.21 10.02 4 (20) 15.31 10.42 0.02
Fatigue 5 (35) 17.12 8.31 5 (35) 14.47 8.63 0.06
Quality of life total score 46 (137) 78.72 34.04 25 (151) 66.37 36.65 0.04
which implies happier life, and as a result, a higher QoL in
recipients from a living donor. In a study by Parsaei Mehr
et al. (2013), males experienced less depression compared
to females in both groups of recipients from living and de-
ceased donors. According to Parsaei Mehr et al. and as
the results of this study showed, since recipients from a
deceased donor spend significant time on the waiting list,
they are more prone to mental disorder risk, and therefore
experience a stronger emotional response. In fact, long
time of waiting for a kidney transplant causes mental dis-
orders in these patients.
5.1. Conclusions
In this study, the QoL and emotional responses in kid-
ney recipients from living and deceased donors were com-
pared. The results showed that recipients from a living
donor were younger, had lower education level, and re-
ceived the kidney from a non-relative donor. Also, recipi-
ents from a living donor felt guiltier toward the donor and
were more worried about transplant disclosure, and there
was a significant difference between these two compo-
nents. Recipients from a living donor experienced higher
QoL, specifically in the emotional aspect, as compared with
recipients from a deceased donor. In general, the trans-
plant team, specifically nursing team, needs to recognize
the feeling of guilty and fear of transplant disclosure and
ensure compatibility in transplant assignment, especially
for recipients from a living donor. The results of this
study can assist healthcare providers, community health
experts, and nurses to improve recipients’ QoL through
identification of feeling or guilty toward the donor and
fear of transplant disclosure, and thereby provide consul-
tations to mitigate these emotions. Our results can help
healthcare policymakers to recognize the impact of psy-
chological interventions and managerial approaches in
improving patients’ self-sufficiency, happiness, and QoL.
The results of this study showed that nursing team’s
supports in transplant and dialysis wards can develop pa-
tient’s quality of life and their mental and emotional sta-
tus. For future studies, intervention on emotional and
mental supports before transplantation can be useful on
quality of life and adaptive reaction in recipients from liv-
ing and deceased donors.
Acknowledgments
The authors would like to appreciate all the patients in
the Nephrology Clinics of the university hospitals: Erfan,
Modarres, Laleh, and Milad.
Footnotes
Authors’ Contribution: Study concept and design: Man-
soureh Madadi and Roghaye Esmaieli. Analysis and inter-
Nephro-Urol Mon. In Press(In Press):e100728. 5
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Esmaeili R et al.
pretation of data: Mansoureh Madadi and Mahdi Khabbaz
Khoob. Drafting of the manuscript: Mansoureh Madadi.
Critical revision of the manuscript for important intellec-
tual content. Ziba Farahani Barzabadi. Statistical analysis:
Mahdi Khabbaz Khoob.
Conflict of Interests: The authors confirm that they have
no conflict of interest.
Ethical Approval: This study was approved by the Ethics
Committee of Shahid Beheshti University of Medical Sci-
ences (IR.SBMU.PHNM.1396.738). Written informed con-
sent was obtained from all patients.
Funding/Support: The author(s) received no financial
support for the research, authorship, and/or publication of
this article.
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