Emotional management and quality of life in mother living versus multi-organ donor renal transplant recipients

Abstract

The aim of this study was to evaluate psychological differences and quality of life between kidney recipients from living (mother) and multi-organ donor. Overall, 40 patients who had undergone both living (mother) and multi-organ kidney transplantation 3–6 months before were asked to complete four self-report instruments: Toronto Alexithymia Scale, Short Form Health Survey, Regulatory Emotional Self-efficacy, and Attachment Style Questionnaire. A greater difficulty in emotional, social, and mental health functioning was found in recipients receiving kidney from mother living donor. Moreover, in these patients, higher levels of avoidant attachment dimensions were associated with a worse quality of life.

Keywords

alexithymia avoidant attachment dimensions emotional management living donor quality of life renal transplant

Introduction

Recent studies showed that donation from multi-organ or living donor is associated with different consequences on biological (Guimarães et al., 2015; Guirado et al., 2008), ethical (Delmonico et al., 2015; Panocchia et al., 2013), and psychological (Branco et al., 2013; Cabral et al., 2015) outcomes.

The transplant from living donor offers numerous advantages, such as the possibility to reduce the distressing transplantation waiting list time and to increase the biological matching (Ponticelli, 2003). Previous studies showed that transplant from multi-organ source reduced by 11 percent long-term survival rate, within 5-year follow-up, compared to transplant from living donor with human leukocyte antigen (HLA) compatibility (Lindahl et al., 2014; Opelz et al., 1999). Moreover, HLA matching decreased the risk of graft failure of about 40 percent (Foster et al., 2013; Legendre et al., 2014; Ponticelli, 2003; Takemoto et al., 2004). For these reasons, in the last years, living donor kidney transplantation has progressively grown up (Foster et al., 2013; Kikuchi et al., 2000; Legendre et al., 2014; Miura et al., 2001; Takemoto et al., 2004).

Despite living donor transplantation increases the chance of finding a great HLA match, it could be associated with a psychological impairment, due to the fact that almost always the graft comes from a person belonging to the patient’s family (Fukunishi et al., 2003; Griva et al., 2002). This situation could have an impact on recipient’s quality of life (QoL) because of the relationship with the donor is affected by recipient’s relevant feelings of guilt or helplessness due to the physical consequences for the donor and to the inability reciprocate the donation (Hanson et al., 2015; Ummel and Achille, 2015; Ummel et al., 2011).

Studies on living donor renal transplant recipients showed contrasting results. Some studies emphasized the association between the living kidney donation, an higher survival rates (98% and 86% at 1 and 5 years vs 95% and 77% at 1 and 5 years) (Collins et al., 2009; Lindahl et al., 2014) and an improved QoL of the recipients (Álvarez-Rangel et al., 2015; Mokarram Hossain et al., 2014; Parsaei Mehr et al., 2011; Russcher et al., 2015) compared to multi-organ donation. On the other hand, a poorer QoL due to a relevant feeling of guilty toward the donor has been showed (Fukunishi et al., 2003; Griva et al., 2002). Multi-organ donor kidney recipients often refuse the possibility of receiving the organ from the potential available living donor because of their concern about the donor’s health and for their expectation about negative relationship changes. On the contrary, living donor kidney recipients do not show those concerns (De Groot et al., 2012, 2013).

Fukunishi et al. proposed a possible psychopathological outcome defined “paradoxical psychiatric syndrome (PPS)” in recipients and donors after living transplantation. PPS refers to a psychopathological disease which occurs despite successful transplantation, absence of graft rejection, or other medical complications (Fukunishi et al., 2003). Depression, somatization, and conversion are the symptoms reported for the proposed PPS (Fukunishi et al., 2003).

Aim of this study was to investigate QoL, attachment style dimensions, and emotional management in patients who underwent living (mother) and multi-organ donor transplantation. The hypothesis was that the patients who underwent transplant from a living (mother) donor may show a greater difficulty in managing emotions and a poorer QoL compared to multi-organ donor renal transplant recipients; and that, in patients who underwent transplant from a living (mother) donor, the lower levels of secure attachment may be associated with lower levels of QoL.

Materials and methods

Subjects

After local Ethical Committee approval, 40 consecutive patients (24 males and 16 females) who underwent living (mother) or multi-organ kidney transplantation were enrolled from 1 January 2013 to 30 April 2013, during a follow-up visit (3–6 months after transplant), at A. Gemelli Hospital in Rome. The inclusion criteria were as follows: to be recipients of kidney transplantation from living mother or multi-organ donor, time distance from the transplant at least 3 months and no more than 6 months, Italian nationality, age > 18 years, at least primary school, and absence of psychopathological diagnoses. All the patients who came at the follow-up visit in the hospital during the period between 3 and 6 months after kidney transplantation were identified as possible participants. Patients were recruited if all inclusion criteria were satisfied and they were then instructed on the study design. After informed consent, four self-report questionnaires were administered to the patients in a quiet room of the hospital.

Procedure

The Toronto Alexithymia Scale (TAS-20) is the most commonly used self-report measurement of alexithymia (Bagby et al., 1994; De Gucht and Heiser, 2003). It is a 20-item self-report scale with three factors: F1 (difficulty in identifying feelings); F2 (difficulty in describing feelings); and F3 (externally oriented thinking) (Bagby et al., 1994). The internal consistency of TAS-20 scores was good: Cronbach’s alpha of the total score was 0.88; of the F1 subscale was 0.86; of the F2 subscale was 0.80; and of the F3 subscale was 0.58 (Leising et al., 2009).

The Regulatory Emotional Self-efficacy (RESE) measures the ability to regulate positive (five items) and negative (nine items) emotions within a range from 1 (not well at all) to 5 (very well). The internal consistency was Cronbach’s alpha = 0.82 for positive and negative emotions (Caprara and Gerbino, 2001).

The 40 items Attachment Style Questionnaire (ASQ) measures the internal representations of the interpersonal distance, which come out when the subjects are requested to describe themselves. It consists of five quantitative dimensions related to the attachment styles (on a continuum secure vs insecure): confidence, need for approval, preoccupation with relationships, relationships as secondary, and discomfort with closeness. Confidence, need for approval, and preoccupation with relationships are associated with the anxious attachment style, whereas confidence, relationships as secondary, and discomfort with closeness with the avoidant attachment style. The 40 items are rated on a 6-point Likert-type scale (Feeney et al., 1994). A previous study (Fraley and Waller, 1998) suggested the use of the scores on dimensional scales rather than discrete categorizations. Internal consistency coefficients of the five dimensions in both clinical and nonclinical samples were acceptable (0.64 < Cronbach’s alpha < 0.74) (Fossati et al., 2003).

The Short Form Health Survey (SF-36) contains 36 questions (with a score from 0 to 100) that assess eight aspects of QoL: physical functioning, role-physical functioning, bodily pain, general health, vitality, social functioning, role-emotional functioning, and mental health (Ware and Sherbourne, 1992).

The SF-36 is the most widely employed and has been used across a number of patient populations (Apolone and Mosconi, 1998; Ware, 2000). A systematic review identified 13 studies reporting on short form (SF-36) scores in surgical patients (Parikh et al., 2010). Internal consistency coefficients of the scales in a normative sample were excellent (0.77 < Cronbach’s alpha < 0.93) (Apolone and Mosconi, 1998; Mingardi et al., 1999).

Creatinine and blood urea nitrogen were also assessed at the time of the follow-up visit in all the patients.

Statistical analyses

Analyses of variance (ANOVA; Fisher’s F) (Ercolani et al., 2002) were performed in order to verify the presence of significant differences between living and multi-organ renal transplant recipients on age, RESE, TAS-20, ASQ, SF-36, creatinine, and blood urea nitrogen.

Correlation analyses (Pearson’s r) were performed between subscales of ASQ-40 and determinants of QoL in living donor renal transplant recipients.

Statistical analyses were performed using Statistica Version 8.0 software (StatSoft, Tulsa, OK, USA).

Results

Overall, 31 (19 males and 12 females) received a kidney transplant from a multi-organ donor and nine (five sons and four daughters) from a living donor (mothers) as reported in Figure 1. As shown in Table 1, ANOVA revealed that living renal transplant recipients, compared to multi-organ renal transplant recipients, were younger (p = 0.009) and showed significantly higher levels of alexithymia (p = 0.004), especially for difficulty in identifying feelings (F1) (p = 0.0008) and for difficulty in describing feelings (F2) (p = 0.02), as well as lower levels of social functioning (p = 0.04), and mental health (p = 0.002).

Figure 1.

Demographic characteristics of the sample (mean ± standard deviation of age).

Table 1.

ANOVA between mother living and multi-organ renal transplant recipients on age, emotional management, attachment dimensions, alexithymia, quality of life, and biological parameters.

	Multi-organ donor renal transplant recipients (N:31)	Mother living donor renal transplant recipients (N:9)	F (1,38)	p value
Age	53.3 ± 13.6	37.5 ± 16.9	7.7	0.009
Emotional management
Negative emotions	27.3 ± 5.5	25.1 ± 4.1	1.2	0.28
Positive emotions	28.5 ± 5.5	32.7 ± 2.9	1.3	0.26
Attachment style dimensions
Confidence	31.0 ± 6.6	32.6 ± 6.8	0.0	0.83
Need for approval	25.8 ± 9.5	30.0 ± 8.8	0.6	0.43
Preoccupation with relationships	22.0 ± 8.1	29.1 ± 13.5	2.2	0.15
Relationships as secondary	17.5 ± 7.8	18.6 ± 7.0	0.0	0.92
Discomfort with closeness	31.0 ± 10.2	42.0 ± 11.0	3	0.09
Alexithymia
Total TAS-20	46.4 ± 10.8	59.3 ± 14.5	9.2	0.004
Difficulty in identifying feelings F1	14.9 ± 6.1	23.3 ± 7.4	13.1	0.0008
Difficulty in describing feelings F2	13.0 ± 4.4	17.3 ± 5.5	6.4	0.02
Externally oriented thinking F3	19.1 ± 4.0	19.1 ± 5.3	0.0	0.99
Quality of life
Physical functioning	71.7 ± 29.6	75 ± 20.4	0.4	0.53
Role-physical functioning	56.4 ± 43.3	28.6 ± 36.6	2	0.16
Bodily pain	68.3 ± 25.0	68.3 ± 27.6	0.3	0.59
General health	53.8 ± 20.6	49.1 ± 18.6	0.1	0.71
Vitality	57.7 ± 21.6	44.3 ± 27.4	1.8	0.19
Social functioning	75.7 ± 22.9	51.7 ± 25.4	4.5	0.04
Role-emotional functioning	67.6 ± 38	19.0 ± 37.8	4	0.05
Mental health	69.6 ± 17.9	41.7 ± 13.2	11	0.002
Biological parameters
Creatinine	1.5 ± 0.6	1.7 ± 0.9	0.9	0.35
Blood urea nitrogen	36.9 ± 26.8	42.6 ± 35.2	0.1	0.81

ANOVA: analysis of variance; TAS-20: Toronto Alexithymia Scale.

The alexithymia scores were significantly and inversely correlated with QoL aspects (role-physical functioning: r = −0.32; p = 0.044, general health: r = −0.41; p = 0.009, role-emotional functioning: r = −0.44; p = 0.004, and mental health: r = −0.41; p = 0.008).

Moreover, in the nine mother living renal transplant recipients (n = 9), the relationships as secondary were significantly and inversely correlated with the vitality (r = −0.67; p = 0.047) and mental health (r = −0.67; p = 0.048); moreover, discomfort with closeness was significantly and inversely correlated with mental health (r = −0.73; p = 0.026).

Discussion

The main finding of this study was that living donor renal transplant recipients showed a significantly greater impairment in emotional management and lower QoL compared to multi-organ donor renal transplant recipients at 3- to 6-month follow-up. Moreover, the emotional impairment was significantly and negatively correlated with QoL, showing the important role of the ability to manage emotions on post-transplantation outcome. In previous studies, we demonstrated that there are psychological risk factors for graft rejection in patients undergoing kidney (Calia et al., 2011a) and liver transplantation (Calia et al., 2011b) and that specific attachment style dimensions, together with alexithymia, were able to predict non-compliance to immunosuppressant treatment, poor QoL, and reduced renal function after multi-organ kidney transplantation (Calia et al., 2015a).

In this study, living donor renal transplant recipients showed a greater difficulty in managing emotions compared to multi-organ donor renal transplant recipients. Coherently, living donor renal transplant recipients showed a worse QoL in terms of significantly higher mental and physical health compared to multi-organ donor renal transplant recipients. On the nine mother living donor renal transplant recipients, a more insecure attachment style (relationships as secondary and discomfort with closeness) was significantly associated with worse QoL (vitality and mental health). It was interesting that the two dimensions associated with the poorer QoL, relationships as secondary and discomfort with closeness, belong to avoidant attachment style and not to anxious attachment, showing that a more avoidant relationship with the mother can negatively affect the post-transplant outcome.

A possible explanation of our findings is that donating a kidney to a member of own family can deeply affect the relationships inside the family with important consequences on the recipient’s QoL due to the fact that donation could evoke ambivalent feelings of gratitude, guilt, or anger toward parents (Hanson et al., 2015; Ummel et al., 2011).

Based on these results, it seems important to plan a pre- and postoperative psychological support in order to improve the relationship between donor and recipient inside the family. The results highlight that the representation of the organ and the expectations associated with the mother living donor transplantation could affect the outcome in terms of QoL. For this reason, mother living donor recipients need not only a psychological support focused on increasing compliance to treatment, as well as recipients of multi-organ donor (Calia et al., 2015b), but also require a more complex approach based on the family environment.

Limitations of this study are the small sample of mother living donor renal transplantation recipients. This was due to the limited number of living kidney donations in the hospital where the study was conducted. Despite this limitation, the findings of this study provide interesting insights for further studies. As the relationship between living donor and recipient was only mother versus son/daughter and this could have affected the results, it seems also necessary in future studies to investigate other types of living donation relationship. Moreover, the psychological evaluation was performed only in the early post-transplantation period.

In conclusion, this study showed a significantly greater difficulty in emotional, social, and mental health functioning in recipients receiving kidney from mother living donor compared to multi-organ donor renal transplant recipients. Moreover, higher levels of avoidant attachment dimensions are significantly associated with worse QoL in patients receiving kidney from the mother living donor. It could be useful, in further studies, to test differences between the two groups at a later follow-up (1–2 years). Future research should be planned in order to investigate whether a preventive psychological intervention on the mother donor/son or daughter recipient could improve the long-term QoL of living donor renal transplant recipients.

Footnotes

Acknowledgements

Rosaria Calia and Carlo Lai equally contributed to this study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Álvarez-Rangel

Cruz-Santiago

Meza-Jiménez

. (2015) Modification of health-related quality of life in kidney transplant recipients. Revista Medica del Instituto Medicano del Seguro Social 53(Suppl. 1): S66–S73.

Apolone

Mosconi

(1998) The Italian SF-36 health survey: Translation, validation and norming. Journal of Clinical Epidemiology 51: 1025–1036.

Bagby

Parker

Taylor

(1994) The twenty-item Toronto Alexithymia Scale: I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research 38: 23–32.

Branco

Cavadas

Rocha

. (2013) Living versus cadaveric-donor renal transplant recipients: A comparison on sexual function. Transplantation Proceedings 45: 1066–1069.

Cabral

Cavadas

Silva Ramos

. (2015) Female sexual function and depression after kidney transplantation: Comparison between deceased- and living-donor recipients. Transplantation Proceedings 47: 989–991.

Calia

Lai

Aceto

. (2011a) Preoperative psychological factors predicting graft rejection in patients undergoing kidney transplant: A pilot study. Transplantation Proceedings 43: 1006–1009.

Calia

Lai

Aceto

. (2011b) Psychological risk factors for graft rejection among liver transplant recipients. Transplantation Proceedings 43: 1123–1127.

Calia

Lai

Aceto

. (2015a) Attachment style predict compliance, quality of life and renal function in adult patients after kidney transplant: Preliminary results. Renal Failure 37: 678–680.

Calia

Lai

Aceto

. (2015b) Emotional self-efficacy and alexithymia may affect compliance, renal function and quality of life in kidney transplant recipients: Results from a preliminary cross-sectional study. Physiology & Behaviour 142: 152–154.

10.

Caprara

Gerbino

(2001) Affective perceived self-efficacy: The capacity to regulate negative affect and to express positive affect. In: Caprara

(ed.) Self-Efficacy Assessment. Trento: Erickson Edition, pp. 35–50.

11.

Collins

Chang

Russ

. (2009) Outcomes of transplantation using kidneys from donors meeting expanded criteria in Australia and New Zealand, 1991 to 2005. Transplantation 87: 1201–1209.

12.

De Groot

Schipper

van Dijk

. (2012) Decision making around living and deceased donor kidney transplantation: A qualitative study exploring the importance of expected relationship changes. BMC Nephrology 13: 103.

13.

De Groot

Veen

van

der

Boog

. (2013) Difference in quality of life, fatigue and societal participation between living and deceased donor kidney transplant recipients. Clinical Transplantation 27: E415–E423.

14.

De Gucht

Heiser

(2003) Alexithymia and somatisation. Journal of Psychosomatic Research 54: 425–434.

15.

Delmonico

Martin

Domínguez-Gil

. (2015) Living and deceased organ donation should be financially neutral acts. American Journal of Transplantation 15: 1187–1191.

16.

Ercolani

Areni

Leone

(2002) Statistica per la psicologia: Volume II. Statistica inferenziale e analisi dei dati. Bologna: Il Mulino.

17.

Feeney

Noller

Hanrahan

(1994) Assessing adult attachment. In: Sperling

Berman

(eds) Attachment in Adults: Clinical and Developmental Perspectives. New York: Guilford Press, pp. 128–154.

18.

Fossati

Feeney

Donati

. (2003) On the dimensionality of the Attachment Style Questionnaire in Italian clinical and nonclinical participants. Journal of Social and Personal Relationships 20: 55–79.

19.

Foster

Dahhou

Zhang

. (2013) Relative importance of HLA mismatch and donor age to graft survival in young kidney transplant recipients. Transplantation 96: 469–475.

20.

Fraley

Waller

(1998) Adult attachment patterns: A test of the typological model. In: Simpson

Rholes

(eds) Attachment Theory and Close Relationships. New York: Guilford Press, pp. 77–114.

21.

Fukunishi

Kita

Sugawara

. (2003) Paradoxical psychiatric syndrome and DSM-IV psychiatric disorders in recipients after living donor transplantation. Transplantation Proceedings 35: 293–294.

22.

Griva

Ziegelmann

Thompson

. (2002) Quality of life and emotional responses in cadaver and living related renal transplant recipients. Nephrology, Dialysis, Transplantation 17: 2204–2211.

23.

Guimarães

Araújo

Santos

. (2015) Living-donor and deceased-donor renal transplantation: Differences in early outcome-a single-center experience. Transplantation Proceedings 47: 958–962.

24.

Guirado

Vallespín

Clèries

. (2008) Why living-donor renal transplant yields better outcomes than cadaver renal transplant? Nefrologia 28: 159–167.

25.

Hanson

Chadban

Chapman

. (2015) The expectations and attitudes of patients with chronic kidney disease toward living kidney donor transplantation: A thematic synthesis of qualitative studies. Transplantation 99: 540–554.

26.

Kikuchi

Narumi

Hama

. (2000) Kidney transplantation from spousal donors. Transplantation Proceedings 32: 1817–1818.

27.

Legendre

Canaud

Martinez

(2014) Factors influencing long-term outcome after kidney transplantation. Transplant International 27: 19–27.

28.

Leising

Grande

Faber

(2009) The Toronto Alexithymia Scale (TAS-20): A measure of general psychological distress. Journal of Research in Personality 43: 707–710.

29.

Lindahl

Jenssen

Hartmann

(2014) Long-term outcomes after organ transplantation in diabetic end-stage renal disease. Diabetes Research and Clinical Practice 105: 14–21.

30.

Mingardi

Cornalba

Cortinovis

. (1999) Health-related quality of life in dialysis patients. A report from an Italian study using the SF-36 Health Survey. DIA-QOL Group. Nephrology, Dialysis, Transplantation 14: 1503–1510.

31.

Miura

Okazaki

Sato

. (2001) Long-term results of spousal renal donor transplants with donor-specific blood transfusions. Transplantation Proceedings 33: 3417–3419.

32.

Mokarram Hossain

Masud Iqbal

Rafiqul Alam

. (2014) Quality of life in renal transplant recipient and donor. Transplantation Proceedings 47: 1128–1130.

33.

Opelz

Wujciak

Döhler

. (1999) HLA compatibility and organ transplant survival. Collaborative transplant study. Reviews in Immunogenetics 1: 334–342.

34.

Panocchia

Bossola

Silvestri

. (2013) Ethical evaluation of risks related to living donor transplantation programs. Transplantation Proceedings 45: 2601–2603.

35.

Parikh

Ladner

Abecassis

. (2010) Quality of life for donors after living donor liver transplantation: A review of the literature. Liver Transplantation 16: 1352–1358.

36.

Parsaei Mehr

Hami

Moshtagh Eshgh

(2011) Anxiety and depression: A comparison between living and cadaveric renal transplant recipients. International Journal of Organ Transplantation Medicine 2: 178–183.

37.

Ponticelli

(2003) Altruistic living renal transplantation. Journal of Nephrology 16: S6–S9.

38.

Russcher

Nagtegaal

Nurmohamed

. (2015) The effects of kidney transplantation on sleep, melatonin, circadian rhythm and quality of life in kidney transplant recipients and living donors. Nephron 129: 6–15.

39.

Takemoto

Port

Claas

. (2004) HLA matching for kidney transplantation. Human Immunology 65: 1489–1505.

40.

Ummel

Achille

(2015) Transplant trajectory and relational experience within living kidney dyads. Qualitative Health Research. Epub ahead of print 19 February. DOI: 10.1177/1049732315570128.

41.

Ummel

Achille

Mekkelholt

(2011) Donors and recipients of living kidney donation: A qualitative metasummary of their experiences. Journal of Transplantation 2011: 626501.

42.

Ware

Jr (2000) SF-36 health survey update. Spine 25: 3130–3139.

43.

Ware

Jr Sherbourne

(1992) The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Medical Care 30: 473–483.