Irshad Ahmed ( Department of Neuropsychiatry, Jinnah Postgraduate Medical Centre, Karachi. )
S. Haroon Ahmed ( Department of Neuropsychiatry, Jinnah Postgraduate Medical Centre, Karachi. )
Renal Transplantation is fairly new in our country and is expected to be the only satisfactory long-term treatment for patients with End Stage Renal Disease. Such treatment offers them a chance for near normal life. Seventeen patients who underwent kidney transplant during 1987-88 at the department of Nephrourology of J.P.M.C. Karachi, were reviewed. The result of ten patients who were assessed for their psychosocial adaptation is presented (JPMA 41:97, 1991).
Renal transplantation offers a new life to patients with end stage renal disease (ESRD) after a prolonged period of chronic illness and haemodialysis. Observations about psychosocial adjustment of these patients vary in various studies. Simmons et al1 reported an increased sense of well being and better overall functioning among patients who had received kidney transplant. Kalman et al2 on the other hand noted that 47% of a group of 57 transplant patients showed a significant psychiatric morbidity on the “General Health Questionnaire”. In another study of a group of eleven transplant patients only 30% were working full-time and 82% had restricted or had no social activities3. This study assesses the psychosocial adjustment of transplant recipients at the department of Nephrourology, Jinnah Postgraduate Medical Centre (JPMC), Karachi.
PATIENTS AND METHODS
Case records of seventeen patients who had kidney transplant surgery performed at Jinnah Postgraduate Medical Centre, Karachi during 1987 -88 were reviewed. Only those patients were selected who had survived atleast 2 months. Of 17 patients 3 died and 4 inspite of best efforts were not accessible, during the period of this study. Ten patients were therefore given the question naire with multiple options. The areas of enquiry related to physical, social and psychological aspects of the life. Another set of questionnaire on the same areas of enquiry was administered to one of the close relations of the patients to test its validity. Special attention was paid to the physical well being, psychological status and inter-personal relationships before and after the procedure. The last of the 20 questions had a stem which was open-ended for any voluntary comments or suggestion by the patient and his relation. Patients were also given the urdu version of Beck’s Depression Inventory for rating depression.
Of seventeen patients ten could be assessed in detail and the questionnaire was administered. The time interval between transplant surgery and interview varied from 2 to 20 months. All the patients were cooperative and completed the questionnaire and the Depression Inventory. Though the latter was found difficult by the patients and in fact sounded irrelevant to them since there was hardly any question which fitted into their condition. As a result none of the patients could score above 13, (total range being 63, and a score between 14 and 24 was required to label medium level of depression). Thus depression was ruled out in all patients according to Beck’s Inventory. The results were compatible with the clinical impression.
All the patients reported improvement in general health and absence of symptoms prior to surgery. The only exception was a boy whose illness was promptly diagnosed and operated before usual symptoms could develop. He had there fore no difference to report.
All except four patients had resumed their work. Of the four, two were fresh transplantees, one was jobless having worked as a primary school teacher previously. The fourth, who was an experienced professional was planning to start his own enterprise. Thus post-operative unemployment, was not noted as a pressing issue. Of those who had resumed their work only two reported decreased performance compared to previous level. The second admitted that though he had the capability and vigour but the overprotective employers did not assign him the usual work load. All the transplantees were taking interest in their work.
Certain questions were directed to assess the emotional status. They served as double check on the clinical assessment and score on Beck’s Inventory. All ten patients recorded feeling of satisfaction over the results of the procedure, thus ruling out any element of anxiety.
Similarly none of the patients reported depressed mood when specifically asked. Answers to certain questions pertained to biological aspects of depression like sleep, appetite and libido. They were enjoying undisturbed sleep and improved appetite. Only two patients reported decreased sexual desire. None of the patients reported lack of interest in work or environment.
Six patients found an overprotective family environment on returning home, but soon adjusted themselves. Six patients had already resumed their daily routine. At work, interpersonal relationships remained unchanged. Compared to previous standing, all cases except one, reported a change towards improvement. Five out of 10 patients reported that they were sparing more time now for leisure activities, while only one gave less time now.
Three patients reported a greater inclination towards religion post-operatively. The others maintained their pre-existing religious practice.
When asked about their future in terms of aspirations and expectations in reference to the whole experience, seven were hoping to lead a useful life, while three recorded a wait and see response. None of the transplantees were disenchanted about future. Similarly, when asked whether they would advise this surgery to others suffering from a similar ailment, i.e., ESRD, all of them replied in the affirmative. Two suggested that transplantation would be advisable when reliable arrangement could be made to provide the required drugs post-operatively which happen to be priced exhorbitantly.
Relationship With Donor
Five patients reported a closer relationship with the person who donated the kidney. Others reported that there was not much difference in feelings after receiving the kidney.
Better survivals are reported in cases where donation is taken from, a living parent or sibling. Simmons et al4 have noted a much quicker and more complete return to work. This might be one of the reasons for better post operative results in the transplant clinic of JPMC Karachi, for the cadaver transplant is not recommended. Mortality rate was 18%. The three deaths were due to tuberculosis, myocardial infarction and rejection of graft due to non-compliance of medication. Contrary to the western observations of factors affecting recovery after renal transplantation which highlights unemployment, unmarried status and the need to change one’s place of residence as significant social stressors, this study recommends lesser emphasis on these factors. In our culture it is different. Such patients donot face the similar problems of social adjustment. Because of the supportive and understanding attitude of the other family members, being unmarried and/or unemployed does not interfere with the process of adjustment. Almost all the patients experienced a feeling of well being. This can well be explained by the use of steroids which are known to cause euphoria but majority were seen months after the surgery when doses of steroids were already tapered. An interesting feature observed at this centre was relationship among the transpiantees themselves. Patients awaiting surgery were regularly visited by those who already had transplant done. The prospective recipients were encouraged and thus better equipped for the event. As far as the monetory part was concerned, the most encouraging aspect was the provision of totally free services. The problem arises only when it comes to the drugs required after the transplant procedure, which are exceedingly expensive. Most of the times they arc arranged by philanthropic organizations or individuals. If this important problem is not solved before hand and availability of drugs is not assured the surgery could well be a constant source of anxiety and hardship to the patient and the family.
We are grateful to Dr. S. Mi Jaffar Naqvi, Dr. M.H. Osmani and Dr. Amjad Mir of the Nephrourology Department, and Dr. Shifa Naeem, Dr. M. Arif, Dr. Sirajuddin, Dr. Zaheeruddin and Dr. Qasim Brohi of the Neuropsychiatry Department of Jinnah Postgraduate Medical Centre, Karachi. for their help in this Study.
1. Simmons, E.G., Kamstra - Hennen, Land Thompson, C.R. Psychosocial adjustment five to nine years post transplant. Transplant. Proc., 1981; 13: 40.
2. Kalman, T. P.. Wilson, P. G. and Kalman, C. M. Psychiatric morbidity in long-term renal transplant recepients and patients undergoing hemodialysis. JAMA.. 1983; 250: 55.
3. De-Nour, A.l( and Shanan, J. Quality of life of dialysis and transplanted patients. Ncphron, 1980; 25: 117.
4. Simmons, R.G., Klein, S. 0. and Simmons, R.L Gift to life: The social and psychological impact of organ transplantation. New York. Wily, 1977.