Introduction:
Renal transplantation (RT) number increases steadily, as the best possible treatment for End Stage Renal Disease, as it confers less morbidity and mortality, considerable cost savings in the long-term and relatively a normal lifestyle is reestablished. The RT offers maximum quality and quantity of life while minimizing the effects of renal disease.(1) But, even after a successful RT patients exhibit varying degrees of physical and psychological symptoms,(2),uremic sickness,(3) reduced muscle mass, abnormal muscle metabolism and an uremic myopathy.(4,5) The improvement in physical capacity plateaus unless they actively participate in an exercise program.(6) The physical inactivity after RT affects the Quality of Life (QOL), which is an important measure of patient outcome. QOL after RT of young is affected more than the older adults as many important life events occur then. In absence of structured training, the kidney transplant recipients experience limitations to lead normal lives, including education, family building and socialization.(7)
Physical activity (PA) is one of the major components influencing the QOL after RT. In adults, cardiorespiratory fitness reduced before kidney transplantation or during dialysis increases soon after RT, (5) but the improvement is not sustained after 1-year in absence of continuous training.(8) Regular physical activity improves graft function and lowers cardiovascular risk after RT. (10-12) Regular exercise training and follow up after RT is yet limited, (13,14) hence PA remains the only way to maintain Physical wellbeing. The dearth of published literature on physical activity and quality of life after renal transplantation and their association in developing countries warrants this study.
Materials and Methods
This cross-sectional study was taken up after Institutional Ethical Committee clearance. RT patients from multispecialty center were screened and recruited after due informed consent. Medically stable RT recipients with functional graft aged 18 to 60 years were included while subjects with organ dysfunction, coronary artery disease, acute rejection or uremic sickness, neuromuscular disability were excluded. Ninety RT recipients who underwent RT between 2010 and 2014 were invited for participating in this study, from the transplant registry. Among them, five patients expired, three patients not met the inclusion criteria, and two patients had renal failure after transplantation and 17 patients have migrated to other places. The Body Mass Index (BMI), transplant duration, BUN, creatinine, measurement of physical activity and QOL using IPAQ and RAND- 36 respectively were assessed from 63 eligible subjects with their consent.
Outcome measures
The IPAQ developed by the World Health Organization for physical activity surveillance is a valid and reliable tool.(15) It collects PA in five activity domains (job, transportation, Housework, house maintenance and caring for family, Recreation, sport and leisure time physical activity and time spent sitting) asked independently which includes twenty seven questions. The QOL was assessed with RAND 36 – It is a valid and most widely used questionnaire.(16) It comprises 36 items that assess eight health domains (Physical health, Role limitation due to physical health, Role limitation due to emotional problems, Energy/fatigue, Emotional wellbeing, Social functioning, Pain, General health).
Results
The descriptive analysis (Table 1) was done for PA and QOL data collected with categorization as per IPAQ scoring into low (<600), Moderate (601-3000) and high (>3000). Further the association between PA and QOL was analyzed using Pearson’s correlation. The level of significance was defined as 0.05 for all statistical analysis. There were 46 males and 8 females, 53 live-related renal transplantation (LLRT) recipients and 10 deceased-donor transplantation (DDRT) recipients. In this study the age was 35.73±3.7 years and the post RT duration was 24.62±7.43 months (95% CI 22.74-26.48, IQR-9).
| Table 1 Demographics of the study sample as per PA levels (n=63) |
|
Low PA (28) |
Moderate PA (24) |
High PA (11) |
Age (in years-mean/SD) |
42.2/4.6 |
36.5/3.4 |
28.5/3.1 |
Gender (Male/Female) |
20/8 |
18/6 |
8/3 |
Type of transplantation (LRRT/DDRT) |
23/5 |
21/3 |
9/2 |
BMI(Kg/m2) |
27.5(2.1) |
22.5(1.8) |
24.1(1.7) |
BUN {Mean(SD)} |
18.5(2.1) |
17.3(1.8) |
16.5(1.9) |
Serum Creatinine |
1.3/0.75 |
1.08/0.62 |
1.1/0.41 |
Hemoglobin in mg/dl{mean(SD)} |
9.7(0.9) |
11.6 (1.4) |
12.5(1.1) |
BMI-Body Mass Index, PA –Physical activity, LRRT-Live-related renal transplantation; DDRT-Deceased donor renal transplantation, BMI-Body Mass Index, BUN-Blood urea nitrogen |
The Role limitations due to Physical health / emotional problems and social functions were reduced while all other domains have remained above the IPAQ average scores. (Table 2). The overall physical activity level was at moderate level (932±720 MET. minute/week) and Pain score was topping among all domains of QOL. The male gender outlaid female number in all levels of physical activity as well the total recipients of kidneys. The physical health (r-0.556), role limitation due to physical health(r- 0.476), emotional well-being(r- 0.433) and general health (r-0.650) were positively correlated with Physical activity levels (p<0.05). All domains of QOL were negatively related to Post transplantation duration (p<0.05), implying the reduction in physical activity levels and QOL over period of time (Table 4, Figure 1).
| Table 2 Physical activity levels and quality of Life (n=63) |
|
Mean (SD) |
Median |
Range |
IQR |
95%CI |
Post RTx duration (months) |
24.62 (7.43) |
25 |
36 |
9 |
22.74-26.48 |
PA total(MET-min/week) |
932.09 (720.82) |
673 |
2780 |
766 |
750-1113 |
PH |
73.68 (10.85) |
75 |
52 |
14 |
70.95-76.41 |
RLPH |
50.19 (12.72) |
50 |
50 |
18 |
46.98-53.39 |
PLEP |
37.20 (16) |
30 |
78 |
3 |
33.17-41.23 |
Energy/Fatigue |
71.49 (10.6) |
75 |
50 |
15 |
68.82-74.16 |
EWB |
76.22 (10.02) |
78 |
37 |
17 |
73.69-78.74 |
Social functioning |
77.23 (15.85) |
78 |
100 |
19.50 |
73.24-81.22 |
PAIN |
90.12 (10.28) |
90 |
32.50 |
20 |
90.13-87.54 |
GH |
74.95 (12.29)2 |
75 |
60 |
20 |
71.85-78.04 |
RTx- Renal transplantation, PA-Physical activity, MET-Metabolic equivalents, min-Minutes, PH-Physical health, RLPH-Role limitations due to PH, PLEP- Physical limitations due to Emotional problems, EWB- Emotional wellbeing, GH-General health |
| Table 3 Post transplantation duration, gender distribution and Quality of Life domains among levels of PA(n=63) |
PA Levels (n) |
Gender (M/F) (%) |
Post RTxDuration Mean (SD) |
PA Mean(SD) |
PH Mean(SD) |
RLPH Mean (SD) |
PLEP Mean (SD) |
Energy/Fatigue Mean(SD) |
EWB Mean(SD) |
SF Mean(SD) |
Pain Mean(SD) |
GH Mean(SD) |
Low (28) |
71/29 |
30.17 (5.43) |
412.38 (170.05) |
70.57 (12.09) |
48.6 (9.23) |
42.18 (17.57) |
70.57 (12.57) |
72.21 (10.83) |
72.04 (17.75) |
88.59 (8.98) |
69.32 (13.05) |
Moderate (24) |
75/25 |
20.25 (5.95) |
904.59 (250.63) |
73.83 (9.04) |
47.29 (14.06) |
27.63 (8.53) |
72.50 (9.21) |
79.13 (9.29) |
80.85 (14.81) |
89.69 (12.92) |
75.04 (8.19) |
High (11) |
73/27 |
20 (4.97) |
2315.05 (370) |
81.27 (7.52) |
60.55 (13.13) |
45.45 (14.94) |
71.64 (8.33) |
80.09 (5.03) |
82.59 (7.98) |
95 (4.47) |
89.09 (3.75) |
| PA-Physical activity, RTx- Renal transplantation, PH- physical health, RLPH-Role limitation due to PH,PLEP-Physical limitations due to Emotional problems, EWB-Emotional well-being, SF- Social functioning, GH-General Health, n-number |
| Table 4 Correlation between Physical activity, Post renal transplantation duration and Quality of life domains (n=63) |
|
|
PH |
RLPH |
PLEP |
Energy/ fatigue |
EWB |
SF |
PAIN |
GH |
PA Total |
R-value |
.556 |
.476 |
.215 |
.228 |
.433 |
.331 |
.258 |
.650 |
p value |
.000 |
.000 |
.090 |
.072 |
.000 |
.008 |
.041 |
.000 |
Post RTx Duration |
R-value |
-.660 |
-.308 |
-.094 |
-.454 |
-.704 |
-.656 |
-.303 |
-.485 |
p value |
.000 |
0.014 |
.463 |
.000 |
.000 |
.000 |
.016 |
.000 |
| PA-Physical activity, RTx- Renal transplantation, PH- physical health, RLPH-Role limitation due to PH,PLEP-Physical limitations due to Emotional problems, EWB-Emotional well-being, SF- Social functioning, GH-General Health |
 |
Figure 1 Correlation between Physical activity , Post transplantation duration and QOL domains
PA Physical activity, PH physical health, QOL Quality of life |
Discussion
In this study, it was found that the patients falling under the category of low physical health values were more in number .This could be due to low physical activity, low participation in leisure, household activities and sedentary life style adopted after transplantation. A similar finding noted in a study done by Painter (5) and found out that low physical health is due to lack of awareness of exercises and or boredom of exercises.
In this study, it was found that the physical activity improved in the initial stages of surgery as the graft to function (6-24 months), which could be due to the better participation in daily activities and moderate level of physical activity like walking which is a subset of exercise. The physical activity in the post-transplant duration of above 30 months has gradually reduced. Similar result of physical activity was found in a previous study done by Painter (2); in which it was found that physical activity gradually improved from 1 to 5 years, no much improvement after 5 years. Although the patient physical health has improved over the years, the fatigue component in the quality of life had inconsistent improvement. The physical activity and physical health reduces with increase in post transplantation years.
In this study, it was found that the physical activity was more in the people who had BMI greater than the 22. It indicates the physical activity depends on enhanced nourishment possible after successful transplantation. At same time Overweight BMI showed reducing Physical activity level. Similar results shown previous study (8) and concluded that diet control is an important factor in controlling weight along with physical exercises. This weight gain could be due to the better appetite, rich nutrition and more usage of steroids (drug effect). Physical activity could be affected by lack of formal follow-up for exercise training, medication interaction effects and social support systems, which was not examined in the current study.
The correlation between physical activity, physical health and Post transplantation duration were significant. When patients are active, the physical health improves and reduced emotional disturbances were seen in the patients. The Negative correlations between QOL domains, Physical activity levels and duration post transplantation emphasis the need for structured training and education of patient and family, beyond the initial training. The Physical activity directly influences the QOL, which remains the ultimate measure of well-being. Hence there is a compelling need to establish strategies to improve exercise capacity and Physical activity and sustain the initial improvement by health care providers and social support system.(17,18) Hence counselling and training sessions would be needed to improve the physical activity and exercise tolerance.
Conclusion
The physical activity level and quality of life becomes low than the healthy individuals following renal transplantation after 24 months. There was a positive correlation between the physical activity and physical health domains of quality of life. This risk of health deterioration warrants interventions to improve the Physical activity levels and exercise capacity by systematic counselling and graded exercise training in post renal transplantation patients in population of developing nation wherein renal rehabilitation is yet to establish.
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