key: cord-0961983-9gc3hbe0
authors: Zgoura, Panagiota; Seibert, Felix S.; Waldecker, Christoph; Doevelaar, Adrian; Bauer, Frederic; Rohn, Benjamin; Schenker, Peter; Wunsch, Andreas; Viebahn, Richard; Babel, Nina; Westhoff, Timm H.
title: Psychological responses to the Covid-19 pandemic in renal transplant recipients
date: 2020-09-03
journal: Transplant Proc
DOI: 10.1016/j.transproceed.2020.08.043
sha: 82fc1c6940911872de7cee4e074964c75c2ea2db
doc_id: 961983
cord_uid: 9gc3hbe0

Background Renal transplant recipients are at increased risk for an adverse course of Covid-19, most likely due to immunosuppression and the high level of cardiovascular comorbidity. Many transplant reci-pients are aware of these facts. The psychological effects of this knowledge, however, remain elusive. Methods Cross-sectional study on 62 renal transplant recipients. 50 cardiovascular outpatients without immunosuppression and 55 healthy subjects served as control. We performed a focused psychological assessment during the pandemic (April 2020) and compared the data to a moment six months before. Additionally, an intergroup analysis was performed for the data during the pandemic. The analysis was performed by means of a questionnaire derived from KPD-38. We extracted five questions focusing on the parameters "life satisfaction" and perceived "action competence". Life satisfaction score ranged from 2 to 8, the score for action competence from 5 to 20. Results Both life satisfaction and perceived action competence were significantly lower during the pandemic than six months before in all the three groups (p<0.005 each). During the pandemic median levels of life satisfaction did not significantly differ between the three groups (transplant recipients 6, IQR 4-7; cardiovascular patients 5, IQR 4-6; healthy controls 6, IQR 5-7; Kruskall Wallis p>0.05). In contrast, the perceived action competence was higher in healthy subjects (15, IQR 12-17) than in both renal transplant recipients (13, IQR 10-15) and cardiovascular patients (13, IQR 8-14, Kruskall Wallis p=0.0003). Conclusion The Covid-19 pandemic has negative effects on life satisfaction and perceived action competence in renal transplant recipients, cardiovascular patients without immunosuppression and healthy subjects. The effects on life satisfaction in transplant recipients did not differ from non-immunocompromised patients or healthy controls. In contrast, the feeling of reduced action competence exceeded healthy controls, most likely due to a subjective need for stricter social distancing to avoid infection.

Health status has an important impact on quality of life. 1 Health-related quality of life measurements are part of a multidimensional concept including domains related to physical, emotional, mental and social functioning. 2, 3 Many studies have shown that mean health-related quality of life of renal transplant recipients is superior to hemodialysis patients. 4 In some cases it reached levels similar to healthy controls. The current coronavirus disease 2019 (COVID-19) pandemic, however, may elicit crucial changes in life satisfaction of renal transplant recipients. Due to their comorbidities and immunosuppressive therapy they are supposed to be at increased risk for adverse outcome.

Indeed, there is an increasing number of reports on the clinical course of COVID-19 in solid organ transplant recipients, most of them showing a substantially increased number of severe and fatal courses. [5] [6] [7] In a cohort of transplant patients in New York City mortality was 28% compared to 0.5-5%

in the general population. 6 Since risk factors for adverse outcome in COVID-19 have been transparently presented by the media, transplant recipients may suffer from increased levels of anxiety. Many of them might maintain social distancing in a rigid manner beyond lockdown measures in order to avoid infection. Thus, it may be speculated that the perceived competence to act and quality of life of renal transplant recipients may be extraordinarily affected. To date, there are no data on the psychological effects of the COVID-19 pandemic of transplant recipients.

The present cross-sectional study investigates the perceived change of life satisfaction and competence to act from October 2019 to April 2020. In order to differentiate the impact of immunosuppression, results are compared to patients with cardiovascular disease without immunosuppressive medication and to healthy controls.

in the outpatient clinic of the transplant center. They were informed that the survey was being done for research only and that their privacy would be protected. Inclusion criteria were age >18 years, successful transplantation (defined as no current need for dialysis) >6 months ago, and capability to understand the questionnaire. There were two control groups: The first group consisted of subjects admitted to an outpatient clinic for nephrology, hypertensiology and lipidology at Ruhr-University Bochum, the other one comprised a group of healthy subjects. Data on age, gender, time of transplantation, transplant function, cardiovascular comorbidities, immunosuppressive medication, and hospitalizations within the last 12 months were recorded. Ethical approval was obtained by the ethics committee of Ruhr-University Bochum (Nr. 20-6895). Patients provided written informed consent to participate in the study.

The study aimed at an assessment of life satisfaction and perceived competence to act during the pandemic (April 2020) and six months before. The questionnaire was derived from "The Clinical Psychological Diagnosis System 38" (KPD-38). It was developed for the purpose of quality assurance and outcome monitoring in psychotherapy and psychosomatic medicine in Heidelberg. 8 The KPD-38 encompasses six scales with a total of 38 items: 1. Physical impairment, 2. Mental impairment, 3.

Social problems, 4. Action competence, 5. General life satisfaction, 6. Social support. In order to reduce the patients' expenditure of time and thereby to increase the rate of participation, we extracted formulated 6 questions focusing on two parameters: "Action competence" and "general life satisfaction". The corresponding scales ranged from 1 to 4 (2 questions on life satisfaction, 5 questions on perceived action competence). Patients were asked to answer questions with regard to the current state and six months before. Questionnaires that were returned within four weeks were analyzed and included in the study. 

Questionnaires were completed and returned by 62 renal transplant recipients (41.3%). 50 cardiovascular outpatients without immunosuppression and 55 healthy persons were enrolled as control groups. All of them completed the questions of the questionnaire. Table 1 and Table 2 summarize the characteristics of all the three groups including epidemiologic data, transplant data, immunosuppression, prevalence of cardiovascular comorbidity, underlying renal disease, serum creatinine concentration/ eGFR and events necessitating hospitalization in the past 12 months. The majority (n=53, 85.5%) of the renal transplant patients had a triple immunosuppressive regime consisting of a calcineurin inhibitor, mycophenolic acid, and prednisolone.

Median age of the transplant population was 57 (interquantile range (IQR) 48-67). The majority of the patients were male (n=37, 59.7%). Mean time after transplant was 77 months (IQR 37.3-164).

The most frequent cardiovascular comorbidities were hypertension (n=54, 87.1%), diabetes (n=8, 13%), hyperlipidemia (n=44, 71%), and coronary artery disease (n=6, 1%). The cardiovascular patients without immunosuppression did not differ from the renal transplant population in terms of age (median 58, IQR 39-67; p=0.90), gender (male n=21 (42%), female n=29 (58%); p=0.087), the prevalence of hyperlipidemia (n=28, 56%; p=0.116) and diabetes (n=11, 22%; p=0.217). In contrast, serum creatinine concentrations (median 1.0, IQR 0.8-1.1) and proteinuria (median 0.09, IQR 0.09-0.12) were lower than in the transplant population (p<0.001; p=0.006). The prevalence of the cardiovascular comorbidities hypertension (n=34, 68%; p=0.02) and coronary artery disease (n=16, 32%; p=0.004) was statistically different from the transplant population. The number of hospitalizations were higher in renal transplant recipients than in the cardiovascular patients (n=38 (61.2%) vs. n=2 (4%); p<0.001).

The healthy population differed in age (median 39, IQR 28-56; p<0.001) and gender (male n=21 (38.1%), female n=34 (61.8%); p=0.045). None of them suffered of hypertension, diabetes, hyperlipidemia, chronic kidney disease and coronary artery disease. There were no numbers of hospitalizations.

The parameter "action competence" included five questions with 20 points as maximal score. Figure   1A illustrates the results in transplant recipients, cardiovascular outpatients and healthy controls for Using the KPD-38 questionnaire as a validated measurement for health-related quality of life we focused on the items "action competence" and "general life satisfaction", since these were likely affected by menacing circumstances associated with the Covid-19 pandemic. In order to differentiate the impact of immunosuppression and cardiovascular comorbidities on perceived health threat, we made use of a control group with cardiovascular diseases but without immunosuppression and a group with neither immunosuppression nor cardiovascular diseases. The transplant and cardiovascular patients were homogeneous for age, gender, and cardiovascular comorbidities like hyperlipidemia and diabetes as well.

The participation rate of 41.3% among transplant patients is comparable to the majority of health surveys with participants suffering from chronic or severe illness. 9 This is of importance, since the participation rate may have substantial impact on the findings of a survey. The higher the rate of participation, the lower the anticipated selection bias.

In accordance with the basic hypothesis, general life satisfaction was significantly reduced during the COVID-19 pandemic in renal transplant recipients. The individual reasons are beyond the scope of this investigation. Since this phenomenon occurred in the same way in non-immunocompromised subjects, however, immunosuppression does not appear to be the primary driver of this emotional disturbance. The analogous findings in the control group of cardiovascular outpatients and healthy J o u r n a l P r e -p r o o f controls implicate a more generalized concern. The question arises, whether the impairment of life satisfaction may merely be the consequence of lockdown-associated restrictions in daily life activities. Very likely, these restrictions indeed contribute to the reduced satisfaction. It should be kept in mind, however, that the questionnaire focuses on health related quality of life, not overall quality of life.

The perceived action competence depends on both the individual predispositions to conduct an activity and the external limitations to do so. The lockdown-associated restrictions in social activities will thereby have a strong impact on action competence. Subjects with risk factors for a severe course of COVID-19 might extend the social distancing beyond the requested lockdown regulations due to anxiety of infection. The present findings show that the reduction in perceived action competence is indeed more pronounced in subjects with risk factors than in healthy persons.

Interestingly, it did not matter, whether these risk factors consisted of immunosuppression or cardiovascular comorbidities. Thus, the general knowledge of belonging to a risk population for a severe course of COVID-19 is of greater determinative significance for the degree of anxiety during the pandemic than individual variations in comorbidities.

Prior to the pandemic, many reports showed a superior life satisfaction in transplant patients compared to patients with end-stage renal disease. 10, 11, 12 In a representative sample of 1424 renal transplant recipients from five kidney centers in France the need for medication for cardiovascular diseases had a negative impact on life satisfaction. However, there was no association between immunosuppressive drugs and quality of life. 13 Somewhat surprising, this finding remained unchanged during the pandemic in the present population. In fact, the role of immunosuppression in the clinical course of COVID-19 is still incompletely understood. A comparative study on patients with and without rheumatological diseases from Erlangen, Germany, did not show more severe courses in subjects with immunosuppression. 14 J o u r n a l P r e -p r o o f 

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