Quality of Life After Kidney Transplantation: The Bright Side of Life?

This review describes the state-of-the-art on quality of life (QOL) in kidney transplant (KTx) recipients. More specifically, posttransplant QOL is compared with the pretransplant evaluation, with other chronically ill patient populations, and with healthy subjects. Determinants, consequences, and potential interventions to improve QOL are also summarized. However, because of the methodological diversity of published articles, this review starts with addressing some conceptual and methodological concerns surrounding research on QOL in general and in KTx recipients specifically. The ultimate goal of this review was to identify the gaps in the state-of-the-art evidence and to provide some guidelines for conduct of research in the future.     

Patterns of β-Cell Autoantibody Appearance and Genetic Associations During the First Years of Life

We analyzed demographic and genetic differences between children with various diabetes-associated autoantibodies reflecting the autoimmune process. In a prospective birth cohort comprising children with HLA-conferred susceptibility to type 1 diabetes (T1D), the pattern of autoantibody appearance was analyzed in 520 children with advanced β-cell autoimmunity associated with high risk for disease. In 315 cases, a single biochemical autoantibody could be identified in the first positive sample as insulin (insulin autoantibody [IAA]) in 180, as GAD (GAD antibody [GADA]) in 107, and as IA-2 antigen (IA-2 antibody [IA-2A]) in 28. The age at seroconversion differed significantly between the three groups (P = 0.003). IAA as the first autoantibody showed a peak time of appearance during the second year of life, whereas GADA as the first autoantibody peaked later, between 3 and 5 years of age. The risk-associated insulin gene rs689 A/A genotypes were more frequent in children with IAA as the first autoantibody compared with the other children (P = 0.002). The primary autoantigen in the development of β-cell autoimmunity and T1D seems to strongly correlate with age and genetic factors, indicating heterogeneity in the initiation of the disease process.Immune destruction of the insulin-producing β-cells leading to clinical type 1 diabetes (T1D) is often a long-lasting process. During this preclinical period, antibody responses to several autoantigens can be detected. The number of detectable autoantibodies usually increases with time and correlates with the probability of disease development (1). It is not clear whether a primary autoantigen does exist and immune responses against other molecules represent secondary antigen spreading, or whether multiple molecules can be primary targets (2). Heterogeneities in the preferential age of appearance and in HLA associations have been described for various autoantibodies (3–6). The early appearance and association with younger age at diagnosis of insulin autoantibodies (IAAs) together with the essential role of the insulin molecule in the NOD mouse model have implied (prepro)insulin as the primary antigen (7). Antibody responses to all major antigens nevertheless accumulate with increasing age during the follow-up.Natural history studies of children at high risk who have undergone sequential blood sampling during short intervals provide a unique possibility for analyzing the appearance of autoimmunity in detail and for helping to resolve the question of whether one or multiple primary antigens exist. In the current study, we analyzed the Finnish Type 1 Diabetes Prediction and Prevention (DIPP) study children who developed advanced β-cell autoimmunity, indicating multiple autoantibodies and high risk of disease, and correlated the specificity of the primary autoantibody with demographic and genetic parameters.     

Does First Ray Amputation in Diabetic Patients Influence Gait and Quality of Life?

It has recently been suggested that first ray amputation in diabetic patients with serious foot complications can prolong bipedal ambulatory status, and reduce morbidity and mortality. However, no data are available on gait analysis and quality of life after this procedure. In the present case-control study (6 amputee and 6 nonamputee diabetics, 6 healthy non-diabetic), a sample of amputee diabetic patients were evaluated and compared with a sample of nonamputee diabetic patients and a group of age-matched healthy subjects. Gait biomechanics, quality of life, and pain were evaluated. Compared with the other 2 groups, amputee patients displayed a lower walking speed and greater variability and lower ankle, knee, and hip range of motion values. They also tended to have a more flexed hip profile. Pain and lower quality of life were related to worsening biomechanical data. Our study results have shown that gait biomechanics in diabetic patients with first ray amputation are abnormal, probably owing to the severity of diabetes and the absence of the push-off phase provided by the hallux. Tailored orthotics and rehabilitation programs and a specific pain management program should be considered to improve the gait and quality of life of diabetic patients with first ray amputation.     

Long-term Functional and Quality of Life Outcomes of Patients After Repair of Large Perianal Skin Defects for Paget’s and Bowen’s Disease

Introduction  

The assessment of long- term functional and quality of life outcomes of these patients following repair of large defects after surgical excision has not been reported.     

Does the Size of Ureteral Stent Impact Urinary Symptoms and Quality of Life? A Prospective Randomized Study

OBJECTIVE: To evaluate the effect of stent diameter on patients' symptoms and quality of life (QoL) by using dedicated questionnaires. METHODS: We prospectively enrolled 34 patients with unilateral ureteral obstruction due to urinary stone undergoing to ureteral stenting (17 pts with 4.8 F and 17 pts with 6 F) before treatment of stone disease. Twenty-one patients with lower urinary symptoms from other causes were used as a control group. Two questionnaires, one on QoL and another on stent specific symptoms, were administered to patients one week after stent positioning and 4 week after removal. RESULTS: There was a significant association between stent state and answers on pain and discomfort on QoL questionnaire. A high percentage of patients reported anxiety and depression associated with the stent. Similar significant association was found between stent state and urinary symptoms and pain. No differences in QoL and urinary symptoms and pain were detected using stents with different size. CONCLUSIONS: Ureteral stents are invariably associated with urinary symptoms and impaired QoL. We did not find any difference between stent with different size, whereas there was a tendency for stent with smaller diameter to dislodge more often.     

Role of Quality of Life in Men with Metastatic Hormone-Refractory Prostate Cancer: How Does Atrasentan Influence Quality of Life?

OBJECTIVE: Progression of hormone-refractory prostate cancer (HRPC) is associated with skeletal complications and bone pain, which contribute to deterioration in quality of life (QOL). The effects of new HRPC therapies on patients' QOL need to be studied. Patient-based assessments that help quantify the risk-benefit profile of HRPC therapies are warranted. This review summarizes the known QOL literature and estimates the potential effect of atrasentan, a novel, selective endothelin A receptor antagonist (SERA), on the QOL of HRPC patients. METHODS: Published studies were identified through a structured, detailed literature review. Clinical studies that report QOL data were reviewed, along with recent QOL data from atrasentan studies. RESULTS: HRPC studies have begun to use QOL assessments as primary endpoints, but different assessments and therapies are not comparable. Very few data integrate QOL with clinical endpoints. Atrasentan clinical trials demonstrated a statistically significant difference in the prostate cancer-specific QOL in favor of atrasentan (p=.032) and an increased quality-adjusted time to progression in men with HRPC. CONCLUSIONS: Atrasentan provides QOL benefits relevant to HRPC. The quality-adjusted analyses applied in the atrasentan studies have begun to lay the foundation for interpreting clinical endpoints in conjunction with QOL. These analyses will facilitate better QOL comparisons within studies and across trials. Further evaluation of atrasentan in HRPC is warranted.     

Intestinal Surgery for Crohn’s Disease: Predictors of Recovery, Quality of Life, and Costs

Introduction  

The aim of this prospective study was to analyze the impact of different surgical techniques on patients undergoing intestinal surgery for Crohn’s disease (CD) in terms of recovery, quality of life, and direct and indirect costs.     

The efficacy assessment of the treatment of degenerative lumbar scoliosis combined with spinal stenosis with posterior ＂responsibility segment＂ decompression and instrumented fusion

Objective： To evaluate the efficacy of the decompression of posterior responsibility segment and the corrective fixation for DLSS. Methods： This is a retrospective review of the charts and radiographs of 79 patients with DLSS treated by posterior responsibility segment decompression and instrumented fusion. The upper instrumented vertebra was T12 in 30 cases and L1 in 49 cases. The lowest instrumented vertebra was L5 in 51 cases and S1 in 28 cases. The Visual Analogue Scale, Japanese Orthopaedic Association, was -29 score. The radiographical measurements and demographic data were reviewed before operation, 1 year after operation and at follow-up. Results： The mean follow-up time was 4.9 years （range, 3～7 years）. Compared with the pre-op data, postoperative JOA score and VAS score as well as Cobb＇s angle were improved significantly （P〈0.05）. 5 cases （6.3%, 5/79） suffered from adjacent segment disease, including junctional kyphosis in 2 cases and progression of disc wedging in 3 cases, without compression fractures or spinal restenosis. In 3 patients, 6 months after surgery, the bilateral S1 pedicle screw was loosed, and L5/S1 facet joints was unfused. Conclusion： For DLSS, the confirmation of ＂responsibility segment＂ is most important, and instrumented fusion at TI2 or L1 could not increase adjacent segment disease significantly and can get a satisfactory effect.     

Does Limb-salvage Surgery Offer Patients Better Quality of Life and Functional Capacity than Amputation?

Introduction  

Patients with aggressive lower extremity musculoskeletal tumors may be candidates for either above-knee amputation or limb-salvage surgery. However, the subjective and objective benefits of limb-salvage surgery compared with amputation are not fully clear.     

Short-, Intermediate-, and Long-Term Quality of Life After Laparoscopic Radical Prostatectomy—Does the Learning Curve of LRP Have a Negative Impact on Patients’ Quality of Life?

OBJECTIVES: To evaluate quality of life (QoL) after laparoscopic radical prostatectomy (LRP) and investigate whether the learning curve of laparoscopic novices has a negative influence on patients' QoL. METHODS: Evaluation of QoL with the EORTC QLQ C-30 and the PR25 preoperatively (t0) as well as postoperatively after 1-3 mo (t1), 4-6 mo (t2), 7-12 mo (t3), 13-24 mo (t4), and yearly thereafter (t5-t7). Surgeons were grouped according to their prior experience in laparoscopy into experienced and novices. RESULTS: LRP was performed in 343 patients; 268 (78%) participated in the study. The mean patient age was 63.3+/-6.3 yr; mean PSA, 10.0+/-9.2 ng/ml; mean follow-up, 26 mo. Global health was impaired for t1 (p<0.001) and then returned to baseline. Emotional functioning improved (p<0.001) for t2-t7 versus baseline. Physical functioning remained impaired for t1-t2, and role and social functioning for t1-t6. Only sexual functioning did not return to baseline for t1-t7. Urinary symptoms were worse at t1 and then improved gradually (p<0.001). No significant difference in any QoL domain could be identified for experienced surgeons versus novices except for financial difficulties at t2-t3, which related to social differences. Thirty-one (9%) patients with adjuvant therapy had significantly worse global health, bowel symptoms, urinary symptoms, fatigue, and sexual functioning. CONCLUSIONS: The learning curve of laparoscopic novices does not have a negative impact on patients' QoL. For intermediate- to long-term follow-up, patients reach their baseline or score even better in all domains except for sexual functioning but are significantly impaired if adjuvant treatment is performed.     

Predictors of Weight Loss at 1 Year After Laparoscopic Adjustable Gastric Banding and the Role of Presurgical Quality of Life

Background

There is uncertainty regarding preoperative predictors of a successful outcome for bariatric surgery (BarSurg), on which to determine appropriateness for such a procedure. Our aims were to identify preoperative clinical and psychosocial predictors of success following BarSurg and to explore the influence of body mass index (BMI) on these parameters.

Methods

Preoperative data, including Impact of Weight on Quality of Life—Lite (IWQOL-Lite) scores transformed to Health-Related Quality of Life (HRQOL) scores, were accrued from 76 morbidly obese adults awaiting BarSurg. Pre- and postoperative data were also accrued for 26 patients who had completed 1-year follow-up post-bariatric surgery (laparoscopic adjustable gastric banding—LAGB). Statistical analysis was performed to assess the relationships between preoperative HRQOL scores, preoperative BMI and excess weight loss 1 year following BarSurg (EWL-1 year).

Results

Preoperative BMI showed a significant independent, negative linear correlation with the public distress domain of preoperative quality of life (QOL) (r?=??0.368, p?=?0.001; β?=??0.245, p?=?0.009). Preoperative BMI had a significant, positive and independent association with EWL-1 year (r?=?0.499, p?=?0.009; β?=?0.679, p?=?0.015). Preoperative QOL scores had no association with EWL-1 year.

Conclusions

Preoperative BMI appears to predict EWL-1 year following restrictive bariatric surgery (LAGB). Preoperatively, patients with higher BMI appear to manifest greater public distress. Preoperative QOL scores, however, do not appear to have any predictive value for EWL-1 year post-LAGB. Preoperative BMI should therefore be employed as a predictor of EWL-1 year post-LAGB. Other measures of successful outcomes of bariatric surgeries (such as effects on QOL scores at 1 year) should be explored in future, larger and longer term studies.     

Is Bilateral Lower Limb Lengthening Appropriate for Achondroplasia?: Midterm Analysis of the Complications and Quality of Life

Background  

Use of the Ilizarov technique for limb lengthening in patients with achondroplasia is controversial, with a high risk of complications balancing cosmetic gains. Although several articles have described the complications of this procedure and satisfaction of patients after surgery, it remains unclear whether lengthening improves the quality of life (QOL) of these patients.     

Evaluation of Gastric Bypass Patients 1 Year After Surgery: Changes in Quality of Life and Obesity-Related Conditions

Background  Obesity has recently been cited as the number one killer in the USA. This problem is both a national and regional epidemic. The health care costs of obesity and obesity-related illnesses are ever increasing, and gastric bypass surgery is becoming a popular treatment strategy. Recently, reports describe not only surgical outcomes, but also quality of life outcomes. The bigger issue of obesity-related illness resolution is still evolving. Our institution has performed well over 500 gastric bypasses since 2002. We evaluated over 100 patients prior to and 1 year after gastric bypass surgery. Methods  A prospective study was designed in order to systematically examine quality of life in gastric bypass patients and couple the results with both objective and subjective assessment of bariatric surgery outcomes. One hundred nineteen patients undergoing gastric bypass at our institution from January 2005 to December of 2005 were enrolled in the study. In addition to routine preprocedural and postprocedural follow-up, completion of quality of life forms and anthropometric measurements were performed. Using these data, we then correlated the change in quality of life scores with social factors, weight loss success, and status of obesity-related conditions. We also examined the impact of alcohol intake and other demographic factors on both quality of life and obesity related conditions. Results  A total of 119 patients were enrolled in the study during the calendar year 2005. Follow-up at approximately 1 year (average 12.86 months) postsurgery was obtained in 75 patients. A significant reduction in weight (144.4 ± 34.4 vs. 91.5 ± 28.8; p < 0.0001), body mass index (52.4 ± 12.2 vs. 32.3 ± 8.6; p < 0.0001), mean systolic blood pressure (140.4 ± 14.7 vs. 130.0 ± 21.7; p < 0.001), and lipids (194.3 ± 33.8 vs. 165.7 ± 32.1; p < 0.0001) was noted. Quality of life scores 1 year after gastric bypass surgery were also significantly improved (35.9 ± 19.5 vs. 82.2 ± 23.5; p < 0.0001). There was also a significant reduction in the reported usage of medications for obesity related conditions. Various measures of success (change in BMI, change in quality of life scores, and follow up health ranking) were compared across demographic and social factors and no significant associations were identified. Conclusions  Gastric bypass is associated with a reduction in weight, BMI, mean systolic blood pressure, cholesterol, and the usage of medications for obesity-related conditions. A significant improvement in quality of life was also noted 1 year after surgery.