Original article

Back to work? Socioeconomic status after kidney transplantation

DOI: https://doi.org/10.4414/smw.2015.14169
Publication Date: 28.07.2015
Swiss Med Wkly. 2015;145:w14169

Leila Eppenberger, Patricia Hirt-Minkowski, Michael Dickenmann

Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Switzerland

Summary

PRINCIPLES: Employment after kidney transplantation is an important marker of health recovery. The study addresses the impact of successful kidney transplantation on socioeconomic factors and employment in a Swiss cohort.

METHODS: Patients who received a kidney allograft at the University Hospital of Basel between 2000 and 2011 were investigated. A standardised survey was used to obtain information on socioeconomic factors 1 year before and after successful transplantation.

RESULTS: A total of 610 patients were contacted; 354 (58%) answered the survey. The median age of respondents was 53.5 (interquartile range 42‒61) years at the time of transplantation, 31.2% were females. Overall, 201 out of 282 working-age patients (71.3%) were working 1 year after transplantation: 102 full-time, 55 part-time, 30 patients part-time with additional disability pension, and 14 housework. Seventy-two patients (25.3%) did not work 1 year after transplantation: 63 patients had a full or partial disability pension, and nine patients were unemployed. Thirty out of 282 working-age patients (10.6%) had improved working ability after transplantation. Employment after transplantation was favoured by: living donor transplantation (p <0.0001), pre-emptive transplantation (p <0.0001), dialysis duration ≤1 year (p <0.0001), preserved employment before transplantation (p <0.0001), and higher education (p = 0.003), whereas age above 50 years (p = 0.006), and dialysis duration > 1 year (p <0.0001) had a negative impact.

CONCLUSION: The employment rate in this Swiss cohort before and after successful kidney transplantation is high compared with the literature. A high number of living donors, of pre-emptive transplantations, and short dialysis vintages contribute to this observation.

Key words: socioeconomic status; disability pension; working ability; relationship; kidney transplantation

Introduction

Kidney transplantation is considered to be the most successful therapy for end-stage renal disease (ESRD) regarding patient survival [1, 2]. Many data are available on the medical outcome of kidney allograft recipients [3, 4]. Outcome data for all Swiss kidney allograft recipients have been collected and analysed by the Swiss Transplant Cohort Study since 2008 [4]. But the impact of transplantation on the socioeconomic status (SES), especially working ability, is less well investigated. Research on working ability after successful kidney transplantation has been conducted in different countries and the results are controversial [5–16]; for example, employment rates after successful renal transplantation are 30%–40% in the United States [5], 67% in the Netherlands [17], 40% in Finland [12], and 64.8% in Italy [15]. Overall, the rate of full- or part-time employment varies between 18% and 82% in these analyses. Patients with ESRD requiring renal replacement therapy are often considered as disabled and thus receive a partial or full disability pension [16]. At least a part of patients of working age is expected to go back to work after successful renal transplantation. Data from Switzerland regarding the change in working ability are lacking. The current study addresses socioeconomic factors and the change of working ability after successful kidney transplantation in a Swiss single centre population with a high proportion of living kidney donors. The aim of the study was, therefore, to evaluate the socioeconomic status of kidney recipients 1 year before transplantation and to compare the data with their status 1 year after successful kidney transplantation.

Patients and methods

This study was approved by the ethics committee of north-western Switzerland. Between 1 January 2000 and 31 December 2011, a total of 745 renal transplants were performed at the University Hospital of Basel. In autumn 2013, all living kidney allograft recipients with a functioning graft for at least 1 year were contacted with a two-page questionnaire, an explanatory letter and an informed consent form. Minimal time between transplantation and the survey was 18 months. The questionnaire consisted of 12 questions and was available in German (basic version, see appendix), French and Italian languages. Translations to French and Italian were made by professional translators. Respondents gave their answers using tick boxes and wrote additional information in the provided spaces. Questions regarding health or activity perception could be answered by setting a mark on a 0 to 10 scale. Five out of the 12 questions were used for the current analysis. Question 1: education and training, applicable answers: no graduation, graduated, completed apprenticeship, higher education or university degree. Question 2: type of profession 1 year before transplantation, e.g. “workman”, “journalist”. Questions 3/4: working status 1 year before / 1 year after kidney transplantation, applicable answers: working (if “yes”: percentage of working ability), retired, disability pension (if “yes”: percentage of disability pension), unemployed, others (e.g. housework, studies). Question 5: time of transplantation, applicable answers: too early, just in time, too late. Patients who had given unclear or illegible answers were contacted by telephone to clarify and confirm the answers.

Baseline characteristics (age, gender, time/type of dialysis, number of transplantations, donor type) were extracted from the patient documentation system of the University Hospital of Basel and were collected for all contacted patients. Working ability was defined as the ability to work, full- or part-time, from the medical point of view. Unemployment was considered as being formally able to work.

Statistical analysis

Data were analysed using JMP Pro Version 11 software (SAS Institute Inc., Cary, NC). For categorical data Pearson’s chi-square or Fisher’s exact tests were used and data presented as counts and percentages. For continuous data such as age two sample t-tests were conducted and summarised as mean (±standard deviation [SD]). Univariate and multivariate logistic regression analysis was performed to demonstrate determining factors of employment as a categorical dependent variable. All significant variables in the univariate analyses as indicated in table 3 were selected as explanatory variables for the multivariable models. A two-tailed p-value of <0.05 was considered to indicate statistical significance.

Results

Overall, 354 out of 610 patients (58%) gave their informed consent and completed the questionnaire (see fig. 1). Respondents were significantly older than nonrespondents, with mean (±SD) age at transplantation 51 (±13) vs 48 (±14) years (p = 0.0025), but did otherwise not significantly differ regarding baseline characteristics (data not shown). Baseline data of the respondents are shown in table 1.

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Figure 1
Patients' recruitment.
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Figure 2
Working status after transplantation.

Working status after transplantation

Of 282 working-age patients, 210 (74.5%) were working or able of work 1 year after transplantation as compared with 216 out of 292 patients (74%) before transplantation (p = 0.92). Table 2 provides detailed data on working status before and after transplantation.

Thirty out of 282 working-age patients (10.6%) improved their working ability after transplantation: 19 of 61 part-time working patients (27.9%) proceeded to a full-time work quota. Four of 28 patients (14.3%) with partial disability pension restarted full-time work, and seven patients (25%) restarted part-time work. No patient with a full disability pension proceeded to a 100% work quota after transplantation. Sixteen patients became dependent on a partial or full disability pension despite successful transplantation. Eight patients became unemployed. Patients who interrupted their work because of transplantation had a median time interval of 3 months (interquartile range [IQR] 2‒5 months) until re-uptake of work.

Factors with impact on working ability after transplantation

Overall, 201 out of 282 working age patients (71.3%) were working 1 year after transplantation: 102 full-time, 55 part-time, 30 part-time with an additional disability pension, and 14 had dedicated themselves to housework. Seventy-two patients (25.3%) did not work 1 year after kidney transplantation: 63 patients had a full or partial disability pension, and 9 patients were unemployed. Six patients were in training and the working status of three was unknown. Categorisation of employment after transplantation is shown in figure 2. Table 3 summarises factors with impact on working ability post-transplantation: age ≤50 years, living donor transplantation, pre-emptive transplantation, higher education, a dialysis period ≤1 year, and preserved employment before transplantation were associated with increased working ability after transplantation, whereas age above 50 years and a dialysis period >1 year showed a negative correlation. The multivariate logistic regression confirmed working status before transplantation to be the most important predictive factor (multivariate p <0.0001).

Time of transplantation

Sixty-six of the 354 patients (19%) could be transplanted pre-emptively. Of these 66, 36 (55%) were working full-time 1 year before transplantation, and 6/66 (9%) had some kind of disability pension at the time of transplantation.

A total of 304 of the 354 (86%) patients declared that transplantation was performed at the right time; 40/354 patients (11%) answered that transplantation was performed too late; 1.5% (5/354) felt that transplantation was carried out too early. Five out of 354 (1.5%) did not respond to this question.

Table 1: Baseline data of respondents.
Number (n)Percentage women 354

31.2%
Age at transplantation (years)
Mean (± standard deviation)

51 (±13)
Dialysis before transplantation (n, %) 
Pre-emptive transplantation

≤12 months on dialysis
 >12 months on dialysis

Unknown
66 (19%)

98 (27%)

188 (53%)

2 (1%)
Number of transplants (%)
1

2

≥3

85%

14%

1%
Donor type (%)
Deceased donor

Living donor

46.5%

53.5%
Education and training (%) 
No graduation

Graduated

Apprenticeship completed

Higher education or university degree

Unknown
4%

16%

64%

15%

1%
Table 2: Working ability before and after transplantation.
 One year before transplantationOne year after transplantation
All patients (n)354 354
Retired (n)62 72
Patients of working age, n (%) 292 (100%)282 (100%)
Gender: female91 (31.2%)86 (29.5%)
Working full-time96 (32.9%)102 (36.2%)
Working part-time61 (20.9%)55 (19.5%)
Part-time working and part disability pension35 (11.9%)30 (10.6%)
Housework18 (6.2%)14 (5.0%)
Unemployed6 (2.1%)9 (3.1%)
In training10 (3.4%)6 (2.1%)
Full disability pension35 (11.9%)38 (13.5%)
Partial disability pension28 (9.6%)25 (9.0%)
Not known3 (1.0%)3 (1.0%)
Education / training, n (%) 292 (100%)282 (100%)
No graduation12 (4.1%)11 (3.9%)
Graduated46 (15.8%)42 (14.9%)
Apprenticeship completed186 (63.7%)181 (64.2%)
Higher education or university degree45 (15.4%)45 (16%)
Unknown3 (1.0%)3 (1.0%)
Age groups, n (%) 292 (100%)282 (100%)
<25 years16 (5.5%)16 (5.7%)
26‒50 years135 (46.2%)135 (47.9%)
51–65 years141 (48.3%)131 (46.4%)
Table 3: Factors with impact on employment after transplantation.
 Working
after tx
(n = 201) *
Not-working
after tx (n = 72)
p-valueOdds ratio(95% confidence interval)
Gender    
Female, n (%)61 (30%)21 (29%)0.85 
Age group, n (%)    
<25 years

26‒50 years 

51‒65 years
10 (5%)

109 (54%)

82 (41%)
6 (8%)

23 (32%)

43 (60%)

0.006#
0.46

(0.27–0.80)
Donor Type, n (%)    
Living

Deceased
134 (67%)

67 (33%)
21 (29%)

51 (71%)
<0.00014.86

(2.74–8.88)
Number of transplants, n (%)    
1
 >1169 (84%)

32 (16%)
60 (83.5%)

12 (16.5%)
0.88 
Dialysis before tx, n (%)     
No dialysis = pre-emptive

≤12 months on dialysis
 >12 months on dialysis

Unknown
53 (26%)

68 (34%)

80 (40%)

-
4 (6%)

11 (15%)

56 (78%)

1 (1%)
<0.0001
 <0.0001
 < 0.00015.95 (2.31–20.2)

4.33 (2.17–9.31)

0.23 (0.11–0.46)
Education and training, n (%)    
No graduation

Graduated 

Apprenticeship completed

Higher education/ university degree 

Unknown
4 (2%)

20 (10%)

137 (68%)

39 (19%)

1 (1%)
8 (11%)

22 (30.5%)

36 (50%)

4 (5.5%)

2 (3%)



0.003§

4.0

(1.53–13.7)
Work status before tx, n (%)    
Working

Not working

Unknown
181 (90%)

13 (6.5%)

7 (3.5%)
20 (28%)

51 (71%)

1 (1%)
<0.000135.5 

(17.0–79.1)
tx = transplantation

* Working full-time (102) + part-time (55) + part-time and disability pension(30) + housework (14)

† Full disability pension (38) + part disability pension (25) + unemployed (9)

# Logistic regression analysis of age >50 years vs ≤50 years old patients.

¶ Logistic regression analysis of living vs deceased donors.

§ Logistic regression analysis of higher education vs others (patients with unknown education status were excluded).

Discussion

Kidney transplantation is the medical treatment of choice for ESRD. It improves life expectancy [18] and quality of life [19, 20] as compared with dialysis. The preservation of jobs before transplantation as well as the resumption of work after successful transplantation is crucial from the economic point of view and for the self-esteem of the recipient. Data on employment rates after transplantation differ from country to country [11, 12, 21–23]. National factors such as type of healthcare system, rate of unemployment, social welfare and economic climate complicate and limit the comparison of data.

The current study provided for the first time data on the employment rate before and after successful kidney transplantation in Switzerland. Pretransplant employment (part- or full-time) of working-age patients in the current analysis was 65.7%; 21.6% of patients awaiting kidney transplantation had a full or partial disability pension. These numbers on pretransplant employment differ significantly from those in other European countries such as Finland (about 30%; [12] or Denmark (22%, [22]), and even more from the US (18.9%) [21]. We assume that the avoidance of a dialysis period by pre-emptive transplantation (about 20%) or by transplantation after a short dialysis duration (about 25%) is mainly responsible for the preservation of employment before transplantation in the analysed population. Our data and data from others [10, 23] show that a preserved pretransplant employment status is crucial for the post-transplant working status. The avoidance or shortening of dialysis duration is mainly achieved by the high number of living donors (>50%) in this analysis and not by a sufficient rate of deceased donors in Switzerland [24]. Therefore, early planning of living donor transplantation is crucial to avoid time on dialysis, and to preserve employment. This interpretation is in line with the patient’s statement in nearly 90% (question 5) that the transplantation was performed at the right time. A high educational and training status of the analysed population might have also favoured the positive outcome [25, 26].

Seventy-one percent of working age patients in this analysis were fully or part-time working 1 year after transplantation. This number is higher than most reported rates in the literature [12, 23, 27]. Ten percent of patients could improve their employment status after a successful kidney transplant, not a big increase at first glance. But it has to be taken into account that the rate of employment before transplantation in the current analysis (65.7%) was already as high as many reported post-transplant rates in other countries [12, 23, 27]. Nevertheless, a careful evaluation of disability pensions after successful kidney transplantation might further improve the number of patients able to work. But it remains doubtful whether overall the rate of employment can further be increased as the employability of chronically ill patients is difficult [5, 7–10].

This study has several limitations. First, it is a retrospective analysis. Second, the respondents’ rate was 58%, and nonrespondents were slightly, but significantly younger than respondents, leading to the assumption that younger, working patients were reluctant to participate. Third, results relied upon the respondents’ accuracy and honesty in their answers. Furthermore, the study format poses the question about recall bias ‒ some patients were >11 years post-transplant at the time of the survey ‒ but usually patients remember well their working ability and their disability pension. In addition, unmeasured factors may have had an additional impact on the results and the questionnaire has not been validated.

In conclusion, the employment rate in this Swiss cohort before and after successful kidney transplantation is high as compared with the literature. A high number of living donors, of pre-emptive transplantations, and short dialysis duration may contribute to this observation.

Appendix

Questionnaire “Health status of kidney transplant patients in Basel”

> Download PDF file http://www.smw.ch/fileadmin/smw/pdf/SMW-14169-Appendix.pdf

Acknowledgements: The authors express their special thanks to Glena Iten, MA in Psychology, for the reviewing and standardising of the questionnaire, to Catherine Hänlin and Cathrine Wohlhüter for the French translation, and to Serenella Eppenberger, PhD, for the Italian translation. Also the authors express their thanks to Margrit Bucher and Heike Markus for the assistance in collecting the questionnaires.

Disclosures: The study was supported by a grant from Novartis AG. The authors of this manuscript have no potential competing interests to disclose as described by the Journal of Swiss Medical Weekly.

Correspondence

Correspondence: Leila Sara Eppenberger, Clinic for Transplantation, Immunology and Nephrology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland, l.eppenberger[at]unibas.ch

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