Abstract
-
Purpose
Concern about graft rejection is a major issue among kidney transplant recipients. However, integrated studies that examine diverse factors influencing the perceived threat of the risk of graft rejection (PTGR) remain rare. This study explored levels of PTGR and the factors associated with PTGR in kidney transplant recipients.
-
Methods
A cross-sectional study was conducted with 194 kidney transplant recipients recruited from a tertiary hospital in South Korea. The PTGR scale assesses graft-related threat, intrusive anxiety, and lack of control, and was administered alongside measures of transplant-related symptoms, anxiety, depression, social support, and self-efficacy.
-
Results
Approximately 70.1% of participants reported strong graft-related threat beliefs, 57.2% experienced high intrusive anxiety, and 46.9% reported a low sense of control related to PTGR. Demographic factors (age, gender, education level, and kidney donor), clinical factors (transplant complications, posttransplant duration, and symptoms), and psychosocial factors (anxiety, depression, and social support) were associated with PTGR. Women, higher education levels, longer posttransplant duration, and donor relationship predicted graft-related threat, whereas anxiety and donor relationship predicted intrusive anxiety.
-
Conclusion
Many kidney transplant recipients experience high levels of PTGR, which are associated with demographic, clinical, and psychosocial factors. Healthcare providers should consider these factors when assessing PTGR and incorporate them into targeted interventions to support kidney transplant recipients.
-
Key Words: Anxiety; Graft rejection; Kidney transplantation; Perception; Transplant recipients
INTRODUCTION
Kidney transplantation is a renal replacement therapy and represents the optimal treatment for patients with end-stage renal disease [
1]. Globally, the number of kidney transplantations has increased in recent years [
2]. In 2023, approximately 43,090 kidney transplants were performed in the Americas, 27,229 in Europe, and 21,108 in the Western Pacific [
2]. Advances in surgical techniques, immunosuppressants, and desensitization therapies have contributed to improved outcomes [
3]. In 2024, 1-year graft survival rates in South Korea were predicted to be 98.77%, with 5-year survival rates estimated at 96.17% [
4].
Because transplantation involves the implantation of an organ or tissue from another person, graft rejection can occur. A systematic review reported that the incidence of acute rejection ranges from 1.1% to 21.5%, with most studies reporting rates of 3.0% to 12.0% within the first-year posttransplantation [
5]. Chronic rejection occurs in 7.5% to 20.1% of kidney recipients up to ten years after transplantation, and rejection is a well-established risk factor for graft failure [
5]. As a result, recipients are educated to recognize early symptoms of graft rejection and to maintain vigilance in their daily lives [
6].
Transplant recipients perceive graft rejection as a serious threat [
7,
8]. The perceived threat of the risk for graft rejection (PTGR) refers to the persistent fear experienced by organ transplant recipients [
9]. High PTGR contributes to psychological stress and reduced quality of life [
9], adverse emotional responses that affect psychophysiological and social well-being [
8,
9], and disruptions to daily life [
6].
PTGR has been associated with demographic, clinical, and psychosocial characteristics. Older age and women are associated with higher PTGR [
9,
10], as have a history of graft rejection–related symptoms and longer posttransplant duration [
10]. Depression and anxiety are also correlated with PTGR [
10], and PTGR has been shown to be negatively associated with self-efficacy in lung and heart transplant recipients [
10,
11].
Kidney transplant recipients often experience changes in self-identity, adjustment difficulties, and both psychological and physical problems as they adapt to a transplanted organ [
12]. Accordingly, adequate physiological, psychological, and social resources are essential for successful adaptation. Support from family members and healthcare professionals facilitates adjustment and helps recipients overcome posttransplant challenges [
13]. Social support has been associated with illness perceptions and psychosocial adaptation in kidney transplant recipients [
14], and support from family and friends facilitates self-management, including emotional management, in this population [
15]. Thus, social support may play an important role in PTGR among kidney transplant recipients.
Although kidney transplant recipients report greater PTGR related to acute rejection than recipients of liver, heart, or lung transplants [
9], studies focusing exclusively on kidney transplant recipients remain limited. Existing studies on PTGR have primarily focused on demographic and clinical factors. Self-efficacy has been reported as a factor associated with PTGR in lung and heart transplant recipients, but studies examining this relationship in kidney transplant recipients are scarce. Social support has been identified as a major factor influencing disease awareness and psychological adaptation in this population [
14,
15], yet its relationship with PTGR has not been sufficiently examined. Previous studies have rarely comprehensively evaluated factors related to PTGR, including depression, anxiety, self-efficacy, social support, and clinical factors, in kidney transplant recipients. Therefore, this study aimed to identify PTGR levels and to investigate demographic, clinical, psychosocial (depression, anxiety, and social support), and cognitive (self-efficacy) factors associated with PTGR in kidney transplant recipients.
METHODS
1. Study Design
A descriptive, cross-sectional study design was used. The study is reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines.
2. Setting and Samples
This study included 194 kidney transplant recipients recruited from a tertiary hospital in South Korea. Convenience sampling was used to enroll patients who were visiting the transplant surgery outpatient clinic or receiving inpatient treatment in the transplant surgery ward. The inclusion criteria were as follows: 1) age ≥20 years, 2) receipt of a kidney transplant from either a living or deceased donor, and 3) not undergoing dialysis after kidney transplantation. The exclusion criteria were as follows: 1) diagnosis of a major psychiatric disorder (e.g., major depression, bipolar disorder), and 2) confirmed graft rejection based on renal biopsy.
Participants in the outpatient clinic were approached either before or after their scheduled appointments. Inpatients were approached during rest periods following examinations or treatments. All participants were provided with detailed information about the study, and written informed consent was obtained prior to participation.
The sample size for this study was calculated using the G*Power 3.1.9.7 program. A medium effect size of .15 for multiple regression analysis, a power of 0.80 (1−β), a significance level of .05, and 22 predictor variables were specified for the calculation, resulting in a required sample size of 163 participants. Considering a 20% dropout rate, the target sample size was set at 204 participants. To recruit 204 participants, 300 kidney transplant recipients were invited to participate in the study; however, 96 declined participation. After data collection, ten participants were excluded because they had undergone two kidney transplants. Consequently, data from 194 participants were included in the final analysis.
3. Instruments
1) Perceived threat of the risk for graft rejection
In this study, the PTGR instrument developed by Nilsson et al. [
9] was used, with permission obtained from the original author for Korean translation. The Korean translation of the PTGR followed a multistep process, including initial translation, expert review, back-translation, and a pilot study, resulting in a final Korean version developed in accordance with the World Health Organization guidelines for translation and cultural adaptation of instruments [
16].
During the initial translation phase, two bilingual nursing researchers independently translated the English instrument into Korean. A third researcher compared the two translated versions to determine the most appropriate Korean wording. The research team then reconciled discrepancies, with particular attention to Item 9 (“Graft rejection was almost always in my mind”), and revised the item accordingly. Subsequently, another bilingual expert conducted a back-translation, after which the researchers compared the original and back-translated versions for conceptual equivalence. The Korean version was then pilot-tested with ten kidney transplant recipients hospitalized in the transplant unit. Due to the lack of institutional review board approval at that stage, demographic and clinical information were not collected. During the pilot testing phase, participants reported difficulty understanding Item 10 (“I can’t affect graft rejection personally”) and Item 11 (“I can’t affect how it will turn out to be”). The researchers revised both items to enhance clarity while maintaining consistency with the original meanings. The revised and supplemented scale was subsequently pilot-tested with five additional kidney transplant recipients, and no items were found to be incomprehensible. Based on these results, the final Korean version of the PTGR was completed.
The PTGR scale consists of 12 items across three subscales, rated on a 5-point Likert scale: three items assessing graft-related threat, six items assessing intrusive anxiety, and three items assessing lack of control. The PTGR scale is designed to be interpreted at the subdomain level and does not generate a total score [
9]. Graft-related threat reflects perceived risk of harm, including concerns that the primary disease may recur, health may deteriorate, or an explicit fear of graft loss. Scores for graft-related threat range from 3 to 15, with scores greater than 9 indicating a strong perceived threat. Intrusive anxiety reflects stress responses and anxiety related to graft rejection, with scores ranging from 6 to 30, and scores greater than 18 indicating high intrusion. Lack of control reflects the perception that graft rejection is beyond personal control, with scores ranging from 3 to 15, and scores greater than 9 indicating a low perceived ability to reduce the risk of graft rejection [
9,
10]. In the original study, Cronbach’s α values were .81 for graft-related threat, .91 for intrusive anxiety, and .82 for lack of control [
9]. In the present study, Cronbach’s α values were .86 for graft-related threat, .90 for intrusive anxiety, and .65 for lack of control.
2) Modified Transplant Symptom Occurrence and Distress Scale
Transplant-related symptoms were assessed using the Korean version of the modified Transplant Symptom Occurrence and Distress Scale [
17,
18], which was used with permission from the copyright holder. The scale consists of two domains: symptom occurrence and symptom distress. Each domain includes 59 items rated on a 5-point Likert scale ranging from 0 to 4. Total scores for each domain range from 0 to 236, with higher scores indicating greater symptom occurrence or symptom-related distress [
17].
3) Anxiety and depression
Anxiety and depression were measured using the Korean version of the Hospital Anxiety and Depression Scale [
19,
20]. Permission for use in this study was obtained from the copyright holder. The scale consists of 14 items, with seven items assessing anxiety and seven assessing depression, each rated from 0 (none) to 3 (severe). Higher scores indicate greater levels of anxiety and depression. In the original study [
20], Cronbach’s α ranged from .80 to .93 for anxiety and from .81 to .90 for depression. In the Korean validation study [
19], Cronbach’s α was .89 for anxiety and .86 for depression. In the present study, Cronbach’s α was .84 for anxiety and .73 for depression.
4) Multidimensional Scale of Perceived Social Support
Social support was measured using the Korean version of the Multidimensional Scale of Perceived Social Support [
21,
22]. For use in this study, approvals were obtained from both the developers of the original scale and those of the Korean version. This scale has previously been used to measure social support in patients who underwent liver transplantation [
23]. The 12-item scale assesses perceived support from family, friends, and significant others. Each item is rated on a 5-point Likert scale, with higher scores indicating greater perceived social support. Cronbach’s α ranged from .84 to .92 in the original study [
22], was .91 in the Korean validation study [
21], and was .90 in the present study.
5) Self-efficacy scale
Self-efficacy was measured using the Korean version of the self-efficacy scale [
24,
25], which is publicly available and was used with permission from the developer of the Korean version. This scale has been used previously to assess self-efficacy in kidney transplant recipients [
24]. The scale consists of 17 items rated on a 5-point Likert scale, with higher scores indicating greater self-efficacy. Cronbach’s α was .86 in the original study [
25], .86 in the study of Korean kidney transplant recipients [
24], and .90 in the present study.
6) Other demographic and clinical characteristics
Demographic characteristics included gender, age, education level, occupation, marital status, and religion. Clinical characteristics included duration of dialysis, cause of kidney injury, posttransplant duration, donor relationship, history of transplant rejection, transplant complications, number and type of immunosuppressive drugs, transplant surgery complications, and body mass index. Demographic and clinical characteristics were assessed through participant self-report or by reviewing medical records.
4. Data Collection
Data were collected between January 25 and March 21, 2024, from kidney transplant recipients who visited the transplant surgery outpatient clinic or were hospitalized in the transplant surgery ward. Data collection was conducted using structured questionnaires. When participants had difficulty completing the questionnaire independently, the researcher read the questionnaire verbatim and recorded participants’ responses. Completion of the questionnaire required approximately 20 to 25 minutes when self-administered and approximately 40 minutes when read aloud. When a considerable amount of time had elapsed, the researcher periodically assessed participants’ comfort and reminded them that participation could be discontinued at any time. Because the social support questionnaire included questions related to family support, participants completed the survey in a quiet and private setting. In the outpatient clinic, empty consultation or patient education rooms were used. In the ward, surveys were conducted either in single-patient rooms or in interview rooms designated for multi-patient wards.
5. Ethical Considerations
This study was approved by the Institutional Review Board of Asan Medical Center (IRB No. 2024-0108). The researcher explained the study’s purpose and procedures to all participants and obtained written informed consent prior to participation. All collected data will be used exclusively for research purposes. To ensure participant anonymity, questionnaire data will be coded and stored on a password-protected, encrypted computer for three years following completion of the study. In addition, participants were informed that they could withdraw from the study at any time without penalty.
6. Data Analysis
Collected data were analyzed using IBM SPSS ver. 29.0 (IBM Corp., Armonk, NY, USA). Demographic, clinical, psychosocial, and cognitive characteristics, as well as PTGR levels, were summarized using descriptive statistics. Differences in PTGR according to demographic and clinical characteristics were examined using independent t-tests, analysis of variance (ANOVA) with post hoc Scheffé tests, and nonparametric analyses using the Kruskal-Wallis test. For variables that did not meet the assumption of normality, the Kruskal-Wallis test was applied. Correlations between PTGR and study variables were examined using Pearson correlation coefficients. Because the study was not based on an explicit theoretical framework and the explanatory variables were not clearly established, stepwise multiple regression analysis was conducted. Statistical significance was set at p <.05.
RESULTS
1. Demographic, Clinical, Psychosocial, and Cognitive Characteristics of the Participants
Regarding demographic characteristics, 106 participants (54.6%) were men, with a mean age of 50.98 years, and the largest age group was 50 to 59 years (28.9%). Approximately 62.4% of participants had attained education beyond the college level, and 151 participants (77.8%) were employed (
Table 1).
With respect to clinical characteristics, 17 participants (8.8%) experienced graft rejection, including manifestations such as increased creatinine levels, decreased urine output, or weight gain associated with reduced graft kidney function. The mean posttransplant duration was 85.47 months. Donor types included deceased donors (n=57, 29.4%), siblings or relatives (n=44, 22.7%), spouses (n=39, 20.1%), and parents (n=35, 18.0%). Six participants (3.1%) received organs from friends or nonprofit organizations. Eighty-four participants (43.3%) experienced transplant-related complications, including cytomegalovirus infection,
Pneumocystis carinii pneumonia, urinary tract infection, and immunosuppressant-induced diabetes. The mean number of immunosuppressive medications was 2.73±0.46, and tacrolimus use was reported in 88.7% of participants. Sixteen percent of participants experienced transplant surgery complications, including bleeding, infections, ureteral leak, and ureteral stricture. According to the modified Transplant Symptom Occurrence and Distress Scale, mean symptom occurrence was 48.99±29.15 and mean symptom distress was 43.66±30.57 (
Table 1). These scores were slightly lower than those reported in previous Korean studies [
26].
Among psychosocial and cognitive characteristics, mean scores for depression, anxiety, social support, and self-efficacy were 5.47±3.63, 5.01±3.91, 3.62±0.76, and 61.98±10.11, respectively.
2. Descriptive Data of PTGR among the Participants
The mean scores for the PTGR subdomains of graft-related threat, intrusive anxiety, and lack of control were 10.95±3.37, 17.38±6.28, and 9.06±2.41, respectively. Among participants, 136 (70.1%) reported strong graft-related threat beliefs, 111 (57.2%) experienced significant intrusive anxiety, and 91 (46.9%) perceived low control over their ability to reduce the risk of graft rejection (
Table 2).
1) Demographic, clinical, psychosocial, and cognitive characteristics associated with graft-related threat in PTGR
With respect to the graft-related threat subdomain, women (t=−3.20,
p=.002) and participants with higher education levels (≥college) (t=3.09,
p=.002) had significantly higher graft-related threat scores. Significant differences in graft-related threat were also observed according to donor type (χ²=15.05,
p=.010), with higher perceived threat reported when the donor was a deceased donor or a parent. In addition, participants who experienced transplant complications had higher graft-related threat scores than those without complications (t=1.98,
p=.049) (
Table 3). Correlation analysis showed that a longer posttransplant duration (r=.18,
p=.015) was associated with higher graft-related threat (
Table 4).
2) Demographic, clinical, psychosocial, and cognitive characteristics associated with intrusive anxiety in PTGR
In the intrusive anxiety subdomain, women (t=−2.01,
p=.046) demonstrated higher intrusive anxiety scores than men (
Table 3). Higher symptom occurrence (r=.16,
p=.029), higher symptom distress (r=.18,
p=.010), greater depression (r=.15,
p=.040), and higher anxiety (r=.36,
p<.001) were significantly associated with increased intrusive anxiety scores (
Table 4).
3) Demographic, clinical, psychosocial, and cognitive characteristics associated with lack of control in PTGR
Older age (r=.17,
p=.021), higher anxiety (r=.20,
p=.005), and lower social support (r=−.15,
p=.043) were significantly associated with higher lack-of-control scores (
Table 4). Lack-of-control scores were not significantly associated with any demographic or clinical characteristics in group comparison analyses (
Table 3).
Stepwise multiple regression analysis was conducted to identify factors influencing PTGR in kidney transplant recipients. Variables with p-values less than .10 in univariate analyses were included as independent variables.
1) Factors influencing graft-related threat in PTGR among kidney transplant recipients
Factors influencing graft-related threat included gender (women) (β=.27, p<.001), higher education level (≥college) (β=.26, p<.001), longer posttransplant duration (β=.16, p=.015), and donor type (brain-dead donor or parent) (β=.16, p=.019). These variables explained 16.3% of the variance in graft-related threat (adjusted R²=.16, F=10.22; p<.001).
To assess multicollinearity among independent variables, tolerance values and variance inflation factors (VIFs) were calculated. Tolerance values ranged from 0.926 to 0.997, exceeding the minimum threshold of 0.10, and VIFs ranged from 1.003 to 1.080, remaining well below 10, indicating that multicollinearity was not present. The Durbin-Watson statistic was 2.030, which is close to the ideal value of 2.0, suggesting independence of error terms and the absence of autocorrelation.
2) Factors influencing intrusive anxiety in PTGR among kidney transplant recipients
Factors influencing intrusive anxiety included anxiety (β=.34, p<.001) and donor type (excluding “others”) (β=.15, p=.025). These variables accounted for 14.3% of the variance in intrusive anxiety (adjusted R²=.14, F=6.78; p<.001). The tolerance value was 0.979, the VIF was 1.022, and the Durbin-Watson statistic was 1.827, indicating the absence of multicollinearity.
3) Factors influencing lack of control in PTGR among kidney transplant recipients
Factors influencing lack of control included anxiety (β=.23,
p=.001), older age (β=.19,
p=.008), and transplant surgery complications (β=−.16,
p=.021). These variables explained 8.2% of the variance in lack of control (adjusted R²=.08, F=6.78;
p<.001) (
Table 5). Tolerance values ranged from 0.978 to 0.993, VIFs ranged from 1.007 to 1.993, and the Durbin-Watson statistic was 2.189, indicating that multicollinearity was not present.
DISCUSSION
This study was conducted to examine the level of PTGR and to identify factors associated with PTGR among kidney transplant recipients. The PTGR scale is designed to be interpreted at the subdomain level rather than as a total score; accordingly, analyses in this study were conducted separately for each subdomain. Among kidney transplant recipients, PTGR was associated with demographic, clinical, and psychosocial factors.
In this study, 70.1% of participants demonstrated a strong belief in graft-related threat, 57.2% reported high intrusive anxiety, and 46.9% reported a high level of lack of control. These findings indicate that PTGR levels among kidney transplant recipients are higher than those reported in previous studies involving lung transplant recipients and mixed organ transplant populations [
10,
11], with a particularly high proportion exhibiting strong graft-related threat beliefs. This difference may be attributable to the higher proportion of women and the longer posttransplant duration in the present study compared with prior studies [
10,
11]. Accordingly, healthcare professionals should systematically assess PTGR in kidney transplant recipients, with particular attention to graft-related threat among the PTGR subdomains.
In this study, demographic factors, including gender, education level, and age, were associated with PTGR. Gender (women) and higher education level influenced graft-related threat, whereas older age was associated with lack of control. A previous study reported higher graft-related threat among women than men, although the difference was not statistically significant, and also found higher intrusive anxiety in women, supporting the importance of considering gender when evaluating PTGR [
10]. Education level has not been examined previously; however, higher education was associated with higher graft-related threat in this study. This finding is consistent with research on fear of cancer recurrence, in which higher education predicted greater fear, possibly because individuals with higher educational attainment are more likely to seek additional information about their illness, treatment, and prognosis [
27]. Although graft-related threat is not identical to fear of cancer recurrence, both constructs reflect heightened awareness of potential future health threats. Recipients with higher education levels may acquire more information about rejection risk and, paradoxically, experience stronger graft-related threat. Further research is needed to examine differences in graft-related threat according to educational level and to ensure that information provided to recipients is accurate and balanced to prevent unnecessary fear. In a previous study examining the relationship between age and PTGR [
10], recipients aged 50 years or older had higher graft-related threat; however, in the present study, age was associated only with lack of control. Because few studies have examined demographic characteristics in relation to PTGR, additional research is warranted.
Among clinical factors, posttransplant duration and donor type influenced PTGR. The association between posttransplant duration and PTGR may reflect awareness of the expected lifespan of a transplanted kidney, which is generally reported to be 11.7 to 19.2 years [
4], potentially heightening graft-related threat as time since transplantation increases. In a previous study, PTGR according to posttransplant duration was described, but differences were not statistically analyzed [
10]. Therefore, further studies are needed to examine PTGR levels across different posttransplant time periods. In this study, donor type was also influential, with graft-related threat being significantly higher when the donor was a deceased donor or a parent. This finding is likely related to donor age and graft prognosis. Previous studies have reported lower graft survival when donors are older, and when the donor is a parent, the donor is necessarily older than the recipient [
28-
30]. In addition, graft survival is shorter among recipients of deceased donors compared with those receiving kidneys from living donors [
31], and survival is further reduced when deceased donors are older [
28]. Therefore, donor type should be carefully considered when evaluating graft-related threat.
With respect to psychosocial factors, anxiety influenced PTGR, and both depression and anxiety were associated with intrusive anxiety in this study. These findings are consistent with previous studies demonstrating associations among anxiety, depression, and intrusive anxiety [
10,
11]. Anxiety and depression are also associated with clinical parameters such as serum creatinine, hemoglobin levels, and both physical and mental health in kidney transplant recipients [
32]. Consequently, interventions aimed at reducing anxiety and depression may contribute to improvements in both clinical and psychological outcomes. In addition, higher levels of social support were associated with lower levels of lack of control. Although direct comparison is limited by the paucity of prior studies, a recent study involving kidney transplant recipients with graft failure reported similar findings [
33]. In that study, participants indicated that support from family members, healthcare professionals, fellow patients, and friends provided comfort and strength to overcome difficulties [
33]. Because social support may enhance recipients’ perceived control over their situation, healthcare professionals and families should work collaboratively to strengthen support systems.
Unlike findings from previous studies, self-efficacy as a cognitive factor was not directly associated with PTGR in this study. However, self-efficacy was associated with depression and anxiety, which were themselves related to intrusive anxiety. In a prior study, self-efficacy showed strong associations with intrusive anxiety during heart transplantation [
10]. Therefore, future research is needed to clarify the relationships among self-efficacy, depression, anxiety, and intrusive anxiety using advanced analytical approaches such as path analysis. Additionally, the lack of association between self-efficacy and PTGR observed in this study may be attributable to the measurement instrument used. Because no transplant-specific self-efficacy scale currently exists, generic instruments, such as the Self-Efficacy for Managing Chronic Disease 6-Item Scale, are often used in transplant populations [
34]. Given that self-efficacy is behavior-specific and that transplant recipients must manage complex self-care behaviors, including adherence to immunosuppressive therapy and monitoring for symptoms and signs of graft rejection [
5], the development of a transplant-specific self-efficacy scale is warranted.
This study has several limitations. First, generalizability is limited because the study was conducted among inpatients and outpatients at a single tertiary hospital. Second, the reliability of the lack-of-control subdomain of the PTGR scale was relatively low, likely due to the small number of items comprising this subscale (three items) [
35]. Furthermore, during pilot testing of the Korean version, participants reported difficulty understanding Items 10 and 11, which necessitated multiple revisions. Consequently, further research is needed to examine and refine the psychometric properties of the Korean version of the PTGR scale. Finally, factors influencing PTGR were examined without an explicit theoretical framework and were selected based on previous studies. Because this study employed a cross-sectional design, causal relationships among variables could not be clearly established. Future research should incorporate theoretical frameworks and apply analytic approaches such as path analysis or structural equation modeling, as well as longitudinal designs, to better clarify causal relationships.
This study also has several strengths. First, it highlights PTGR levels in kidney transplant recipients, a population with substantial concern about acute rejection, thereby addressing the limited number of PTGR studies conducted among organ transplant recipients. Second, this study integrates demographic, clinical, psychosocial, and cognitive factors associated with PTGR in kidney transplant recipients, contributing to a more comprehensive understanding of PTGR in this population.
1. Implications for Clinical Practice
Because women may experience higher PTGR levels than men, nurses should pay particular attention to graft-related threat among female recipients and assess their PTGR levels carefully. In addition, it is important to identify factors associated with PTGR in women and to implement interventions tailored to those factors. As age and education level are related to PTGR, healthcare professionals should verify whether recipients possess accurate information about graft rejection and should provide clear explanations that take age and educational background into account to avoid unnecessarily heightened threat perceptions. In particular, older adults and individuals with lower educational levels should receive information presented in an accessible and understandable manner to ensure accurate comprehension of transplantation-related issues. Moreover, graft-related threat increased with longer posttransplant duration. Therefore, the graft-related threat subdomain of PTGR should be evaluated even in long-term recipients who do not exhibit overt physical problems.
Strategies are needed to manage modifiable factors related to PTGR, including transplant surgery complications and anxiety. Nurses should closely monitor recipients for complications following transplant surgery, and early detection and timely treatment of these complications may help reduce PTGR. Because anxiety predicts intrusive anxiety and is associated with social support, healthcare professionals should implement interventions that incorporate social support to reduce anxiety among recipients, which may represent an effective strategy for managing PTGR.
CONCLUSION
Many kidney transplant recipients experience high levels of PTGR, which are associated with demographic, clinical, and psychosocial factors. Healthcare providers should consider these characteristics when assessing PTGR in transplant recipients.
Although kidney transplantation is a primary and highly effective treatment option for patients with end-stage renal disease, recipients continue to face multiple challenges following the procedure. To prevent recipients from experiencing vague or persistent concerns about potential graft rejection, healthcare providers should consistently attend to patients’ PTGR and ensure that recipients receive systematic and comprehensive education to support effective PTGR management.
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CONFLICTS OF INTEREST
The authors declared no conflict of interest.
-
AUTHORSHIP
Study conception and/or design acquisition - SB, SRK, KK, and YP; analysis - SB and SRK; interpretation of the data - SB, SRK, KK, and YP; and drafting or critical revision of the manuscript for important intellectual content - SB, SRK, KK, and YP.
-
FUNDING
None.
-
ACKNOWLEDGEMENT
This article is a revision of the Seolhwa Baek’s master’s thesis from Korea University.
-
DATA AVAILABILITY STATEMENT
The data can be obtained from the corresponding authors.
Table 1.Demographic and Clinical Characteristics of Participants (N=194)
|
Variables |
Categories |
n (%) |
M±SD |
|
Demographic characteristics |
|
|
|
|
Gender |
Men |
106 (54.6) |
|
|
Women |
88 (45.4) |
|
|
Age (year) |
≤39 |
34 (17.5) |
50.98±11.82 |
|
40–49 |
50 (25.8) |
|
|
50–59 |
56 (28.9) |
|
|
≥60 |
54 (27.8) |
|
|
Education level |
High school |
73 (37.6) |
|
|
≥College |
121 (62.4) |
|
|
Employment |
Yes |
151 (77.8) |
|
|
No |
43 (22.2) |
|
|
Spouse |
Yes |
157 (80.9) |
|
|
No |
37 (19.1) |
|
|
Religion |
Yes |
108 (55.7) |
|
|
No |
86 (44.3) |
|
|
Clinical characteristics |
|
|
|
|
Dialysis duration (month) |
<3.0 |
43 (22.2) |
47.47±62.66 |
|
3.0–5.9 |
12 (6.2) |
|
|
6.0–11.9 |
33 (17.0) |
|
|
12.0–119.9 |
71 (36.6) |
|
|
≥120 |
35 (18.0) |
|
|
Diseases causing kidney injury†
|
Hypertension |
52 (26.8) |
|
|
Diabetes mellitus |
41 (21.1) |
|
|
Polycystic kidney disease |
8 (4.1) |
|
|
Unknown |
47 (24.2) |
|
|
Glomerulonephritis |
10 (5.2) |
|
|
Others |
46 (23.7) |
|
|
Posttransplant duration (year) |
<1.0 |
36 (18.6) |
7.12±7.01 |
|
1.0–2.9 |
38 (19.6) |
|
|
3.0–9.9 |
64 (33.0) |
|
|
≥10 |
56 (28.9) |
|
|
Kidney donor |
Deceased donor |
57 (29.4) |
|
|
Parent |
35 (18.0) |
|
|
Spouse |
39 (20.1) |
|
|
Children (daughter or son) |
13 (6.7) |
|
|
Sibling or relative |
44 (22.7) |
|
|
Others‡
|
6 (3.1) |
|
|
History of graft rejection |
Yes |
17 (8.8) |
|
|
No |
177 (91.2) |
|
|
Transplant complication |
Yes |
84 (43.3) |
|
|
No |
110 (56.7) |
|
|
No. of immunosuppressants |
|
|
2.73±0.46 |
|
1–2 |
52 (26.8) |
|
|
3 |
141 (72.7) |
|
|
≥4 |
1 (0.5) |
|
|
Use of immunosuppressant†
|
Tacrolimus |
172 (88.7) |
|
|
Cyclosporine |
18 (9.3) |
|
|
Sirolimus |
12 (6.2) |
|
|
Everolimus |
6 (3.1) |
|
|
Leflunomide |
1 (0.5) |
|
|
Adrenocorticoids |
176 (90.7) |
|
|
Mycophenolate |
144 (74.2) |
|
|
Transplant surgery complication |
Yes |
31 (16.0) |
|
|
No |
163 (84.0) |
|
|
Body mass index (kg/m2) |
<18.5 |
18 (9.3) |
22.73±3.59 |
|
18.5–22.9 |
95 (49.0) |
|
|
23.0–24.9 |
42 (21.6) |
|
|
≥25.0 |
39 (20.1) |
|
|
Modified Transplant Symptom Occurrence and Distress Scale |
|
Symptom occurrence |
|
|
48.99±29.15 |
|
Symptom distress |
|
|
43.66±30.57 |
Table 2.Psychosocial and Cognitive characteristics and Perceived Threat of the Risk for Graft Rejection of the Participants (N=194)
|
Variables |
Categories |
M±SD (range) or n (%) |
|
Psychosocial and cognitive characteristics |
|
|
Depression |
|
5.47±3.63 (0–21) |
|
Anxiety |
|
5.01±3.91 (0–21) |
|
Social support |
|
3.62±0.76 (1–5) |
|
Self-efficacy |
|
61.98±10.11 (17–85) |
|
Perceived threat of the risk for graft rejection |
|
|
Graft-related threat |
|
10.95±3.37 (3–15) |
|
Strong belief (>9) |
136 (70.1) |
|
Not strong belief (≤9) |
58 (29.9) |
|
Intrusive anxiety |
|
17.38±6.28 (6–30) |
|
Great (>18) |
111 (57.2) |
|
Not great (≤18) |
83 (42.8) |
|
Lack of control |
|
9.06±2.41 (3–15) |
|
Low control (>9) |
91 (46.9) |
|
Not low control (≤9) |
103 (53.1) |
Table 3.Perceived Threat of the Risk for Graft Rejection According to Demographic and Clinical Characteristics
|
Variables |
Categories |
Graft-related threat |
Intrusive anxiety |
Lack of control |
|
M±SD |
t or χ2 (p) |
M±SD |
t or χ2 (p) |
M±SD |
t or χ2 (p) |
|
Demographic characteristics |
|
|
|
|
|
|
|
Gender |
Men |
10.26±3.44 |
–3.20 (.002) |
16.56±5.87 |
–2.01 (.046) |
9.11±2.34 |
0.36 (.721) |
|
Women |
11.77±3.10 |
18.36±6.64 |
8.99±2.50 |
|
Education level |
High school |
10.01±3.57 |
3.09 (.002) |
17.15±6.99 |
0.37 (.711) |
9.04±2.31 |
0.07 (.944) |
|
≥College |
11.51±3.12 |
17.51±5.83 |
9.07±2.48 |
|
Employment |
Yes |
10.73±3.51 |
–1.99 (.050) |
17.21±6.13 |
–0.68 (.496) |
9.13±2.38 |
0.82 (.413) |
|
No |
11.72±2.70 |
17.95±6.83 |
8.79±2.52 |
|
Spouse |
Yes |
10.94±3.40 |
0.11 (.910) |
17.30±6.40 |
0.35 (.726) |
9.17±2.34 |
–1.30 (.195) |
|
No |
11.00±3.24 |
17.70±5.81 |
8.59±2.68 |
|
Religion |
Yes |
10.95±3.40 |
0.05 (.962) |
17.56±6.25 |
0.45 (.657) |
9.25±2.41 |
1.25 (.211) |
|
No |
10.94±3.34 |
17.15±6.35 |
8.81±2.40 |
|
Clinical characteristics |
|
|
|
|
|
|
|
Diseases causing renal failure |
|
|
|
|
|
|
|
Hypertension |
Yes |
11.35±3.12 |
1.01 (.315) |
17.54±6.21 |
0.22 (.828) |
8.98±2.57 |
–0.27 (.791) |
|
No |
10.80±3.45 |
17.32±6.32 |
9.08±2.36 |
|
Diabetes mellitus |
Yes |
10.59±3.68 |
–0.77 (.445) |
17.00±6.09 |
–0.43 (.667) |
8.41±2.70 |
–1.94 (.054) |
|
No |
11.04±3.29 |
17.48±6.34 |
9.29±2.30 |
|
Kidney donor |
Deceased donor |
11.67±3.34 |
15.05‡ (.010) |
17.44±6.09 |
9.54‡ (.090) |
9.04±2.07 |
0.69‡ (.228) |
|
Parent |
11.83±3.48 |
18.17±5.73 |
8.71±2.79 |
|
Spouse |
10.03±3.61 |
17.00±6.76 |
9.05±2.44 |
|
Children (daughter or son) |
9.46±2.50 |
18.08±6.25 |
8.31±2.69 |
|
Sibling or relative |
10.61±2.94 |
17.75±6.49 |
9.77±2.30 |
|
Others†
|
10.67±4.08 |
10.33±3.62 |
7.67±2.42 |
|
History of graft rejection |
Yes |
10.94±3.49 |
–0.01 (.998) |
17.12±7.02 |
–0.18 (.859) |
8.18±2.04 |
–1.58 (.115) |
|
No |
10.95±3.36 |
17.40±6.22 |
9.14±2.43 |
|
Transplant complication |
Yes |
11.48±3.03 |
1.98 (.049) |
17.70±6.25 |
0.63 (.529) |
9.20±2.50 |
0.74 (.463) |
|
No |
10.54±3.57 |
17.13±6.32 |
8.95±2.53 |
|
Transplant surgery complication |
Yes |
11.65±3.24 |
1.26 (.209) |
18.19±5.76 |
0.79 (.431) |
8.39±2.33 |
–1.70 (.091) |
|
No |
10.82±3.38 |
17.22±6.38 |
9.18±2.41 |
Table 4.Correlations among Perceived Threat of the Risk for Graft Rejection and Other Variables
|
Variables |
X1
|
X2
|
X3
|
X4
|
X5
|
X6
|
X7
|
X8
|
X9
|
X10
|
X11
|
X12
|
|
r (p) |
|
X2
|
.11 (.117) |
|
|
|
|
|
|
|
|
|
|
|
|
X3
|
.30 (<.001) |
–.01 (.928) |
|
|
|
|
|
|
|
|
|
|
|
X4
|
.03 (.712) |
–.20 (.006) |
.11 (.143) |
|
|
|
|
|
|
|
|
|
|
X5
|
–.07 (.352) |
–.01 (.960) |
–.12 (.094) |
.01 (.980) |
|
|
|
|
|
|
|
|
|
X6
|
–.03 (.713) |
–.06 (.402) |
–.13 (.083) |
.02 (.770) |
.91 (<.001) |
|
|
|
|
|
|
|
|
X7
|
–.16 (.022) |
–.02 (.824) |
–.02 (.816) |
.11 (.116) |
.53 (<.001) |
.48 (<.001) |
|
|
|
|
|
|
|
X8
|
–.06 (.448) |
–.03 (.665) |
–.04 (.605) |
.07 (.322) |
.64 (<.001) |
.58 (<.001) |
.54 (<.001) |
|
|
|
|
|
|
X9
|
–.08 (.269) |
–.09 (.197) |
–.10 (.167) |
–.03 (.672) |
–.25 (<.001) |
–.21 (.003) |
–.44 (<.001) |
–.31 (<.001) |
|
|
|
|
|
X10
|
–.12 (.104) |
–.05 (.516) |
.04 (.630) |
–.03 (.701) |
–.30 (<.001) |
–.29 (<.001) |
–.38 (<.001) |
–.33 (<.001) |
.47 (<.001) |
|
|
|
|
X11
|
–.09 (.197) |
.01 (.872) |
.18 (.015) |
–.02 (.750) |
.09 (.190) |
.11 (.146) |
.01 (.999) |
.12 (.097) |
.01 (.924) |
–.02 (.802) |
|
|
|
X12
|
–.07 (.362) |
.09 (.213) |
.04 (.571) |
.09 (.192) |
.16 (.029) |
.18 (.010) |
.15 (.040) |
.36 (<.001) |
–.13 (.072) |
–.12 (.092) |
.36 (<.001) |
|
|
X13
|
.17 (.021) |
–.02 (.780) |
.05 (.485) |
.08 (.243) |
.09 (.200) |
.10 (.183) |
.05 (.462) |
.20 (.005) |
–.15 (.043) |
–.03 (.700) |
.23 (.001) |
.37 (<.001) |
Table 5.Multiple Regression Analysis of Factors Influencing Perceived Threat of the Risk for Graft Rejection
|
Variables |
B |
SE |
β |
t |
p
|
|
Graft-related threat |
|
(Constant) |
7.93 |
0.52 |
|
15.20 |
<.001 |
|
Gender (women) |
1.82 |
0.46 |
.27 |
3.95 |
<.001 |
|
Education level (≥college) |
1.81 |
0.48 |
.26 |
3.82 |
<.001 |
|
Posttransplant duration |
0.01 |
0.01 |
.16 |
2.45 |
.015 |
|
Donor type (deceased donor or parent) |
1.06 |
0.45 |
.16 |
2.36 |
.019 |
|
R2
|
.18 |
|
Adjusted R2
|
.16 |
|
F (p) |
10.22 (<.001) |
|
Intrusive anxiety |
|
(Constant) |
9.34 |
2.38 |
|
3.92 |
<.001 |
|
Anxiety |
0.54 |
0.11 |
.34 |
5.01 |
<.001 |
|
Donor type (not others) |
5.50 |
2.44 |
.15 |
2.26 |
.025 |
|
R2
|
.15 |
|
Adjusted R2
|
.14 |
|
F (p) |
17.07 (<.001) |
|
Lack of control |
|
|
|
|
|
|
(Constant) |
6.57 |
0.78 |
|
8.45 |
<.001 |
|
Anxiety |
0.14 |
0.04 |
.23 |
3.32 |
.001 |
|
Age |
0.04 |
0.01 |
.19 |
2.70 |
.008 |
|
Transplant surgery complication |
–1.07 |
0.46 |
–.16 |
–2.33 |
.021 |
|
R2
|
.10 |
|
Adjusted R2
|
.08 |
|
F (p) |
6.78 (<.001) |
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