Chronic renal failure is the final phase of kidney disease where an individual has completely lost functioning of his/her kidneys. Unlike acute renal failure where the individual losses functioning of his/her kidneys suddenly as a result of an illness, injury, or toxin that stresses the kidneys; chronic renal failure is the culmination of a progressive disease process that overtime, results in the loss of functioning of the kidneys. Acute renal failure usually can be treated and reversed, but chronic renal failure usually cannot be treated or reversed. An individual suffering from chronic renal failure will never regain his/her kidney functioning and will never be cured. In the absence of a renal replacement therapy such as dialysis or renal transplant, death will occur within a short period of time.
The two primary modalities for renal replacement therapy are dialysis and renal transplantation, both designed to remove excess water and metabolic wastes.
Dialysis cleanses the body by removing waste products and extra fluids either through the blood or through the peritoneal membrane in the abdominal cavity. When performed through the blood, it is called hemodialysis; requiring that the patient be connected to a dialysis machine, three times a week for approximately three to four hours each time. This involves diffusion of solutes and blood flow across a semi permeable membrane to achieve ultra filtration of the bodily fluids. When done through the peritoneal membrane, it is called peritoneal dialysis and the patient is again connected to a dialysis machine where fluid is diffused through a permanent tube in the abdomen, and filtered out every night, or through regular exchanges throughout the day. Both of these treatment modalities sustain life, but the patient’s quality of life is not comparable to being healthy. As earlier noted, renal transplantation is another renal replacement therapy that helps remove waste products and excess water from the individual’s body. It involves the transfer of a kidney from either a living donor or a cadaver donor into the recipient’s body. Although these therapies sustain the individual, studies show that most patients perceive their quality of life to be better with a renal transplant than when on maintenance dialysis.
Life after dialysis however varies from individual to individual, with a complex combination of positives and negatives, based on the individual’s health history, education level, and socio-economic status. The bottom line is that, all the benefits of a renal transplant come with related costs, both on the recipient and their primary groups of contact (family, co-workers etc).
Kidney transplant has been proven to enhance the quality of life of the patient, increase the patient’s independence, and normalize their medical parameter; hence offering a significant survival advantage and improved quality of life. This improved quality of life is indicated by an improved sexual functioning, increase in appetite, physical endurance; a better sleep cycle, and ultimately the absence of Uremia. At the same time, it also requires special psychological adjustment, as kidney transplant recipients have shown to develop emotional distress and psychological disorders associated with a compromised quality of life; usually as a result of uncertainty about future health and finances, as well as side effects of medicines.
Despite its prevalence in transplant recipients, only a few papers are available which analyze the presence and significance of emotional distress and psychological disorders in kidney transplant patients.
As reported; the following are some of the psychological effects experienced post renal transplant:
Irritability: right after transplant, most patients are required to take high doses of steroids such as prednisone, which easily causes steroid rage in some patients and for the most part some form of irritability. In the later stages when patients are on maintenance doses, the steroid rage subsides and most patients reported being really emotional and sentimental. One patient reported getting so emotional a simple commercial could bring them to tears.
Depression: depression in post renal transplant recipients stems as a result of the following:
- Fear of progressive allograft dysfunction and having to go back on dialysis (fear of losing the transplanted kidney)
- Need for constant health monitoring
- Demand for strict monitoring of immunosuppressive therapy
- The guilt of having to deal with the fact that, they profited out of someone else’s loss (would they be able to do same if placed in similar positions, what if the person loses their other kidney, the fact that they are indebted forever to the living donor; which in some worse scenarios; could get manipulative, with the recipient being the victim)
- Having to constantly deal with family members, peers and even coworkers who continue to perceive him/her as fragile and that the recipient will be permanently changed physically or mentally from receiving a kidney from another individual
- Having to deal with the fact that loved ones perceive of them as fragile and disable and so become overly protective
- Financial Hardship: post transplant drugs are expensive; and most patient’s coverage only last 3years in some states and so patients face the stress of not having their post transplant medications
- Non compliance: due to financial hardship and lack of a means to get medications, patients end up having to stretch their medications to last longer; which unfortunately could cause the allograft to fail
- The need to want to belong (e.g. drinking alcohol); leading to low compliance; and ultimately allograft failure etc
Anxiety: anxiety in most post transplant patients is as a result of most patients feeling like they have a shelf life, and the fear of losing their transplanted kidney; most often due to non-compliance, for various reasons including financial hardship.
Karrfelt and Frazier explain in attenuation the cause of such emotions in post transplant individuals to be a form of psychological adaptation; a coping strategy to the transplantation experience. This finding is consistent with a number of existing studies that describe these patients using defensive mechanics such as avoidance, minimization, and distance (1, 2). There are several accounts that report the use of avoidance defensive mechanisms by transplant patients, suggesting that in short term, it acts as a protective mechanism in the face of what is a stressful situation, but in the long term, turns into a source of psychological fragility and becomes a predictor of low compliance to medical follow ups (1, 2)
Patients appear to read to negative emotional stimuli by using these psychological mechanics as defensive measures. The effects of tacrolimus and cyclosporine (post transplant drugs) are of partial interest in explaining the emotional profile of post transplant patients. This is because, they are used to lower the risk of rejection but at the same time they increase the risk of mood/depressive disorder (3, 4). Since this pharmalogical treatment interferes centrally with mono-aminergic transmission both single doses and repeated treatment with cyclosporine significantly enhance serotonin neuron activity which leads to depression.
It should be noted that depressive symptoms are an independent predictor of patient survival and death censored graft loss in kidney transplant patients. Hence, screening for depressive symptom is advised during the regular follow-up of kidney transplant patients.
Family and social support of psychotherapy may be important in improvement of quality of life and compliance in drug consumption, and so extend the life of their allograft. Unfortunately, these mood depression disorders could worsen any illness, and in extreme cases, may weaken the immunological system
The following are ways of dealing with your emotional distress or psychological disorder:
- Exercise: as approved by their doctor
- Massage: as affordable; simple as work with a family member
- Talking to someone: pastor, rabbi, priest, social worker
- Support groups
- Patient education
- Individual resolve
When Professional Help Should Be Sought
- Depression lasting more than two weeks
- Thoughts about suicide
- Loss of appetite or increased appetite
- Too much or too little sleep
- Loss of interest in activities you used to enjoy
- Repeated angry outburst
- Drug or alcohol abuse
- Lability to make decisions
- Social isolation
(1) Karrfelt HM, Lindblad FI, Crafoord J, et al: Renal transplantation: long term adaptation and the children’s own reflections. Pediatr Transplant 7:69, 2003
(2) Frazier PA, Davis-Ali SH, Dahl KE: Correlates of noncompliance among renal transplant recipients. Clin Transplant 8:550, 1994
(3) Kemper MJ, Sparta G, Laube GF, et al: Neuropsychologic side effects of tacrolimus in pediatric renal transplantation. Clin Transplant 17:130, 2003
(4) Van der Molen LR, van Son WJ, Tegzess AM, et al: Severe vital depression as the presenting feature of cyclosporine-A-associated thrombotic microangiopathy. Nephrol Dial Transplant 14:998, 1999