Improved Selection of Elderly (> 65 Years) for Kidney Transplantation

Study Overview
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Brief Summary
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Kidney transplantation has been shown to provide improved survival even in patients older than 70 years of age. The purpose of the study is to determine whether kidney transplantation provides any improvement of health related quality of life (HRQOL) in patients over the age of 65 years. HRQOL wil be monitored using the Kidney Disease and Quality of Life (KDQOL-SF)form. Patients will be recruited at the time of acceptance to the Norwegian transplant wait list and followed every 6 months until transplantation. Thereafter a new form will be completed after 10 weeks post transplant, 6 months, 1 year, 3 years and 5 years. In addition the study will explore the transplant candidates expectations in a qualitative study design and explore the relationship between pre-transplant comorbidity, HRQOL and survival.

Detailed Description
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Aim 1: Evaluate the HRQoL longitudinally from time of wait listing and until 1 year after kidney transplantation among kidney transplant candidates older than 65 years of age. Data collection The HRQoL will be monitored in a prospective, longitudinal study (QUESTION65). A minimum of 200 patients will be included and the inclusion period is estimated to 2-3 years. All patients give informed consent when entering the study. In addition, all patients have signed an informed consent when included in the Norwegian Renal Registry which allows the use of unidentified data from the registry in research protocols. HRQoL will be assessed using the Kidney Disease Quality of Life Short Form (KDQOL-SF-36) health Survey. This survey consists of two parts, a generic and disease specific part. The same questionnaire is used before and after transplantation. For improved evaluation of HRQoL data on response shift will be captured through questions related to personal preferences, values and internal standards. The result gathered will also be compared with data from an age matched Norwegian cohort. All patients over the age of 65 who are accepted for the kidney transplantation waiting list or living donor transplantation will receive an invitation to be included in the study. A new form will be distributed to included patients with intervals of six months until they are transplanted, permanently removed from the transplant waiting list or until death. Patients who are transplanted will receive a form at discharge from Oslo University Hospital, Rikshospitalet (10 weeks after transplantation), after six months and at one year. Aim 2: Explore the expectations of older kidney transplant candidates prior to transplantation and one year after transplantation. Data Collection: For the qualitative evaluation, 15-20 patients in dialysis will be included and a qualitative individual in-depth interview will be performed approximately one month after baseline HRQoL and repeated one year after transplantation. Selection will be made according to age and gender. Inclusion will continue until saturation is reached. Convenient variation and broadness in information will be secured in the sample. To secure shared decision making, patients will be invited to discuss the interview guide and design of the qualitative evaluation. Furthermore, the interview guide will be tested in a pilot study. An interview-manual will be used. We believe the results from the qualitative interviews also can be used to gain an improved understanding of the answers in the survey. Aim 3: Investigate the relationship between pre-transplant comorbidity, described by the Liu comorbidity index and post-operative complications, post-transplant 1 year survival and HRQoL. Data collection From 2012 we have included pre-transplant data according to the Liu comorbidity index as part of the routine work up of candidates for kidney transplantation. Complete data describing patient and transplant characteristics, including the Liu comorbidity index will be extracted from the Norwegian Renal Registry. These data will only be used as explanatory variables for the outcome of HRQoL/survival and are not reported as separate outcomes. In addition post-transplant morbidity and mortality will be extracted from the Norwegian Renal Registry. The data will be exported from the registry without any identification except from a patient number. In case of missing data from the registry, data will be retrieved from the patient records at Oslo University Hospital, Rikshospitalet. The key necessary for identification will be stored at the registry. Aim 4 Health economic evaluation. In this sub-study, we will use data from the Short Form 36 (SF36) part of the KDQOL-SF questionnaire to calculate Quality Adjusted Life Years (QALY). Costs will be estimated for each patients using data from their hospital records.

Official Title
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Improved Selection of Elderly (> 65 Years) for Kidney Transplantation

Conditions
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Quality of Life, End Stage Renal Disease, End Stage Renal Failure on Dialysis

Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: End stage renal disease listed for transplantation Age > 65 years Exclusion Criteria: Not able to fulfill the HRQOL form

Ages Eligible for Study
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Minimum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Changes in Short-term (One Year) Health Related Quality of Life, Measured by the KDQOL-SF Questionnaire | Longitudinally monitoring of health related quality of life (HRQOL) by the Kidney Disease and Quality of Life Short Form (KDQOL-SF) questionnaire from listing for transplantation and up to one year post transplantation. The KDQOL-SF scores are organized in 18 dimensions and the Scores for each Dimension are reported within the range 0-100, higher scores indicate better Health related quality of life. Scores are obtained at baseline and every six months while patients were on the waiting list are performed. In addition scores are obtained obtained at two, six and twelve months after transplantation. Comparisons between last score obtained on the waiting list and score at twelve months after transplantation are performed. The results are reported as absolute values and changes from baseline/last score before transplantation and the scores at one year post transplant. | Change in health related quality of life from baseline to one year after transplantation | 
| Health Economic Analyses | Quality Adjusted Life Years (QALY) are calculated based on Short Form-6D extracted from the SF-36 part of the KDQOL survey while patients were on the waiting list and after transplantation. QALYs are compared between the waiting list and up to three years after transplantation. Costs will be calculated based on information from the patients records and cost/QALY will be compared for the two periods | From baseline to three years post transplant | 
| Survival | Patient survival on the waiting list and after transplantation will be calculated and compared using the Kaplan Meier method and a Cox regression analysis with a time dependent variable. | From baseline/last score before transplantation to transplantation/up to ten years post transplant | 
| Changes in Intermediate Term (Three Years) Health Related Quality of Life, Measured by the KDQOL-SF Questionnaire | Longitudinally monitoring of health related quality of life (HRQOL) by the Kidney Disease and Quality of Life Short Form (KDQOL-SF) questionnaire from listing for transplantation and up to three years post transplantation. The KDQOL-SF scores are organized in 18 dimensions and the Scores for each Dimension are reported within the range 0-100, higher scores indicate better Health related quality of life. Scores obtained at baseline and every six months while patients were on the waiting list. In addition scores are obtained at two, six, twelve months and at three years after transplantation. For this outcome, comparison between last score obtained on the waiting list and the score at three years post transplant is performed. The results are reported as absolute values and changes from baseline/last score before transplantation and the score at three years post transplant. | From baseline to three years post transplant | 
| Changes in Long Term (5-10 Years) Health Related Quality of Life, Measured by the KDQOL-SF Questionnaire | Longitudinally monitoring of health related quality of life (HRQOL) by the Kidney Disease and Quality of Life Short Form (KDQOL-SF) questionnaire from listing for transplantation and up to three years post transplantation. The KDQOL-SF scores are organized in 18 dimensions and the Scores for each Dimension are reported within the range 0-100, higher scores indicate better Health related quality of life. Scores obtained at baseline and every six months while patients were on the waiting list. In addition, scores are obtained at two, six, twelve months and at three years after transplantation. For this outcome, comparisons between last score obtained on the waiting list and the score at five and ten years post transplant are performed. The results are reported as absolute values and changes from baseline/last score before transplantation and the score at five and ten years post transplant. | From last score before transplantation to ten years post transplant | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Associations Between Pre-transplant Patient and Transplant Characteristics and Intermediate Term (Three Years) Change in HRQoL | Demographic, medical and transplant characteristics were included in multivariable regression models to analyze any associations between these variables and any change in HRQoL described as KDQOL-SF scores between last score before transplantation and three years post transplantation | From last score before transplantation to three years post transplant | 
| Associations Between Pre-transplant HRQoL/Comorbidity and Post Transplant Survival | Any associations between pre-transplant HRQoL/comorbidity and post transplant survival will be investigated using multivariable cox regression models. | From transplantation and up to ten years post tx |