Quality of life of individuals receiving kidney transplantation in Amazonas State

Abstarct Objective: to analyze the quality of life of kidney transplant receivers in the State of Amazonas. Method: a cross-sectional, descriptive study, performed with 222 individuals after renal transplantation registered in a private clinic and in a health public ambulatory. Data collection took place through structured interviews where the quality of life was measured by the Kidney Disease Quality of Life - Short Form. Descriptive statistics were used for data analysis. Results: the quality of life scores found ranged from 36.5 to 83.1. The quality of life domains, specifics of renal disease, have proved to be superior to generic ones. The most compromised were work situation; sleep; physical function and emotional function, with scores of 36.5; 53.7; 52.4; 55.1, respectively, and correlated moderately and significantly with each other. Conclusion: the majority (63.2%) of the quality of life domains obtained high scores and the specific component of renal disease had higher scores than the generic component.


Introduction
The worldwide prevalence of end-stage chronic kidney disease (CKD) has increased considerably in recent years.
The technological advances related to Renal Replacement Therapies (RRT) -hemodialysis (HD), peritoneal dialysis (PD) and renal transplantation (Tx) have made possible greater survival for patients, even with some sequels and/ or comorbidities (1) . In this scenario, Brazil stands out in the coordination and regulation of organ transplants in public services, ranking 2 nd in absolute number of transplants in the world (2) , but it falls to 25 th place when the proportion of its population is considered (3) .
It is important to emphasize that renal Tx has already been characterized as the best alternative, financially and clinically, in cases of end-stage CKD, generating significant savings to the State coffers (4) .
Despite this, Brazil has remained with the renal Tx rate unchanged for the last six years: 28.5 pmp and less than 50% of the estimated need for kidney Tx was actually accomplished in the last year. There is also a drop (32.9%) in the rate of transplantations with a living donor in contrast to the small increase (10.3%) in the rate with a deceased donor (3) .
Although kidney failure has gained importance in the list of chronic diseases, there is a reduced number of articles concerning the subject. Among them, those referring to hemodialysis users predominate, highlighting the health dimensions related to CKD and how they influence the quality of life (QL) (5) .
To evaluate the effectiveness and even assist the choice among the available treatment modalities, quality of life has often been used as a parameter around the world (6) . For this purpose, studies have been presenting instruments designed to measure QL generically and also specifically in groups of individuals with different characteristics of the population in general, such as those with CKD.  (7) .
In 2006, a study in Budapest/Hungary demonstrated that KDQOL-SF is also reliable and valid for post-Kidney Transplantation patients, and can even be used to compare different populations with end-stage kidney disease (8) . However, few studies have been published that analyze the quality of life of kidney transplant receivers through KDQOL and only one of them is Brazilian (6) .
This single national study was carried out in the Southern region fo the country that, which in turn has discrepancies with the northern region as regards population, geography, culture, development, economy, access to health goods and services, in addition to the differences in the transplant service which place the two regions at opposite ends with regard to the kidney transplant rate, with the southern region standing at 1 st place, with a rate 11.16 times higher than that of the North, last place in the country (3) . This is also due to the fact that three of the seven states that make up the Northern region did not perform

Method
This is a descriptive, cross-sectional, quantitative approach study that was carried out in the only two For patient selection, the following criteria were followed: be of legal age (≥18 years); be based in the in addition to the items specific to the chronic renal patient particularities (7) . KDQOL-SF is of public domain, available at the Research and Development Corporation (RAND) (9) website, the developer, and composed of 19 dimensions of Stimulation of the dialysis team; Patient satisfaction and a general health item computed separately (7) . In this study, five items corresponding to two dimensions of the specific part of the instrument were excluded because they were aimed at dialysis patients.
KDQOL-SF's responses yield scores from zero to 100, where higher values always represent better quality of life states. Each dimension of QL corresponds to the arithmetic mean of the items that compose it. The manual with the coding and interpreting instructions is available on the RAND website (9) .

Results
The final sample of the study consisted of 222 kidney The results regarding the health-related QL of the study group are shown in Table 1    We observed a population similar to that found in other national (6,(10)(11) and international (8,12) studies with regard to sex, age, marital status, place of residence (capital/upstate), work and complete years of study.
As for the color/race self-reported, few studies on the subject have disclosed this characteristic of the population and, among them, the white color/race was predominant (11,13) , where the majority of the population declares itself brown (66.9%) (14) . In general, observing the results of Table 1, it can be seen that the scores of the instrument's specific domains were better than those of the generic domains.
Even so, it was also in the specific part that the two dimensions with the worst KDQOL scores were found, demonstrating the importance of using instruments that take into account the specificities of a group with differentiated characteristics such as CKD carriers.
When comparing the QL results of other studies with those presented here, it was found that, in Amazonas, the post-Kidney Tx patient's QL is lower, in most dimensions, than the receivers in Rio Grande do Sul (6) , state located in the South region of the country, which, in turn, is more developed and with much better rates and evaluations than those of the North region regarding the national transplant system.
In relation to other countries around the world, the transplanted individuals in this study had higher scores than most countries that published KDQOL-SF results in this type of population, such as Norway, Hungary, Poland, United States of America (USA), among others (8,(16)(17)(18) , which may be a reflection of the Brazilian Public Health System (SUS), based on a comprehensive concept of universality, which provides coverage and comprehensive health care for the entire population, not excluding, of course, other possible related factors (19) .
Regarding the labor situation, the majority of jobs are more easily adaptable, and kidney-transplanted can choose the best activity that suits their capabilities, general condition, schedules and more flexible periods (20) .
This aspect directly reflected in the "Work situation" dimension that ended up presenting the lowest score (36.5±40) among transplanted patients. This dimension was also one of the most compromised in similar studies with post-Kidney Tx patients in Brazil (6) and in other countries (16)(17)20) .
Another specific domain of KDQOL-SF that was quite compromised was Sleep (53.7±17.3), with a score very below that of a similar study carried out in the South region of Brazil, with a mean equal to 77.4 (±19.5) (6) .
In international studies that used the same instrument after kidney transplantation, the lowest score found in the Sleep domain was in Boston/Massachusetts in the USA, in 2016 (18) , with 64,1(±16.7) of mean.
As Function obtained scores 11.1% and 15.7% higher than those in the Amazonas (6) . No other generic QL dimension of the study conducted there had scored so low as those found here.
Among similar international studies, some also had the dimension Physical Function among those with lower scores (8,17,21) , however, the Emotional Function got good scores in these studies. Only two studies, one conducted in Warsaw/Poland and the other in Daka/Bangladesh, had such a compromised Emotional Function, lower than the study presented here, with scores of 37.33 (±43. 6) and 46 (±44), respectively (17,22) .
As mentioned above, there was a moderate and It is also necessary to raise awareness among the population about transplantation and campaigns to promote organ donation, making public studies that show the improvement in QL, both of the receiver and the donor (22) , as well as investments in the service of attracting local organs and in performing transplants.
A limitation found in this study concerns the crosssectional cut, which hinders the determination of causeeffect relationships between the variables studied.