Knowledge, attitude, and practice of kidney transplant patients regarding post-transplant complications: a cross-sectional study

Introduction

Kidney transplantation is a widely accepted treatment for end-stage renal disease, offering improved quality of life and increased survival rates (1,2). However, post-transplant complications can significantly impact patient prognosis and overall transplant outcomes (3-5). Complications after kidney transplantation can occur within minutes to months after transplantation. Late complications will occur when the patient is back home and likely between medical visits. Therefore, the patient has to watch for signs and symptoms that would prompt a medical consultation, either in the emergency room or as an outpatient. Furthermore, to optimize prognosis, the patient has to understand the need to take medication on time and to maintain proper lifestyle habits. Therefore, post-transplantation patients have to display some level of self-management. Therefore, adequate knowledge, positive attitudes, and proper practices related to post-transplant complications are crucial for informed decision-making, effective management, and optimal long-term graft function of kidney transplant patients. Despite the importance of addressing these factors, the current understanding of knowledge, attitudes, and practices (KAP) on post-transplant complications remains limited in kidney transplant patients. Some previous studies reported limited KAP toward kidney transplantation in general (6-10) but did not focus on complications. Nevertheless, one study in China reported good KAP toward self-management after self-management after kidney transplantation (11). Tepel et al. (12) emphasized the importance of knowledge among kidney recipients for coping with short-term issues and long-term outcomes post-transplantation. They designed a questionnaire to survey kidney recipients and assess their knowledge levels, finding a significant correlation between the longer duration of kidney disease and improved knowledge levels, which suggests that increased knowledge better prepares individuals for life after transplantation. In addition, Tucker et al. (13) conducted a qualitative analysis in which they evaluated the perspectives of transplant recipients on life after transplantation. They emphasized the importance of understanding recipients’ views on lifestyle adjustments, medical management, and quality of life post-transplantation to better support kidney recipients and enhance patient experiences. Furthermore, previous studies have demonstrated the need for comprehensive education and support programs tailored to the specific needs of transplant recipients (14,15). However, deeper exploration of patients’ KAP is required to develop targeted interventions and enhance patient outcomes.

KAP is a methodology involving structured surveys designed to identify the gaps, misconceptions, and misunderstandings that hinder the optimal performance of a given health-related subject (16,17). KAP studies also allow for the quantification of the KAP levels through scoring, allowing comparisons among subgroups and determining the factors influencing the KAP toward the subject of interest. The KAP methodology can be used to investigate kidney transplant patients’ KAP of post-transplant complications and how these factors may influence patient prognosis. However, the current understanding of KAP on post-transplant complications among kidney transplant patients remains unclear.

Therefore, it is crucial to elucidate the KAP of post-kidney transplant patients regarding transplant complications, as it directly impacts patient prognosis and quality of life. This study aimed to explore the KAP of kidney transplant patients regarding post-transplant complications. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2024-683/rc).

Methods

Study design and participants

This cross-sectional study surveyed patients who underwent kidney transplantation and were being followed up in our hospital between August and October 2023. The participants were enrolled through convenience sampling. Inclusion criteria were (I) patients who underwent renal transplantation and were undergoing regular post-transplant follow-ups, (II) >18 years, and (III) did not undergo transplant nephrectomy. Patients with incomplete clinical sample information were excluded. The study received ethical approval from the Ethics Committee of The Third Affiliated Hospital of Soochow University [(2023) Section No. 152]. All study participants provided informed consent. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Questionnaire

The questionnaire was designed by the authors with reference to “The current nursing situation of post-transplant complications” (18) and “A brief discussion on post-transplant complications and nursing measures” (19). The final version was revised according to the comments from three senior experts (>25 years of experience) with experience in kidney transplantation. A small-scale pretest (52 copies) revealed a Cronbach α=0.826.

The final questionnaire was in Chinese, and it comprised four dimensions and a total of 40 items, including 16 items on basic characteristics (gender, age, education, ethnicity, work status, income, marital status, having children, smoking, drinking alcohol, medical insurance, post-transplant complications, secondary kidney transplant, relation to the donor, time since transplant, and comorbidities), 10 on knowledge, six on attitude, and eight on practice. The knowledge dimension was scored according to the options available for the items. The attitude and practice dimensions were evaluated on a five-point Likert scale. Items 2–6 were scored from 5 (strongly agree) to 1 (strongly disagree), while item 1 was scored from 1 (strongly disagree) to 5 (strongly agree). All eight items in the practice dimension were scored from 5 (always) to 1 (never).

The KAP dimension scores were categorized according to Bloom’s criteria (20,21). Scores <60% were considered poor, while scores of 60–79% were considered moderate, and scores ≥80% were considered good.

Questionnaires were distributed to the study participants via WeChat groups and renal transplant follow-up clinics. Three trained urologists with professional knowledge of the research content worked as research assistants; they identified the patients through the hospital kidney transplant follow-up system to determine when they were due for follow-up and proposed to participate in the study. In addition, the hospital kidney transplant follow-up outpatient department identified the patients who did not undergo transplant surgery but had follow-up visits in the study hospital.

At the same time, the questions and options that patients found unclear or confusing were explained, making sure the patients fully understood the intended meaning of the options. A research assistant was trained extensively in the questionnaire and kidney transplantation in general and was available to answer any questions or clarify any uncertainties. It was made clear to all participants that the research assistant could explain any questions that were not understood. In order to control the quality of the questionnaire, two senior urological experts and professional personnel were selected to conduct the questionnaire screening and evaluation. The two experts evaluated each questionnaire before it was included in the final data analysis. In addition, when the data were cleaned, questionnaires with many blanks and abnormal values, incomplete answers to the basic information section, and contradictory or abnormal answers were considered invalid.

Outcomes

The primary outcome was the KAP level toward complications after kidney transplantation in patients who underwent renal transplantation. The secondary outcome was the factors influencing the KAP levels.

Sample size

The following formula was used to calculate the sample size of cross-sectional surveys.

n=(z1−α/2δ)2×p×(1−p)[1]

In the formula, n represents the sample size for each group, α represents the type I error (which is typically set at 0.05), Z_1-α/2=1.96, δ represents the allowable error (typically set at 0.05), and p is set at 0.5 (as setting it at 0.5 maximizes the value and ensures a sufficiently large sample size). Hence, the calculated sample size was 384. Considering an estimated questionnaire response rate of 80%, a minimum of 480 valid questionnaires were needed.

Statistical analysis

SPSS 26.0 software (IBM Corp., Armonk, NY, USA) was used for statistical analysis. A confirmatory factor analysis (CFA) was performed to confirm the questionnaire construct. A good fit was considered for root mean square error of approximation (RMSEA) <0.08, standardized root mean square residual (SRMR) <0.08, Tucker-Lewis index (TLI) >0.80, and comparative fit index (CFI) >0.80. Continuous variables that conformed to normal distribution were expressed as mean ± standard deviation and compared by Student’s t-test or one-way analysis of variance (ANOVA). Categorical data were expressed as n (%). Pearson’s correlation analysis was used to evaluate the correlation among KAP dimensions. Structural equation modeling (SEM) was used to explore the directional associations between KAP and the basic information. In the KAP theoretical framework, knowledge is the basis for attitude and practice, while attitude is the force driving practice (16,17). The SEM was based on the following hypotheses: (I) the knowledge positively affected attitude; (II) the attitude positively affected practice; (III) the knowledge positively affected practice; (IV) age, duration since kidney transplant, post-transplant complications, education, and drinking alcohol affected KAP. Two-sided P<0.05 represented statistical significance.

Results

A total of 499 (89.7%) valid questionnaires were included; 327 were filled out by men and 172 by women aged 44.41±10.54 years. The Kaiser-Meyer-Olkin (KMO) was 0.725. RMSEA was 0.061, SRMR was 0.064, TLI was 0.819, and CFI was 0.840, indicating a good fit.

Among the participants, 164 (32.87%) had post-transplant complications, and 12 (2.40%) had a secondary kidney transplant. The mean knowledge, attitude, and practice scores were 6.00±1.99 (possible range, 0–10), 22.29±1.96 (possible range, 6–30), and 29.28±3.78 (possible range, 8–40), respectively, indicating insufficient knowledge, positive attitude, and proactive practice. In addition, patients’ education (K: P<0.001; A: P=0.003; P: P<0.001), work status (K: P<0.001; P: P<0.001), monthly per capita income (K: P<0.001; A: P=0.005; P: P<0.001), marital status (K: P=0.002; P: P<0.001), having children (K: P<0.001; P: P<0.001), smoking (K: P<0.001; P: P<0.001), drinking alcohol (K: P<0.001; P: P<0.001), post-transplant complications (K: P=0.001; A: P=0.008), and underlying or chronic illnesses (A: P=0.002; P: P<0.001) significantly affected KAP scores (Table S1). There were large variations in the responses to the different KAP items. The distribution of the responses is shown in Tables S2-S4.

Pearson’s correlation analysis showed a significantly positive correlation between knowledge and attitude score (r=0.129, P=0.004), between practice and knowledge (r=0.334, P<0.001), and between attitude and practice score (r=0.416, P<0.001) (Table 1).

In the univariate analyses, education, work status, monthly per capita income, marital status, having children or not, smoking, drinking alcohol, and post-transplant complications significantly affected knowledge scores. Education, monthly per capita income, post-transplant complications, and underlying or chronic illnesses significantly affected attitude scores. Gender, education, work status, monthly per capita income, marital status, having children or not, smoking, drinking alcohol, and underlying or chronic illnesses significantly affected practice scores (Table S1).

Moreover, SEM showed that post-transplant complications and education were associated with knowledge while drinking alcohol, age, and duration since kidney transplant were negatively associated with knowledge. Knowledge and education were associated with attitude, while post-transplant complications were negatively associated with attitude. Attitude, knowledge, duration since kidney transplant, and education were associated with practice, while age was negatively associated with practice (Tables S5,S6, Table 2 and Figure 1).

Figure 1 Structural equation modeling. Oval shapes represent latent variables. The measured variables are drawn in rectangular shapes. The circles with the caption starting with ‘e’ indicate measurement errors in each observed variable. Solid straight lines refer to direct effects, while curved solid lines represent indirect effects. Each number on the arrows indicates an individual standardized regression coefficient of each dependency.

Discussion

The present study found that kidney transplant patients had insufficient knowledge, positive attitudes, and proactive practice regarding post-transplant complications. Age, education, drinking alcohol, post-transplant complications, and duration since kidney transplant might affect their KAP. These findings are valuable as they can guide the development of targeted interventions and education programs for better post-transplant management.

Previous studies have rarely investigated postoperative complications in renal transplant recipients, focusing more on personal aspects and characteristics. However, the knowledge level of renal transplant patients is not optimistic. Ma et al. (22) surveyed renal transplant candidates and recipients in China on their knowledge about renal transplantation, reporting that the knowledge level of both candidates and recipients was unsatisfactory and highlighting the need for increased emphasis on health education among this population. Providing renal transplant recipients with more educational resources is essential for enhancing overall health outcomes. In another study, Massey et al. (23) surveyed young adult renal transplant recipients, revealing that two-thirds of the participants were considered non-compliant. It emphasized the continuous need for adherence support and medication training among young renal transplant recipients. Previous studies showed that kidney transplantation patients have a limited KAP toward kidney transplantation in general (6-10). Therefore, it is necessary to enhance the overall knowledge level of renal transplant patients. Nevertheless, a study in China reported good KAP of post-transplant patients toward postoperative self-management (11), indicating that achieving a proper KAP would be possible.

The present study indicated that renal transplant patients have a moderate level of knowledge on postoperative complications but a positive attitude, probably due to the relatively limited patient education provided by healthcare professionals in their daily lives. However, patients showed a positive attitude towards managing complications. Therefore, providing postoperative complication education to patients and promoting early self-recognition is necessary. Knowledge level has a crucial role in disease management. In a recent study, Pehlivan et al. (24), nursing researchers, surveyed renal transplant recipients, finding that patients lacked information about the impact of transplant complications in their daily lives, which may affect overall daily functioning and quality of life. The results reported by Du et al. (25) suggest that medication-related knowledge is associated with self-efficacy. When renal transplant patients have higher levels of relevant knowledge, their long-term medication adherence (practical ability) is consistently strengthened. Therefore, in clinical practice, it is crucial to focus on the knowledge level of renal transplant patients. Additionally, practical ability was correlated with knowledge and attitude, which can further enhance patients’ practical skills.

The strength of this study is the use of a questionnaire tailored to the specific patient population to determine their KAP toward complications after kidney transplantation. Nevertheless, there are some limitations in this study. First, the sample was from a single center, and the sample size was inadequate. More multicenter studies with expanded sample sizes are needed in the future. The KAP survey was self-designed; despite the high Cronbach’s alpha, it may need to be further validated by other institutions. Some data (e.g., the degree of vigorous exercise, smoking, and drinking) were not available and could not be analyzed. The research assistants were available to explain the questionnaire or any unclear item to the participants, but there is no guarantee that all participants needing clarification sought help, but it is an inevitable limitation of all questionnaire studies. This study was cross-sectional, and causal relationships could not be determined. This study used a SEM, which allows the analysis of directional associations based on predefined hypotheses, but the results are inevitably biased by those predefined hypotheses (26-28).

Self-management is crucial after kidney transplantation to optimize prognosis. The clinical implication of this study was the identification of specific KAP items that could be targeted and improved by educational interventions such as lectures, brochures, podcasts, and websites. Future studies should design and test such interventions and examine whether they could translate into improved patient prognosis and quality of life.

Conclusions

Kidney transplant patients showed insufficient knowledge, positive attitude, and proactive practice regarding post-transplant complications. Age, education, drinking alcohol, post-transplant complications, and duration since kidney transplant might affect their KAP. Targeted interventions and educational programs can apply these insights to improve patient prognosis and long-term transplant success.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2024-683/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2024-683/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2024-683/prf

Funding: This work was supported by the Youth Talent Technology Project of the Changzhou Health Commission and the Young Talent Development Plan of the Changzhou Health Commission (No. 2020-045).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2024-683/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study received ethical approval from the Ethics Committee of The Third Affiliated Hospital of Soochow University [(2023) Section No. 152]. All study participants provided informed consent. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Augustine J. Kidney transplant: New opportunities and challenges. Cleve Clin J Med 2018;85:138-44. [Crossref] [PubMed]
2. Viklicky O, Novotny M, Hruba P. Future developments in kidney transplantation. Curr Opin Organ Transplant 2020;25:92-8. [Crossref] [PubMed]
3. Boeva I, Karagyozov PI, Tishkov I. Post-liver transplant biliary complications: Current knowledge and therapeutic advances. World J Hepatol 2021;13:66-79. [Crossref] [PubMed]
4. Fasullo M, Patel M, Khanna L, et al. Post-transplant biliary complications: advances in pathophysiology, diagnosis, and treatment. BMJ Open Gastroenterol 2022;9:e000778. [Crossref] [PubMed]
5. Phawanawichian C, Kaolawanich Y, Skulratanasak P, et al. Prognostic value of dobutamine stress echocardiography for the long-term outcomes in kidney transplant candidates. Cardiovasc Diagn Ther 2024;14:899-910. [Crossref] [PubMed]
6. Saxena K, Banerjee S, Engineer D, et al. WCN25-4188 Barriers to transplantation in patients on maintenance hemodialysis: a cross-sectional assessment of knowledge, attitude and practices. Kidney Int Rep 2025;10:S550-1.
7. Al Rahbi F, Al Salmi I. Commercial Kidney Transplantation: Attitude, Knowledge, Perception, and Experience of Recipients. Kidney Int Rep 2017;2:626-33. [Crossref] [PubMed]
8. Iqbal M, Hossain RM, Hossain K, et al. Knowledge, Attitude and Perception (KAP) about Renal Transplantation of CKD Patients and their Care Givers. Transplantation 2017;101:S80. [Crossref] [PubMed]
9. Barth A, Szőllősi GJ, Nemes B. Measuring Patients' Level of Knowledge Regarding Kidney Transplantation in Eastern Hungary. Transplant Proc 2021;53:1409-13. [Crossref] [PubMed]
10. Bruns C, Giese J, Phillippi D, et al. Knowledge and Attitudes Toward Renal Transplantation in Individuals Undergoing Transplant Evaluation. Prog Transplant 2021;31:271-8. [Crossref] [PubMed]
11. Huang X, Xi B, Xuan C, et al. Knowledge, attitude, and practice toward postoperative self-management among kidney transplant recipients. BMC Med Educ 2024;24:652. [Crossref] [PubMed]
12. Tepel M, Nagarajah S, Saleh Q, et al. Pretransplant characteristics of kidney transplant recipients that predict posttransplant outcome. Front Immunol 2022;13:945288. [Crossref] [PubMed]
13. Tucker EL, Smith AR, Daskin MS, et al. Life and expectations post-kidney transplant: a qualitative analysis of patient responses. BMC Nephrol 2019;20:175. [Crossref] [PubMed]
14. Chang YH, Lai YH, Tsai MK, et al. Care Needs for Organ Transplant Recipients Scale: Development and psychometric testing. J Ren Care 2021;47:123-32. [Crossref] [PubMed]
15. Jamieson NJ, Hanson CS, Josephson MA, et al. Motivations, Challenges, and Attitudes to Self-management in Kidney Transplant Recipients: A Systematic Review of Qualitative Studies. Am J Kidney Dis 2016;67:461-78. [Crossref] [PubMed]
16. Andrade C, Menon V, Ameen S, et al. Designing and Conducting Knowledge, Attitude, and Practice Surveys in Psychiatry: Practical Guidance. Indian J Psychol Med 2020;42:478-81. [Crossref] [PubMed]
17. World Health Organization. Advocacy, communication and social mobilization for TB control: a guide to developing knowledge, attitude and practice surveys. Accessed November 22, 2022. Available online: https://iris.who.int/handle/10665/43790
18. Zhang HM, Zheng LL, Huang J, et al. Current status of care for complications after renal transplantation. Qilu Nursing Journal 2011;17:43-4.
19. Wang TQ, Wei H, Di WJ. An overview of postoperative complications and nursing measures after renal transplantation. Seek Medical and Ask the Medicine 2013;11:40-1.
20. Bloom BS. Learning for Mastery. Instruction and Curriculum. Regional Education Laboratory for the Carolinas and Virginia, Topical Papers and Reprints, Number 1. Evaluation Comment 1968;1:n2.
21. Kaliyaperumal K. Guideline for conducting a knowledge, attitude and practice (KAP) study. AECS Illumination 2004;4:7.
22. Ma H, Hu M, Wan J. Kidney transplant-related knowledge and influencing factors in Chinese kidney transplant candidates and recipients: A cross-sectional study. Front Public Health 2023;11:1027715. [Crossref] [PubMed]
23. Massey EK, Meys K, Kerner R, et al. Young Adult Kidney Transplant Recipients: Nonadherent and Happy. Transplantation 2015;99:e89-96. [Crossref] [PubMed]
24. Pehlivan S, Vatansever N, Arslan İ, et al. Level of Daily Life Activities and Learning Needs in Renal Transplant Patients. Exp Clin Transplant 2020;18:498-504. [Crossref] [PubMed]
25. Du C, Wu S, Liu H, et al. Correlation of long-term medication behaviour self-efficacy with social support and medication knowledge of kidney transplant recipients. Int J Nurs Sci 2018;5:352-6. [Crossref] [PubMed]
26. Beran TN, Violato C. Structural equation modeling in medical research: a primer. BMC Res Notes 2010;3:267. [Crossref] [PubMed]
27. Fan Y, Chen J, Shirkey G. Applications of structural equation modeling (SEM) in ecological studies: an updated review. Ecol Process 2016;5:19.
28. Kline RB. Principles and Practice of Structural Equation Modeling (Fifth Edition). New York: The Guilford Press; 2023.