Employment outcomes following successfulrenal transplantation

Patients on chronic renal replacement therapy areautomatically considered ‘‘disabled’’ and are eligi-ble for Medicare benefits. After a successful renaltransplant, chronic renal replacement therapy is nolonger required and one may expect such patientsto return to work. Historically, only 28–58% ofrenal transplant patients are employed after suc-cessful transplantation (1–3). We conducted thissurvey study to try to identify favorable factors foremployment after transplantation.

Materials and methods

After approval from the Institutional ReviewBoard, surviving patients between 18 and 65 yr ofage at the time of transplantation who underwentrenal transplantation at JewishHospital (Louisville,KY, USA) between January 1, 2002 and December31, 2007 were identified. Patients who underwent

multi-organ transplantation or whose graft failedwithin one yr of transplantation were excluded.Patients included in the study were at least24 months after transplantation.

A 13 question survey was designed with inputfrom the renal transplantation social workers andnurse coordinators. The survey was written inEnglish and took approximately 10 min to com-plete. Respondents used tick boxes to indicate theirresponses. Space was provided to welcome addi-tional comments. The surveys were distributed tothe study population by mail and in person at thetime of office visits.

Statistical analysis

Data were analyzed using chi-squared and Fisher�sexact tests. A p-value<0.05 was considered statisti-cally significant.

Eng M, Zhang J, Cambon A, Marvin MR, Gleason J. Employmentoutcomes following successful renal transplantation.

Abstract: Background: Data on employment outcomes after successful re-nal transplantation are few. We conducted this study to identify favorablefactors for employment after transplantation.Methods: Adult patients <65 yr of age who underwent renal transplanta-tion between January 1, 2002 and December 31, 2007 were surveyed. Pa-tients with graft survival <1 yr were excluded. We also tested theirknowledge of Medicare coverage after transplantation. Data were analyzedusing chi-squared and Fisher�s exact tests. p-Value <0.05 was consideredstatistically significant.Results: A 55% response rate was obtained where 56% of respondents wereemployed after transplantation. Race, marital status, previous transplant,and complicated post-operative course did not influence employment.Favorable factors include male gender (p = 0.04), younger age (<40[p = 0.0003] or <50 yr [p < 0.0001]), having ‡1 dependent (p = 0.04),higher education (minimum high school degree [p = 0.003] or some college[p = 0.002]), live donor recipient (p = 0.004), wait time <2 yr (p = 0.03),dialysis <2 yr (p < 0.0001) or pre-dialysis (p = 0.04), and pre-transplan-tation employment (p < 0.0001). Mean time for employment was4.9 ± 6.3 months (median three months). Common reasons for unem-ployment were disability (59%) and retirement (27%). Finally, 7% correctlyresponded that Medicare benefits end 36 months following transplantation.Conclusions: Potentially modifiable factors to improve employment areearlier referral and better education regarding Medicare eligibility.

Mary Enga, Jie Zhangb, AlexanderCambonb, Michael R. Marvina andJohn Gleasonc

aDepartment of Surgery, Division of

Transplantation, bDepartment of Bioinformatics

and Biostatistics, University of Louisville andcNephrology Associates of Kentuckiana, Jewish

Hospital, Louisville, KY, USA

Key words: disability – employment – end stage

renal disease – Medicare – renal transplant

Corresponding author: Mary Eng, MD,

Department of Surgery, University of Louisville,

Ambulatory Care Building, 2nd Floor, Louisville,

KY 40292, USA.

Tel.: 502 587 4607; fax: 502 587 4140;

e-mail: mary.eng@louisville.edu

Conflict of interest: The authors have no conflicts

of interest to declare.

Accepted for publication 23 February 2011

Clin Transplant 2012: 26: 242–246 DOI: 10.1111/j.1399-0012.2011.01441.xª 2011 John Wiley & Sons A/S.

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Results

Of the 396 surviving patients identified, 27 experi-enced graft loss within one yr of transplantationand were excluded from the study. Of the 369surveys distributed, 204 were completed (responserate 55%). Demographics of respondents andstudy population were similar (Table 1). Aftertransplantation, 56% of the respondents wereemployed.

Race and marital status did not appear toinfluence employment after transplantation. Hav-ing had a previous renal transplant and compli-cated post-operative course were not factors inemployment status (Table 2).

Male patients were more likely to work aftertransplantation (p = 0.04) as were youngerpatients whereas patients aged 60–65 yr were morelikely to be retired. Patients with at least onedependent (p = 0.04) and those with higher edu-cation tend to be employed after transplantation(minimum high school degree or equivalent[p = 0.003], or at least some college [p = 0.002]).Recipients of a live donor kidney (p = 0.004),those on renal replacement therapy <2 yr (p <0.0001) or recipients of pre-emptive transplant(p = 0.04) and those with time on the wait list<2 yr (p = 0.03) were more likely to work aftertransplantation. The most favorable factor wasemployment at the time of transplantation(p < 0.0001).

Of the unemployed, 20% indicated capabilityand desire for employment. The most commonreasons for unemployment were disability (59%)and retirement (27%). Although space was pro-vided for respondents to state their disability,many chose to leave this blank. However, 19% ofthose who stated disability as the reason for notworking reported end-stage renal disease (ESRD)as their disability. Retirement was the reason forunemployment in the older patients, age range 53–65, where >50% of those aged >60 yr wereretired.

Table 1. Demographics of respondents and study population

Respondents(n = 204)

Study population(n = 369)

Male gender (%) 56.9 57.5Age (median) 48.1 ± 10.7 47.9 ± 11.3Race (%)Caucasian 72.5 77African American 25 21Hispanic 1.5 1.5Asian 1 1.5Deceased donor recipient 78.4 77.2

Table 2. Variables affecting post-transplantation employment

VariableWorking(n = 114)

Non-working(n = 90) p-Value

GenderMale 72 (62%) 44 (38%) 0.04Female 42 (48%) 46 (52%)Age (yr)18–29 11 (79%) 3 (21%)30–39 30 (77%) 9 (23%) 0.0003

(<40 vs. ‡40)40–49 38 (60%) 25 (40%) <0.0001

(<50 vs. ‡50)50–59 31 (50%) 31 (50%)60–65 4 (15%) 22 (85%)Marital statusSingle 21 (53%) 19 (47%) NSMarried 73 (57%) 56 (43%)Divorced 16 (59%) 11 (41%)Widowed 2 (40%) 3 (60%)Other 2 (67%) 1 (33%)RaceCaucasian 86 (58%) 62 (42%) NSAfrican American 26 (51%) 25 (49%)Hispanic 2 (67%) 1 (33%)Asian 0 2 (100%)Dependents0 64 (50%) 63 (50%) 0.04 (0 vs. ‡1)1 20 (59%) 14 (41%)2 21 (84%) 4 (16%)3 6 (67%) 3 (33%)5 0 1 (100%)Unstated 3 (33%) 5 (67%)EducationNo HS 0 5 (100%)Some HS 5 (33%) 10 (67%) 0.003 (min HS/GED

vs. less)HS/GED 26 (49%) 27 (51%) 0.002 (min some

college vs. less)Tech/Voc 10 (50%) 10 (50%)Some college 30 (54%) 26 (46%)College 34 (79%) 9 (21%)Graduate school 9 (75%) 3 (25%)Donor typeDeceased 81 (51%) 79 (49%) 0.004Live 33 (74%) 11 (26%)First transplantYes 94 (55%) 78 (45%) NSNo 20 (63%) 12 (37%)Wait time (months)<12 60 (63%) 35 (37%)12–24 30 (56%) 24 (44%) 0.05 (<12 vs. ‡12)24–36 13 (57%) 10 (43%) 0.03 (<24 vs. ‡24)36–48 6 (33%) 12 (67%)>48 5 (36%) 9 (64%)DialysisHD 75 (52%) 69 (48%) 0.04 (HD or

PD vs. none)PD 14 (56%) 11 (44%)None 25 (71%) 10 (29%)Time CRRT (months) (n = 169)<12 36 (71%) 15 (29%) 0.003 (<12 vs. ‡12)12–24 26 (67%) 13 (33%) <0.0001 (<24 vs. ‡24)24–36 9 (31%) 20 (69%)36–48 5 (28%) 13 (72%)>48 13 (41%) 19 (59%)

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In the questionnaire, we included a question to testthe patient�s knowledge regarding Medicare bene-fits after successful renal transplantation. Re-sponses are indicated in Table 3. Only 7%correctly responded that Medicare benefits end36 months following successful renal transplanta-tion for patients aged <65 yr, whereas 19%thought disability continued indefinitely and 67%admitted to not knowing or did not respond.

Discussion

Medicare benefits are available to people aged>65 yr, <65 yr with certain disability or people ofany age with ESRD requiring dialysis or renaltransplantation. In the case of ESRD, patientsbecome eligible for Medicare benefits upon initiat-ing chronic peritoneal dialysis, three months afterstarting hemodialysis or at the time of kidneytransplantation. If they have been previouslyemployed and contributed to Social Security, theymay also claim disability benefits. For patientseligible for Medicare only because of ESRD,

benefits terminate 12 months after stopping dialy-sis treatment or 36 months after renal transplan-tation. For transplant recipients, coverage isextended if the kidney allograft fails and thepatients return to dialysis or they receive anotherkidney transplant, where coverage will continue for36 months after the most recent transplantation.

At the time the survey study was conducted, thenational unemployment rate was 9.3% of the laborforce, with an unemployment rate for the state ofKentucky >10% (4). Employment among ESRDpatients fared worse with <40% employed (5).Although previous studies indicate that 60–70% ofkidney transplant recipients are capable of work-ing, only 28–58% were employed (1–3). Our study,likewise, has an employment rate of 56%.

A single study by Russell et al. reported anexcellent number of employed patients (71%) aftertransplantation (6). However, the mean age in hisstudy population was 42 yr. If only patients aged<50 yr were studied, we would have an employ-ment rate of 68%, which would be comparable toRussell�s study. We were more interested in deter-mining employment outcomes of adult renal trans-plant recipients aged <65 yr, as these patientswould not be eligible for Medicare benefits unlessthey had another condition resulting in disability.As expected, younger patients were more likely tobe employed. Many older patients declared retire-ment as the reason for unemployment, despitebeing <65 yr. An early retirement option likelyexplains these underage retirees.

In our study, race and marital status did notappear to be significant indicators for employment.Comparable with a previous study, male patientswere more likely to work after transplantation (6).Although one may expect patients with compli-cated post-transplant course as indicated bydelayed graft function or those requiring multiplere-admissions to the hospital to be unemployed,this was not the case. Moreover, re-transplantationdid not negatively affect employment after trans-plantation.

The presence of dependents was an indicator foremployment after transplantation. If a transplantrecipient had at least one dependent, they weremore likely to be employed. As the number ofdependents increased, the likelihood of employ-ment did not.

In contrast to Slakey�s observation, our studyshowed that higher level of education improvedemployment status after transplantation (1).Patients who completed high school or equivalentwere more likely to be employed. Likewise,patients with some college education had higherrates of employment.

Table 2. (Continued)

VariableWorking(n = 114)

Non-working(n = 90) p-Value

Delayed graft functionYes 10 (40%) 15 (60%) NSNo 104 (58%) 75 (42%)Re-admission0 69 (57%) 52 (43%) NS1 22 (52%) 20 (48%)2 13 (59%) 9 (41%)3+ 10 (53%) 9 (47%)Pre-workYes 93 (89%) 11 (11%) <0.0001No 21 (21%) 79 (79%)

HS, high school; GED, general equivalency diploma; Tech/Voc, technical/voca-tional school; HD, hemodialysis; PD, peritoneal dialysis; CRRT, chronic renalreplacement therapy.

Table 3. Patient�s answer to disability length after renal transplantation

Indefinitely 38 (19%)1 Month 3 (1.5%)3 Monthsa 1 (0.5%)1 Yr 11 (5%)3 Yr 14 (7%)5 Yr 1 (0.5%)18 Monthsa 1 (0.5%)Don�t know 87 (43%)No answer 48 (23%)

aThese answers were not options for respondents to select, individuals wrote inthe responses.

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Shorter time on the recipient wait list and shorterduration of renal replacement therapy prior totransplantation favorably influence employmentafter transplantation. Recipients of a pre-emptivetransplant and those with live donor were also morelikely to be employed. As expected, patients withlive donors had shorter duration of waiting timeand renal replacement therapy.

As previously reported, the greatest indicator foremployment after transplantation was employmentprior to transplantation (3, 7, 8). In our study, 89%of those who were employed at the time oftransplantation were employed after transplanta-tion and 79% of these patients returned to theirprevious jobs. There were rare circumstances whereour physicians did not allow the recipientsto return to their previous jobs. For patientswho obtained employment, the median time wasthree months after transplantation (mean 4.9 ±6.3 months). Many did not require a release toreturn to work.

Non-working patients listed disability (59%)and retirement (27%) as the most common reasonfor unemployment. Various types of disabilitylisted include cerebral vascular accident, cardio-myopathy, blindness and peripheral vascular dis-ease. Many respondents did not state theirdisability while 19% listed ESRD as their disabil-ity. Of those who listed ESRD, all had a function-ing renal allograft at the time of the survey andseven of the nine respondents were >36 monthsafter transplantation. For those declaring retire-ment, more than 50% were >60 yr of age. Ofthose unemployed, 20% indicated a desire to work.Although a few stated difficulty finding a job, it isunclear why the remainder did not secure employ-ment.

Our final question of the survey tested thepatient�s knowledge of Medicare coverage afterrenal transplantation. This was a multiple choicequestion with six possible choices. It is disappoint-ing that only 7% correctly answered this question.Most respondent selected ‘‘don�t know’’ or simplydid not answer (67%). Although all patients beingevaluated for transplantation attend an educationclass in which termination of Medicare benefits36 months after transplantation was discussed(unless >65 yr or has another disability), it isclear that patients do not retain this information.

Conclusion

Based on our study, factors influencing employ-ment can be categorized as those which can bealtered and those which cannot. Gender, age attime of transplant, number of dependents, level of

education, availability of a live donor, and time onthe waiting list exemplify characteristics that can-not be altered. Factors that can be modifiedinclude less time on dialysis or the pre-emptivetransplant. These seem to be the most criticalqualities for employment post-transplant. As such,it behooves us as healthcare providers to identifypotential transplant candidates when they reach anestimated glomerular filtration rate of <25 mL/min (stage 4 chronic kidney disease). Transplantcenters should enlist their referring physicians torecruit individuals for evaluation at this time. Inprograms with anticipated long donor wait times,this may allow for pre-emptive deceased donorkidney transplants with improved employmentrates post-transplant.The second issue is the transplant recipients�

poor understanding of their Medicare eligibility.The diagnosis of ESRD and the process oftransplantation evaluation are overwhelming.However, healthcare coverage for these patients isequally important. Clearly, healthcare personnelcaring for renal transplant candidates and recipi-ents should do better to ensure that they under-stand that Medicare coverage is not indefiniteunless they are >65 yr of age or have anotherdisability. Without knowledge of their Medicarebenefits, renal transplantation recipients can beunprepared when they reach 36 month after trans-plantation. They may find themselves withouthealthcare coverage and unable to afford therequired immunosuppressive agents to maintaintheir allograft.

Limitations

This study has several limitations. First, becausethis was a survey study, we relied on the respon-dent�s accuracy and honesty in their answers.Some respondents were >7 yr post-transplant atthe time of the survey. Secondly, although thesurveys did not contain identifiers, employedrespondents may be reluctant to participate forfear of loss of disability benefits. Likewise, failureto return to work may be viewed negatively by therespondents.

Acknowledgements

The authors express their special thanks to Bette Lee, CSWfor her assistance in designing the questionnaire, and toGuy Brock, PhD, for statistical assistance. The authorswould also like to express their thanks to Nancy Bellis,BSN, Eileen Kearney, BSN, Joseph Coutee and the officestaff at Nephrology Associates of Kentuckiana for theirassistance in the distribution and collection of the ques-tionnaires.

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References

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3. Markell MS, DiBenedetto A, Maursky V et al.Unemployment in inner-city renal transplant recipients:predictive and sociodemographic factors. Am J KidneyDis 1997: 29: 881.

4. Bureau of Labor Statistics Data; http://data.bls.gov;assessed February 4, 2011.

5. 2010 USRDS Annual Data Report; http://USRDS.org;assessed February 4, 2011.

6. Russell JD, Beecroft ML, Ludwin D, Churchill DN.The quality of life in renal transplantation – a prospectivestudy. Transplantation 1992: 54: 656.

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