The frequency of at least one GIS (GSRS score of > 1) in the study sample is shown in Figure 3.1, being 90.7% and 83.3% at baseline and six month follow-up respectively.
The final Cronbach’s Alpha for the global mean at baseline and six month follow-up, was 0.813 and 0.862 respectively. GSRS for all GIS in the whole group (Figure 3.2) was higher at baseline
59
than at six month follow-up. At baseline, the global mean GSRS was 1.80 ± 0.76 and lower at six months at 1.55 ± 0.74. The individual GIS show a similar order of severity at each assessment time point. Indigestion and diarrhoea had the highest and lowest GSRS respectively.
Frequency and severity of GIS in transplant candidates
Overall, 88.9% of dialysed participants reported at least one GIS at baseline and 81.5% at six month follow-up (Figure 3.1). At baseline, indigestion (79.6%), abdominal pain (64.8%) and reflux (48.1%) were the most commonly reported GIS, while diarrhoea and constipation were experienced to a lesser extent at 44.4% and 42.6%, respectively (Figure 3.3). At six month follow-up, indigestion was still the most frequent GIS, albeit to a lesser extent (66.7%).
However, more participants complained of constipation, increasing in frequency to 51.0%.
The GSRS scores indicated the severity of symptoms (Table 3.3) for each treatment group. The most severe GIS for PD patients (n=3) was diarrhoea at six months (GSRS 4). For HD patients, indigestion was slightly more severe than the other GIS at both times (GSRS 1.67). Females had significantly higher median GSRS for several GSRS subscales as well as the global mean at baseline (p = 0.030).
In the transplant candidate group, Spearman’s correlations with GSRS (Table 3.4) were positive for the global mean score with the length of time on dialysis at baseline and six months (baseline rho = 0.287, p =0.036 and rho=0.440, p= 0.001). Age correlated negatively with GIS global mean (rho= -0.338, p= 0.015).
Prevalence and severity of GIS in transplant recipients
Over nine out of ten (95.2%) of the transplant group experienced GIS at baseline. However, the prevalence of symptoms decreased by 19.0% to 76.2% at six month follow-up. The frequency of symptoms across the five subscales is depicted in Figure 3.4. Transplant recipients reported indigestion as the most prevalent symptom at baseline (85.7%), this was followed by abdominal pain (81.0%), reflux (42.9%), with diarrhoea and constipation both occurring at a prevalence of 38.1%. At six month follow-up, frequency of GIS symptoms deceased by 19%, from 95.24%
to 76.19%. The frequency in each symptom category also decreased but maintained a similar frequency sequence. Indigestion was the most frequently experienced GIS in the transplant
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group with 85.7% prevalence at baseline and 61.9% at six month follow-up. Only one participant reported diarrhoea (4.8%) at six month follow-up.
Indigestion was the most severe GIS with the highest median GSRS score of 2.33 at baseline and 1.33 at six months (Table 3.3). All GSRS were lower at six month follow-up with the global mean decreasing from 1.86 to 1.15. In the transplant group, WC was positively associated with constipation at baseline (rho=0.471, p=0.048).
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Table 3.1: Socio-demographic and clinical characteristics of the study sample Patient Characteristics Whole group
(N = 76)
Transplant (n = 22)
Dialysis (n = 54)
Age (years): mean ± SD 43.6 ± 8.1
range: 28.0 – 63.0 Gender
Male 46 (60.5)
Female 30 (39.5)
Ethnicity
Black 71 (93.4)
Coloureda 4 (5.3)
White 1 (1.3)
Type of treatment
Transplant 22 (28.9)
Haemodialysis 51 (67.1)
Peritoneal dialysis 3 (3.9)
Length of time on current treatment (years)
2.7 ± 2.3 range: 0.0 – 6.8
3.9 ± 3.0 range: 0.3 - 11.5 Chronic illness
Diabetes 1 (4.5)* 16 (29.6)*
Hypertension 19 (86.4) 51 (94.4)
Hypercholesteraemia 1 (4.5) 3 (5.6)
CD4 (cells/µL)b 447.25 ± 282.70 382.12 ± 178.02
Viral load (copies /ml)c
LDL 18 (94.7) 39 (79.6)
≤ 10 000 1 (5.3) 7 (14.3)
> 10 000 0 (0.0) 3 (6.1)
Data expressed as percentages or means with standard deviation
a Coloured is the term used in South Africa denoting mixed racial ancestry
b transplant patients: n = 20, dialysis recipients: n = 52
c transplant patients: n = 19, dialysis patients: n = 49
*Significant difference in the number of patients with diabetes between transplant recipients and transplant candidates patients (p = 0.017)
LDL: lower than detectable limit
62
63
Table 3.2: Nutritional characteristics of transplant candidates and recipients (N = 76).
Nutritional Characteristics
Transplant (n = 22)
Dialysis (n = 54)
n Baseline n 6 months n baseline n 6 months
Albumin (g/L) 20 43.1 ± 4.1 22 41.3 ± 4.1 48 35.9 ± 4.5 52 37.2 ± 4.8 BMI (kg/m2) 21 24.5 ± 4.6 22 25.6 ± 5.8 52 26.3 ± 4.8 49 25.7 ± 4.8
Underweight 1 (4.5) 1 (1.9) 1 (2.0)
Normal 15 (71.4) 13 (59.1) 19 (36.5) 19 (38.8)
Overweight 2 (9.5) 2 (9.1) 20 (38.5) 20 (40.8)
Obese Class I 4 (19.0) 6 (27.3) 11 (21.2) 8 (16.3)
Obese Class II 1 (1.9) 1 (2.0)
WC (cm) 18 89.6 ± 13.1a 18 95.8 ± 12.3a 36 92.2 46 90.7 ± 4.2
Data expressed as percentages or means with standard deviation or frequency with percentages
aWC is significantly larger at 6 months than at baseline, paired samples t-test: t(14) = -2.861, p 0.013
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Figure 3.1: Frequency of gastrointestinal symptoms for the whole group and per treatment modality at baseline and six month follow-up (N= 76).
Figure 3.2: GSRS for the whole group across each subscale at baseline and six month follow- up.
1.86 1.86 2.05
1.78 1.53 1,80
1.36 1.63 1.82
1.52 1.33 1.55
0 1 2 3 4 5 6 7
Abdominal pain Reflux Indigestion Constipation Diarrhoea Global Baseline (n= 75) 6 Months (n= 72)
90.7
83.3 95.2
88.9
76.2 81.5
0 10 20 30 40 50 60 70 80 90 100
Baseline 6 Months
Patients (%) Whole group
Transplant Dialysis
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Figure 3.3: Frequency of gastrointestinal symptoms in transplant candidates at baseline and six month follow-up.
Figure 3.4: Frequency of gastrointestinal symptoms in transplant recipients at baseline and six month follow-up.
64.8
48.1
79.6
42.6 44.4
43.1
37.3
66.7
51.0
31.4
0 10 20 30 40 50 60 70 80 90
Abdominal pain
Reflux Indigestion Constipation Diarrhoea
Dialysis patients (%)
Gastrointestinal Symptoms
Baseline (n= 54) 6 Months (n= 51)
81,0
42.9
85.7
38.1 38.1
52.4
33.3
61.9
28.6
4.8 0
10 20 30 40 50 60 70 80 90
Abdominal pain
Reflux Indigestion Constipation Diarrhoea
Transplant Patients (%)
Gastrointestinal Symptoms
Baseline (n= 21) 6 Months (n= 21)
66 Table 3.3: GSRS scores per treatment group at baseline and six month follow-up
Haemodialysis Peritoneal Dialysis
Transplant Dialysis (HD + PD)
Subscale Baseline 6 months Baseline 6 months Baseline 6 months Baseline 6 months
n = 51 n = 48 n = 3 n = 3 n = 54 n = 51 n = 21 n = 21
Abdominal pain 1.67 (4) g 1 (2.5) 2 (2.67) 1 (6) 1.67 (1) a 4 (6) e 1.67 (4.67) 1 (1)
Reflux 1 (5) 1 (4) 1 (4) 1 (5.5) 1 (1) 5 (5.5) 1 (4) 1 (5)
Indigestion 1.67 (6) h 1.67 (5) 2 (1) 1 (3) 1.67 (1.67) b 6 (5) f 2.33 (3) 1.33 (2.33)
Constipation 1 (6) 1.33 (6) 2 (4.5) 1 (1.67) 1 (1.33) 6 (6) 1 (2) 1 (2)
Diarrhoea 1 (3) 1 (4.5) 1 (6) 4 (5) 1 (1) c 6 (5) 1 (2) 1 (0)
Global mean 1.57 (3.14) 1.38 (3.62) 1.5 (3.5) 1.77 (3.62) 1.57 (1.38)d 3.93 (3.62) 1.86 (1.79) 1.15 (1.46) GSRS scores as median (range)
a Significantly higher for females (mean rank = 32.66) than males ( mean rank=23.95), p = .040
b Significantly higher for females (mean rank = 34.00) than males ( mean rank= 23.03), p = .011
c Significantly higher for females (mean rank = 32.27) than males ( mean rank= 22.22), p = .022
d Significantly higher for females (mean rank = 33.09) than males ( mean rank= 23.66), p = .030
e Significantly higher for females (mean rank = 30.85) than males ( mean rank= 22.87), p = .025
f Significantly higher for females (mean rank = 31.83 ) than males ( mean rank= 22.24), p = .020
g Significantly higher for females (mean rank = 30.83 ) than males ( mean rank= 22.62), p = .045
h Significantly higher for females (mean rank = 31.93) than males ( mean rank= 21.85), p = .016
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Table 3.4: Correlations of GSRS scores with clinical and nutritional parameters in transplant candidates and recipients at baseline and at six month follow-up
Variable Global mean Reflux Indigestion Constipation Diarrhoea Abdominal pain
n rho p rho p rho p rho p rho p rho p
Dialysis
Duration of treatment
Baseline 54 0.287* 0.036 0.279* 0.041
6 months 51 0.44** 0.001 0.457** 0.001 0.3** 0.033
Age
Baseline 54
6 months 51 -0.338* 0.015 -0.317* 0.023 -0.354* 0.011
Transplant
WC (cm)
Baseline 18 0.471* 0.048
*Correlation is significant at the 0.05 level (2-tailed)
** Correlation is significant at the 0.01 level (2-tailed)
68 3.4 Discussion
The occurrence of at a least one GIS (GSRS > 1) in the total group, at baseline and at 6 months was high. At 90.7% and 83.3% respectively, this finding supports previous research that renal patients experience a greater frequency of GIS than non-renal patients (23) and the general population (14,24,25).