General description of included studies
The search yielded 2,310 references addressing kidney failure and employment. From the titles 133 studies were considered relevant for evaluation, and of those 58 met the inclusion criteria. Figure 1 shows the results of the systematic search strategy.
Table 1 summarizes the general characteristics of the studies. In total 27 studies described employment in kidney failure-patients during dialysis [17–43]; 25 after kidney transplantation [3, 4, 12, 13, 44–64]; and 6 [14, 65–69] addressed both dialysis and kidney transplantation. In total 33 studies regarding dialysis, and 31 regarding kidney transplantation were included with a total of 162,059 and 137,742 participants, respectively. The publication year of the included studies ranged from 1981 to 2020 (median 2013). Most of the studies (81%) were cross-sectional in design, analysing data at a specific point in time. The cross-sectional studies [3, 12–14, 17–19, 21, 22, 24–39, 41–49, 51, 54, 55, 57, 59, 61–64, 66–69] were small to medium sized with a median of 139–233 participants for kidney transplant and dialysis patients, respectively, while the cohort studies [4, 20, 23, 40, 50, 52, 53, 56, 58, 60, 65] were mainly larger population studies (median 2,103 for dialysis patients and 1,254 for kidney transplant patients). More than half of the studies were single-center studies, and the studies were mainly from high income countries. Study details are shown in Tables 1 to 3.
Table 1
General characteristics of the included studies, by dialysis and kidney transplantion
Geography
|
Dialysis
(n = 33)
|
Kidney transplantion
(n = 31)
|
Europe
|
10
|
13
|
North America
|
11
|
14
|
Others (Asia, South America, New Zealand)
|
12
|
4
|
Study design
|
|
|
Cross sectional
|
29
|
23
|
Cohort study
|
4
|
8
|
Study sampling method
|
|
|
Single centre
|
13
|
24
|
Multicentre
|
13
|
2
|
Registry
|
7
|
5
|
Type of dialysis*
|
|
|
Hemodialysis
|
15
|
|
Peritoneal dialysis
|
10
|
|
Dialysis-modality unknown
|
17
|
|
Number of participants
|
|
|
Cross sectional studies
|
|
|
median
|
233
|
139
|
range
|
43–105,636
|
34 − 1,278
|
SD
|
22,449
|
255
|
Cohort studies
|
|
|
median
|
2,103
|
1,253
|
range
|
359-4,734
|
358 − 71,976
|
SD
|
1,997
|
27,826
|
*Does not sum up to 33 because some studies included more than one type of dialysis |
Table 2
Characteristics of the Individual Studies among kidney failure patients receiving dialysis
Reference
|
Country
|
Study design
|
Study population
|
Study period
|
Participation rate
|
Age years
(mean)
|
Sex
(Male) %
|
Results
|
Quality assessment
|
Albatineh 2019
|
Kuwait
|
Cross sectional
|
336 HD patients from six dialysis centers
|
n.a
|
n.a.
|
> 21
|
43.5
|
Employed 17.9 %
|
4
|
Al -Jumaih 2011
|
Saudi Arabia
|
Cross sectional
|
100 HD patients selected randomly from 3 centers
|
n.a.
|
n.a.
|
(53.4)
|
68
|
Employed 28%
|
3
|
AlShahrani 2018
|
Saudi Arabia
|
Cross sectional
|
233 patients from all hemodialysis centers
|
2016-17
|
n.a.
|
> 20
|
78.5
|
Employed 26.6%
|
3
|
Curtin 1996
|
U.S.
|
Cross sectional
|
359 stratified from 31 centers
|
n.a.
|
n.a.
|
18–62
(43)
|
50
|
Employed: before dialysis 73%; during dialysis 24%
|
7
|
Ghani 2018
|
Sweden
|
Cohort
|
4734 patients; HD = 2667; PD = 2067
|
1995–2012
|
96%
|
HD/PD
(48/47)
|
HD 65;
PD 62
|
Employed: 1 year before dialysis: total 65.3%; HD/PD 57%/76%; during dialysis: total 59.7%; HD/PD 51%/71%
|
6
|
Grubman-Nowak 2020
|
Poland
|
cross sectional
|
60 HD patients
|
2016-19
|
n.a.
|
(60)
|
60
|
Employed: 25%
|
3
|
Gutman 1981
|
U.S.
|
Cross sectional
|
2481 from 17 dialysis centers
|
1979
|
n.a.
|
21–59
(49)
|
55
|
Employed: 24%
|
8
|
Helanterá 2012
|
Finland
|
Cross sectional
|
819 from Finnish Kidney and Liver Association registry
|
2007
|
n.a.
|
15–64
|
62
|
Employed: total 23.9%; HD 19%; homeHD 44%; APD 39%; CAPD 16%
|
7
|
Holley 1994
|
U.S.
|
Cross sectional
|
77 patients; HD = 46; PD = 31
|
1993
|
|
21–54
|
47
|
Employed: 42.8%
|
5
|
Huang 2017
|
China
|
Cross sectional
|
166 patients in working age from 4 dialysis centers in Shanghai
|
2015
|
n.a.
|
(48.5)
|
64
|
Employed 15.7%
|
5
|
Imanishi 2017
|
Japan
|
Cohort
|
3151 dialysis patients in working age < 60
|
1999–2011
|
n.r.
|
18–59
|
n.a.
|
Employed 51%
|
5
|
Jarl 2018
|
Sweden
|
Cohort
|
1056 on dialysis from Swedish Kidney Registry
|
1995–2012
|
n.r.
|
20–60
(50.3)
|
63.5
|
Pre-dialysis:28%;
during dialysis 18%
|
6
|
Julian Mauro 2013
|
Spain
|
Cross sectional
|
161 in dialysis (HD = 83; PD = 78) from 8 centers in Spain in working age
|
2007-9
|
n.a.
|
16–65
(41)
|
61.5
|
Employed : total 30.4%; HD 41%; PD 35.9%
|
3
|
Kasiske 1998
|
U.S.
|
Cross sectional
|
36646 receiving dialysis placed on a waiting list for kidney transplant.
|
1994-96
|
n.r.
|
all ages
|
59
|
Employed pre-dialysis: Fulltime 53.4%; part-time 6.5%; during dialysis: Fulltime 34.5%; part-time 8.2%
|
5
|
Kutner 1991
|
U.S.
|
Cross sectional
|
283 dialysis patients, 15 patents from each of 81 treatment facilities
|
1987
|
99% of invited
|
18–59
(44.7)
|
n.a.
|
Employed 11%
|
4
|
Kutner 2008
|
U.S.
|
Cross sectional
|
105636 dialysis patients from ESRD Facility Survey
|
2004
|
n.r.
|
18–54
|
n.a.
|
Employed 18.9%
|
6
|
Kutner 2010
|
U.S.
|
Cross sectional
|
1643 from US Renal Data System
|
2009
|
n.r.
|
> 18
(59.6)
|
55
|
Pre-dialysis 35.6%; During dialysis 11.6% (4 months after start)
|
5
|
Kwan 2013
|
Hong Kong
|
Cross sectional
|
All new consecutive automated PD-patients matched to CAPD-controls; 270; APD/CAPD 90/180
|
1995–2001
|
n.a.
|
APD/CAPD
(50.5/57.8)
|
ADP 67;
CAPD 54
|
Employed: Total 35.2%; APD/CAPD 71.2%/17%
|
5
|
Li 2018
|
Hong Kong
|
Cross sectional
|
101 (20 NHHD; 81 CAPD)
|
2009-14
|
87%
|
18–64
(47/52)
|
55
|
Employed: total 42.6%; NHHD: 80%; CAPD: 33.3%
|
4
|
Molsted 2004
|
Denmark
|
Cross sectional
|
112 from one university hospital; 59 in working age < 60 year:
|
n.a.
|
75%
|
> 18
(57.8)
|
64
|
Employed (in working age): 22%
|
4
|
Nakayama 2015
|
Japan
|
Cross sectional
|
179 (102 PD; 77 HD) from 5 dialysis centers
|
2013
|
n.a.
|
(63)
|
68
|
Pre-dialysis: 63%; during dialysis 49.2%.
|
7
|
Neumann 2018
|
Germany
|
Cross sectional
|
353 (1 year follow-up) stratified sample of 153 PD; 200 HD from 55 dialysis unit 6–24 months after initiation of dialysis
|
2014–2015
|
74%
|
> 18
(63.1)
|
68
|
Employed: total 17.1%; (PD 26.9%; HD 13.2%)
|
4
|
Panagopoulou 2009
|
Greece
|
Cross sectional
|
40 HD; 36 PD
|
n.a.
|
n.a.
|
HD/PD
(57/59)
|
PD 58;
HD 50
|
Employed before dialysis: HD: 78%; PD 43%; During dialysis: total 25%; HD: 20%; PD 31%
|
3
|
Parajuli 2016
|
U.S.
|
Cross sectional
|
200 from one kidney transplant center; dialysis > 1 year before transplant
|
n.a.
|
48%
|
> 18
(57)
|
60
|
Employed before dialysis: HD 93.5%
During dialysis HD 35%
|
4
|
Ravindan 2020
|
India
|
Cross sectional
|
503 HD patients from 11 centers
|
2015
|
95%
|
13-
|
74
|
Employed:11.1%
|
3
|
Takaki 2006
|
Japan
|
Cross sectional
|
317 HD patients from 4 dialysis centers
|
n.a.
|
n.a.
|
18–64
(54.2)
|
66
|
Employed:
Total 42.3%; Male 54.1%; Female 19.4%
|
5
|
Tanaka 2020
|
Japan
|
Cross sectional
|
229; 36 PD + HD; 103 HD; 90 PD
|
2012-15
|
69.9%
|
PD + HD (57.4);
HD (62.7);
PD (65.5)
|
PD + HD 75;
HD 80;
PD 69
|
Employed: Total 52.8%; PD + HD 63.9%; HD 53.4%; PD 47.8%
|
4
|
Theorell 1991
|
Sweden
|
Cross sectional
|
470 patients in Sweden on dialysis
|
1988
|
65.5%
|
25–64
|
59.8
|
Employed: 20%
|
6
|
Walker 2016
|
New Zealand
|
Cross sectional
|
43; a part of a larger study
|
2014-15
|
n.a.
|
22–79
|
48
|
Employed: 27.9%
|
3
|
van Manen 2001
|
The Netherlands
|
Cohort
|
659 consecutive patients on dialysis; 359 completed follow-up
|
1997-99
|
54.5%
|
18–65
(48.7)
|
60
|
Employed: before dialysis 35%; 1 year on dialysis: 29.8%
|
3
|
Wilk 2019
|
U.S.
|
Cross sectional
|
759 from one dialysis centers
|
2010-18
|
65%
|
HD (59)
INHD (50)
|
n.a.
|
Employed 10.5%
|
5
|
Wolcott 1988
|
U.S.
|
Cross sectional
|
33 PD; 33 HD matched by sex, age and diabetic status
|
n.a.
|
n.a.
|
20–65
|
70
|
Employed: 19.7%
PD:30%; HD:9%
|
5
|
Zimmerman 2006
|
Canada
|
Cross sectional
|
81 patients randomly selected from a waiting list for donor transplant
(1/3 not in dialysis)
|
n.a.
|
66%
|
(48.4)
|
56.2
|
Employed: 32.9%
|
4
|
n.a: not analyzed; n.r.: not relevant; HD: hemodialysis; PD: peritoneal dialysis; yr: year; APD: Automated Peritoneal Dialysis ; CAPD: Continuous Ambulatory Peritoneal Dialysis; NHHD nocturnal home hemodialysis |
Table 3
Characteristics of the Individual Studies Among Kidney Failure Patients Receiving a Kidney Transplantion.
Reference
|
Country
|
Study design
|
Study population
|
Study period
|
Participation rate (%)
|
Age years (mean)
|
Sex (Male) %
|
Results
|
Quality assessment
|
Bohlke 2008
|
Brazil
|
cross sectional
|
272 with kidney transplant-a systematic random sampling of 1512 kidney transplant patients from 11 centers stratified by transplantation centers
|
2003- 4
|
97%
|
> 18
(40.8)
|
n.a.
|
Pre-transplant employed:
Full-time 11.8%; part-time 13.2%;
Post-transplant employed: Full-time 23.2%; part-time 6.3%
|
9
|
Chen 2007
|
Taiwan
|
cross sectional
|
113 with kidney transplant
|
5 months (2003-4)
|
98%
|
> 18 (43.7)
|
54.9
|
Post-transplant employed: Full-time 50.4%; part-time 8%
|
3
|
Chisholm-Burnes 2011
|
U.S.
|
cross sectional
|
75 > 1 year post-transplant
|
n.a.
|
90%
|
21–65
(47.6)
|
57.3
|
Post-transplant employed 39%
|
8
|
Danuser 2017
|
Switzerland
|
cohort
|
689 from the Swiss Transplant Cohort Study
|
2008-12
|
65%
|
18–65
|
65
|
Pre-transplant employed 58.9%; Post-transplant employed 56.2%
|
7
|
De Baere 2010
|
Belgium
|
cross sectional
|
79 with kidney transplant
|
n.a.
|
77.3%
|
18–65
|
62
|
Pre-transplant employed 63.1%; Post-transplant employed 58.6%
|
4
|
De Pasquale 2019
|
Italy
|
cross sectional
|
81 consecutive kidney transplant patients from one center
|
2016-17
|
72%
|
(46.3)
|
58
|
Pre-transplant employed 68%; Post-transplant employed 38%
|
5
|
Eng 2012
|
U.S.
|
cross sectional
|
204 with graft survival > 1 yr
|
2002-7
|
55%
|
18–65
(48.1)
|
57
|
Post-transplant employed 56%
|
7
|
Eppenberger 2015
|
Switzerland
|
cross sectional
|
354 with kidney transplant in one hospital; 282 in working age
|
2000-11
|
58%
|
42–61 (53.5)
|
71
|
Pre-transplant employed: Fulltime 33%; part-time 21%; 1 year post-transplant: full-time 36%; part-time 20%
|
7
|
Grubman-Nowak 2020
|
Poland
|
cross sectional
|
101 patients with kidney transplant
|
2016-19
|
n.a.
|
(48)
|
60
|
Post-transplant employed 57%
|
3
|
Helanterá 2012
|
Finland
|
cohort
|
1818 with kidney transplant from Finnish Kidney and Liver Association registry
|
2007
|
n.r.
|
15–64
(49)
|
62
|
Post-transplant employed 40%
|
7
|
Jarl 2018
|
Sweden
|
cohort
|
3247 with kidney transplant from Swedish Kidney Registry
|
1995–2012
|
n.r.
|
20–60 (43.3)
|
64.5
|
Pre-transplant employed 62%; Post-transplant employed 61.1%
|
6
|
Jordakieva 2020
|
Austria
|
cross sectional
|
139 with kidney transplant in a multi-center questionnaire study
|
2012
|
n.a.
|
18–55
|
58
|
Post-transplant employed:
Full-time 36%; part-time 13.7%
|
5
|
Julian Mauro 2013
|
Spain
|
cross sectional
|
82 with kidney transplant from 8 centers in Spain in working age
|
2007-9
|
n.a.
|
16–65
(46)
|
58.5
|
Post-transplant employed: 39%
|
3
|
Markell 1997
|
U.S.
|
cross sectional
|
58 with kidney transplant patients from one outpatient clinic
|
1994
|
58%
|
20–67
(43)
|
50
|
Post-transplant employed: 43%
|
6
|
Matas 1996
|
U.S.
|
Cohort
|
636 with functioning kidney transplant
|
1985–1993
|
83%
|
> 18
(41)
|
62
|
Pre-transplant employed:
Full-time 39%; part-time 5% Post-transplant employed:
Full-time 32%; part-time 1%
|
5
|
Matas 2001
|
U.S.
|
Cross sectional
|
1278 with primary living donor kidney transplant
|
1990-98
|
n.a.
|
(32)
|
62
|
Post-transplant employed:
Full-time 41%; part-time 4%
|
5
|
Messias 2014
|
Brazil
|
Cohort
|
358 with primary kidney transplants
|
2005-9
|
61.7
|
17–72
(37–49)
|
67
|
Post-transplant employed: 26%
|
6
|
Miyake 2019
|
Japan
|
Cohort
|
515 from one outpatient clinic being in paid employment at the time of transplant
|
2017-18
|
98%
|
20–64
|
68
|
Post-transplant employed:
Full-time 76%; part-time 9%
|
5
|
Monroe 2005
|
U.S.
|
Cross sectional
|
78 with kidney transplant; in working age; a stratified sample from one center during a 10 year period
|
n.a.
|
33%
|
23–62
(46.5)
|
52
|
Post-transplant employed 49%
|
4
|
Nour 2015
|
Canada
|
Cross sectional
|
60 with kidney transplant and functioning graft from one clinic
|
2003-8
|
41.7%
|
18–65
(52)
|
63.5
|
Pre-transplant employed 68.3%; Post-transplant employed 38.3%
|
6
|
Panagopoulou 2009
|
Greece
|
Cross sectional
|
124 patients with kidney failure and 48 with kidney transplant
|
n.a.
|
n.a.
|
(39)
|
67
|
Pre-transplant employed: 86%; Post-transplant employed 56%
|
3
|
Parajuli 2016
|
U.S.
|
Cross sectional
|
200 form one kidney transplant center; dialysis > 1 year before transplant; investigated > 1 year after transplant
|
n.a.
|
48%
|
28–82
(57)
|
60
|
Employed: Prior to dialysis 93.5%; during dialysis 35%; Post-transplant 35.5%
|
4
|
Petersen 2008
|
U.S.
|
Cohort
|
47123 1 year post kidney transplant from United States Renal Data System
|
1995–2002
|
n.r.
|
> 18 (45.9)
|
60
|
Employed: Pre-transplant: Fulltime 34.2%; part-time 6%; Post-transplant: Fulltime 38.1%; part-time 4.3%
|
7
|
Raiz 1997
|
U.S.
|
Cross sectional
|
180 with kidney transplant from one transplant center
|
n.a.
|
61.4%
|
> 19
|
53
|
Employed: Prior to kidney failure: 86%; Pre-transplant 53%; 1 year post-transplant: 58%
|
8
|
Sangalli 2014
|
U.S
|
Cross sectional
|
227 with kidney transplant; in working age; 6 months follow-up from two outpatient clinics
|
2007-9
|
67%
|
18–65
|
59
|
Post-transplant employed: 56.5%
|
4
|
Slakey 2007
|
U.S
|
cross sectional
|
70 at least 48 months after kidney transplant; questionnaire study
|
1998–2000
|
47.9%
|
20–75 (47)
|
51
|
Post-transplant employed or in school 28.6%
|
4
|
Tzvetanov 2014
|
U.S.
|
Cohort
|
94,511 with kidney failure (baseline); N = 71,976 post-transplant from the United Network for Organ sharing database
|
2004-11
|
n.r.
|
18–64
|
n.a.
|
Employed pre-transplant: 33% 1 year post-transplant 32.1%
|
6
|
van der Mei 2006
|
Netherlands
|
Cross sectional
|
239 with kidney transplant;
210 in working age
|
1996–2001
|
76.8%
|
19–71
(50.3)
|
n.a.
|
Employed:52.4%
|
5
|
van der Mei 2007
|
Netherlands
|
Cross sectional
|
61 (3-month post-transplant); 58 (1 year post-transplant)
|
2002-3
|
79%
|
18–64
(44.2)
|
52.5
|
Employed: Pre-dialysis: 72%;
1 year post-transplant: 52%;
|
5
|
van der Mei 2011
|
Netherlands
|
Cross sectional
|
34 (T3) from one outpatient clinic in paid employment at the time of transplant
|
2002-3
|
n.a.
|
18–64
(50.5)
|
55.9
|
Employed 6 year post-transplant: 67%
|
5
|
Whitlock 2017
|
U.S.
|
Cross sectional
|
325 from one kidney transplant center
|
2011-15
|
n.a.
|
(52.3)
|
60.9
|
Post-transplant employed 14.2%
|
5
|
n.a: not analyzed; n.r.: not relevant; yr: year |
General description of study participants
Dialysis patients were on average 52.6 (16–79) years old and kidney transplant patients 46.7 (18–78) years old. More than half of dialysis and kidney transplant patients were males, 60.3% and 59.8%, respectively.
Employment rate during dialysis, pre- and post-transplant
Before and during dialysis
The weighted mean for the employment rate during dialysis was 26.3% (range 10.5–59.7) in- and between continents as shown in Table 4. The employment rate was 21.6% in the 16 studies which excluded patients more than 65 years of age [14, 20, 22, 23, 25, 26, 29, 30, 33, 35, 39–42, 65, 66, 69].
In general, the employment rate decreased after initiation of dialysis. In 9 studies data before and after initiating dialysis were available [20, 24, 27, 31, 39, 40, 65, 67, 68]. In these studies, the change in the employment rate decreased 16.4% (weighted mean) ranging from a decrease of 5.2–58.5% in- and between countries. In a study from U.S. of 1,643 dialysis patients 36% were employed before dialysis and 11.6% after start of dialysis [27]. In a Japanese study, 63% were employed before dialysis and 49% after start of dialysis; 50.7% of HD-patients and 48% of PD-patients were employed [31].
Patients receiving peritoneal dialysis had a higher employment rate, 58.8% [14, 20, 28, 29, 31, 32, 34, 39, 41, 42, 66, 67] compared to patients in hemodialysis, 39.5% [14, 17–20, 22, 23, 29–34, 37, 39, 41, 42, 66–69].
Pre- and post-transplant
The employment rate pre-transplant was 36.9 % (weighted mean) ranging from 25 to 86% in-between continents. The post-transplant employment rate was 38.2% (weighted mean, all studies) ranging between 14.2% and 85% in- and between continents as shown in Table 4. The employment rate was 34.4% when only including the 18 studies of kidney transplant patients, which had excluded patients 65 years or more (not in working age) [3, 4, 12–14, 46, 48, 49, 52–55, 58, 60, 61, 63, 65, 66].
In 14 studies data pre- and post-transplant were available [4, 13, 44, 46, 47, 50, 55, 57, 60, 62, 65, 67, 68]. In these studies, the change in the employment rate pre- and post-transplant ranged from a decrease of 30% to an increase of 3,5% in- and between countries.
A Swiss study including 354 patients identified 32.9% working full-time one year before transplantation, 20.9% part-time and 11.9% part-time with part disability pension; in total, 65.7% were employed. One-year post-transplant 36.2% worked full-time, 19.5% part-time, and 10.6% part-time with part-time disability pension, in total 66.3% [13]. Another Swiss study found approximately the same relatively high rate of employment pre- and post-transplant [4]. In a cohort study performed in the U.S among 105,181 post-kidney transplant patients, 34.2% worked full-time, and 6% part-time pre-transplant. One year post-transplant, 38.1% worked full-time, and 4.3% part-time [56]. In another U.S study from 2014 among 27,981 kidney failure-patients in the working age (18–64 years) a total of 33% worked pre-transplant and 32.1% one-year post-transplant [60].
Predictors for employment during dialysis and post-transplant
During dialysis
Twelve studies had information of normative comparison data to use for meta-analysis of predictors for employment during dialysis and only for few of the predictors wanted: dialysis modality (peritoneal vs hemodialysis), diabetics vs non-diabetics, educational level (more than vs high school or less), and gender (male vs female) [4, 20, 22, 23, 27, 33, 34, 39, 40, 42, 55, 58]. Predictors for employment during dialysis was non-diabetics, educational level more than high school, peritoneal dialysis, and male. Heterogeneity was small for non-diabetics, moderate for educational level and substantial/high for peritoneal dialysis and gender as indicted by the I2 values, Table 5 and Fig. 2a-d (Supplementary).
Table 4.b. Employment Rate in Patients Pre-dialysis and During Dialysis, by Continent (Weighted Mean, Standard deviation, SD, and Range)
|
Continent
|
Pre-dialysis
|
|
|
During Dialysis
|
|
|
|
Weighted mean
(%)
|
SD
|
range
|
Weighted
mean
(%)
|
SD
|
range
|
Europe
|
57.1
|
16.7
|
28.0-65.3
|
45.8
|
12.3
|
17.1-59.7
|
North America
|
59.1
|
21.9
|
35.6-93.5
|
24.8
|
12.0
|
10.5-42.9
|
Other (Asia, South America, New Zealand)
|
63.0
|
|
|
41.4
|
14.3
|
11.1-52.8
|
Total
|
59.0
|
22.0
|
28.0-93.5
|
26.3
|
13.5
|
10.5-59.7
|
Table 4.b. Employment Rate in Patients Pre- and Post-kidney Transplantation, by Continent (Weighted Mean, SD, Range)
|
Continent
|
Pre-transplant
|
|
|
Post-transplant
|
|
|
|
Weighted mean
(%)
|
SD
|
range
|
Weighted
mean
(%)
|
SD
|
range
|
Europe
|
61.3
|
11.1
|
54.0-86.0
|
53.7
|
8.9
|
38.0-67.0
|
North America
|
36.0
|
21.2
|
33.0-85.6
|
36.3
|
9.7
|
14.2-58.0
|
Other (Asia)
|
25.0
|
|
|
53.8
|
27.6
|
26.0-85.0
|
Total
|
36.9
|
19.3
|
25.0-86.0
|
38.2
|
14.6
|
14.2-85.0
|
|
|
|
|
|
|
|
|
|
Table 5. Predictors for Employment During Dialysis and Post-transplant
|
|
|
|
|
Heterogeneity
|
Meta-analysis
|
DIALYSIS
|
Studies
|
Participants
|
Chi2
|
p
|
I2 (%)
|
OR
|
(95% CI)
|
Diabetes (non-diabetic/diabetic)
|
7
|
479
|
6.34
|
0.39
|
5%
|
1.68
|
(1.46, 1.93)
|
Education (>high school/<=high school)
|
6
|
1704
|
10.0
|
0.08
|
50%
|
2.57
|
(2.06, 3.21)
|
Dialysis type (peritoneal dialysis /hemodialysis)
|
6
|
6081
|
19.3
|
0.002
|
74%
|
2.24
|
(2.01, 2.51)
|
Gender (male/female)
|
6
|
215
|
128
|
<0.001
|
96%
|
4.09
|
(3.59, 4.67)
|
|
No of
|
|
Heterogeneity
|
Meta-analysis
|
POST TRANSPLANT
|
Studies
|
Participants
|
Chi2
|
p
|
I2 (%)
|
OR
|
(95% CI)
|
Gender (male/female)
|
12
|
253
|
13.1
|
0.29
|
16%
|
1.41
|
(1.19, 1.67)
|
Education (>high school/<=high school)
|
10
|
2139
|
11.9
|
0.22
|
24%
|
2.25
|
(1.85, 2.75)
|
Kidney donor (living donor /deceased donor)
|
10
|
2597
|
8.7
|
0.47
|
0%
|
2.74
|
(2.30, 3.27)
|
Pretransplant employed (employed/unemployed)
|
8
|
74408
|
26.8
|
<0.001
|
74%
|
13.63
|
(13.1, 14.2)
|
Diabetes (non-diabetic/diabetic)
|
8
|
3114
|
15.2
|
0.03
|
54%
|
1.62
|
(1.36, 1.92)
|
Ethnicity (white/other than white)
|
5
|
944
|
5.1
|
0.28
|
21%
|
1.95
|
(1.44, 2.64)
|
Age (<50 yr/>=50 yr)
|
5
|
1566
|
6.5
|
0.17
|
38%
|
2.29
|
(1.85, 2.84)
|
Dialysis type (peritoneal/hemodialysis)
|
4
|
749
|
2.7
|
0.45
|
0%
|
1.55
|
(1.02, 2.35)
|
Waiting time ( <2 yr/>=2 yr)
|
4
|
1226
|
0.2
|
0.98
|
0%
|
1.82
|
(1.37, 2.42)
|
Depression (no depression/depression)
|
3
|
1084
|
2.2
|
0.33
|
9%
|
2.24
|
(81.5, 3.27)
|
Dialysis duration (<2 yr/>=2 yr)
|
2
|
477
|
3.2
|
0.08
|
68%
|
3.82
|
(2.51, 5.83)
|
Post-transplant
Fifteen of the studies reporting employment rate post-transplant also had information of normative comparison data to use for a meta-analysis of predictors for employment post-transplant [3, 4, 12, 13, 44, 48–52, 55, 58–60, 63, 69]. There was only enough normative data for some of the wanted predictors: pre-employment, educational level, donor type, dialysis modality, diabetics, waiting time for transplant, time on dialysis, depression, gender, age, and ethnicity. The predictors for employment post-transplant with low heterogeneity was having a living donor, educational level more than high school, peritoneal dialysis, male, younger age, being white, waiting-time for transplant, and depression, and with moderate heterogeneity pre-transplant employment, non-diabetics, and shorter time in dialysis (< 2 years), Table 5 and Fig. 3a-k (Supplementary).
Assessment of quality of included studies
The studies addressing employment during dialysis were assessed as of low quality (n = 8; 24.2%) [18, 19, 36, 40, 43, 66, 67, 69] medium quality (n = 20; 60.6%) [17, 20, 22–30, 32–35, 37, 41, 42, 65, 68]; and high quality (n = 4; 12.1%) [14, 21, 31, 39].
According to The Newcastle-Ottawa criteria of assessment, studies of post-transplant employment were assessed of low quality (score 1–3) (n = 4; 12.9%) [45, 66, 67, 69]; medium (score 4–6) (n = 19; 61.3%) [46–55, 58–65, 68]; and high quality (score 7–9) (n = 8; 25.8%) [3, 4, 12–14, 44, 56, 57].
Many studies were cross-sectional single center studies, with a relatively small number of participants and self-reported patient data. Only 3 studies were prospective cohort studies [4, 40, 50]. When only including the high-quality studies in the analyses the employment for dialysis patients changed from 26.3% (weighted mean, all studies) to 25.2% (weighted mean, high quality studies). The post-transplant employment rate changed from 36.9% (weighted mean, all studies), to 42.5% (weighted mean, high quality studies). The quality assessment is shown in Supplementary Tables 6a-6d.