Journal of Psychosomatic Research 145 (2021) 110464

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Journal of Psychosomatic Research

journal homepage: www.elsevier.com/locate/jpsychores

Organ integration in kidney transplant patients – Results of a

KTx360◦ substudy
Khira Hennemann a, g, Maximilian Bauer-Hohmann a, g, Felix Klewitz a, g, Uwe Tegtbur b, g,
Lars Pape c, d, g, Lena Schiffer c, g, Mario Schiffer e, f, g, Martina de Zwaan a, g, Mariel Nöhre a, g, *
a
Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hannover, Germany
b
Department of Sports Medicine, Hannover Medical School, Hannover, Germany
c
Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
d
Department of Pediatrics II, University Hospital Essen, Essen, Germany
e
Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
f
Department of Nephrology and Hypertension, University Hospital Erlangen, Erlangen, Germany
g
Project Kidney Transplantation 360◦ (NTx360◦ ), Hannover Medical School, Hannover, Germany

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: Organ transplantation is the treatment of choice for patients with end-stage organ disease. From early
Coping on, the psychological perspective on integrating the organ has been of interest. As quantitative studies on organ
Kidney transplantation integration are scarce, we aimed at evaluating this aspect in a large sample of kidney transplant (KTx) recipients.
Organ integration
Methods: For this cross-sectional study, 684 patients after KTx were recruited within the structured post-
Renal transplantation
transplant care program KTx360◦ . To measure organ integration and donor relationship, a previously devel­
oped and published questionnaire (FOSP), generated explicitly for this purpose, was used. Associations with
sociodemographic, medical, donation-specific, and psychological variables were investigated.
Results: Overall, more than 90% of the patients perceived the transplant as part of themselves; however, a small
minority reported perceiving it as a foreign object. Frequent thoughts about the donor and the belief of having
adopted some of the donor’s traits were common (52% and 14%, respectively), specifically in living donor re­
cipients. Higher anxiety and depression scores and reduced kidney functioning were associated with less ideal
organ integration, while a more extended period since KTx and more perceived social support correlated with
better organ integration. No association between organ integration and adherence, as well as organ integration
and cognitive functioning, could be found.
Conclusion: Organ integration and donor relationship were unproblematic in most KTx patients. However, of­
fering psychosocial support to those struggling with organ integration and donor relationship is crucial from a
clinical perspective.

1. Introduction
In the preceding decades, organ transplantation has become the
treatment of choice for patients with end-stage organ disease. Early on,
psychological and psychoanalytical perspectives were of interest,
focusing on the recipient’s ability to adapt to and integrate the donated
organ, with most articles on organ integration being published at the
beginning of the era of organ transplantation [1–9]. To this day, the
topic is frequently addressed in mainstream media; however, qualitative
studies and case reports dominate the research field on organ
integration, and quantitative studies are scarce [8]. In 2009, Goetzmann
et al. [10] evaluated 76 lung transplant (LTx) recipients regarding organ
integration and donor relationship using a newly developed structured
questionnaire on organ integration and donor relationship (FOSP).
Overall, organ integration was good, with difficulties being reported
only by a small proportion of patients. Even though kidney transplant
(KTx) recipients represent the largest group of organ recipients, infor­
mation on organ integration in this group is limited. In 1999, Schlitt
et al. [11] compared attitudes of transplant patients concerning the
donated organ using self-developed questions. Overall only 1%

* Corresponding author at: Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover,
Germany.
E-mail address: noehre.mariel@mh-hannover.de (M. Nöhre).

https://doi.org/10.1016/j.jpsychores.2021.110464
Received 10 December 2020; Received in revised form 15 March 2021; Accepted 23 March 2021
Available online 25 March 2021
0022-3999/© 2021 Elsevier Inc. All rights reserved.
K. Hennemann et al. Journal of Psychosomatic Research 145 (2021) 110464

perceived the allograft as a “foreign body”; however, KTx patients Table 1

perceived the donated kidney significantly more often as a foreign organ Descriptive statistics of the FOSP items (N = 684).
compared to liver, lung, and heart transplant recipients. FOSP-Items Mean Median Frequency
Previous studies suggest that poor organ integration might lead to (SD) (IQR)
(totally) unsure, (totally)
relevant psychological conflicts [11], while the successful integration of incorrect, n (%) correct, n
the donated organ is associated with psychosocial wellbeing [10]. n (%) (%)
Goetzmann et al. [10] found that a very close relationship to the post- The transplanted 4.6 5.0 (1.0) 6 (0.9%) 24 654
mortal donor correlated with higher levels of stress and worries. At kidney became a (0.6) (3.5%) (95.6%)
the same time good organ integration was associated with better part of myself
adherence to the immunosuppressive medication [10]. High adherence I perceive the graft 1.4 1.0 (1.0) 640 19 25
as a foreign object (0.8) (93.6%) (2.8%) (3.6%)
to the immunosuppressive medication (ISM) is important to prevent
in myself
organ rejection. Non-adherence is common in organ transplant re­ I often think of the 3.2 4.0 (2.0) 251 75 358
cipients and affects between 28% and 52% of the KTx patients [12–14]. donor (1.4) (36.7%) (11.0%) (52.3%)
Therefore, recognizing non-adherence and factors associated with non- The events 3.6 4.0 (3.0) 182 57 445
adherent behavior is of great importance. accompanying (1.3) (26.6%) (8.3%) (65.1%)
transplantation
Our study aimed at evaluating organ integration and donor rela­ don’t matter to
tionship in a large sample of German KTx patients using the only me today
available questionnaire (FOSP) [10]. Additionally, we investigated as­ Sometimes I have 1.9 1.0 (2.0) 493 98 93
sociations between organ integration and donor relationship and soci­ the impression (1.2) (72.1%) (14.3%) (13.6%)
that I adopted
odemographic, medical, donation-specific, and psychological variables.
some of the
donor’s traits
2. Methods
The response options “totally incorrect” and “incorrect” as well as “totally cor­
rect” and “correct” were combined in this table.
2.1. Participants
FOSP = Questionnaire on Organ Integration and Donor Relationship, IQR =
interquartile range, SD = standard deviation.
The participants were recruited within the structured post-transplant
care program KTx360◦ [15] that included patients who underwent KTx
their ratings. Cronbach’s α in our sample was 0.643.
at two kidney transplantation centers. Participants of this substudy had
to be at least 16 years of age and capable of filling out the question­
2.1.4. Cognitive functioning
naires.Of the first 726 consecutive KTx patients included in the KTX360◦
Cognitive functioning was evaluated with the DemTect, a brief and
trial between May 2017 and July 2019, a total of 684 (94.2%) fit the
sensitive screening instrument for mild cognitive impairment [23]. It
inclusion criteria and completed the FOSP. Comparing participants and
consists of five tasks: a word list, a number transcoding task, a word
non-participants, non-participants were significantly older, but we
fluency task, digit span reverse, and delayed recall of the word list. The
found no differences regarding sex, donation type and educational level
performance lasts 8 to 10 min. A maximum score of 18 can be reached. A
(data not shown).The Institutional Ethics Review Board of Hannover
score of 13 to 18 corresponds to an age-adequate cognitive performance,
Medical School approved the study (Number 3464–2017). All partici­
a score of 9 to 12 corresponds to mild cognitive impairment, and a score
pants gave written informed consent.
of 8 or below raises the suspicion of the presence of dementia. There are
different cut-offs for score transformation for participants younger than
2.1.1. Organ integration
60 years, and for those who are 60 years or older to control for age
Organ integration and donor relationship were evaluated using the
effects.
questionnaire developed by Goetzmann et al. (FOSP) [10,16]. The five
items can be found in Table 1. They focus on different dimensions,
2.1.5. Perceived social support
including the degree of organ integration (“organ as a foreign object or
The German F-SozU K7 is a self-report instrument to measure prac­
part of the self”), being preoccupied with the donor (“thoughts of the
tical support, emotional support, and social integration to give infor­
donor and adoption of donor’s traits”), and being preoccupied with events
mation on general perceived social support [24,25]. A total score
accompanying the transplantation (“current perceived importance of
between 7 and 35 can be reached, with higher scores indicating higher
transplant events”) [10]. The items are rated on a 5-point Likert scale,
perceived social support. In our sample, Cronbach’s α was 0.90.
ranging from 1 (“totally incorrect”) to 5 (“totally correct”). The calcu­
lation of a sum score is not recommended.
2.1.6. Sociodemographic and donation-specific variables
Sociodemographic and donation-specific variables, including sex,
2.1.2. Symptoms of depression and anxiety
age, educational level, donation type, time on dialysis and time since
Anxiety and depression were evaluated using the German version of
KTx, were assessed using a self-report questionnaire. The estimated
the Hospital Anxiety and Depression Scale (HADS) [17,18]. The ques­
glomerular filtration rate (eGFR) and missing information were
tionnaire comprises two subscales, “depression” and “anxiety,” con­
collected from the medical records.
sisting of seven items each, yielding a total score between 0 and 21.
Higher scores indicate higher levels of depression or anxiety. Cronbach’s
α in our sample was 0.86 for depression and 0.82 for anxiety. 2.2. Statistics

2.1.3. Adherence
The measure adherence to the immunosuppressive medication the
German version of the Medication Adherence Rating Scale (MARS-D)
was used [19,20]. The five-item self-report instrument is rated on a five-
point Likert scale [19], with the total score ranging from 5 to 25. Higher
scores are indicative for higher adherence. Patients were considered to
be non-adherent if they scored below 25 [21,22]. For this study, patients
were asked to exclusively consider immunosuppressive medication in
Questionnaire scores were calculated for the entire sample. For each
variable descriptive statistic (percentage or mean and standard devia­
tion or median and interquartile range) was determined. Spearman
correlations were calculated between FOSP items and continuous vari­
ables. Mann-Whitney U tests were used for comparison of FOSP items
between two groups. For all analyses, p < .05 was considered statisti­
cally significant. All statistical analyses were performed using IBM®
Statistical Software Package of Social Science (SPSS®, Chicago, IL, USA)

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K. Hennemann et al. Journal of Psychosomatic Research 145 (2021) 110464

version 26.
3. Results
3.1. Sample characteristics
This study included 684 participants, 283 women (41.4%) and 401
men (58.6%). The mean age was 52.3 years (SD 14.3). Twenty six %
reported a school attendance of 12 years or more. Regarding donation
type, 29.5% of the participants had received their kidneys from a living
donor. Mean time since transplantation was 65.2 months (SD 68.5) and
the mean time on dialysis was 61.3 months (SD 49.7). Time on dialysis
differed statistically significantly between recipients of a living donation
and a post-mortal organ donation (23.2 vs. 77.3 months, Z = -13.5, p ≤
.001). The mean eGFR was 45.8 ml/min/1.73 m2. The mean value
reached on the anxiety scale of the HADS was 5.1 (SD 3.9) and on the
depression scale 4.4 (SD 4.0). Regarding adherence, 40.1% (270) par­
ticipants reported non-adherent behavior defined by a MARS-D score <
25. One hundred and two participants (15.8%) reached a DemTect score
below 13, suggesting at least mild cognitive impairment.
3.2. Results of the FOSP
The means of the five FOSP items and the categorical responses can
be found in Table 1. Regarding organ integration, the vast majority (>
90%) reported that the kidney became part of themselves; however,
3.6% perceived the graft as a foreign object. Additionally, 52.3% re­
ported to often think about the donor, and 13.6% believed that they
might have adopted some of the donor’s traits, and an additional 14.3%
were unsure about it. Concerning the transplantation events, 26.6%
were still preoccupied with the earlier transplantation events.
Spearman correlations between FOSP subscales and other variables
are reported in Table 2. Overall, the correlation coefficients - even
though statistically significant - were small. Higher anxiety scores
correlated significantly with lower organ integration scores, with
thinking more about the donor, with a more pronounced impression to
have adopted donor’s traits, and with more preoccupation with trans­
plant events. Correlations with the depression scale faced in the same
direction. Lower organ integration was also associated with lower kid­
ney functioning (eGFR). Both higher perceived social support and longer
time since transplantation were associated with better organ integration
and a lower probability of being occupied with the transplantation
events. Time on dialysis was correlated with different items of the FOSP
as well, however direction of the correlation differed between items.
When calculating correlations between the FOSP items and time on
dialysis within the subgroups (patients having received a living donation
and patients having received a post-mortal organ donation), only one
statistically significant, but small correlation remains with FOSP item 3
(“I often think of the donor”) in the group of patients after post-mortal
organ donation (r = − 0.10).
Comparisons of the FOSP items between dichotomous variables
using Mann-Whitney-U Tests are reported in Table 3. The most pro­
nounced differences in the items on organ integration and relationship
to the donor were found between living donor and post-mortal donor
recipients with patients after living donation exhibiting slightly better
organ integration and significant and large differences with regard to
thinking about the donor and adopting some of the donor’s traits. Sex,
age at assessment, adherence, cognitive functioning and educational
level did not show a strong association with the FOSP items.
4. Discussion
Overall, most patients in our sample of KTx recipients perceived the
transplant as part of themselves, but a minority (4%) reported diffi­
culties adapting to the allograft. This is in line with the findings of others
[10,11], showing the patients’ propensity for adaptation. The percent­
age of patients who perceived the transplant as a foreign object should
not be ignored, particularly since we found a weak but significant as­
sociation between lower organ integration scores and higher levels of
anxiety and depression as well as a lower kidney function underlining
the clinical importance. Even though the cross-sectional design does not
allow causal interpretation, this might be seen as a hint that patients
with more psychopathology, less perceived social support, and reduced
transplant function might have more difficulties to perceive the trans­
plant as part of their body. Alternatively, failed organ integration may
increase the risk of developing psychological problems. A longer time
since transplantation was associated with better organ integration. This
result corresponds to early descriptions of a long-term step-by-step
process of organ integration with an initial “foreign body stage” fol­
lowed by a “stage of partial incorporation” and finally by a “stage of
complete integration” [3,26,27]. Interestingly, associations between age
and sex and organ integration were of little relevance in our sample.
More than 50% of the KTx patients in our sample reported to often
think about the donor. In patients receiving a post-mortal organ

Table 2
Spearman correlations between FOSP subscales and variables.
FOSP-Item HADS HADS F-SozU (perceived Age Time since eGFR Time on dialysis
anxiety scale depression scale social support) transplantation (months) (months)

N = 672 N = 673 N = 665 N= N = 684 N= N = 673

684 675

The transplanted kidney became a part of r = − 0.24 r = − 0.26 r =0.25 r= r = 0.18 r = 0.09 r = − 0.10
myself − 0.04
p < .001 p < .001 p < .001 p = .26 p < .001 p= p = .007
.023
I perceive the graft as a foreign object in r = 0.22 r = 0.25 r = − 0.21 r= r = − 0.17 r= r = 0.05
myself − 0.05 − 0.10
p < .001 p < .001 p < .001 p = .16 p < .001 p¼ p = .175
.011
I often think of the donor r = 0.10 r = − 0.002 r = 0.004 r = 0.04 r = 0.08 r = 0.05 r = − 0.29
p = .008 p = .96 p = .92 p = .29 p = .027 p = .22 p < .001
The events accompanying transplantation r = − 0.24 r = − 0.20 r = 0.13 r = 0.10 r = 0.20 r = 0.02 r = − 0.07
don’t matter to me today p < .001 p < .001 p ¼ .001 p¼ p < .001 p= .59 p = .092
.013
Sometimes I have the impression that I r = 0.15 r = 0.09 r = − 0.10 r= r = − 0.01 r = 0.02 r = − 0.10
adopted some of the donor’s traits − 0.14
p < .001 p ¼ .015 p ¼ .01 p< p = .71 p = .63 p = .008
.001

FOSP = Questionnaire on Organ Integration and Donor Relationship, HADS = Hospital Anxiety and Depression Scale, F-SozU = Questionnaire on Perceived Social
Support, eGFR = estimated glomerular filtration rate; statistically significant results (p < .05) are reported in bold print.

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K. Hennemann et al. Journal of Psychosomatic Research 145 (2021) 110464

Table 3
Comparisons of FOSP items between dichotomous variables using Mann-Whitney-U Tests.
FOSP-Items Sex Donation type Years of school Adherence Cognitive functioning
attendance

Male Female Living Deceased <12 ≥12 Adherent Nonadherent DemTect ≥ DemTect <
years years 13 13

N= N= N= N = 482 N = 501 N= N = 404 N = 270 N = 544 N = 102

401 283 202 178

The transplanted kidney became a part of myself

Mean (SD) 4.6 4.7 4.7 4.6 (0.6) 4.6 4.7 4.7 (0.6) 4.6 (0.7) 4.6 (0.6) 4.5 (0.8)
(0.7) (0.6) (0.6) (0.6) (0.6)
Median (IQR) 5.0 5.0 5.0 5.0 (1.0) 5.0 5.0 5.0 (1.0) 5.0 (1.0) 5.0 (1.0) 5.0 (1.0)
(1.0) (1.0) (0.0) (1.0) (1.0)
Mann-Whitney-U Test Z = -1.03, p = .30 Z ¼ -2.68, p ¼ .007 Z = -1.03, p = .30 Z = -1.48, p = .14 Z = -1.0, p = .30
I perceive the graft as a foreign object in myself,
Mean (SD) 1.4 1.3 1.3 1.4 (0.8) 1.4 1.4 1.4 (0.8) 1.4 (0.7) 1.3 (0.7) 1.6 (1.0)
(0.8) (0.7) (0.7) (0.8) (0.7)
Median (IQR) 1.0 1.0 1.0 1.0 (1.0) 1.0 1.0 1.0 (1.0) 1.0 (1.0) 1.0 (1.0) 1.0 (1.0)
(1.0) (1.0) (0.0) (1.0) (1.0)
Mann-Whitney-U Test Z = -0.98, p = .33 Z ¼ -2.07, >p> ¼ Z = -1.71, p = .48 Z = -1.46, p = .14 Z ¼ -2.07, >p> ¼ .04
.039
I often think of the donor
Mean (SD) 3.1 3.3 4.1 2.8 (1.3) 3.2 3.2 3.1 (1.4) 3.3 (1.4) 3.2 (1.4) 3.2 (1.4)
(1.5) (1.3) (1.2) (1.4) (1.4)
Median (IQR) 3.0 4.0 4.0 3.0 (2.0) 4.0 4.0 4.0 (2.0) 4.0 (2.0) 4.0 (2.0) 4.0 (2.0)
(2.0) (2.0) (1.0) (2.0) (2.0)
Mann-Whitney-U Test Z ¼ -2.09, p ¼ Z ¼ -11.05, p < Z = -0.59, p = .56 Z = -1.44, p = .15 Z = -0.20, p = .84
.036 .001
The events accompanying transplantation don’t
matter to me today
Mean (SD) 3.6 3.5 3.7 3.5 (1.3) 3.6 3.6 3.5 (1.3) 3.6 (1.2) 3.6 (1.3) 3.5 (1.3)
(1.3) (1.3) (1.3) (1.3) (1.3)
Median (IQR) 4.0 4.0 4.0 4.0 (2.3) 4.0 4.0 4.0 (3.0) 4.0 (2.0) 4.0 (3.0) 4.0 (3.0)
(3.0) (3.0) (2.0) (3.0) (3.0)
Mann-Whitney-U Test Z = -0.973, p = .33 Z = -1.38, p = .17 Z = -0.21, p = .83 Z = -0.86, p = .39 Z = -0.77, p = .44
Sometimes I have the impression that I adopted
some of the donor’s traits
Mean (SD) 1.9 2.0 2.3 1.8 (1.1) 1.9 1.9 1.9 (1.2) 2.0 (1.2) 1.9 (1.2) 1.9 (1.2)
(1.2) (1.2) (1.3) (1.2) (1.2)
Median (IQR) 1.0 1.0 2.0 1.0 (1.0) 1.0 1.0 1.0 (1.8) 2.0 (2.0) 1.0 (2.0) 2.0 (2.0)
(2.0) (2.0) (2.0) (2.0) (2.0)
Mann-Whitney-U Test Z = -1.62, p = .10 Z ¼ -4.92, p < .001 Z = -0.18, p = .86 Z = -1.77, p = .08 Z = -0.74, p = .46

IQR = interquartile range, SD = standard deviation.

statistically significant results (p < .05) are reported in bold print

donation frequent thoughts about the donor are seen as a sign of poor
organ integration [10]. However, it is important to keep in mind that
29.5% of the participants of our study had received their kidneys from a
living donor. Therefore, frequent thoughts about the donor are not
surprising and should be interpreted with caution, especially as we are
unaware of the nature of the thoughts regarding the donor. Additionally,
13.6% believed that they might have adopted some of the donor’s traits,
and an additional 14.3% were unsure about it. While recipients’ con­
cerns about possible personality changes caused by the graft are not
unheard of [5,8,11,28], the percentage was higher in our KTx sample
compared, e.g., to LTx patients (7.9%; [10]). This is most likely due to
differences in the response behavior between living (30%) and post-
mortal donation recipients. In Germany, for living organ donation, a
close relationship between donor and recipient is mandatory, and do­
nors are predominantly first degree relatives or partners. Therefore, an
identification with the donor appears conceivable, especially as the
literature suggests that a positive donor-recipient relationship before
and after living kidney donation seems to be common [29,30]. The new
organ might serve as an object for projection [26]. Ott et al. [31] sug­
gested that a close emotional relationship with the donor might even
support organ integration in living kidney donation. This outcome is in
line with our results, as we also found slightly better organ integration in
living donor recipients.
Concerning time on dialysis, there is some evidence that in this study
the associations are predominantly explained by the differences between
recipients of a living donation and a post-mortal organ donation.
Our KTx patients seemed to be less preoccupied with the events
accompanying the transplantation than LTx patients (47.4%, [10]). We
can only speculate on the reasons. LTx is undoubtedly a more risky
operation with a higher complication rate compared to KTx [32,33]. We
found a positive association between more preoccupation and higher
anxiety and depression scores as well as negative associations with
perceived social support, age, and time since transplantation. Goetz­
mann et al. [34] found that transplantations that are experienced as
particularly stressful are associated with reduced quality of life over
time. Also, social support is often seen as a stabilizing and protective
factor for negative sequelae of stressful experiences [35]. In summary,
ongoing preoccupation with the events accompanying the trans­
plantation should be taken seriously and addressed adequately.
Interestingly and in contrats to previous research [10], we found no
association between adherence and organ integration. However, we
recommend assessing adherence in individuals struggling with organ
integration, due to the possible serious adverse effects of non-adherent
behavior.
Regarding cognitive functioning, only in one item of the FOSP a
statistically significant difference could be found, suggesting that pa­
tients with cognitive impairment slightly more often perceive the
donated organ as a foreign object. This finding has to be interpreted with
caution as cognitive functioning is only impaired in a small proportion of
patients, comparable to a different substudy of the KTx360◦ trial [36].
To our knowledge, there is no information available on whether and
how cognitive impairment affects the process of organ integration.

4
K. Hennemann et al.
However, it can be hypothesized that impaired cognitive functioning
might extend the process of organ integration. Further research on this
aspect seems necessary.
Addressing the limitations, only correlates can be described due to
the cross-sectional study design, thus not allowing causal in­
terpretations. Furthermore, the effects found in our study were rela­
tively small. Regarding the FOSP, Goetzmann et al. [10] emphasize that
it is not a validated questionnaire; however, it is the only standardized
instrument available to our knowledge. Further research on organ
integration especially in the form of longitudinal, prospective studies
seems necessary to explore possible causal relationships between organ
integration and psychosocial risk factors. To better understand the
process of organ integration, frequent evaluations should be performed
particularly in the first weeks following transplantation based on the
assumption that the process of integration might occur rapidly as sug­
gested by Schlitt et al. [11].
In our large sample of KTx patients, we could confirm that organ
integration and donor relationship is mostly unproblematic. Difficult
organ integration was associated with mental stress, e.g. higher anxiety
and depression scores. Due to the cross-sectional design of our study, no
assumptions regarding cause and effect can be made. However, from a
clinical perspective, identifying difficulties with these aspects and of­
fering psychosocial support to KTx patients struggling with organ inte­
gration is necessary, particularly to be able to address and overcome
mental stress and potentially adverse outcomes associated with poor
organ integration, including non-adherent behavior.
Statement of ethics
The studies involving human participants were reviewed and
approved by the Institutional Ethics Review Board of Hannover Medical
School (Number 3464–2017). Written informed consent to participate in
this study was provided by the participant. All subjects gave written
informed consent in accordance with the Declaration of Helsinki.
Author contributions
LP, MS, MZ, and UT designed the KTx360◦ trial and obtained
research funding. MZ and MN designed this substudy. LS was essential in
the recruitment process of the study. MN, FK and MB-H collected the
data. KH was responsible for data entry. MN, MZ and KH analyzed the
data. MN wrote the first draft of this paper. All authors critically revised
the manuscript and read and approved the final version.
Declaration of Competing Interest
The authors have no conflicts of interest to declare.
Acknowledgement
We thank Eva-Marie Kyaw Tha Tun for her part in data collection and
Melanie Hartleib-Otto and Raoul Gertges for their management support.
Additionally, we thank the Department of General Practice and Health
Services Research and Department of Internal Medicine VI, Clinical
Pharmacology and Pharmacoepidemiology, University Hospital Hei­
delberg, Heidelberg, Germany for providing the translation of the
MARS-D. This work has been supported in part by the Ellen Schmidt
Habilitation Program of Hannover Medical School for Mariel Nöhre
The study is supported by a grant from the Federal Joint Committee
of the Federal Republic of Germany under the number 01NVF16009.
The funding source was not involved in the study design, in the collec­
tion, analysis and interpretation of data, in the writing of the report, and
in the decision to submit the article for publication.
5
Journal of Psychosomatic Research 145 (2021) 110464
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