The global incidence of end-stage renal disease (ESRD) is rising due to an aging population, the growing prevalence of chronic illnesses (e.g., diabetes mellitus [DM] and hypertension), increased consumption of processed foods, and various environmental factors (e.g., air pollution) [[1], [2], [3]]. In 2020, Taiwan, China had the world's highest ESRD incidence, affecting 525 individuals per million, while South Korea ranked fourth with a rate of 355 individuals per million [4].

ESRD, a condition characterized by diminished renal function, necessitates one of three treatments: hemodialysis, peritoneal dialysis, or kidney transplantation (KT). KT is identified as the most efficacious treatment for ESRD, enhancing both lifespan and quality of life (QOL) [[5], [6], [7], [8], [9]]. Preemptive kidney transplantation (PKT), where the transplant occurs before the initiation of dialysis, is considered advantageous in several aspects [10]. By avoiding the onset of dialysis, PKT not only eliminates the complications and costs associated with dialysis but also has been shown to contribute to improved clinical outcomes, including lower rates of graft rejection and enhanced long-term patient survival [[11], [12], [13]]. This approach accounts for 30 % of KT surgeries worldwide [14].

Although PKT is widely considered advantageous, the clinical and psychological experiences of PKT and non-preemptive kidney transplantation (NPKT) patients differ substantially, warranting further investigation into how these differences may impact patient outcomes.

KT necessitates complex self-care requirements to minimize the risk of transplant rejection and other post-transplantation complications [15,16]. Essential self-care practices for KT recipients include accurate administration of immunosuppressants, infection prevention, and early detection, transplant rejection identification, dietary management, balancing activity with rest, and regulating body weight and blood pressure [14]. Noncompliance with these practices leads to a 1.5-fold and 65 % higher risk of transplant rejection and KT failure, respectively [17]. Patient outcomes underscore the significance of self-care, leading to concerted efforts to raise awareness and promote self-care compliance among KT recipients [[18], [19], [20], [21], [22]]. However, roughly 30–50 % of these patients do not strictly adhere to their immunosuppressant regimens, largely due to a knowledge gap regarding their benefits [[23], [24], [25], [26]]. This suggests that KT patients may find self-care daunting, highlighting the continued need for initiatives to boost self-care practices.

Studies on self-care predictors in KT patients have identified several key factors: post-transplantation durations, comprehension of health-related information, support from healthcare professionals and family, as well as stress and depression [[27], [28], [29], [30], [31]]. Notably, the psychological impact of stress and the social dynamics of support play pivotal roles in the self-care behaviors of transplant recipients. Stress manifests as a multifactorial symptom in these patients, stemming from a complex interplay of physical problems—such as cardiovascular disease, cancer, DM, osteoporosis, infections, and weight gain due to long-term immunosuppressant use—and psychological factors, including fear of rejection, resumption of dialysis, and uncertainties about the future [8,[32], [33], [34], [35]]. The degree of perceived stress is significantly correlated with adopting health-promoting behaviors. A heightened level of stress negatively impacts self-care [29,36]; however, a moderate stress level can catalyze patients [37], fostering self-regulation and resilience in self-care, thereby aiding their treatment [38]. It is necessary to closely scrutinize the stress levels in KT patients and further investigate the potential impact of stress on their self-care behaviors.

Moreover, social support from family and healthcare providers is vital components in fostering effective self-care among KT recipients. Recent advancements in community healthcare and the continuation of nursing care have highlighted the crucial role of social support in this patient group [39]. It is widely accepted that health outcomes strongly correlate with the extent of social support; enhanced support generally leads to improved health [40,41]. In the context of KT recipients, the emphasis on self-care is critical to ensuring the transplanted organ's functionality and preventing rejection [17]. Accordingly, social support is pivotal in bolstering these self-care routines [41]. Key sources of this support are family members and healthcare professionals, who encourage patient adherence to self-care practices and create an optimal environment for such care [31,42]. Therefore, it is essential to examine the degree of social support KT patients receive and determine its potential impact on their adherence to self-care regimens.

Patients receiving PKT who do not require pre-transplant dialysis may have a different perception of KT than those receiving non-preemptive kidney transplantation (NPKT). PKT recipients often perceive kidney failure as an acute rather than a chronic condition, with their disease trajectory shortened by the absence of dialysis [43,44]. In contrast, NPKT patients endure a longer and more complex pre-transplant pathway, marked by the physical and emotional challenges of dialysis [45,46]. These differing experiences may influence not only the patients' perceptions of their illness but also their approach to post-transplant care, including adherence to medical regimens and lifestyle modifications.

Furthermore, the literature presents a degree of controversy regarding which group demonstrates better post-transplant outcomes [[47], [48], [49]]. Some studies suggest that PKT patients exhibit better clinical outcomes and higher adherence to post-transplant care, likely due to the greater prevalence of factors commonly associated with better adherence, such as higher socioeconomic status and educational attainment, among those who receive preemptive transplantation [[50], [51], [52]]. However, other research posits that the experience of dialysis may prompt NPKT patients to be more diligent in their self-care, as they are more acutely aware of the consequences of non-adherence [53]. Given this controversy, it is critical to examine the predictors that may influence self-care and other patient outcomes in PKT and NPKT recipients. Therefore, this study aimed to identify predictors of self-care with a focus on preoperative dialysis to establish a foundation for developing improved nursing interventions and educational programs for transplant patients.

This study aimed to explore the general and disease-specific characteristics, stress levels, social support, and self-care among PKT and NPKT groups, as well as identify predictors of self-care, thereby proposing strategies to enhance self-care in KT patients and providing evidence for the development of efficacious nursing interventions to improve QOL.

In our study cohort, the average age was 51.22 ± 11.59 years, with 24.9 % aged 60 or above. This highlights the current trend of an increasing number of older patients undergoing KT. The 2019 Annual Statistics report from the Korea Network for Organ Sharing indicated a significant increase of 179.2 % in organ transplants in patients aged 65 or above, from 250 cases in 2015 to 448 in 2019. Similarly, the 2021 Annual Data Report from the United States Renal Data System demonstrated a consistent rise in KT among older adults aged 65 and over (5,095 in 2019) [4]. KT is no longer seen as contraindicated in older age groups, with survival rates, QOL improvement, and financial benefits comparable to those of younger recipients [[58], [59], [60], [61]]. Considering that older patients frequently present with comorbidities, personalized treatment, and management support are essential [[62], [63], [64]]. Additionally, older adults often have ingrained lifestyle habits that can affect adherence to self-care protocols [65]. As such, to promote self-care adherence among older adults, healthcare providers must account for these patients' personal, socioeconomic, and environmental characteristics and understand their specific self-care needs in a manner that respects their autonomy. Moreover, providing tailored educational interventions suitable for older adults is crucial to guiding them toward effective self-care rather than adhering to potentially harmful lifestyle habits.

Significant disparities were observed between the PKT and NPKT groups regarding monthly income, number of cohabiting family members, donor type, ABO compatibility, and surgery motivation. Approximately half (49.5 %) of the PKT group reported a monthly income of 5.01 million KRW or above. In contrast, a slightly lower percentage (48.1 %) of the NPKT group reported an income within the 2.01–4.99 million KRW range.

While there was no statistically significant difference in employment status between the PKT and NPKT groups (p = .407), the income disparity may still be partially related to employment patterns. Previous research indicates that employment is more prevalent among PKT recipients, potentially due to the shorter recovery time and reduced dialysis-related fatigue, which enhances their ability to maintain stable employment [[66], [67], [68]].

In addition to employment status, donor type and ABO compatibility likely contributed to income differences between the groups. The PKT group predominantly received organs from living donors (99.0 %), bore the full costs associated with surgery and subsequent treatment. Furthermore, ABO incompatible transplantations necessitate additional preoperative therapeutic plasma exchange and immunosuppressant therapy, which results in longer hospital stays and increased expenses [69]. These factors may contribute to the higher proportion of high-income patients in the PKT group, where the rates of living donor and ABO-incompatible transplantations were also greater.

However, it is important to recognize that other factors, such as educational level, health status, and the presence of comorbidities, may also influence income and employment outcomes in kidney transplant patients. Research shows that younger age, better health, and the absence of comorbidities are significant predictors of sustained employment among kidney transplant recipients [68,70]. Further exploration into these factors could provide a more comprehensive understanding of the financial disparities between PKT and NPKT groups.

In terms of donor type, a significant portion (41.6 %) of the PKT group received an organ from their spouse, compared to a much smaller percentage (15.7 %) in the NPKT group, where more than half (54.6 %) received organs from deceased donors. The spousal relationship likely affects the level of emotional and practical support available post-transplant. This dynamic, where the spouse may act as both caregiver and donor, requires further investigation to determine how it impacts self-care behaviors. The increased of spousal donors can be attributed, in part, to the rise of ABO-incompatible transplantations, which has allowed for greater flexibility in matching [71]. Furthermore, “family persuasion” was cited as the main motivation for surgery by roughly 39.6 % of PKT patients. Particularly in spousal transplantation scenarios, the donating spouse often becomes a significant advocate for the transplant [71], reinforcing previous findings suggesting that the degree of intimacy between donor and recipient is a crucial factor in deciding to undergo KT [72].

Examining the comparison of major study variables scores between the PKT and NPKT cohorts, PKT group demonstrated greater levels of family support (53.77 ± 6.09 out of 60) compared to their NPKT counterparts (48.96 ± 10.65 out of 60). The median wait time for transplantation in the United States stood at 4 years in 2011 [73], with approximately 18 % of patients experiencing a wait of 5 years or more by 2016. A similar trend was observed in Korea, with the average waiting time reaching 5 years in 2013 [74]. This study noted an average dialysis duration of 5 years or more for NPKT group. Yun and Lee's [75] research supports the premise that family support diminishes when dialysis extends beyond 5 years. Thus, these observations substantiate the hypothesis that prolonged dialysis induces alterations in family dynamics [76], and the degree of family support tends to diminish with an increase in dialysis duration [75].

Concerning the variations in self-care regarding general and disease-specific characteristics, it was noted that female patients attained better self-care than male patients. This aligns with numerous studies that reveal females exhibit superior levels of self-care knowledge and practice than males, and our findings corroborate this conclusion [[77], [78], [79], [80]]. The observed discrepancy may be linked to men's higher engagement in social activities, such as employment, which may impede their adherence to self-care protocols.

Considering the predictors of self-care relative to preoperative dialysis status, marital status, and family support, they emerged as predictors explaining 20.7 % of the variance in the PKT group. Conversely, marital status, employment status, post-transplantation duration, and stress level were identified as predictors accounting for 24.6 % of the variance in the NPKT group. However, several other potential factors may account for the remaining variance observed but were not the focus of this study. These could include variables such as the patient's level of health literacy, access to post-transplant care, psychological resilience, and the presence of comorbid conditions. Future research should explore these additional factors to provide a more comprehensive understanding of the predictors influencing self-care in kidney transplant patients.

Within the PKT cohort, a significant predictor of self-care was observed family support, demonstrating that elevated family support resulted in improved self-care adherence. This observation corroborates prior research, emphasizing family support's influential role in enhancing health behavior compliance among pre-dialysis patients with chronic kidney failure [81]. Enhanced family support bolsters a positive perception of health status, subsequently fostering adherence to self-care [82]. Unlike NPKT patients, who consistently received support from their families during the dialysis period before transplantation, PKT patients received support from their families after transplantation, and it is thought that they greatly valued the role of their families in post-transplant self-care. Despite these findings, it remains challenging to discern which specific aspects of family support—be it emotional expressions of love, assistance with lifestyle habits such as dietary and medication adherence, financial support, or the general presence and emotional involvement of family members—most significantly impact self-care practices. Consequently, we recommend further research that explicitly categorizes and measures the various dimensions of family support. Such studies should aim to distinguish the differential effects of these support types on patient outcomes, thus enabling a more nuanced understanding of how family dynamics contribute to the health management of transplant recipients.

In the NPKT cohort, employment status emerged as a significant predictor of self-care, with unemployed patients exhibiting increased self-care adherence. The unique experiences of NPKT patients who underwent extended dialysis before transplant, regardless of gender, limited their social engagement. As these patients reintegrated into social activities, including employment, the physical burdens and fatigue they incurred presumably negatively impacted their self-care adherence. These findings align with earlier studies positing difficulties in resuming work post-transplant, with challenges escalating with longer preoperative dialysis durations [[83], [84], [85]]. Therefore, it is imperative to develop effective interventions assisting NPKT patients in self-care, coupled with institutional and policy support promoting post-transplant societal and occupational reintegration. Interestingly, other studies propose a positive correlation between employment and self-care [86,87], indicating a need for further research to elucidate this complex relationship.

For NPKT group, it is crucial to consider the post-KT to improve self-care. Our findings reveal improved self-care engagement in the early post-transplantation stages, a trend similarly observed, albeit insignificantly, in PKT group. This reflects previous studies indicating a decline in treatment adherence as time since transplantation increases [27,86,88,89]. Bae and Kim [27] further elucidated that self-care compliance areas decline variably with time post-transplantation. Similarly, Noh and Park [19] highlighted evolving unmet postoperative needs over time post-KT, advocating for time-conscious nursing interventions to foster self-care in KT patients. Therefore, it is imperative to pinpoint factors contributing to declining self-care over time in both NPKT and PKT cohorts and to develop nursing intervention protocols to augment self-care.

In addition, NPKT group exhibiting high-stress levels exhibited poorer self-care. Dialysis patients bear significant stress, primarily due to dietary restrictions, the continual treatment burden, and future uncertainties [90]. While NPKT patients experience fewer restrictions post-KT, they still grapple with dietary constraints, prolonged immunosuppressive medication usage, concerns over potential immunosuppressive side effects, fear of graft loss, and future uncertainties [91]. These persistent stressors manifest as physical and psychological symptoms, hindering the treatment journey [92] and serving as barriers to self-care. Hence, identifying major stressors for NPKT patients and devising effective nursing strategies to manage them is paramount.

The presence of a spouse was found to significantly influence self-care outcomes in both PKT and NPKT groups. The emotional support derived from a spouse is a significant facilitator of self-care behaviors in KT patients [93]. This can be attributed to the mutual sharing of health-related knowledge and the encouragement of beneficial health behaviors [94]. This assertion aligns with prior research, where it was established that transplant patients with a supportive spouse demonstrated improved compliance with self-care practices [71,88,93]. Moreover, studies in other health conditions similarly underscore the significance of spousal support. For instance, in patients with multiple sclerosis (MS), spouses have been shown to enhance intrinsic motivation for physical activity, prompting the development of partner-oriented interventions that foster competence, autonomy, and relationship strength [95]. Similarly, in patients with type 2 diabetes, higher confidence in a spouse's ability to provide dietary support correlated with greater relationship satisfaction, further illustrating the emotional and practical benefits of spousal involvement in chronic disease management [96]. Given the evidence from both transplant and non-transplant patient populations, healthcare providers, especially registered nurses, should emphasize the crucial role of spouses in post-transplant care. This involves training spouses to assist in medication management, recognize signs of complications, and provide emotional support, thereby improving the overall management of the patient's condition.

For patients lacking spousal support, it is critical to establish tailored interventions designed to replicate the psychosocial benefits typically provided by a spouse. These interventions could include peer support groups and enhanced community resource engagement, which are vital in maintaining the quality of care and outcomes for these individuals. Recognizing the instrumental role of spousal support in the self-care of KT patients, healthcare providers must proactively identify and leverage comparable support mechanisms. This approach ensures that KT patients, particularly those without a spouse, receive continuous encouragement and assistance in adopting and maintaining health-promoting behaviors. Effective implementation of these targeted interventions is essential for fostering robust support networks that enhance patient outcomes.

Our findings indicate a varying set of self-care predictors according to the preoperative dialysis status of the patients. Among patients with PKT, we identified marital status and family support as crucial predictors. Conversely, in NPKT patients, predictors encompass marital status, employment status, post-transplantation duration, and stress levels. Therefore, it is essential for nursing strategies designed to bolster post-KT self-care to consider these disease-associated characteristics alongside the preoperative dialysis status.

Hyeiyeon Im: Writing – review & editing, Writing – original draft, Methodology, Formal analysis, Data curation, Conceptualization. Hye-Young Jang: Writing – review & editing, Supervision, Formal analysis, Conceptualization.

Data will be available on request.

This research did not receive any specific funding.

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.