The association between perceived stress with sleep quality, insomnia, anxiety and depression in kidney transplant recipients during Covid-19 pandemic

Dilek Barutcu Atas; Esra Aydin Sunbul; Arzu Velioglu; Serhan Tuglular

doi:10.1371/journal.pone.0248117

Peer Review History

Original SubmissionDecember 30, 2020
29 Jan 2021 Decision Letter - Stanislaw Stepkowski, Editor PONE-D-20-40967 The Association Between Perceived Stress Related with Sleep Quality, Insomnia, Anxiety and Depressionin Kidney Transplant Recipients During the Covid-19 Pandemic PLOS ONE Dear Dr. Atas, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. The authors need to address all Reviewers' comments: Reviewer # 1: This paper was aimed at providing an insight into the impact of the current pandemic on psychological well-being and associated sleep quality in kidney transplant recipients. Sleep quality and stress levels were measured by having patients fill out corresponding questionnaires during clinical visits, and the responses were analyzed in combination with laboratory test results. Overall, the paper addresses a novel and interesting question. As is, the paper's message is that high perceived stress is associated with other psychological indicators such as bad sleep and high anxiety. However, without showing that the psychological impact of the pandemic is associated with increased graft loss risk or any other significant outcome in patients, or at least that the increased stress levels contribute to health issues in patients, it has moderate significance. My main concern is the authors need to more clearly show the connection between sleep quality, stress levels and kidney transplant function, in order to make a case for significance of this study. The importance of the study can at least be shown by citing previous research showing the importance of emotional well-being in kidney transplant recipients overall. Though a statement about this connection is made in abstract and introduction, there were no references provided. In addition, whether the stress levels are impacted by the Covid-19 pandemic was also shown, with moderate to weak evidence. Finally, lack of correlation between PSS/PSQL/ISI/HAD readouts and kidney function from laboratory tests, shown in the results, does not add to the importance of the paper. Going into more detailed analysis, it would be very interesting to see any possible association between stress levels and hypertension, whose impact on kidney function is widely recognized. And to make the paper more useful, it would help to identify what exactly about the pandemic (whether it is lack of human interaction, fear of socializing, loss of job, loss in the family) makes kidney transplant recipients prone to psychological disorders. My smaller notes would be about methods description and results presentation. It would be nice to know at which transplant center(s) the patients included in the study were followed-up. It would be also nice to see the breakdown of stress/sleep scores among patients grouped by creatinine/BUN levels. Most of tables should better be re-designed to focus on differences that are significant, rather than showing everything. Table 3 can be presented such that patients are grouped by GFR and/or by measured stress levels. Some statements (such as “psychiatric disorders may lead to noncompliance” and “Outbreaks of infectious diseases and current Covid-19 may trigger…” in introduction) need to be provided with references. Reviewer # 2: Is a very interesting paper looking at sleep disturbances and psychological issues in renal transplant recipients during the early phases of Covid 19 The authors study is subset of renal transplant recipients early in 2020. This was early in the COVID-19 pandemic. It is unclear what the baseline rate of sleep disturbances and concerns would be in this set of patients. For instance "post holiday blues", other concerns with the renal transplant as well as family concerns Please submit your revised manuscript by Mar 14 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Stanislaw Stepkowski Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Thank you for your ethics statement: "The investigation conforms with the principles outlined in the Declaration of Helsinki. The local ethics committee approved the study, and all participants gave written informed consent (Protocol number: 09.2020.991)." Please amend your current ethics statement to include the full name of the ethics committee/institutional review board(s) that approved your specific study. Once you have amended this/these statement(s) in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”). For additional information about PLOS ONE ethical requirements for human subjects research, please refer to http://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research. Additional Editor Comments: The authors need to address all Reviewers' comments: Reviewer # 1: This paper was aimed at providing an insight into the impact of the current pandemic on psychological well-being and associated sleep quality in kidney transplant recipients. Sleep quality and stress levels were measured by having patients fill out corresponding questionnaires during clinical visits, and the responses were analyzed in combination with laboratory test results. Overall, the paper addresses a novel and interesting question. As is, the paper's message is that high perceived stress is associated with other psychological indicators such as bad sleep and high anxiety. However, without showing that the psychological impact of the pandemic is associated with increased graft loss risk or any other significant outcome in patients, or at least that the increased stress levels contribute to health issues in patients, it has moderate significance. My main concern is the authors need to more clearly show the connection between sleep quality, stress levels and kidney transplant function, in order to make a case for significance of this study. The importance of the study can at least be shown by citing previous research showing the importance of emotional well-being in kidney transplant recipients overall. Though a statement about this connection is made in abstract and introduction, there were no references provided. In addition, whether the stress levels are impacted by the Covid-19 pandemic was also shown, with moderate to weak evidence. Finally, lack of correlation between PSS/PSQL/ISI/HAD readouts and kidney function from laboratory tests, shown in the results, does not add to the importance of the paper. Going into more detailed analysis, it would be very interesting to see any possible association between stress levels and hypertension, whose impact on kidney function is widely recognized. And to make the paper more useful, it would help to identify what exactly about the pandemic (whether it is lack of human interaction, fear of socializing, loss of job, loss in the family) makes kidney transplant recipients prone to psychological disorders. My smaller notes would be about methods description and results presentation. It would be nice to know at which transplant center(s) the patients included in the study were followed-up. It would be also nice to see the breakdown of stress/sleep scores among patients grouped by creatinine/BUN levels. Most of tables should better be re-designed to focus on differences that are significant, rather than showing everything. Table 3 can be presented such that patients are grouped by GFR and/or by measured stress levels. Some statements (such as “psychiatric disorders may lead to noncompliance” and “Outbreaks of infectious diseases and current Covid-19 may trigger…” in introduction) need to be provided with references. Reviewer # 2: Is a very interesting paper looking at sleep disturbances and psychological issues in renal transplant recipients during the early phases of Covid 19 The authors study is subset of renal transplant recipients early in 2020. This was early in the COVID-19 pandemic. It is unclear what the baseline rate of sleep disturbances and concerns would be in this set of patients. For instance "post holiday blues", other concerns with the renal transplant as well as family concerns [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #2: No ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: No ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Is a very interesting paper looking at sleep disturbances and psychological issues in renal transplant recipients during the early phases of Covid 19 The authors study is subset of renal transplant recipients early in 2020. This was early in the COVID-19 pandemic. It is unclear what the baseline rate of sleep disturbances and concerns would be in this set of patients. For instance "post holiday blues", other concerns with the renal transplant as well as family concerns etc. Reviewer #2: This paper was aimed at providing an insight into the impact of the current pandemic on psychological well-being and associated sleep quality in kidney transplant recipients. Sleep quality and stress levels were measured by having patients fill out corresponding questionnaires during clinical visits, and the responses were analyzed in combination with laboratory test results. Overall, the paper addresses a novel and interesting question. As is, the paper's message is that high perceived stress is associated with other psychological indicators such as bad sleep and high anxiety. However, without showing that the psychological impact of the pandemic is associated with increased graft loss risk or any other significant outcome in patients, or at least that the increased stress levels contribute to health issues in patients, it has moderate significance. My main concern is the authors need to more clearly show the connection between sleep quality, stress levels and kidney transplant function, in order to make a case for significance of this study. The importance of the study can at least be shown by citing previous research showing the importance of emotional well-being in kidney transplant recipients overall. Though a statement about this connection is made in abstract and introduction, there were no references provided. In addition, whether the stress levels are impacted by the Covid-19 pandemic was also shown, with moderate to weak evidence. Finally, lack of correlation between PSS/PSQL/ISI/HAD readouts and kidney function from laboratory tests, shown in the results, does not add to the importance of the paper. Going into more detailed analysis, it would be very interesting to see any possible association between stress levels and hypertension, whose impact on kidney function is widely recognized. And to make the paper more useful, it would help to identify what exactly about the pandemic (whether it is lack of human interaction, fear of socializing, loss of job, loss in the family) makes kidney transplant recipients prone to psychological disorders. My smaller notes would be about methods description and results presentation. It would be nice to know at which transplant center(s) the patients included in the study were followed-up. It would be also nice to see the breakdown of stress/sleep scores among patients grouped by creatinine/BUN levels. Most of tables should better be re-designed to focus on differences that are significant, rather than showing everything. Table 3 can be presented such that patients are grouped by GFR and/or by measured stress levels. Some statements (such as “psychiatric disorders may lead to noncompliance” and “Outbreaks of infectious diseases and current Covid-19 may trigger…” in introduction) need to be provided with references. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: Deepak Malhotra Reviewer #2: Yes:** Dulat Bekbolsynov [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0248117.r001
Revision 1
12 Feb 2021 Author Response 12.02.2021 Dear Editor in Chief In response to your letter dated 29.01.2021, we have revised our manuscript entitled “The Association Between Perceived Stress Related with Sleep Quality, Insomnia, Anxiety and Depression in Kidney Transplant Recipients During the Covid-19 Pandemic” taking into account the reviewer’s comments and proposals. Please find below our itemized response to the points raised by the reviewer. Please inform us if you require further revision. Thank you for your kind interest. Yours sincerely, Dilek Barutcu Atas, MD Explanations to the Comments and Suggestions Raised by the Reviewer Reviewer1: This paper was aimed at providing an insight into the impact of the current pandemic on psychological well-being and associated sleep quality in kidney transplant recipients. Sleep quality and stress levels were measured by having patients fill out corresponding questionnaires during clinical visits, and the responses were analysed in combination with laboratory test results. Overall, the paper addresses a novel and interesting question. As is, the paper's message is that high perceived stress is associated with other psychological indicators such as bad sleep and high anxiety. 1. However, without showing that the psychological impact of the pandemic is associated with increased graft loss risk or any other significant outcome in patients, or at least that the increased stress levels contribute to health issues in patients, it has moderate significance. Response: We would like to thank the reviewer for the kind comments related to our manuscript. We added a paragraph into the introduction section Line 75-81 as follows “Studies of previous quarantines for SARS, influenza A and Ebola revealed high rates of post-traumatic stress and depression up to 4 to 5 times higher in quarantined subjects (4). It has been shown before that transplant recipients are susceptible to anxiety, depression, and post-traumatic stress disorder (5). Some studies report that post-transplant depression and anxiety increases morbidities and mortality risk of the patients, with poorer medical adherence and/or pathophysiological abnormalities which contribute to poor health outcomes (6,7).” And we added a sentence into the introduction section Line 90-91 as follows “Non-adherent patients were seven times more at risk of graft failure than adherent patients (12). 2. My main concern is the authors need to more clearly show the connection between sleep quality, stress levels and kidney transplant function, in order to make a case for significance of this study. Response: We would like to thank reviewer for the kind comments related with our manuscript. We completely agree with the reviewer accordingly we added to the Results section line 283-285 as follows “There were no correlations between glomerular filtration rate and PSS (r: -0.047, p: 0.646), PSQI (r: -0.037, p: 0.725), ISI (r: -0.164, p: 0.115), HAD-A (r: -0.085, p: 0.414) and HAD-D (r: 0.021, p: 0.843).” And we added to the Discussion section line 412-429 as follows “Previous studies suggest that psychological distress and perceived stress affect compliance negatively and non-compliance results in increased morbidity and mortality in kidney transplant recipients (6,7,11). Although an investigation about sleep quality and its related psychosocial variables among 438 renal transplant patients showed that the global PSQI scores were higher in participants with abnormal renal function compared with participants with normal renal function (35), there was no correlation between kidney function and PSS, PSQI, ISI, HAD-A and HAD-D scores in our study. Re-evaluation in short and long term follow-up of our study subjects during and after the Covid-19 pandemic will better reflect the association between sleep quality, stress levels and kidney transplant function.” 3. The importance of the study can at least be shown by citing previous research showing the importance of emotional well-being in kidney transplant recipients overall. Though a statement about this connection is made in abstract and introduction, there were no references provided. Response: We would like to thank reviewer for the kind comments related with our manuscript. We added a sentence into the Introduction section line 97-99 with provided reference as followed “Emotional well-being is important in kidney transplant recipients and improve the treatment compliance and decrease the probability of rejection (17).” 4. In addition, whether the stress levels are impacted by the Covid-19 pandemic was also shown, with moderate to weak evidence. Response: We would like to thank reviewer for the kind comments related with our manuscript. We agree with the reviewer and we mentioned this as a study limitation in the Discussion section line 439-441 as follows “Since the patients’ psychological status and sleep conditions before the out-break were not evaluated, it is difficult to infer a causal relationship between the variables of interest and the latter.” 5. Finally, lack of correlation between PSS/PSQL/ISI/HAD readouts and kidney function from laboratory tests, shown in the results, does not add to the importance of the paper. Response: We would like to thank reviewer for the kind comments related with our manuscript. Transplanted patients tend to be more affected from stress disorders, insomnia, and poor sleep quality even before the Covid-19 pandemic. In fact, we investigated in this study, whether PSS/PSQL/ISI/HAD scores were affected more in those with poor kidney function. Unfortunately, we don’t know the impact of psychiatric and sleep disturbances of progression on kidney function related to Covid-19 pandemic in our kidney transplant recipients. We believe that it’s difficult to show correlation between PSS/PSQL/ISI/HAD score and kidney function at the moment. Re-evaluation after a certain time period of Covid-19 pandemic it would be better to show the connection between sleep quality, stress levels and kidney transplant function. 6. Going into more detailed analysis, it would be very interesting to see any possible association between stress levels and hypertension, whose impact on kidney function is widely recognized. Response: We would like to thank reviewer for the kind comments related with our manuscript. We made more detailed analysis to see any possible association between stress levels, sleep disturbances and hypertension, whose impact on kidney function is widely recognized. We added the following paragraph to Results section line 290-293 as follows “When patients with hypertension (n:17) were compared to those without hypertension (n:89); there were no significant differences in PSS (24.3±6.4 vs 24.9±8.6, p: 0.784), PSQI (6.6±4.0 vs 6.0±3.8, p: 0.547), ISI (7.3±5.0 vs 6.5±5.7, p: 0.597), HAD-A (8.0±4.9 vs 7.0±4.1, p: 0.500) and HAD-D (7.8±3.2 vs 6.2±3.6, p: 0.114) scores between the two groups.” And we added following paragraph into the Discussion section line 430-437 “To address the impact of hypertension due to increased stress on kidney function we analysed the possible association between stress levels, sleep disturbances and hypertension. However, we failed to show any significant association between stress levels, sleep disturbances and hypertension. Xie et al. showed that the global PSQI scores were higher in the hypertension group compared with those in the non-hypertension group (35). The reason for the lack of association in our study may be due to the scarcity of hypertension among our subjects. Future studies may be needed to show the association after Covid-19 pandemic is over.” 7. And to make the paper more useful, it would help to identify what exactly about the pandemic (whether it is lack of human interaction, fear of socializing, loss of job, loss in the family) makes kidney transplant recipients prone to psychological disorders. Response: We would like to thank reviewer for the kind comments related with our manuscript. Unfortunately, we did not ask any questions to identify what exactly about the pandemic makes kidney transplant recipients prone to psychological disorders. However, when we made a literature search we found some possible factors leading to psychiatric disorders in susceptible individuals such as kidney transplant recipients. We added a sentence into the Introduction section line 72-74 as follows “In the pandemic period, restrictions in social life, social isolation, quarantine, boredom, inadequate information, and virus-related fears can lead to various psychiatric disorders in susceptible individuals (3).” 8. My smaller notes would be about methods description and results presentation. It would be nice to know at which transplant center(s) the patients included in the study were followed-up. Response: We would like to thank reviewer for the kind comments related with our manuscript. We agree with reviewer. The transplant center is Marmara University. We added following sentence into the Methods and Materials section line 113-114 “The study population was selected among kidney transplant patients followed up at the Marmara University Hospital Transplantation clinic between 01.09.2020 and 01.12.2020.” 9. It would be also nice to see the breakdown of stress/sleep scores among patients grouped by creatinine/BUN levels. Response: We would like to thank reviewer for the kind comments related with our manuscript. We have grouped patients by GFR to see the breakdown of stress/sleep scores. We added following paragraph into the Results section line 279-283 as follows “When patients with less than 60 ml/min/1.73 m2 glomerular filtration rate (GFR) were compared to those with GFR>60 ml/min/1.73 m2; there were no significant differences in PSS (24.8±8.2 vs 24.5±9.4, p: 0.877), PSQI (6.2±3.5 vs 5.7±4.0, p: 0.547), ISI (7.3±5.4 vs 5.7±5.7, p: 0.168), HAD-A (7.4±4.6 vs 6.5±4.1, p: 0.357) and HAD-D (6.4±3.7 vs 6.7±3.6, p: 0.682) scores between the two groups.” 10. Most of tables should better be re-designed to focus on differences that are significant, rather than showing everything. Response: We would like to thank reviewer for the kind comments related with our manuscript. We completely agree with the reviewer and accordingly we have re-designed tables. We deleted Table 2 and re-ordered the statements of tables so Table 4 is named as Table 2. We changed Table 5 as Figure 1 and so Table 6 is named as Table 4. 11. Table 3 can be presented such that patients are grouped by GFR and/or by measured stress levels. Response: We would like to thank reviewer for the kind comments related with our manuscript. We completely agree with the reviewer and accordingly we changed the Table 3, which is stated in the Results section, as patients grouped by measured stress levels high or low. 12. Some statements (such as “psychiatric disorders may lead to noncompliance” and “Outbreaks of infectious diseases and current Covid-19 may trigger…” in introduction) need to be provided with references. Response: We would like to thank reviewer for the kind comments related with our manuscript. We provided mentioned statements with references 11 and 16. Reviewer2: Is a very interesting paper looking at sleep disturbances and psychological issues in renal transplant recipients during the early phases of Covid 19 The authors study is subset of renal transplant recipients early in 2020. This was early in the COVID-19 pandemic. 1. It is unclear what the baseline rate of sleep disturbances and concerns would be in this set of patients. For instance, "post holiday blues", other concerns with the renal transplant as well as family. Response: We would like to thank reviewer for the kind comments related with our manuscript. Transplanted patients tend to be more affected from stress disorders, insomnia, and poor sleep quality even before the Covid-19 pandemic. Unfortunately, we don’t know baseline rate of sleep disturbances and concerns of our kidney transplant recipients. We mentioned this as a study limitation in the Discussion section line 439-441 as followed “Since the patients’ psychological status and sleep conditions before the out-break were not evaluated, it is difficult to infer a causal relationship between the variables of interest and the latter.” And also after a literature search to identify what exactly about the pandemic makes kidney transplant recipients prone to psychological disorders we added a sentence into the Introduction section line 72-74 as follows “In the pandemic period, restrictions in social life, social isolation, quarantine, boredom, inadequate information, and virus-related fears can lead to various psychiatric disorders in susceptible individuals (3).” and We added a paragraph to show association the psychological impact of the pandemic and health conditions such as graft loss into the introduction section Line 75-81 as follows “Studies of previous quarantines for SARS, influenza A and Ebola revealed high rates of post-traumatic stress and depression up to 4 to 5 times higher in quarantined subjects 4. It has been shown before that transplant recipients are susceptible to anxiety, depression, and post-traumatic stress disorder 5. Some studies report that post-transplant depression and anxiety increases morbidities and mortality risk of the patients, with poorer medical adherence and/or pathophysiological abnormalities which contribute to poor health outcomes 6,7. We completely agree with the reviewer that it’s important to show "post holiday blues" and other concerns with kidney transplant recipients and as well as their family. We believe future studies may reveal the impact of pandemic on physiological and sleep disorders and its association between morbidity and mortality in kidney transplant recipients. Journal Requirements 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. Response: We would like to thank editor for the kind comments related with our manuscript. We have checked our manuscript for PLOS ONE's style requirements. 2. Thank you for your ethics statement: "The investigation conforms with the principles outlined in the Declaration of Helsinki. The local ethics committee approved the study, and all participants gave written informed consent (Protocol number: 09.2020.991)." Please amend your current ethics statement to include the full name of the ethics committee/institutional review board(s) that approved your specific study. Once you have amended this/these statement(s) in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”). Response: We would like to thank editor for the kind comments related with our manuscript. We have edited our current ethics statement as follows “The study design was approved by the institutional review board of Marmara University School of Medicine Ethic Committee and all participants gave written informed consent. (Protocol number: 09.2020.991).” Attachments Attachment Submitted filename: Response to Reviewers Comments.docx https://doi.org/10.1371/journal.pone.0248117.r002
22 Feb 2021 Decision Letter - Stanislaw Stepkowski, Editor The association between perceived stress with sleep quality, insomnia, anxiety and depression in kidney transplant recipients during Covid-19 pandemic PONE-D-20-40967R1 Dear Dr. Atas, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Stanislaw Stepkowski Academic Editor PLOS ONE Additional Editor Comments (optional): None Reviewers' comments: https://doi.org/10.1371/journal.pone.0248117.r003
Formally Accepted
24 Feb 2021 Acceptance Letter - Stanislaw Stepkowski, Editor PONE-D-20-40967R1 The Association Between Perceived Stress with Sleep Quality, Insomnia, Anxiety and Depression in Kidney Transplant Recipients During Covid-19 Pandemic Dear Dr. Barutcu Atas: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Stanislaw Stepkowski Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0248117.r004

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