Nephrologists' Perspectives on Recipient Eligibility and Access to Living Kidney Donor Transplantation

Identifying the barriers to kidney transplantation for patients in rural and remote areas: a scoping review

BACKGROUND

Populations in rural and remote areas have higher rates of chronic kidney disease and kidney failure than those in urban or metropolitan areas, and mortality rates for chronic kidney disease are almost twice as high in remote areas compared to major cities. Despite this, patients residing in regional, rural, or remote areas are less likely to be wait-listed for or receive a kidney transplant. The objective of this scoping review is to identify specific barriers to kidney transplantation for adult patients residing in rural and remote areas from the perspectives of health professionals and patients/carers.

METHODS

Studies were identified through database (MEDLINE, CINAHL, Emcare, Scopus) searches and assessed against inclusion criteria to determine eligibility. A descriptive content analysis was undertaken to identify and describe barriers as key themes.

RESULTS

The 24 selected studies included both quantitative (n = 5) and qualitative (n = 19) methodologies. In studies conducted in health professional populations (n = 10) the most prevalent themes identified were perceived social and cultural issues (80%), burden of travel and distance from treatment (60%), and system-level factors as barriers (60%). In patient/carer populations (n = 14), the most prevalent themes were limited understanding of illness and treatment options (71%), dislocation from family and support network (71%), and physical and psychosocial effects of treatment (71%).

CONCLUSIONS

Patients in regional, rural, and remote areas face many additional barriers to kidney transplantation, which are predominantly associated with the need to travel or relocate to access required medical testing and transplantation facilities.

Paving the way for solutions improving access to kidney transplantation: a qualitative study from a multistakeholder perspective

OBJECTIVES

The aim of this study was to obtain an in-depth perspective from stakeholders involved in access to kidney transplantation to pave the way for solutions in improving access to kidney transplantation. This study qualitatively explored factors influencing optimal access to kidney transplantation from a broad stakeholder perspective.

DESIGN

A qualitative study was performed using semistructured interviews both in focus groups and with individual participants. All interviews were recorded, transcribed and coded according to the principles of grounded theory.

SETTING

Participants were healthcare providers (geographically spread), patients and (former living) kidney donors, policy-makers and insurers.

PARTICIPANTS

Stakeholders (N=87) were interviewed regarding their perceptions, opinions and attitudes regarding access to kidney transplantation.

RESULTS

The problems identified by stakeholders within the domains-policy, medical, psychological, social and economic-were acknowledged by all respondents. According to respondents, more efforts should be made to make healthcare providers and patients aware of the clinical guideline for kidney transplantation. The same opinion applied to differences in medical inclusion criteria used in the different transplantation centres. Stakeholders saw room for improvement based on psychological and social themes, especially regarding the provision of information. Many stakeholders described the need to rethink the current economic model to improve access to kidney transplantation. This discussion led to a definition of the most urgent problems for which, according to the respondents, a solution must be sought to optimise access to kidney transplantation.

CONCLUSIONS

Stakeholders indicated a high sense of urgency to solve barriers in patient access to kidney transplantation. Moreover, it appears that some barriers are quite straightforward to overcome; according to stakeholders, it is striking that this process has not yet been overcome. Stakeholders involved in kidney transplantation have provided directions for future solutions, and now it is possible to search for solutions with them.

Cultural and other beliefs as barriers to pediatric solid organ transplantation

Organ shortage for transplantation is a global problem for both adult and pediatric recipients and this is particularly apparent in certain areas of the world and within specific communities. Cultural and religious beliefs can influence both a decision by a potential donor and/or their family to donate as well as a potential recipient's or their family's decision to accept the need for transplantation, agree to be listed and accept an organ. Globally, there are cultural and religious diversities that can present significant challenges for the transplant professional, particularly those whose practice is based in multicultural communities. In the pediatric population, in particular, barriers to organ transplantation related to culture and religion have not been well-described, with resulting implications for how they should or could be effectively addressed. Therefore, this review was undertaken to elucidate cultural and religious barriers to pediatric organ transplantation and, where feasible, to identify facilitators and strategies for overcoming these barriers.

Treatment Patterns and Characteristics of Dialysis Facilities Randomly Assigned to the Medicare End-Stage Renal Disease Treatment Choices Model

IMPORTANCE

In 2021, Medicare launched the End-Stage Renal Disease Treatment Choices (ETC) model, which randomly assigned approximately 30% of dialysis facilities to new financial incentives to increase use of transplantation and home dialysis; these financial bonuses and penalties are calculated by comparing living-donor transplantation, transplant wait-listing, and home dialysis use in ETC-assigned facilities vs benchmarks from non-ETC-assigned (ie, control) facilities. Because model participation is randomly assigned, evaluators may attribute any downstream differences in outcomes to facility performance rather than any imbalance in baseline characteristics.

OBJECTIVE

To identify preintervention imbalances in dialysis facility characteristics that should be recognized in any ETC model evaluations.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study compared ETC-assigned and control dialysis facility characteristics in the United States from 2017 to 2018. A total of 6062 facilities were included. Data were analyzed from February 2021 to May 2022.

EXPOSURES

Assignment to the ETC model.

MAIN OUTCOMES AND MEASURES

Dialysis facilities' preintervention transplantations and home dialysis use, facility characteristics (notably, profit and chain status), patient demographic characteristics, and community socioeconomic characteristics.

RESULTS

Among 316 927 patients, with 6 178 855 attributed patient-months, the mean (SD) age in January 2017 was 59 (11) years, and 132 462 (42%) were female. Patients in ETC-assigned facilities had 9% (0.2 [95% CI, 0.1-0.2] percentage points) lower prevalence of living donor transplantation, 12% (3.2 [95% CI, 3.0-3.3] percentage points) lower prevalence of transplantation wait-listing, and 4% (0.4 [95% CI, 0.3-0.4] percentage points) lower prevalence of peritoneal dialysis use compared with control facilities. ETC-assigned facilities were 14% (5.1 [95% CI, 0.9-9.4] percentage points) more likely than control facilities to be owned by the second largest dialysis organization. Relative to control facilities, ETC-assigned facilities also treated 34% (6.6 [95% CI, 6.5-6.7] percentage point) fewer patients with Hispanic ethnicity and were located in communities with median household incomes that were 4% ($2500; 95% CI, $500-$4500) lower on average.

CONCLUSIONS AND RELEVANCE

In this study, dialysis facilities in ETC-assigned regions had lower preintervention prevalence of transplantation wait-listing, living donor transplantation, and peritoneal dialysis use, relative to control facilities. ETC-assigned and control facilities also differed with respect to other facility, patient, and community characteristics. Evaluators should account for these preintervention imbalances to minimize bias in their inferences about the model's association with postintervention outcomes.

Using Administrative Health Care Databases to Identify Patients With End-Stage Kidney Disease With No Recorded Contraindication to Receiving a Kidney Transplant

Background

Administrative health care databases can be efficiently analyzed to describe the degree to which patients with end-stage kidney disease (ESKD) have access to kidney transplantation. Measures of access to transplantation are better represented when restricting to only those patients eligible to receive a kidney transplant. The way administrative data can be used to assess kidney transplant eligibility in the absence of clinical data has not been well described.

Objective

To demonstrate a method that uses administrative health care databases to identify patients with ESKD who have no recorded contraindication to receiving a kidney transplant.

Design and setting

Population-based cohort study using linked administrative health care databases in Ontario, Canada.

Patients

Adult patients with ESKD approaching the need for dialysis (predialysis) or receiving maintenance dialysis between January 1, 2013 and March 31, 2015 in Ontario, Canada.

Measurements

Recipient of a kidney-only or kidney-pancreas transplant.

Methods

We assessed more than 80 baseline characteristics, including demographic information, comorbidities, kidney-specific characteristics, and referral and listing criteria for kidney transplantation. We compared these characteristics between patients who did and did not receive a kidney transplant.

Results

We included 23 642 patients with ESKD (11 195 who were predialysis and 12 447 receiving maintenance dialysis). Over a median follow-up of 3.2 years (25th, 75th percentile: 1.3, 5.6), 3215 (13.6%) received a kidney-only or kidney-pancreas transplant. Of the studied characteristics available in administrative databases, >97% of patients with one or more of these characteristics did not receive a kidney transplant during follow-up: ESKD-modified Charlson Comorbidity Index score ≥7 (a higher score represents greater comorbidity), home oxygen use, age above 75 years, dementia, living in a long-term care facility, receiving at least one physician house call in the past year, and a combination of select malignancies (ie, lung, lymphoma, cervical, colorectal, liver, active multiple myeloma, and bladder cancer). Using these combined criteria reduced the total number of patients from 23 642 to 12 539 with no recorded contraindications to transplant (a 47% reduction), while the proportion who received a kidney transplant changed from 13.6% (denominator of 23 642) to 24.9% (denominator of 12 539).

Limitations

Administrative databases are unable to capture all the complexities of determining transplant eligibility.

Conclusion

We identified several criteria available within administrative health care databases that can be used to identify patients with ESKD who have no recorded contraindications to kidney transplant. These criteria could be applied when reporting measures of access to kidney transplantation that require knowledge of transplant eligibility.

Israeli Medical Experts’ Knowledge, Attitudes, and Preferences in Allocating Donor Organs for Transplantation

Medical advancement has increased the confidence in successful organ transplants in end-stage patients. As the waitlist of organ demand is multiplying, the organ allocation process is becoming more crucial. In this situation, a transparent and efficient organ allocation policy is required. This study evaluates the preferences of medical experts to substantial factors for allocating organs in different hypothetical scenarios. Twenty-five medical professionals with a significant role in organ allocation were interviewed individually. The interview questionnaire comprised demographic information, organ donation status, important organ allocation factors, public preference knowledge, and experts’ preferences in different hypothetical scenarios. Most medical experts rated the waiting time and prognosis as the most important, while the next of kin donor status and care and contribution to the well-being of others were the least important factors for organ allocation. In expert opinion, medical experts significantly considered public preferences for organ allocation in making their decisions. Altogether, experts prioritized waiting time over successful transplant, age, and donor status in the hypothetical scenarios. In parallel, less chance of finding another organ, donor status, and successful transplant were prioritized over age. Medical experts are the key stakeholders; therefore, their opinions are substantial in formulating an organ allocation policy.

Clinicians' perspectives on equity of access to dialysis and kidney transplantation for rural people in Australia: a semistructured interview study

OBJECTIVES

People with chronic kidney disease requiring dialysis or kidney transplantation in rural areas have worse outcomes, including an increased risk of hospitalisation and mortality and encounter many barriers to accessing kidney replacement therapy. We aim to describe clinicians' perspectives of equity of access to dialysis and kidney transplantation in rural areas.

DESIGN

Qualitative study with semistructured interviews.

SETTING AND PARTICIPANTS

Twenty eight nephrologists, nurses and social workers from 19 centres across seven states in Australia.

RESULTS

We identified five themes: the tyranny of distance (with subthemes of overwhelming burden of travel, minimising relocation distress, limited transportation options and concerns for patient safety on the roads); supporting navigation of health systems (reliance on local champions, variability of health literacy, providing flexible models of care and frustrated by gatekeepers); disrupted care (without continuity of care, scarcity of specialist services and fluctuating capacity for dialysis); pervasive financial distress (crippling out of pocket expenditure and widespread socioeconomic disadvantage) and understanding local variability (lacking availability of safe and sustainable resources for dialysis, sensitivity to local needs and dependence on social support).

CONCLUSIONS

Clinicians identified geographical barriers, dislocation from homes and financial hardship to be major challenges for patients in accessing kidney replacement therapy. Strategies such as telehealth, outreach services, increased service provision and patient navigators were suggested to improve access.

Effects of Social Deprivation on the Proportion of Preemptive Kidney Transplantation: A Mediation Analysis

Social inequalities in health lead to an increased risk of chronic kidney disease and less access to renal transplantation. The objective of this study was to assess the association between social deprivation estimated by the fifth quintile of the European Deprivation Index (EDI) and preemptive kidney transplantation (PKT) and to explore the potential mediators of this association.

Methods

This retrospective observational multicenter study included 8701 patients who received their first renal transplant in France between 2010 and 2014. Mediation analyses were performed to assess the direct and indirect effects of the EDI on PKT.

Results

Among the 8701 transplant recipients, 32.4% belonged to the most deprived quintile of the EDI (quintile 5) and 16% received a PKT (performed either with a deceased- or living-donor). There was a significant association between quintile 5 of the EDI and PKT (total effect: odds ratio [OR]: 0.64 [95% confidence interval (CI): 0.55-0.73]). Living-donor kidney transplantation was the main mediator of this association (natural indirect effect: OR: 0.92 [0.89-0.95]). To a lesser extent, positive cytomegalovirus and hepatitis C serologies and blood group B were also mediators (respective natural indirect effects: OR: 0.98 [95% CI: 0.95-1.00], OR: 0.99 [95% CI: 0.99-1.00], and OR: 0.99 [95% CI: 0.98-1.00], P < 0.05).

Conclusions

Our study suggests that social deprivation is associated with a decreased proportion of PKT. This association might be mitigated by promoting living-donor transplantation.

Providers' View on the First Kidney Transplantation Center in Ethiopia: Experience From Past to Present

Introduction:

Transplantation is the optimal management for patients with end-stage renal disease. In Ethiopia, the first national kidney transplantation center was opened at St. Paul’s Hospital Millennium Medical College in September 2015. The aim of this study was to explore providers’ views and experiences of the past to present at this center.

Methods:

A qualitative study design was employed from 1^st November to 15^th December, 2019. To ensure that appropriate informants would provide rich study data, 8 health care providers and top management members were purposefully chosen for in-depth interviews. A maximum variation sampling method was considered to include a representative sample of informants. Interviews were digitally audio-recorded, and transcribed verbatim. Transcribed data was coded and analyzed using Qualitative Data Analysis (QDA) Minor Lite software and Microsoft-Excel.

Result:

The participants (5 males and 3 females) approached were from different departments of the renal transplant center, and the main hospital. Eight main themes and 18 sub-themes were generated initially from all interviews totaling to 109 index codes. Further evaluation and recoding retained 5 main themes, and 14 sub-themes. The main themes are; challenges experienced during and after launching the center, commitment, sympathy and satisfaction, outcomes of renal transplant, actions to improve the quality of service, and how the transplant center should operate. Providers claim that they discharge their responsibilities through proper commitment and compassion, paying no attention to incentive packages. They also explained that renal transplantation would have all the outcomes related to economic, humanistic and clinical facets.

Conclusion and Recommendation:

A multitude of challenges were faced during and after the establishment of the first renal transplant center in Ethiopia. Providers discharge their responsibility through a proper compassion for patients. Concerned stakeholders should actively collaborate to improve the quality of renal transplant services in the center.

Non-medical barriers reported by nephrologists when providing renal replacement therapy or comprehensive conservative management to end-stage kidney disease patients: a systematic review

BACKGROUND

Large international differences exist in access to renal replacement therapy (RRT) modalities and comprehensive conservative management (CCM) for patients with end-stage kidney disease (ESKD), suggesting that some patients are not receiving the most appropriate treatment. Previous studies mainly focused on barriers reported by patients or medical barriers (e.g. comorbidities) reported by nephrologists. An overview of the non-medical barriers reported by nephrologists when providing the most appropriate form of RRT (other than conventional in-centre haemodialysis) or CCM is lacking.

METHODS

We searched in EMBASE and PubMed for original articles with a cross-sectional design (surveys, interviews or focus groups) published between January 2010 and September 2018. We included studies in which nephrologists reported barriers when providing RRT or CCM to adult patients with ESKD. We used the barriers and facilitators survey by Peters et al. [Ruimte Voor Verandering? Knelpunten en Mogelijkheden Voor Verbeteringen in de Patiëntenzorg. Nijmegen: Afdeling Kwaliteit van zorg (WOK), 2003] as preliminary framework to create our own model and performed meta-ethnographic analysis of non-medical barriers in text, tables and figures.

RESULTS

Of the 5973 articles screened, 16 articles were included using surveys (n = 10), interviews (n = 5) and focus groups (n = 1). We categorized the barriers into three levels: patient level (e.g. attitude, role perception, motivation, knowledge and socio-cultural background), level of the healthcare professional (e.g. fears and concerns, working style, communication skills) and level of the healthcare system (e.g. financial barriers, supportive staff and practice organization).

CONCLUSIONS

Our systematic review has identified a number of modifiable, non-medical barriers that could be targeted by, for example, education and optimizing financing structure to improve access to RRT modalities and CCM.

Organ donation and transplantation: a multi-stakeholder call to action

Although overall donation and transplantation activity is higher in Europe than on other continents, differences between European countries in almost every aspect of transplantation activity (for example, in the number of transplantations, the number of people with a functioning graft, in rates of living versus deceased donation, and in the use of expanded criteria donors) suggest that there is ample room for improvement. Herein we review the policy and clinical measures that should be considered to increase access to transplantation and improve post-transplantation outcomes. This Roadmap, generated by a group of major European stakeholders collaborating within a Thematic Network, presents an outline of the challenges to increasing transplantation rates and proposes 12 key areas along with specific measures that should be considered to promote transplantation. This framework can be adopted by countries and institutions that are interested in advancing transplantation, both within and outside the European Union. Within this framework, a priority ranking of initiatives is suggested that could serve as the basis for a new European Union Action Plan on Organ Donation and Transplantation.

A RAND-Modified Delphi on Key Indicators to Measure the Efficiency of Living Kidney Donor Candidate Evaluations

BACKGROUND AND OBJECTIVES

Many patients, providers, and potential living donors perceive the living kidney donor evaluation process to be lengthy and difficult to navigate.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We sought consensus on key terms and process and outcome indicators that can be used to measure how efficiently a transplant center evaluates persons interested in becoming a living kidney donor. Using a RAND-modified Delphi method, 77 participants (kidney transplant recipients or recipient candidates, living kidney donors or donor candidates, health care providers, and health care administrators) completed an online survey to define the terms and indicators. The definitions were then further refined during an in-person meeting with ten stakeholders.

RESULTS

We identified 16 process indicators (e.g., average time to evaluate a donor candidate), eight outcome indicators (e.g., annual number of preemptive living kidney donor transplants), and two measures that can be considered both process and outcome indicators (e.g., average number of times a candidate visited the transplant center for the evaluation). Transplant centers wishing to implement this set of indicators will require 22 unique data elements, all of which are either readily available or easily collected prospectively.

CONCLUSIONS

We identified a set of indicators through a consensus-based approach that may be used to monitor and improve the performance of a transplant center in how efficiently it evaluates persons interested in becoming a living kidney donor.

Factors influencing access to kidney transplantation: a research protocol of a qualitative study on stakeholders' perspectives

INTRODUCTION

Unequal access to kidney transplantation is suggested, but no systematic inventory exists about factors influencing access to kidney transplantation. There is an absence of any research that has combined stakeholder perspectives along the complete trajectory of transplantation. The present qualitative study explores the contributing factors from the perspectives of multiple stakeholders in this trajectory, including patients, health professionals and health insurance and financial representatives in the Netherlands. Moreover, stakeholders will be invited to suggesting strategies and solutions for handling the facilitating and hindering factors found. By means of interaction, stakeholder groups will arrive at a consensus for new policymaking in the field of a Dutch transplantation care.

METHODS AND ANALYSIS

The different stakeholders' perspectives and possible solutions will be explored by interviewing in three phases. In the first phase, stakeholders' group perspectives will be explored with individual interviews and focus group interviews without confrontation of views from other perspectives. In the second phase of focus group interviewing, perspectives will be confronted with the other stakeholders' perspectives assessed. Finally, in the third phase, stakeholders will be invited to focus group discussions for suggesting solutions to overcome barriers and promote facilitators for improving access to transplantation. Approximately, groups from six to twelve participants per focus group and four to maximal six focus groups will be held per stakeholder, depending on the level of saturation, as prescribed by grounded theory. The interviews will be audio-recorded and transcribed verbatim, and qualitative data will be analysed according to the principles of grounded theory supported by using NVivo software.

ETHICS AND DISSEMINATION

The Medical Ethical Committee of Erasmus MC, Rotterdam, The Netherlands, has approved this study. The results will be disseminated in peer-reviewed journals and major international conferences.

Association Between Dialysis Facility Ownership and Access to Kidney Transplantation

Importance

For-profit (vs nonprofit) dialysis facilities have historically had lower kidney transplantation rates, but it is unknown if the pattern holds for living donor and deceased donor kidney transplantation, varies by facility ownership, or has persisted over time in a nationally representative population.

Objective

To determine the association between dialysis facility ownership and placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant.

Design, Setting, and Participants

Retrospective cohort study that included 1 478 564 patients treated at 6511 US dialysis facilities. Adult patients with incident end-stage kidney disease from the US Renal Data System (2000-2016) were linked with facility ownership (Dialysis Facility Compare) and characteristics (Dialysis Facility Report).

Exposures

The primary exposure was dialysis facility ownership, which was categorized as nonprofit small chains, nonprofit independent facilities, for-profit large chains (>1000 facilities), for-profit small chains (<1000 facilities), and for-profit independent facilities.

Main Outcomes and Measures

Access to kidney transplantation was defined as time from initiation of dialysis to placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant. Cumulative incidence differences and multivariable Cox models assessed the association between dialysis facility ownership and each outcome.

Results

Among 1 478 564 patients, the median age was 66 years (interquartile range, 55-76 years), with 55.3% male, and 28.1% non-Hispanic black patients. Eighty-seven percent of patients received care at a for-profit dialysis facility. A total of 109 030 patients (7.4%) received care at 435 nonprofit small chain facilities; 78 287 (5.3%) at 324 nonprofit independent facilities; 483 988 (32.7%) at 2239 facilities of large for-profit chain 1; 482 689 (32.6%) at 2082 facilities of large for-profit chain 2; 225 890 (15.3%) at 997 for-profit small chain facilities; and 98 680 (6.7%) at 434 for-profit independent facilities. During the study period, 121 680 patients (8.2%) were placed on the deceased donor waiting list, 23 762 (1.6%) received a living donor kidney transplant, and 49 290 (3.3%) received a deceased donor kidney transplant. For-profit facilities had lower 5-year cumulative incidence differences for each outcome vs nonprofit facilities (deceased donor waiting list: -13.2% [95% CI, -13.4% to -13.0%]; receipt of a living donor kidney transplant: -2.3% [95% CI, -2.4% to -2.3%]; and receipt of a deceased donor kidney transplant: -4.3% [95% CI, -4.4% to -4.2%]). Adjusted Cox analyses showed lower relative rates for each outcome among patients treated at all for-profit vs all nonprofit dialysis facilities: deceased donor waiting list (hazard ratio [HR], 0.36 [95% CI, 0.35 to 0.36]); receipt of a living donor kidney transplant (HR, 0.52 [95% CI, 0.51 to 0.54]); and receipt of a deceased donor kidney transplant (HR, 0.44 [95% CI, 0.44 to 0.45]).

Conclusions and Relevance

Among US patients with end-stage kidney disease, receiving dialysis at for-profit facilities compared with nonprofit facilities was associated with a lower likelihood of accessing kidney transplantation. Further research is needed to understand the mechanisms behind this association.

A Culturally Sensitive Web-based Intervention to Improve Living Donor Kidney Transplant Among African Americans

Introduction

There are pervasive racial disparities in access to living donor kidney transplantation, which for most patients with end-stage renal disease (ESRD) represents the optimal treatment. We previously developed a theory-driven, culturally sensitive intervention for African American (AA) patients with kidney disease called Living ACTS (About Choices in Transplantation and Sharing) as a DVD and booklet, and found this intervention was effective in increasing living donor transplant knowledge. However, it is unknown whether modifying this intervention for a Web-based environment is effective at increasing access to living donor transplantation.

Methods

We describe the Web-based Living ACTS study, a multicenter, randomized controlled study designed to test the effectiveness of a revised Living ACTS intervention in 4 transplant centers in the southeastern United States. The intervention consists of a Web site with 5 modules: Introduction, Benefits and Risks, The Kidney Transplant Process, Identifying a Potential Kidney Donor, and ACT Now (which encourages communication with friends and family about transplantation).

Results

This study will enroll approximately 800 patients from the 4 transplant centers. The primary outcome is the percentage of patients with at least 1 inquiry from a potential living donor among patients who receive Living ACTS as compared with those who receive a control Web site.

Conclusion

The results from this study are expected to demonstrate the effectiveness of an intervention designed to increase access to living donor transplantation among AA individuals. If successful, the Web-based intervention could be disseminated across the >250 transplant centers in the United States to improve equity in living donor kidney transplantation.

Health Professional-Identified Barriers to Living Donor Kidney Transplantation: A Qualitative Study

BACKGROUND

Living donor kidney transplantation (LDKT) has several advantages over deceased donor kidney transplantation. Yet rates of living donation are declining in Canada and there exists significant interprovincial variability. Efforts to improve living donation tend to focus on the patient and barriers identified at their level, such as not knowing how to ask for a kidney or lack of education. These efforts favor those who have the means and the support to find living donors. Thus, a Canadian Institutes of Health Research (CIHR)-organized workshop recommended that education efforts to understand and remove barriers should focus on health professionals (HPs). Despite this, little attention has been paid to what they identify as barriers to discussing LDKT with their patients.

OBJECTIVE

Our aim was to explore HP-identified barriers to discuss living donation with patients in 3 provinces of Canada with low (Quebec), moderate (Ontario), and high (British Columbia) rates of LDKT.

DESIGN

This study consists of an interpretive descriptive approach as it enables to move beyond description and inform clinical practice.

SETTING

Purposive criterion and quota sampling were used to recruit HPs from Quebec, Ontario, and British Columbia who are involved in the care of patients with kidney disease and/or with transplant coordination.

PATIENTS

Not applicable.

MEASUREMENTS

Semistructured interviews were conducted. The interview guide was developed based on a preliminary analytical framework and a review of the literature.

METHODS

Thematic analysis was used to analyze the data stemming from the interviews. The coding process comprised of a deductive and inductive approach, and the use of a qualitative analysis software (NVivo 11). Following this, themes were identified and developed. Interviews were conducted until thematic saturation was obtained. In total, we conducted 16 telephone interviews as thematic saturation was attained.

RESULTS

Six predominant themes emerged: (1) lack of communication between transplant and dialysis teams, (2) absence of referral guidelines, (3) role perception and lack of multidisciplinary involvement, (4) HP's lack of information and training, (5) negative attitudes of some HP toward LDKT, (6) patient-level barriers as defined by the HP. HPs did mention patients' attitudes and some characteristics as the main barriers to discussions about living donation; this was noted in all provinces. HPs from Ontario and British Columbia indicated multiple strategies being implemented to address some of these barriers. Those from Ontario mentioned strategies that center on the core principles of provincial-level standardization, while those from British Columbia center on engaging the entire multidisciplinary team and improved role perception. We noted a dearth of such efforts in Quebec; however, efforts around education and promotion, while tentative, have emerged.

LIMITATIONS

Social desirability and selection bias. Our analysis might not be applicable to other provinces.

CONCLUSIONS

HPs involved with the referral and coordination of transplantation play a major role in access to LDKT. We have identified challenges they face when discussing living donation with their patients that warrant further assessment and research to inform policy change.

Decision aids to increase living donor kidney transplantation

PURPOSE OF REVIEW

For the more than 636,000 adults with end-stage renal disease (ESRD) in the U.S., kidney transplantation is the preferred treatment compared to dialysis. Living donor kidney transplantation (LDKT) comprised 31% of kidney transplantations in 2015, an 8% decrease since 2004. We aimed to summarize the current literature on decision aids that could be used to improve LDKT rates.

RECENT FINDINGS

Decision aids are evidence-based tools designed to help patients and their families make difficult treatment decisions. LDKT decision aids can help ESRD patients, patients' family and friends, and healthcare providers engage in treatment decisions and thereby overcome multifactorial LDKT barriers.

SUMMARY

We identified 12 LDKT decision aids designed to provide information about LDKT, and/or to help ESRD patients identify potential living donors, and/or to help healthcare providers make decisions about treatment for ESRD or living donation. Of these, 4 were shown to be effective in increasing LDKT, donor inquiries, LDKT knowledge, and willingness to discuss LDKT. Although each LDKT decision aid has limitations, adherence to decision aid development guidelines may improve decision aid utilization and access to LDKT.