Concerns regarding the financial aspects of kidney transplantation: perspectives of pre-transplant patients and their family members

Financial Hardship and Age-Related Decrements in Kidney Function Among Black and White Adults in the Midlife in the United States Study

OBJECTIVE

This analysis examined if financial hardship was associated with age-related decrements in kidney function using a material-psychosocial-behavioral framework. We also tested if this association was mediated by comorbidity of cardiometabolic risk factors (obesity, elevated blood pressure, and insulin resistance).

METHODS

Data from 1361 non-Hispanic Black and White adults (ages 26-94 years; non-Hispanic Black = 258) were obtained from the Wave 3 and Refresher phases of the Midlife in the United States project. Kidney function was based on serum creatinine-based estimated glomerular filtration rate (eGFR; Chronic Kidney Disease Epidemiology Collaboration formula without race adjustment). Financial hardship was evaluated in three domains: material (income to poverty line ratio, health insurance coverage, and public/government financial assistance), psychological (perceived financial status, control over financial status, and perceived financial strains), and behavioral responses (financial adjustment/coping such as sold possessions and cutting back on spending).

RESULTS

More severe financial hardship (overall score and in each domain) was associated with age-related decrements in eGFR, even after adjusting for sociodemographic, education, and health-related covariates. The association between financial hardship and age-related decrements in eGFR was conditional on sex but not race. Finally, cardiometabolic risk factors mediated the association between financial hardship and age-related decrements in eGFR.

CONCLUSIONS

These findings affirm the negative effects of financial hardship on age-related decrements in renal clearance. In addition to incorporating traditionally used indicators of SES, such as education and income, future research on social hallmarks of aging should also consider the role of financial hardship on the aging process and age-related diseases.

Impact of delayed listing after initiating kidney transplant evaluation on transplant outcomes

OBJECTIVE

Longer end-stage renal disease time has been associated with inferior kidney transplant outcomes. However, the contribution of transplant evaluation is uncertain. We explored the relationship between time from evaluation to listing (ELT) and transplant outcomes.

METHODS

This retrospective study included 2535 adult kidney transplants from 2000 to 2015. Kaplan-Meier survival curves, log-rank tests, and Cox regression models were used to compare transplant outcomes.

RESULTS

Patient survival for both deceased donor (DD) recipients (p < .001) and living donor (LD) recipients (p < .0001) was significantly higher when ELT was less than 3 months. The risks of ELT appeared to be mediated by other risks in DD recipients, as adjusted models showed no associated risk of graft loss or death in DD recipients. For LD recipients, ELT remained a risk factor for patient death after covariate adjustment. Each month of ELT was associated with an increased risk of death (HR = 1.021, p = .04) but not graft loss in LD recipients in adjusted models.

CONCLUSIONS

Kidney transplant recipients with longer ELT times had higher rates of death after transplant, and ELT was independently associated with an increased risk of death for LD recipients. Investigations on the impact of pretransplant evaluation on post-transplant outcomes can inform transplant policy and practice.

Association of Age and Gender With Concerns About Live Donor Kidney Transplantation Among Black Individuals

Black individuals are less likely to receive live donor kidney transplantation (LDKT) compared to others. This may be partly related to their concerns about LDKT, which can vary based on age and gender. We conducted a cross-sectional, secondary analysis of the baseline enrollment data from the Talking about Living Kidney Donation Support trial, which studied the effectiveness of social workers and financial interventions on activation towards LDKT among 300 Black individuals from a deceased donor waiting list. We assessed concerns regarding the LDKT process, including their potential need for postoperative social support, future reproductive potential, recipient and donor money matters, recipient and donor safety, and interpersonal concerns. Answers ranged from 0 ("not at all concerned") to 10 ("extremely concerned"). We described and compared participants' concerns both overall and stratified by age (≥45 years old vs <45 years old) and self-reported gender ("male" versus "female"). The participants' top concerns were donor safety (median [IQR] score 10 [5-10]), recipient safety (5 [0-10]), money matters (5 [0-9]), and guilt/indebtedness (5 [0-9]). Younger females had statistically significantly higher odds of being concerned about future reproductive potential (odds ratio [OR] 3.77, 95% CI 2.77, 4.77), and older males had statistically higher mean concern about postoperative social support (OR 1.79, 95% CI 0.19, 3.38). Interventions to improve rates of LDKT among Black individuals should include education and counseling about the safety of LDKT for both recipients and donors, reproductive counseling for female LDKT candidates of childbearing age, and addressing older males' needs for increased social support.

Knowledge About Renal Transplantation Among African, Caribbean, and Black Canadian Patients With Advanced Kidney Failure

Introduction

Variable transplant-related knowledge may contribute to inequitable access to living donor kidney transplant (LDKT). We compared transplant-related knowledge between African, Caribbean, and Black (ACB) versus White Canadian patients with kidney failure using the Knowledge Assessment of Renal Transplantation (KART) questionnaire.

Methods

This was a cross-sectional cohort study. Data were collected from a cross-sectional convenience sample of adults with kidney failure in Toronto. Participants also answered an exploratory question about their distrust in the kidney allocation system. Clinical characteristics were abstracted from medical records. The potential contribution of distrust to differences in transplant knowledge was assessed in mediation analysis.

Results

Among 577 participants (mean [SD] age 57 [14] years, 63% male), 25% were ACB, and 43% were White Canadians. 45% of ACB versus 26% of White participants scored in the lowest tertile of the KART score. The relative risk ratio to be in the lowest tertile for ACB compared to White participants was 2.22 (95% confidence interval [CI]: 1.11, 4.43) after multivariable adjustment. About half of the difference in the knowledge score between ACB versus White patients was mediated by distrust in the kidney allocation system.

Conclusion

Participants with kidney failure from ACB communities have less transplant-related knowledge compared to White participants. Distrust is potentially contributing to this difference.

Caregiver Burden in Adult Solid Organ Transplantation

The informal caregiver plays a critical role in supporting patients with various end-stage diseases throughout the solid organ transplantation journey. Caregiver responsibilities include assistance with activities of daily living, medication management, implementation of highly specialized treatments, transportation to appointments and treatments, and health care coordination and navigation. The demanding nature of these tasks has profound impacts across multiple domains of the caregiver's life: physical, psychological, financial, logistical, and social. Few interventions targeting caregiver burden have been empirically evaluated, with the majority focused on education or mindfulness-based stress reduction techniques. Further research is urgently needed to develop and evaluate interventions to improve caregiver burden and outcomes for the patient-caregiver dyad.

Mitigating Financial Toxicity in Breast Cancer From Diagnosis to Treatment and Reconstruction

Breast cancer is the most common cancer affecting women in United States with a significant patient and familial financial burden. Limited resources offer financial support to patients in the form of cost support for bills, health insurance payments, childcare, and post-treatment recovery. Financial resources are often limited to patients of certain geographic regions or low socioeconomic status as determined by the federal poverty level, which may systematically exclude patients in need.

A Population Health Approach to Transplant Access: Challenging the Status Quo

Transplant referral and evaluation are critical steps to waitlisting yet remain an elusive part of the transplant process. Despite calls for more data collection on pre-waitlisting steps, there are currently no national surveillance data to aid in understanding the causes and potential solutions for the extreme variation in access to transplantation. As population health scientists, epidemiologists, clinicians, and ethicists we submit that the transplant community has an obligation to better understand disparities in transplant access as a first necessary step to effectively mitigating these inequities. Our position is grounded in a population health approach, consistent with several new overarching national policy and quality initiatives. The purpose of this Perspective is to (1) provide an overview of how a population health approach should inform current multisystem policies impacting kidney transplantation and demonstrate how these efforts could be enhanced with national data collection on pre-waitlisting steps; (2) demonstrate the feasibility and concrete next steps for pre-waitlisting data collection; and (3) identify potential opportunities to use these data to implement effective population-level interventions, policies, and quality measures to improve equity in access to kidney transplantation.

Evolving Metrics of Quality for Kidney Transplant Candidates: Transplant Center Variability in Delisting and 1-Year Mortality

BACKGROUND

Management of patients on the kidney transplant waitlist lacks oversight, and transplant centers can delist candidates without consequence. To better understand between-center differences in waitlist management, we examined delisting rates and mortality after delisting within 3 years of removal from the kidney transplant waitlist.

STUDY DESIGN

This is a retrospective cohort study using data from the Scientific Registry of Transplant Recipients of adults listed for deceased donor kidney transplant in 2015 and followed until the end of 2018. Patients of interest were those delisted for reasons other than transplant, death, or transfer. Centers were excluded if they had fewer than 20 waitlisted patients per year. We calculated probability of delisting and death after delisting using multivariable competing risk models.

RESULTS

During follow-up, 14.2% of patients were delisted. The median probability of delisting within 3 years, adjusted for center-level variability, was 7.0% (interquartile range [IQR]: 3.9% to 10.6%). Median probability of death was 58.2% (IQR: 40% to 73.4%). There was no meaningful correlation between probability of delisting and death (τ = -0.05, p = 0.34).

CONCLUSIONS

There is significant variability in the rate of death after delisting across kidney transplant centers. Likelihood of transplant is extremely important to candidates, and improved data collection efforts are needed to inform whether current delisting practices are successfully removing patients who could not meaningfully benefit from transplant, or whether certain populations may benefit from remaining on the list and maintaining eligibility.

A Cascade of Structural Barriers Contributing to Racial Kidney Transplant Inequities

Stark racial disparities in access to and receipt of kidney transplantation, especially living donor and pre-emptive transplantation, have persisted despite decades of investigation and intervention. The causes of these disparities are complex, are inter-related, and result from a cascade of structural barriers to transplantation which disproportionately impact minoritized individuals and communities. Structural barriers contributing to racial transplant inequities have been acknowledged but are often not fully explored with regard to transplant equity. We describe longstanding racial disparities in transplantation, and we discuss contributing structural barriers which occur along the transplant pathway including pretransplant health care, evaluation, referral processes, and the evaluation of transplant candidates. We also consider the role of multilevel socio-contextual influences on these processes. We believe focused efforts which apply an equity lens to key transplant processes and systems are required to achieve greater structural competency and, ultimately, racial transplant equity.

Does increasing access-to-care delay accessing of care? Evidence from kidney transplantation

Policies increasing healthcare availability might decrease the cost of delaying accessing of care, leading to potential negative consequences if patients delay treatment. We analyze a policy designed to increase access to kidney transplantation through the use of time since dialysis inception to prioritize patients for transplant, which was piloted at 26 of the 271 kidney transplant centers in the United States in 2006 and 2007. We model the patient's optimization problem comparing the benefits and costs of early waitlisting and predict that the policy change will lead to delayed waitlisting. To empirically test this prediction, we use difference-in-differences fixed effects panel regression techniques to analyze data on patients who began dialysis between 1/1/2000 and 12/31/2009. The results support the model's prediction; patients on dialysis who waitlist for kidney transplantation increase pre-waitlist dialysis duration by 11.6 percent or approximately 76 days from a pre-policy mean of 652 days (SD = 654). With regard to waitlist outcomes, the policy is associated with a 4.5 percentage point decrease in the probability of receiving a deceased donor transplant, somewhat offset by a 3.0 percentage point increase in the probability of receiving a live donor transplant. On the extensive margin, patients on dialysis decrease their likelihood of ever waitlisting by 1.5 percentage points. We find an increase in pre-waitlist dialysis time and a decrease in the likelihood of waitlisting at all, especially among populations likely to have experienced increased access to transplantation through the policy change: patients self-identifying as Black or Hispanic rather than Non-Hispanic White, and patients without private insurance. These results suggest that some individuals may not benefit if their access to care increases, if the increase in access sufficiently decreases the penalty of delaying accessing of care.

Clinical outcomes of renal and liver transplant patients undergoing transcatheter aortic valve replacement: analysis of national inpatient sample database

Background: The transcatheter aortic valve replacement (TAVR) has recently gained traction as a viable alternative to surgical aortic valve replacement (SAVR), but data on its safety and clinical outcomes in transplant patients are limited.Methods: We retrieved relevant demographic and clinical outcome data from the U.S. National Inpatient Sample (NIS) for the year 2012-2015. The clinical outcomes of TAVR in renal transplant (RT) and liver transplant (LT) were ascertained using an adjusted odds ratio (aOR) with a 95% confidence interval (CI) on Mantzel-Hensel test.Results: A total of 62,399 TAVR patients were identified; 62,180 (99.6%) with no history of transplant, 219 (0.4%) with RT and 85 (0.1%) with LT. There was no significant difference in odds of in-hospital mortality (OR 0.61, 95% CI 0.25-1.5, p = 0.37), major cardiovascular, respiratory or neurological complications in patients with and without RT. Similarly, the odds of cardiac complications, renal and neurological complications between patients with and without LT were identical.Conclusion: Compared to non-transplant patients, TAVR appears to be associated with similar odds of major systemic complications or mortality in patients with a history of kidney or liver transplant.

"I Wish Someone Had Told Me That Could Happen": A Thematic Analysis of Patients' Unexpected Experiences With End-Stage Kidney Disease Treatment

BACKGROUND

Preparedness regarding prognosis and treatment options enables patients to cope with uncertainties, make value-based treatment decisions, and set treatment goals. Yet, little is known about the expectedness of end-stage kidney disease (ESKD) patients' treatment experiences beyond their desire for better treatment education.

OBJECTIVE

To describe unexpected adverse treatment experiences among ESKD patients.

METHOD

The authors conducted 7 focus groups with 55 dialysis patients and living-donor kidney transplantation recipients receiving medical care in Baltimore, Maryland. Data were analyzed thematically. Themes present in different treatment groups were highlighted to provide insight into common experiences.

RESULTS

The authors identified 5 themes: (1) psychological reactions, (2) constrained freedom of choice, (3) treatment delivery and logistics, (4) morbidity, and (5) finances.

CONCLUSION

Patients were unprepared for nonclinical, logistical, and clinical aspects of ESKD treatment. The need for providers' use of tailored preparatory techniques and the development of pretreatment interventions to help patients know what to expect from and feel psychologically prepared for treatment, particularly with respect to nonclinical implications, is critical. These efforts have great potential to improve patients' treatment experiences.

Simultaneous Pancreas-Kidney Transplant: A Positive Stimulus in the Medical World

Kidneys are one of the essential organs of our body, with chronic kidney disease being a very prevalent and emotionally, mentally and physically straining condition affecting 1 in 15 people worldwide. The prevalence is further escalating with every passing year. It is slowly progressive in nature, and many times goes unnoticed until symptoms start manifesting and presenting themselves much later in life. In this article, end-stage renal disease (ESRD) due to diabetes mellitus and its effect on different organs is examined, along with the role of simultaneous pancreas-kidney transplant (SPKT) in the management of this condition. Although proven to be an assured treatment with an outstanding allograft acceptance rate, the fact that it is still not widely adopted in many healthcare setups due to financial implications is also studied.

Online databases such as PubMed and Google Scholar were searched for the purpose of data collection; due to the very limited number of randomized controlled trials conducted on this given topic, a limited discussion was retrieved. By applying the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method and several inclusion/exclusion criteria, approximately 66 articles were assessed for eligibility based on the title and abstract. A total of 44 articles were shortlisted and considered in the final review.

Several systematic reviews that have been conducted in the past reveal the importance of SPKT at an early stage of diagnosis towards increasing longevity of the patient with freedom from multiple medications. Transplant is a cost-effective therapy when compared to the prolonged dependence on dialysis, insulin pens, and increased susceptibility to infections.

A greater number of specialists must also train to carry out SPKT and identify the early stages of ESRD, and medical centers should be encouraged to carry out transplant procedures effectively both financially and medically. This can be achieved through the development of global policy mechanisms and establishment of universally adoptable standards.

Family Members' Experiences With Dialysis and Kidney Transplantation

Rationale & Objective

Understanding whether family members’ experiences with patients’ treatment for end-stage kidney disease (ESKD) were expected could guide the development of family-centered interventions that enhance the preparedness of patients and their care partners for kidney replacement therapies. We explored unexpected negative experiences with ESKD treatments among family members of dialysis and posttransplantation patients to identify meaningful directions for family-centered research and clinical care.

Study Design

Qualitative study.

Setting & Participants

8 focus groups comprising 49 family members of dialysis patients and living donor kidney transplant recipients undergoing medical care in Baltimore, MD.

Analytical Approach

Focus groups were stratified by patients’ treatment (in-center hemodialysis, home hemodialysis, peritoneal dialysis, or living donor kidney transplantation) and family members’ self-reported race (African American vs non–African American), resulting in 2 groups per treatment experience. Inductive thematic analysis was used to identify themes in focus group transcripts. Themes shared across different treatment groups were highlighted to provide insight into common experiences.

Results

We identified 4 themes that described family members’ unexpected negative treatment experiences: becoming a care partner (unanticipated responsibilities and sleep disruptions), adverse psychological treatment responses in patients (eg, depression) and family members (eg, anxiety), treatment delivery and logistics (insufficient information, medication regimen, and logistical inconveniences), and patient morbidity (dialysis-related health problems and fatigue). All themes were relevant to discussions in the in-center hemodialysis, peritoneal dialysis, and transplantation groups, whereas psychological responses and morbidity themes did not reflect discussions in home hemodialysis groups.

Limitations

Data collection occurred from 2008 to 2009; family members were recruited through patients undergoing care in 1 geographic area; 1 family member participant per patient.

Conclusions

Family members described a broad range of unexpected negative experiences with ESKD treatments. Efforts to prepare families for ESKD treatments through more family-centered care, early and tailored education, and interventions targeting care partner preparedness, health provider–family member communication, and relationship dynamics in family member–patient dyads are needed.

Effectiveness of informational decision aids and a live donor financial assistance program on pursuit of live kidney transplants in African American hemodialysis patients

BACKGROUND

African Americans have persistently poor access to living donor kidney transplants (LDKT). We conducted a small randomized trial to provide preliminary evidence of the effect of informational decision support and donor financial assistance interventions on African American hemodialysis patients' pursuit of LDKT.

METHODS

Study participants were randomly assigned to receive (1) Usual Care; (2) the Providing Resources to Enhance African American Patients' Readiness to Make Decisions about Kidney Disease (PREPARED); or (3) PREPARED plus a living kidney donor financial assistance program. Our primary outcome was patients' actions to pursue LDKT (discussions with family, friends, or doctor; initiation or completion of the recipient LDKT medical evaluation; or identification of a donor). We also measured participants' attitudes, concerns, and perceptions of interventions' usefulness.

RESULTS

Of 329 screened, 92 patients were eligible and randomized to Usual Care (n = 31), PREPARED (n = 30), or PREPARED plus financial assistance (n = 31). Most participants reported interventions helped their decision making about renal replacement treatments (62%). However there were no statistically significant improvements in LDKT actions among groups over 6 months. Further, no participants utilized the living donor financial assistance benefit.

CONCLUSIONS

Findings suggest these interventions may need to be paired with personal support or navigation services to overcome key communication, logistical, and financial barriers to LDKT.

TRIAL REGISTRATION

ClinicalTrials.gov [ NCT01439516 ] [August 31, 2011].

The Living Donor Lost Wages Trial: Study Rationale and Protocol

PURPOSE OF REVIEW

This paper describes the background, rationale, and design of an NIH-funded, single-center study to test the impact of offering reimbursement for donor lost wages incurred during the post-nephrectomy recovery period on the live donor kidney transplant (LDKT) rate in newly evaluated kidney transplant candidates, to examine whether offering reimbursement for donor lost wages reduces racial disparity in LDKT rates, and to determine whether higher reimbursement amounts lead to higher LDKT rates.

RECENT FINDINGS

LDKT is the optimal treatment for renal failure. However, living kidney donation has declined in the past decade, particularly among men, younger adults, blacks, and low-income adults. There is evidence that donation-related costs may deter both transplant candidates and potential donors from considering LDKT. Lost wages is a major source of financial loss for some living donors and, unlike travel and lodging expenses, is not reimbursed by financial assistance programs.

SUMMARY

The study addresses the transplant community's call to reduce the financial burden of living donation and examine its impact on LDKT rates. Findings have the potential to influence policy, clinical practice, LDKT access, and income-related and racial disparities in LDKT and living donation.

Survey of Living Organ Donors' Experience and Directions for Process Improvement

INTRODUCTION

Understanding living organ donors' experience with donation and challenges faced during the process is necessary to guide the development of effective strategies to maximize donor benefit and increase the number of living donors.

METHODS

An anonymous self-administered survey, specifically designed for this population based on key informant interviews, was mailed to 426 individuals who donated a kidney or liver at our institution. Quantitative and qualitative methods including open and axial coding were used to analyze donor responses.

FINDINGS

Of the 141 survey respondents, 94% would encourage others to become donors; however, nearly half (44%) thought the donation process could be improved and offered numerous suggestions. Five major themes arose: (1) desire for greater convenience in testing and scheduling; (2) involvement of previous donors throughout the process; (3) education and promotion of donation through social media; (4) unanticipated difficulties, specifically pain; and (5) financial concerns.

DISCUSSION

Donor feedback has been translated into performance improvements at our hospital, many of which are applicable to other institutions. Population-specific survey development helps to identify vital patient concerns and provides valuable feedback to enhance the delivery of care.

Inter- and Intrapersonal Barriers to Living Donor Kidney Transplant among Black Recipients and Donors

CONTEXT

End-stage renal disease (ESRD) is more common among Blacks, but Blacks are less likely to receive a live donor kidney transplant (LDKT).

OBJECTIVE

The objective of this study is to identify barriers and coping mechanisms that Black LDKT recipients and donors experienced while receiving or donating a kidney.

DESIGN

A qualitative study was conducted using structured interviews. Thematic analysis was used for data interpretation.

PARTICIPANTS

All 20 participants identified as Black, with two participants identifying themselves as multiracial. The mean age for the 14 recipients was 60, and the average age for the 6 living donors was 47.

RESULTS

Themes emerging from the data suggest both recipients and donors faced barriers in the LDKT experience. Recipients faced barriers associated with their denial and avoidance of the severity of their ESRD, their desire to maintain the privacy of their health status, and their refusal to approach potential donors. Donors encountered negative responses from others about the donors' desire to donate and the initial refusal of recipients to accept a LDKT offer. Recipients identified faith as a coping mechanism, while donors identified normalization of donation as their method of coping. Various types of social support helped donors and recipients navigate the transplant process.

CONCLUSION

Black LDKT recipients and donors must overcome barriers prior to receiving or donating a kidney. Most of these barriers arise from communication and interactions with others that are either lacking or undesirable. Future interventions to promote LDKT among Blacks may benefit by specifically targeting these barriers.

The 1966 Ciba Symposium on Transplantation Ethics: 50 Years Later

In March 1966, the Ciba Foundation sponsored the first international, interdisciplinary symposium focused on ethical and legal issues in transplantation. The attendees included not only physicians and surgeons but also judges and legal scholars, a minister, and a science journalist. In this article, we will consider some of the topics in organ transplantation that were discussed by the attendees, what we have learned in the intervening half century, and the relevance of their discussions today. Specifically, we examine the definition of death and its implications for organ procurement, whether it is ethical and legal to "maim" a living individual for the benefit of another, how to ensure that the consent of the living donor is voluntary and informed, the case of identical twins, the question of whether ethically minors can serve as living donors, the health risks of living donation, the ethics and legality of an organ market, and the economic barriers to living donation. We show that many of the concerns discussed at the Ciba symposium remain highly relevant, and their discussions have helped to shape the ethical boundaries of organ transplantation today.

Educating Prospective Kidney Transplant Recipients and Living Donors about Living Donation: Practical and Theoretical Recommendations for Increasing Living Donation Rates

A promising strategy for increasing living donor kidney transplant (LDKT) rates is improving education about living donation for both prospective kidney transplant recipients and living donors to help overcome the proven knowledge, psychological, and socioeconomic barriers to LDKT. A recent Consensus Conference on Best Practices in Live Kidney Donation recommended that comprehensive LDKT education be made available to patients at all stages of chronic kidney disease (CKD). However, in considering how to implement this recommendation across different healthcare learning environments, the current lack of available guidance regarding how to design, deliver, and measure the efficacy of LDKT education programs is notable. In the current article, we provide an overview of how one behavior change theory, the Transtheoretical Model of Behavior Change, can guide the delivery of LDKT education for patients at various stages of CKD and readiness for LDKT. We also discuss the importance of creating educational programs for both potential kidney transplant recipients and living donors, and identify key priorities for educational research to reduce racial disparities in LDKT and increase LDKT rates.

Direct and Indirect Costs Following Living Kidney Donation: Findings From the KDOC Study

Some living kidney donors (LKDs) incur costs associated with donation, although these costs are not well characterized in the United States. We collected cost data in the 12 mo following donation from 182 LKDs participating in the multicenter prospective Kidney Donor Outcomes Cohort (KDOC) Study. Most LKDs (n = 167, 92%) had one direct cost or more following donation, including ground transportation (86%), health care (41%), meals (53%), medications (36%), lodging (23%), and air transportation (12%). LKDs missed 33 072 total work hours, 40% of which were unpaid and led to $302 175 in lost wages (mean $1660). Caregivers lost $68 655 in wages (mean $377). Although some donors received financial assistance, 89% had a net financial loss in the 12-mo period, with one-third (33%) reporting a loss exceeding $2500. Financial burden was higher for those with greater travel distance to the transplant center (Spearman's ρ = 0.26, p < 0.001), lower household income (Spearman's ρ = -0.25, p < 0.001), and more unpaid work hours missed (Spearman's ρ = 0.52, p < 0.001). Achieving financial neutrality for LKDs must be an immediate priority for the transplant community, governmental agencies, insurance companies, nonprofit organizations, and society at large.

The TALKS study to improve communication, logistical, and financial barriers to live donor kidney transplantation in African Americans: protocol of a randomized clinical trial

Background

Live donor kidney transplantation (LDKT), an optimal therapy for many patients with end-stage kidney disease, is underutilized, particularly by African Americans. Potential recipient difficulties initiating and sustaining conversations about LDKT, identifying willing and medically eligible donors, and potential donors’ logistical and financial hurdles have been cited as potential contributors to race disparities in LDKT. Few interventions specifically targeting these factors have been tested.

Methods/Design

We report the protocol of the Talking about Living Kidney Donation Support (TALKS) study, a study designed to evaluate the effectiveness of behavioral, educational and financial assistance interventions to improve access to LDKT among African Americans on the deceased donor kidney transplant recipient waiting list. We adapted a previously tested educational and social worker intervention shown to improve consideration and pursuit of LDKT among patients and their family members for its use among patients on the kidney transplant waiting list. We also developed a financial assistance intervention to help potential donors overcome logistical and financial challenges they might face during the pursuit of live kidney donation. We will evaluate the effectiveness of these interventions by conducting a randomized controlled trial in which patients on the deceased donor waiting list receive 1) usual care while on the transplant waiting list, 2) the educational and social worker intervention, or 3) the educational and social worker intervention plus the option of participating in the financial assistance program. The primary outcome of the randomized controlled trial will measure potential recipients’ live kidney donor activation (a composite rate of live donor inquiries, completed new live donor evaluations, or live kidney donation) at 1 year.

Discussion

The TALKS study will rigorously assess the effectiveness of promising interventions to reduce race disparities in LDKT.

Trial registration

NCT02369354.

Living-Donor Kidney Transplantation: Reducing Financial Barriers to Live Kidney Donation--Recommendations from a Consensus Conference

Live-donor kidney transplantation (LDKT) is the best treatment for eligible people with late-stage kidney disease. Despite this, living kidney donation rates have declined in the United States in recent years. A potential source of this decline is the financial impact on potential and actual living kidney donors (LKDs). Recent evidence indicates that the economic climate may be associated with the decline in LDKT and that there are nontrivial financial ramifications for some LKDs. In June 2014, the American Society of Transplantation's Live Donor Community of Practice convened a Consensus Conference on Best Practices in Live Kidney Donation. The conference included transplant professionals, patients, and other key stakeholders (with the financial support of 10 other organizations) and sought to identify best practices, knowledge gaps, and opportunities pertaining to living kidney donation. This workgroup was tasked with exploring systemic and financial barriers to living kidney donation. The workgroup reviewed literature that assessed the financial effect of living kidney donation, analyzed employment and insurance factors, discussed international models for addressing direct and indirect costs faced by LKDs, and summarized current available resources. The workgroup developed the following series of recommendations to reduce financial and systemic barriers and achieve financial neutrality for LKDs: (1) allocate resources for standardized reimbursement of LKDs' lost wages and incidental costs; (2) pass legislation to offer employment and insurability protections to LKDs; (3) create an LKD financial toolkit to provide standardized, vetted education to donors and providers about options to maximize donor coverage and minimize financial effect within the current climate; and (4) promote further research to identify systemic barriers to living donation and LDKT to ensure the creation of mitigation strategies.