Thematic analysis of the medical records of patients evaluated for kidney transplant who did not receive a kidney

Referral and evaluation for kidney transplantation among patients with lupus nephritis-related end-stage kidney disease

OBJECTIVE

For the majority of patients with lupus nephritis-related end-stage kidney disease (LN-ESKD), kidney transplant is associated with better outcomes than dialysis. Access to kidney transplant requires an initial referral to a transplant center and medical evaluation prior to waitlisting. The study's objective was to examine access to these early steps in the kidney transplant process among patients with LN-ESKD.

METHODS

Adults who began treatment for ESKD in the Southeast, Northeast, New York, or Ohio River Valley U.S. regions from 1/1/2012 to 12/31/2019, followed through 6/30/2021, were identified from the United States Renal Data System. Referral and evaluation start data were collected from 28 of 48 transplant centers across these regions. The exposure was primary cause of ESKD (LN-ESKD vs other-ESKD). The outcomes were referral and evaluation start at a transplant center. Cox models quantified the association between LN-ESKD (vs other-ESKD) and referral and evaluation start.

RESULTS

Among 192,318 patients initiating treatment for ESKD, 0.4% had LN-ESKD. Over half (58%) of LN-ESKD patients were referred before study end, and among those referred, 66% started the evaluation. In adjusted analyses, patients with LN-ESKD were referred (HR: 1.09, 95% CI: 0.99, 1.19) and started the transplant evaluation (HR: 1.13, 95% CI: 1.00, 1.28) at a higher rate than patients with other-ESKD. Among referred patients with LN-ESKD, the median time from ESKD start to referral was 2.9 months (IQR: <1 to 11.7 months), which is similar to patients with other-ESKD (median 2.6 months, IQR: <1 to 8.8 months).

CONCLUSIONS

Among incident patients with ESKD, having a primary diagnosis of LN-ESKD versus other-ESKD is associated with higher rates of early transplant access outcomes. Despite this, patients with LN-ESKD (vs other-ESKD) are less likely to be preemptively referred (i.e., referred prior to ESKD start) for kidney transplant. While providers may no longer be delaying the early steps in the kidney transplantation process among this patient population, there is still room for improvement in the rates of preemptive referral. Access to kidney transplant referral prior to ESKD could result in increased transplant rates and better transplant outcomes for patients with LN-ESKD.

A Single-Center Retrospective Evaluation of Decision-Making and Factors Motivating Hand Transplant Candidates

INTRODUCTION

Advancements in vascularized composite allotransplantation have made hand transplants possible for persons living with upper limb loss. Hand transplantation is not a life-saving procedure, but rather a quality-of-life enhancing procedure; hence the risk of morbidity and mortality must be weighed against improvements in function and appearance. This study explored the decision-making process of patients evaluated for hand transplantation.

METHODS/APPROACH

A qualitative case series study using retrospective chart data of evaluations was conducted between January 1, 2011 and February 28, 2020. Notes were extracted and read by three reviewers. Each case was summarized noting similarities and differences.

FINDINGS

Nine patients underwent evaluation. Eight were no longer under evaluation and did not receive transplant; one was still undergoing evaluation. Patient motivations for evaluation were dissatisfaction with prostheses or self-image, chronic pain, performing activities of daily living, occupation, burden placed on caregivers, and concerns about overuse of non-affected limbs. Patients chose not to pursue transplantation due to rehabilitation time, immunosuppression, alternative treatments, and social and financial challenges. The clinical team discontinued evaluations due to unmet evaluation requirements, medical contraindications, or treatment alternatives. Different modes of shared decision-making were present depending on the party most heavily featured in the charts as driving decisions.

DISCUSSION

This was an examination of shared decision-making with hand transplant candidates who did not proceed to transplant. Reasons for choosing alternative strategies for management were multifactorial. Lessons learned regarding patient motivations and shared decision-making can inform future interventions to better support patients.

Enacting person-centred care: a multi-perspective study of practices in clinical encounters for people living with chronic kidney disease

BACKGROUND

There is growing emphasis on the need for ensuring person-centred care for patients living with chronic kidney disease as this will benefit patients, providers, and healthcare systems alike. Nevertheless, less emphasis is given to how this complex concept is practiced in clinical encounters and how it is experienced by patients. This qualitative multi-perspective study investigates how person-centred care for people living with chronic kidney disease is practiced and experienced by patients in clinical encounters at a nephrological ward at a hospital in the capital region of Denmark.

METHODS

The study builds upon qualitative methodologies, including field notes from observations of clinical encounters between clinicians and patients in an out-patient clinic (n = ~ 80) and in-person interviews with patients in peritoneal dialysis (n = 4). Key themes from field notes and interview transcripts were identified through thematic analysis. Analyses were informed by practice theory.

RESULTS

Findings illustrate that person-centred care is practiced in a relational and situational encounter between patients and clinicians as dialogues about choice of treatment modality, which is shaped by the individual's life circumstances, preferences, and values. The practice of person-centred care appeared to be complex and interlinked with a range of factors, individual to each patient. We identified three themes of relevance for practices and experiences related to person-centred care: (1) Patients' perceptions of living with chronic kidney disease. Perceptions differed according to medical history, life situation and prior experiences with treatment in the healthcare system. These patient-related factors were perceived to be important for person-centred care to unfold; (2) Relations between patients and healthcare professionals were important for patients' experiences of trust and appeared fundamental for the practice and experiences of person-centred care; and (3) Decision-making on treatment modality that is the best fit for each patient's everyday life, appear to be shaped by the patient's need for knowledge about treatment modalities and level of self-determination in the decision-making.

CONCLUSIONS

The context of clinical encounters influences the practices and experiences of person-centred care, where health policies and lack of embodiment are identified as barriers for providing and experiencing person-centred care.

Advance Care Planning, Shared Decision Making, and Serious Illness Conversations in Onconephrology

Advance care planning, shared decision making, and serious illness conversations are communication processes designed to promote patient-centered care. In onconephrology, patients face a series of complex medical decisions regarding their care at the intersection of oncology and nephrology. Clinicians who aim to ensure that patient preferences and values are integrated into treatment planning must work within a similarly complex care team comprising multiple disciplines. In this review, we describe key decision points in a patient's care trajectory, as well as guidance on how and when to engage in advance care planning, shared decision making, and serious illness discussions. Further research on these processes in the complex context of onconephrology is needed.

[Long-term physical and psychological consequences of chronic kidney disease]

Aufgrund der verbesserten Behandlungsoptionen können Patient:innen mit chronischen Nierenerkrankungen heute deutlich länger überleben als noch vor 10 Jahren. Das Überleben ist für die Betroffenen jedoch immer mit einem Verlust an Lebensqualität verbunden. In diesem Beitrag wird eine kurze Übersicht über die körperlichen und psychischen Erkrankungsfolgen, Begleiterkrankungen und Therapienebenwirkungen bei chronischen Nierenerkrankungen gegeben. Auf bisher bekannte Auswirkungen der COVID-19-Pandemie wird hingewiesen. Abschließend wird aufgezeigt, wie die Langzeitbehandlung weiterentwickelt werden sollte, um die Lebensqualität der Patient:innen zu erhöhen.

Funktionseinschränkungen der Niere haben aufgrund der Kontamination des Blutes mit harnpflichtigen Substanzen (Urämie) schwere Auswirkungen auf den Gesamtorganismus. Zusätzlich sind die Patient:innen von Nebenwirkungen betroffen, die im Zusammenhang mit der medikamentösen Therapie, Dialyse oder Nierentransplantation auftreten können. Patient:innen und Angehörige sind einer großen psychischen Belastung ausgesetzt. Infektionen mit SARS-CoV‑2 können die Nierenfunktion beeinträchtigen und auch die Prognose einer bereits bestehenden Erkrankung verschlechtern.

Die ganzheitliche Versorgung der Patient:innen mit chronischen Nierenerkrankungen muss neben der medizinischen Versorgung auch die psychologischen und psychosozialen Aspekte berücksichtigen. Nephrologie und Psychonephrologie müssen Hand in Hand weiterentwickelt werden, um die medizinische Versorgung und Lebensqualität der betroffenen Patient:innen zu verbessern.

Non-medical barriers in access to early steps of kidney transplantation in the United States - A scoping review

BACKGROUND

In the United States (US), barriers in access to later steps in the kidney transplantation process (i.e. waitlisting) have been well documented. Barriers in access to earlier steps (i.e. referral and evaluation) are less well described due to the lack of national surveillance data. In this review, we summarize the available literature on non-medical barriers in access to kidney transplant referral and evaluation.

METHODS

Following PRISMA guidelines, we conducted a scoping review of the literature through June 3, 2021. We included all studies (quantitative and qualitative) reporting on barriers to kidney transplant referral and evaluation in the US published from 1990 onwards in English and among adult end-stage kidney disease (ESKD) patients (PROSPERO registration number: CRD42014015027). We narratively synthesized results across studies.

RESULTS

We retrieved information from 33 studies published from 1990 to 2021 (reporting data between 1990 and 2018). Most studies (n = 28, 85%) described barriers among patient populations, three (9%) among provider populations, and two (6%) included both patients and providers. Key barriers were identified across multiple levels and included patient- (e.g. demographic, socioeconomic, sociocultural, and knowledge), provider- (e.g. miscommunication, staff availability, provider perceptions and attitudes), and system- (e.g. geography, distance to care, healthcare logistics) level factors.

CONCLUSIONS

A multi-pronged approach (e.g. targeted and systemwide interventions, and policy change) implemented at multiple levels of the healthcare system will be necessary to reduce identified barriers in access to early kidney transplant steps. Collection of national surveillance data on these early kidney transplant steps is also needed to enhance our understanding of barriers to referral and evaluation.

Implementation of Surprise Question Assessments using the Electronic Health Record in Older Adults with Advanced CKD

Background

The Surprise Question (SQ; "Would you be surprised if this patient died in the next 12 months?") is a validated prognostication tool for mortality and hospitalization among patients with advanced CKD. Barriers in clinical workflows have slowed SQ implementation in practice.

Objectives

The aims of this study were: (1) to evaluate implementation outcomes after the use of electronic health record (EHR) decision support to automate the collection of the SQ; and (2) to assess the prognostic utility of the SQ for mortality and hospitalization/emergency room (ER) visits.

Methods

We developed and implemented a best practice alert (BPA) in the EHR to identify nephrology outpatients ≥60 years of age with an eGFR <30 ml/min per 1.73 m2. At appointment, the BPA prompted the physician to answer the SQ. We assessed the rate and timeliness of provider responses. We conducted a post-hoc open-ended survey to assess physician perceptions of SQ implementation. We assessed the SQ's prognostic utility in survival and time-to-hospital encounter (hospitalization/ER visit) analyses.

Results

Among 510 patients for whom the BPA triggered, 95 (19%) had the SQ completed by 16 physicians. Among those completed, nearly all (98%) were on appointment day, and 61 (64%) the first time the BPA fired. Providers answered "no" for 27 (28%) and "yes" for 68 (72%) patients. By 12 months, six (22%) "no" patients died; three (4%) "yes" patients died (hazard ratio [HR] 2.86, ref: yes, 95% CI, 1.06 to 7.69). About 35% of "no" patients and 32% of "yes" patients had a hospital encounter by 12 months (HR, 1.85, ref: yes, 95% CI, 0.93 to 3.69). Physicians noted (1) they had goals-of-care conversations unprompted; (2) EHR-based interventions alone for goals-of-care are ineffective; and (3) more robust engagement is necessary.

Conclusions

We successfully integrated the SQ into the EHR to aid in clinical practice. Additional implementation efforts are needed to encourage further integration of the SQ in clinical practice.

Identifying Needs and Barriers to Engage Family Members in Transplant Candidate Care

INTRODUCTION

Friends and family members provide critical support to patients on the waitlist for deceased donor kidney transplantation. However, little is known about how best to support and engage them effectively to improve patient outcomes.

METHODS

We conducted 5 focus groups with the family members of patients on the waitlist for a deceased donor kidney (n=23) to identify individual- and group-level targets for an intervention. Discussions encouraged participants to reflect on their support roles, experiences at the transplant evaluation, interactions with providers, knowledge of transplant options and expected outcomes. Transcripts of study sessions were coded using an iterative and inductive process.

RESULTS

The thematic analysis produced two main themes related to experiences providing care to patients on the waitlist for kidney transplantation. First, participants revealed that supporting a patient on the waitlist created challenges that reverberate through their entire social structure. Family members discussed frustrations with adapting to their patient's kidney health needs, feelings of isolation, and barriers to identifying and building effective support networks. Second, participants described multiple challenges that prevented their patient-family unit from making informed decisions about transplant care. These challenges included communication with their patient, patients resisting help, difficulty understanding the information, and feeling helpless.

CONCLUSION

Family members providing care to patients with end-stage kidney disease require targeted support to overcome the unique challenges associated with their role in helping to meet their patient's clinical needs. Interventions to engage friends and family members in the care of kidney transplant candidates need to effectively address these challenges.

Thematic Analysis of the Health Records of a National Sample of US Veterans With Advanced Kidney Disease Evaluated for Transplant

IMPORTANCE

To be considered for a kidney transplant, patients with advanced kidney disease must participate in a formal evaluation and selection process. Little is known about how this process proceeds in real-world clinical settings.

OBJECTIVE

To characterize the transplant evaluation process among a representative national sample of US veterans with advanced kidney disease who were referred to a kidney transplant center.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study was a thematic analysis of clinician notes in the electronic health records of US veterans referred for kidney transplant evaluation. In a random sample of 4000 patients with advanced kidney disease between January 1, 2004, and December 31, 2014, cared for in the US Department of Veterans Affairs (VA) health care system, there were 211 patients who were referred to a transplant center during the follow-up period. This group was included in the qualitative analysis and was followed up until their date of death or the end of the follow-up period on October 8, 2019.

MAIN OUTCOMES AND MEASURES

Dominant themes pertaining to the kidney transplant evaluation and selection process identified through thematic analysis.

RESULTS

Among 211 study patients, the mean (SD) age was 57.9 (9.5) years, and 202 patients (95.7%) were male. The following 4 dominant themes regarding the transplant evaluation process emerged: (1) far-reaching and inflexible medical evaluation, in which patients were expected to complete an extensive evaluation that could have substantial physical and emotional consequences, made little accommodation for their personal values and needs, and impacted other aspects of their care; (2) psychosocial valuation, in which the psychosocial component of the transplant assessment could be subjective and intrusive and could place substantial demands on patients' family members; (3) surveillance over compliance, in which the patients' ability and willingness to follow medical recommendations was an important criterion for transplant candidacy and their adherence to a wide range of recommendations and treatments was closely monitored; and (4) disempowerment and lack of transparency, in which patients and their local clinicians were often unsure about what to expect during the evaluation process or about the rationale for selection decisions. For the evaluation process to proceed, local clinicians had to follow transplant center requirements even when they believed the requirements did not align with best practices or the patients' needs.

CONCLUSIONS AND RELEVANCE

In this qualitative study of US veterans with advanced kidney disease evaluated for transplant, clinician documentation in the medical record indicated that, to be considered for a kidney transplant, patients were required to participate in a rigid, demanding, and opaque evaluation and selection process over which they and their local clinicians had little control. These findings highlight the need for a more evidence-based, individualized, and collaborative approach to kidney transplant evaluation.