Evaluation Process for Transplant Can Be Burdensome

Increasing access to kidney transplant for patients with advanced kidney disease has strong public and professional support. Nevertheless, more liberal practices for referral for kidney transplantation may increase the number of patients who are evaluated for transplant but do not receive a kidney. Shared decision making about transplant referral would be supported with a deeper understanding of the implications of being referred for transplant evaluation bit not receiving a kidney.

Catherine Butler and colleagues conducted a qualitative analysis of adults referred to a transplant coordinator with no receipt of a kidney. Results of the analysis were reported during a poster session at Kidney Week 2019 in a poster titled Care Practices for Patients with Advanced Kidney Disease Who Were Evaluated for Transplant but Did Not Receive a Kidney.

The analysis utilized data from the electronic medical record (EMR) for 148 patients with advanced kidney disease who were referred to the Veterans Affairs Puget Sound Health Care System’s transplant coordinator from 2008 to 2018 who did not subsequently receive a kidney during the follow-up period. Patients were followed their death date or January 1, 2018. The researchers conducted an inductive content analysis to determine dominant emergent themes related to transplant evaluation.

At the end of follow-up, 71% of the 209 adults evaluated for transplant during the study period had not received a kidney (n=148/209). Analysis of the EMR for this subset of patients revealed three dominate themes: (1) sources of forward momentum in the process of transplant evaluation; patients were commonly referred for transplant evaluation reflexively and the tendency was for the evaluation process to more forward until identification of an absolute contraindication or the patient passively withdrew; (2) the potential for transplant informs other medical decisions; engagement in the evaluation process may have far-reaching effects on other aspects of medical care; and (3) personal responsibility and psychological burden; patients felt personally responsible for their progress through the evaluation process, creating the possibility that the evaluation process could create a significant emotional toll on patients and families.

In summary, the researchers said, “Most patients evaluated for transplant at our center did not receive a kidney. The evaluation process could be burdensome and emotionally taxing for these patients and their families and could intrude on many other aspects of their care. These findings highlight the potential tradeoffs involved in being evaluated for kidney transplant and argue for engaging patients in a deliberate and shared approach to referral decisions.”

Source: Butler C, Taylor JS, Reese PP, O’Hare AM. Care practices for patients with advanced kidney disease who were evaluated for transplant but did not receive a kidney. Abstract of a poster presented during the American Society of Nephrology Kidney Week 2019 (Abstract TH-PO1150), November 7, 2019, Washington, DC.