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Background: Failure of a previously transplanted kidney is a common cause of end-stage renal disease (ESRD) and represents 5% of incident dialysis patients in the United States. Patients with native kidney failure ESRD (Nat-ESRD) who receive predialysis care from a nephrologist have better outcomes in the first 12 months on dialysis than those who don't. Because many patients with a failed kidney transplant ESRD (Tx-ESRD) receive care from nephrologists, they would also be expected to have good dialysis outcomes. We sought to compare the quality metrics of Tx-ESRD patients and Nat-ESRD patients during the first 12 months of hemodialysis., Methods: We used data from the United States Renal Data System to identify hemodialysis patients who began treatment between May 2012 and December 2013 and who received nephrology care prior to starting hemodialysis. Quality metrics by quarter for the first 12 months of treatment were dichotomized according to practice guidelines to determine the percentage of patients in each quarter who met quality of care goals., Results: Compared to Nat-ESRD (n = 96,063) patients, Tx-ESRD (n = 5,528) patients had 10-19% lower rates of at goal hemoglobin levels, 6-12% lower rates of at goal serum phosphorus, and 3-11% lower rates of at goal albumin levels. Compared to Nat-ESRD patients, -Tx-ESRD patients had a 6% higher rate of fistula use in the first quarter but a 3-7% lower rate in subsequent quarters., Conclusions: Tx-ESRD patients have worse quality metrics related to anemia, phosphorus, albumin, and vascular access compared to Nat-ESRD patients. Nephrology care for patients with Tx-ESRD should be improved to address these quality metrics gaps., (© 2019 S. Karger AG, Basel.)

Background and Objective: The use of trained kidney transplant recipients as patient navigators resulted in increased completion of the steps in the transplant process by dialysis patients. We sought to understand the experiences of these patient navigators., Setting and Participants: Six kidney transplant recipients were hired and employed by transplant centers in Ohio, Kentucky, and Indiana. The transplant navigators received formal training as peer educators, met with dialysis patients on a regular basis, and provided tailored education and assistance about transplantation to each patient. They worked closely with the pretransplant coordinators and social workers to learn the details of each patient's transplant work-up., Methodology: We queried navigators using open-ended questions to learn about their experiences. Navigator responses were coded and common themes identified. A thematic auditor reviewed and refined the coding., Results: Two primary categories of themes emerged about the navigator experience: 1. practical comments that supported programmatic or implementation observations of the navigators, and 2. affective comments that reflected a shared experience among the navigators and patients. The navigators were able to fill voids in the transplant process that were not fulfilled by other caregivers. This was accomplished by a natural bond based upon a shared experience (of dialysis and kidney failure) between the navigator and the patient. The patient and navigator became experiential partners., Conclusion: Kidney transplant recipients trained as patient navigators fill the role of a nontraditional medical provider, offer support during the transplant process, and provide an added benefit to complement routine dialysis and nephrology care., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background and Objectives: Many patients with ESKD face barriers in completing the steps required to obtain a transplant. These eight sequential steps are medical suitability, interest in transplant, referral to a transplant center, first visit to center, transplant workup, successful candidate, waiting list or identify living donor, and receive transplant. This study sought to determine the effect of navigators on helping patients complete these steps., Design, Setting, Participants, & Measurements: Our study was a cluster randomized, controlled trial involving 40 hemodialysis facilities and four transplant centers in Ohio, Kentucky, and Indiana from January 1, 2014 to December 31, 2016. Four trained kidney transplant recipients met regularly with patients on hemodialysis at 20 intervention facilities, determined their step in the transplant process, and provided tailored information and assistance in completing that step and subsequent steps. Patients at 20 control facilities continued to receive usual care. Primary study outcomes were waiting list placement and receipt of a deceased or living donor transplant. An exploratory outcome was first visit to a transplant center., Results: Before the trial, intervention (1041 patients) and control (836 patients) groups were similar in the proportions of patients who made a first visit to a transplant center, were placed on a waiting list, and received a deceased or living donor transplant. At the end of the trial, intervention and control groups were also similar in first visit (16.1% versus 13.8%; difference, 2.3%; 95% confidence interval, -0.8% to 5.5%), waitlisting (16.3% versus 13.8%; difference, 2.5%; 95% confidence interval, -1.2% to 6.1%), deceased donor transplantation (2.8% versus 2.2%; difference, 0.6%; 95% confidence interval, -0.8% to 2.1%), and living donor transplantation (1.2% versus 1.0%; difference, 0.1%; 95% confidence interval, -0.9% to 1.1%)., Conclusions: Use of trained kidney transplant recipients as navigators did not increase first visits to a transplant center, waiting list placement, and receipt of deceased or living donor transplants., (Copyright © 2018 by the American Society of Nephrology.)

Background and Objectives: Despite the benefits of kidney transplantation, the total number of transplants performed in the United States has stagnated since 2006. Transplant center quality metrics have been associated with a decline in transplant volume among low-performing centers. There are concerns that regulatory oversight may lead to risk aversion and lack of transplantation growth., Design, Setting, Participants, & Measurements: A retrospective cohort study of adults (age≥18 years) wait-listed for kidney transplantation in the United States from 2003 to 2010 using the Scientific Registry of Transplant Recipients was conducted. The primary aim was to investigate whether measured center performance modifies the survival benefit of transplantation versus dialysis. Center performance was on the basis of the most recent Scientific Registry of Transplant Recipients evaluation at the time that patients were placed on the waiting list. The primary outcome was the time-dependent adjusted hazard ratio of death compared with remaining on the transplant waiting list., Results: Among 223,808 waitlisted patients, 59,199 and 32,764 patients received a deceased or living donor transplant, respectively. Median follow-up from listing was 43 months (25th percentile=25 months, 75th percentile=67 months), and there were 43,951 total patient deaths. Deceased donor transplantation was independently associated with lower mortality at each center performance level compared with remaining on the waiting list; adjusted hazard ratio was 0.24 (95% confidence interval, 0.21 to 0.27) among 11,972 patients listed at high-performing centers, adjusted hazard ratio was 0.32 (95% confidence interval, 0.31 to 0.33) among 203,797 patients listed at centers performing as expected, and adjusted hazard ratio was 0.40 (95% confidence interval, 0.35 to 0.45) among 8039 patients listed at low-performing centers. The survival benefit was significantly different by center performance (P value for interaction <0.001)., Conclusions: Findings indicate that measured center performance modifies the survival benefit of kidney transplantation, but the benefit of transplantation remains highly significant even at centers with low measured quality. Policies that concurrently emphasize improved center performance with access to transplantation should be prioritized to improve ESRD population outcomes., (Copyright © 2014 by the American Society of Nephrology.)

Numerous factors impact patients' health beyond traditional clinical characteristics. We evaluated the association of risk factors in kidney transplant patients' communities with outcomes prior to transplantation. The primary exposure variable was a community risk score (range 0-40) derived from multiple databases and defined by factors including prevalence of comorbidities, access and quality of healthcare, self-reported physical and mental health and socioeconomic status for each U.S. county. We merged data with the Scientific Registry of Transplant Recipients (SRTR) and utilized risk-adjusted models to evaluate effects of community risk for adult candidates listed 2004-2010 (n = 209 198). Patients in highest risk communities were associated with increased mortality (adjusted hazard ratio [AHR] = 1.22, 1.16-1.28), decreased likelihood of living donor transplantation (adjusted odds ratio [AOR] = 0.90, 0.85-0.94), increased waitlist removal for health deterioration (AHR = 1.36, 1.22-1.51), decreased likelihood of preemptive listing (AOR = 0.85, 0.81-0.88), increased likelihood of inactive listing (AOR = 1.49, 1.43-1.55) and increased likelihood of listing for expanded criteria donor kidneys (AHR = 1.19, 1.15-1.24). Associations persisted with adjustment for rural-urban location; furthermore the independent effects of rural-urban location were largely eliminated with adjustment for community risk. Average community risk varied widely by region and transplant center (median = 21, range 5-37). Community risks are powerful factors associated with processes of care and outcomes for transplant candidates and may be important considerations for developing effective interventions and measuring quality of care of transplant centers., (© Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Background: We sought to determine the accuracy of dialysis medical records in identifying patients' interest in and suitability for transplantation., Study Design: Cluster randomized controlled trial., Setting and Participants: A total of 167 patients recruited from 23 hemodialysis facilities., Intervention: Navigators met with intervention patients to provide transplant information and assistance. Control patients continued to receive usual care., Outcomes: Agreement at study initiation between medical records and (i) patient self-reported interest in transplantation and (ii) study assessments of medical suitability for transplant referral., Measurements: Medical record assessments, self-reports, and study assessments of patient's interest in and suitability for transplantation., Results: There was disagreement between medical records and patient self-reported interest in transplantation for 66 (40%) of the 167 study patients. In most of these cases, patients reported being more interested in transplantation than their medical records indicated. The study team determined that all 92 intervention patients were medically suitable for transplant referral. However, for 38 (41%) intervention patients, medical records indicated that they were not suitable. About two-thirds of these patients successfully moved forward in the transplant process., Conclusion: Dialysis medical records are frequently inaccurate in determining patient's interest in and suitability for transplantation., (© 2013 John Wiley & Sons A/S.)

SRTR report cards provide the basis for quality measurement of US transplant centers. There is limited data evaluating the prognostic value of report cards, informing whether they are predictive of prospective patient outcomes. Using national SRTR data, we simulated report cards and calculated standardized mortality ratios (SMR) for kidney transplant centers over five distinct eras. We ranked centers based on SMR and evaluated outcomes for patients transplanted the year following reports. Recipients transplanted at the 50th, 100th and 200th ranked centers had 18% (AHR = 1.18, 1.13-1.22), 38% (AHR = 1.38, 1.28-1.49) and 91% (AHR = 1.91, 1.64-2.21) increased hazard for 1-year mortality relative to recipients at the top-ranked center. Risks were attenuated but remained significant for long-term outcomes. Patients transplanted at centers meeting low-performance criteria in the prior period had 40% (AHR = 1.40, 1.22-1.68) elevated hazard for 1-year mortality in the prospective period. Centers' SMR from the report card was highly predictive (c-statistics > 0.77) for prospective center SMRs and there was significant correlation between centers' SMR from the report card period and the year following (ρ = 0.57, p < 0.001). Although results do not mitigate potential biases of report cards for measuring quality, they do indicate strong prognostic value for future outcomes. Findings also highlight that outcomes are associated with center ranking across a continuum rather than solely at performance margins., (© Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Background and Objectives: Many patients with ESRD, particularly minorities and women, face barriers in completing the steps required to obtain a transplant. These eight sequential steps are as follows: medical suitability, interest in transplant, referral to a transplant center, first visit to center, transplant workup, successful candidate, waiting list or identify living donor, and receive transplant. This study sought to determine the effect of navigators on completion of steps., Design, Setting, Participants, & Measurements: Cluster randomized, controlled trial at 23 Ohio hemodialysis facilities. One hundred sixty-seven patients were recruited between January 2009 and August 2009 and were followed for up to 24 months or until study end in February 2011. Trained kidney transplant recipients met monthly with intervention participants (n=92), determined their step in the transplant process, and provided tailored information and assistance in completing the step. Control participants (n=75) continued to receive usual care. The primary outcome was the number of transplant process steps completed., Results: Starting step did not significantly differ between the two groups. By the end of the trial, intervention participants completed more than twice as many steps as control participants (3.5 versus 1.6 steps; difference, 1.9 steps; 95% confidence interval, 1.3-2.5 steps). The effect of the intervention on step completion was similar across race and sex subgroups., Conclusions: Use of trained transplant recipients as navigators resulted in increased completion of transplant process steps.

Objective: To evaluate the association of community health indicators with outcomes for kidney transplant recipients., Design: Retrospective observational cohort study using multivariable Cox proportional hazards models., Setting: Transplant recipients in the United States from the Scientific Registry of Transplant Recipients merged with health indicators compiled from several national databases and the Centers for Disease Control and Prevention, including the National Center for Health Statistics, the Behavioral Risk Factor Surveillance System, and the National Center for Chronic Disease Prevention and Health Promotion., Patients: A total of 100 164 living and deceased donor adult (aged 18 years) kidney transplant recipients who underwent a transplant between January 1, 2004, and December 31, 2010., Main Outcome Measures: Risk-adjusted time to posttransplant mortality and graft loss., Results: Multiple health indicators from recipients' residence were independently associated with outcomes, including low birth weight, preventable hospitalizations, inactivity rate, and smoking and obesity prevalence. Recipients in the highest-risk counties were more likely to be African American (adjusted odds ratio, 1.59, 95% CI, 1.51-1.68), to be younger (aged 18-39 years; 1.46; 1.32-1.60), to have lower educational attainment (

Numerous studies report a strong association between pretransplant end-stage renal disease (ESRD) duration and diminished transplant outcomes. However, cumulative waiting time may reflect distinct phases and processes related to patients' physiological condition as well as pre-existing morbidity and access to care. The relative impact of pre- and postlisting ESRD durations on transplant outcomes is unknown. We examined the impact of these intervals from a national cohort of kidney transplant recipients from 1999 to 2008 (n = 112,249). Primary factors explaining prelisting ESRD duration were insurance and race, while primary factors explaining postlisting ESRD duration were blood type, PRA% and variation between centers. Extended time from ESRD to waitlisting had significant dose-response association with overall graft loss (AHR = 1.26 for deceased donors [DD], AHR = 1.32 for living donors [LD], p values < 0.001). Contrarily, time from waitlisting (after ESRD) to transplantation had negligible effects (p = 0.10[DD], p = 0.57[LD]). There were significant associations between pre- and postlisting ESRD time with posttransplant patient survival, however prelisting time had over sixfold greater effect. Prelisting ESRD time predominately explains the association of waiting time with transplant outcomes suggesting that factors associated with this interval should be prioritized for interventions and allocation policy. The degree to which the effect of prelisting ESRD time is a proxy for comorbid conditions, socioeconomic status or access to care requires further study., (© 2010 The Authors Journal compilation © 2010 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Background and Significance: Self-care for kidney transplantation is recommended to maintain kidney function. Little is known about levels of self-care practices and demographic, psychosocial, and health-related correlates., Aim: To investigate patients' self-reported exercise and fluid intake, demographic and psychosocial factors associated with these self-care practices, and health-related quality of life., Methods: Eighty-eight of 158 kidney recipients from two academic medical centers completed a semi-structured interview and surveys 2 months post-transplant., Results: Most patients were sedentary (76%) with a quarter exercising either regularly (11%) or not at current recommendations (13%). One-third (35%) reported drinking the recommended 3 L of fluid daily. Multivariate analyses indicated that private insurance, high self-efficacy, and better physical functioning were significantly associated with engaging in physical activity (p < 0.05); while male gender, private insurance, high self-efficacy, and not attributing oneself responsible for transplant success were significant predictors of adherence to fluid intake (p < 0.05). Despite the significance of these predictors, models for physical activity and fluid intake explained 10-15% of the overall variance in these behaviors. Multivariate analyses indicated that younger age, high value of exercise, and higher social functioning significantly (p < 0.05) predicted high self-efficacy for physical activity, while being married significantly (p < 0.05) predicted high self-efficacy for fluid intake., Conclusion: Identifying patients at risk of inadequate self-care practice is essential for educating patients about the importance of self-care.

Background and Objectives: Waiting times to deceased-donor transplantation (DDTx) have significantly increased in the past decade. This trend particularly affects older candidates given a high mortality rate on dialysis., Design, Setting, Participants, & Measurements: We conducted a retrospective analysis from the national Scientific Registry of Transplant Recipients database that included 54,669 candidates who were older than 60 yr and listed in the United States for a solitary kidney transplant from 1995 through 2007. Using survival models, we estimated time to DDTx and mortality after candidate listing with and without patients initially listed as temporarily inactive (status 7)., Results: Almost half (46%) of candidates who were older than 60 yr and listed in 2006 through 2007 are projected to die before receiving a DDTx. This proportion varied by individual characteristics: Diabetes (61%), age > or =70 yr (52%), black (62%), blood types O (60%) and B (71%), highly sensitized (68%), and on dialysis at listing (53%). Marked variation also existed by United Network for Organ Sharing region (6 to 81%). The overall projected proportion was reduced to 35% excluding patients who initially were listed as status 7., Conclusions: These data highlight the prominent and growing challenge facing the field of kidney transplantation. Older candidates are now at significant risk for not surviving the interval in which a deceased-donor transplant would become available. Importantly, this risk is variable within this population, and specific information should be disseminated to patients and caregivers to facilitate informed decision-making and potential incentives to seek living donors.

Medication adherence is essential for the survival of kidney grafts, however, the complexity of the medication-taking regimen makes adherence difficult. Little is known about barriers to medication-taking and strategies to foster medication-taking. This cross-sectional study involved semi-structured interviews with 82 kidney transplant recipients approximately 2 months post-transplant on medication-related adherence, barriers to medication-taking, and strategies to foster medication-taking. Although self-reported adherence was high (88%), qualitative analysis revealed that half of the patients (49%) reported experiencing at least one barrier to medication-taking. The most common barriers were: not remembering to refill prescriptions (13%), changes to medication prescriptions or dosages (13%), being busy (10%), forgetting to bring medicines with them (10%), and being away from home (10%). The most common strategies to foster medication-taking were: maintaining a schedule of medication-taking (60%), organizing pills using pillboxes, baggies, cups (42%), bringing medicines with them (34%), organizing pills according to routine times (32%), and relying on other people to remind them (26%). Understanding the range of barriers to adherence and strategies kidney recipients devised to promote medication-taking may help transplant clinicians to better educate transplant recipients about appropriate medication-taking, mitigate the risk of medication nonadherence-related rejection, and may help inform patient-centered interventions to improve medication adherence.

Background: This study aimed to examine kidney transplant recipients' ability to afford transplant-related out-of-pocket expenses and the financial impact of these expenses on their lives., Patients and Methods: This cross-sectional study involved 77 kidney recipients. Variables analyzed were: ability to afford daily necessities; impact of immunosuppressant expenses on patients' lives; awareness of Medicare support terminating three yr post-transplant; and strategies used to pay for out-of-pocket transplant expenses. The Economic Strain Scale measured financial strain., Results: Twenty-nine percent of kidney recipients experienced financial strain. Poor, less educated, and younger patients were more likely to report financial strain. Out-of-pocket expenses relating to kidney transplantation adversely affected patients' ability to afford leisure activities (35%), a house (27%), and a car (26%). Thirty-one percent reported that immunosuppressant expenses have had somewhat to great (adverse) impact on their lives. Of those on Medicare and not disabled (n = 41), 51% were unaware Medicare coverage will terminate and 71% did not know how long coverage lasts., Conclusions: Financial strain presents a considerable risk to kidney recipients' ability to purchase immunosuppression. Socioeconomic disparities in recipients' financial strain may be a source of disparities in graft survival. Transplant professionals should better inform transplant candidates about financial consequences of transplantation.

Context: Many countries have a shortage of kidneys available for transplantation. Paying people to donate kidneys is often proposed or justified as a way to benefit recipients by increasing the supply of organs and to benefit donors by improving their economic status. However, whether individuals who sell their kidneys actually benefit from the sale is controversial., Objective: To determine the economic and health effects of selling a kidney., Design, Setting, and Participants: Cross-sectional survey conducted in February 2001 among 305 individuals who had sold a kidney in Chennai, India, an average of 6 years before the survey., Main Outcome Measures: Reasons for selling kidney, amount received from sale, how money was spent, change in economic status, change in health status, advice for others contemplating selling a kidney., Results: Ninety-six percent of participants sold their kidneys to pay off debts. The average amount received was 1070 US dollars. Most of the money received was spent on debts, food, and clothing. Average family income declined by one third after nephrectomy (P<.001), and the number of participants living below the poverty line increased. Three fourths of participants were still in debt at the time of the survey. About 86% of participants reported a deterioration in their health status after nephrectomy. Seventy-nine percent would not recommend that others sell a kidney., Conclusions: Among paid donors in India, selling a kidney does not lead to a long-term economic benefit and may be associated with a decline in health. Physicians and policy makers should reexamine the value of using financial incentives to increase the supply of organs for transplantation.

Background: Kidney transplantation rates differ by patient and dialysis-facility characteristics, yet little is known about the sources of this variation or how access to transplantation can be improved. Examining specific steps in the transplantation process may guide quality improvement efforts that ultimately improve the equity and efficiency of transplantation., Methods: We sought to examine variation across dialysis facilities in the completion of four specific steps (medical suitability, interest in transplantation, pretransplantation workup, and waiting list) after adjustment for patient characteristics. Using 11,674 patients on chronic hemodialysis therapy between January 1993 and December 1996 at 206 facilities in Indiana, Kentucky, and Ohio, we derived facility-specific: (1) actual completion rates at each step; (2) expected completion rates based on patient age, race, sex, and cause of renal failure; and (3) ratio of actual to expected completion rates., Results: Actual completion rates varied greatly, with facilities at the 75th percentile having a twofold greater completion rate than facilities at the 25th percentile (eg, 59% versus 32% at the first step). Although patient characteristics were strongly associated with step completion, adjustment for these characteristics did not decrease variation across facilities. At each step, approximately 20% of facilities had a significantly greater than expected completion rate, whereas approximately 15% had a significantly lower than expected completion rate., Conclusion: There is substantial variation across dialysis facilities in access to kidney transplantation, even after adjustment for patient characteristics. Identifying steps with less than expected completion rates may help facilities target such efforts as treatment of medical conditions, patient education, and early referral for pretransplantation workup and waiting list placement., (Copyright 2002 by the National Kidney Foundation, Inc.)

The cadaveric renal transplantation process involves steps related to medical suitability, interest in transplantation, pretransplantation workup, and movement up a waiting list. Failure to complete specific steps may be caused by remaining stationary at that step, moving backward to a previous step, or dying. Knowing the relative importance of these types of movement may enable the development of strategies that improve the efficiency and equity of the transplantation process. We examined 4,597 new dialysis patients to determine the likelihood of remaining stationary, moving backward, or dying at each of the following steps: (A) being medically suitable and possibly interested in transplantation, (B) being definitely interested, (C) completing the pretransplantation workup, and (D) moving up a waiting list and receiving a transplant. Failure to complete a step was generally caused by remaining stationary rather than moving backward or dying. The likelihood of remaining stationary ranged from 78% at step A to 90% at step D. The likelihood of backward movement ranged from 3% to 7%, whereas the likelihood of death ranged from 7% to 22%. Compared with whites, blacks were more likely to remain stationary at steps A (odds ratio [OR], 1.96) and B (OR, 1.52), more likely to move backward at step B (OR, 1.79), and less likely to die at steps A through C (ORs, 0.45 to 0.60). In conclusion, failure to move through the transplantation process is usually caused by remaining stationary at specific steps rather than moving backward or dying. The relative importance of these types of movement differs among blacks and whites.

The kidney transplantation process involves a series of steps related to interest in transplantation, medical suitability, pretransplant workup, and eventual transplantation. We developed transplant status codes to monitor the progress of dialysis patients in Ohio, Kentucky, Indiana, and Illinois as they move through these steps. Of the first 2,137 dialysis patients monitored with these new codes, 29% were interested in receiving a transplant, 31% were medically suitable to receive a kidney transplant, 15% had completed a pretransplant workup, 13% were on a cadaveric transplant waiting list, and 2% were awaiting a living-related transplant. Examination of these steps by gender showed differences in interest (men 32% v women 26%, P =.01) and medical suitability (men 33% v women 28%, P =.01). The proportion of patients successfully completing each step differed across facilities. In conclusion, transplant status codes are a useful method to monitor access to transplantation. As part of a facility-specific quality improvement program, such codes may be used to develop targeted interventions to help patients move through the transplant process as expeditiously as possible., (Copyright 2000 by the National Kidney Foundation, Inc.)

The outcomes of renal replacement therapy differ dramatically by race and gender. Compared with white patients, black patients have poorer outcomes in five clinical parameters (anemia, hypertension, vascular access, adequacy of dialysis, compliance), employment, and access to transplantation. Compared with males, females have poorer outcomes in hospitalization, three clinical parameters (anemia, vascular access, nutrition), quality of life, and access to transplantation. Despite several poorer intermediate outcomes, blacks and women do better than whites and men in survival. Eliminating racial and gender differences in outcomes of renal replacement therapy requires that we (1) become aware of such differences, (2) determine barriers to optimal outcomes, and (3) develop interventions to overcome these barriers. This approach can lead to improved outcomes not just among blacks and women but among all renal patients. Examining racial and gender differences can also lead to an increased understanding of renal disease.

Little is known about how nephrologists discuss transplantation as a treatment option with end-stage renal disease patients. The authors sought to describe the content and manner of patient-nephrologist discussions about transplantation. Using a cross-sectional study design, we interviewed 79 chronic hemodialysis patients and 12 nephrologists using a semistructured questionnaire that focused on nephrologist and patient reports of discussions about transplantation. The authors found that nephrologists provided information on treatment options gradually over several weeks to months. They generally presented the option of dialysis first, then transplantation, but avoided discussing mortality data. Nephrologists said they encouraged most patients, but especially young patients, to seek transplantation. Of all patients, 68% reported being encouraged to seek transplantation by nephrologists. Low socioeconomic status patients were less likely to report being encouraged to seek transplantation even after adjustment for transplant suitability. Both nephrologists and patients avoided discussing life expectancy data. In conclusion, patient age and socioeconomic status appear to influence discussions of transplantation as a treatment option. Further work is needed to determine how the content and manner of such discussions affect treatment decisions.

Context: Cadaveric renal transplantation rates differ greatly by race, sex, and income. Previous efforts to lessen these differences have focused on the transplant waiting list. However, the transplantation process involves a series of steps related to medical suitability, interest in transplantation, pretransplant workup, and movement up a waiting list to eventual transplantation., Objective: To determine the relative importance of each step in explaining differences in cadaveric renal transplantation rates., Design: Prospective cohort study., Setting and Patients: A total of 7125 patients beginning long-term dialysis between January 1993 and December 1996 in Indiana, Kentucky, and Ohio., Main Outcome Measures: Completion of 4 separate steps during each patient-year of follow-up: (A) being medically suitable and possibly interested in transplantation; (B) being definitely interested in transplantation; (C) completing the pretransplant workup; and (D) moving up a waiting list and receiving a transplant., Results: Compared with whites, blacks were less likely to complete steps B (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.61-0.76), C (OR, 0.56; 95% CI, 0.48-0.65), and D (OR, 0.50; 95% CI, 0.40-0.62) after adjustment for age, sex, cause of renal failure, years receiving dialysis, and median income of patient ZIP code. Compared with men, women were less likely to complete each of the 4 steps, with ORs of 0.90, 0.89, 0.80, and 0.82, respectively. Poor individuals were less likely than wealthy individuals to complete steps A, B, and C, with ORs of 0.67, 0.78, and 0.77, respectively., Conclusions: Barriers at several steps are responsible for sociodemographic differences in access to cadaveric renal transplantation. Efforts to allocate kidneys equitably must address each step of the transplant process.

Offering financial incentives to families of brain-dead individuals has been proposed as a way to increase the supply of organs for transplantation. However, such incentives may lead to weakening of altruism and exploitation of poor families. We investigated dialysis patient attitudes toward the potential benefits and problems of incentives. Using a structured questionnaire, we interviewed 60 randomly selected patients at three chronic hemodialysis units. Subjects were asked to make an explicit trade-off between maintaining altruism versus increasing the supply of kidneys. They were also asked to make a trade-off between protecting poor families versus increasing the supply of kidneys. In addition, we asked subjects how they thought incentives would affect donation by different types of families. We found that 37% of all subjects placed more emphasis on maintaining altruism, 42% placed more emphasis on increasing the supply of kidneys, and 22% placed an equal emphasis on maintaining altruism and on increasing the supply of kidneys. Similarly, 35% of all subjects placed more emphasis on protecting poor families, 33% placed more emphasis on increasing the supply of kidneys, and 32% placed an equal emphasis on protecting poor families and on increasing the supply of kidneys. Subjects thought financial incentives would greatly increase donation by poor families while having little impact on rich families. In conclusion, even though dialysis patients are likely to benefit from increasing the supply of kidneys, many of them want to maintain altruism and protect poor families even if that means fewer kidneys. These concerns should be addressed in proposals to modify the transplant system.