Everyoneʼs Got Their Own Threshold. Nephrologistsʼ Perspectives On Patient Eligibility and Access to Living Donor Kidney Transplantation.

Abstract

Background: Wide variations in access to living donor kidney transplantation are apparent. We aimed to describe nephrologists' beliefs and attitudes towards recipient eligibility and access to living donor kidney transplantation to determine if these may impact decisions regarding patient suitability for living donor transplantation. Methods: Face-to-face semi-structured interviews were conducted with 41 nephrologists from 22 centers in Australia and New Zealand. Transcripts were analyzed thematically. Results: We identified five major themes: justifying donor sacrifice (ensuring reasonable graft survival, warranting adherence, reciprocal donor benefits, perceived urgency); championing recipient outcomes (responsibility for patient advocacy, maximizing survival, earning trust and confidence); cognizance of boundaries (avoiding coercion, guarding against external pressure, minimizing conflict of interest, emphasizing patient accountability, maintaining center performance); entrenched inequalities (self-perpetuating disadvantage, exclusivity of suitable donors, selective recommendations); contending with infrastructural inadequacy (limited transparency, geographical disadvantage, frustrating inefficiency, visibility of transplantation). Conclusions: There is substantial variability in the attitudes and preferences of nephrologists' regarding recipient eligibility which may explain some of the differences in living donor kidney transplantation rates. An explicit pathway for patient education and referral to transplant services and comprehensive guidelines which include recommendations on complex medical and psychosocial considerations might promote transparent decision-making and target inequalities in access to living donor kidney transplantation.