Is It Time to Make Renal Transplantation Referral Mandatory?

Abstract

In the last 2 decades, renal transplantation has been established as the best form of replacement therapy for most patients with end-stage kidney disease.1,2 Yet, the majority of patients who can benefit from renal transplantation are referred late or never referred to a transplant center.3 Barriers to referral have 3 different sources: the treating nephrologist, the patient, and the medical system. Often, treating physicians may have considered a transplant option but judged the patient to be too old or have many comorbidities to be eligible for renal transplantation. Sometimes, the nephrologists have to concentrate on the immediate initiation of dialysis due to the patient’s rapid deterioration of renal function. Patients have to overcome the complexity of the referral process that can be lengthy and exhausting, including medical suitability, pretransplant workup, and interest in transplantation, before they can be waitlisted. Some patients may simply give up or become too ill. Finally, there are both financial incentives and disincentives for nephrologists, dialysis centers, and eligibility for Medicare coverage for end-stage renal disease.4 It is important to point out that similarly restrictive practices to transplantation referral also exist in public healthcare systems such as in Canada and the United Kingdom.5,6 Part of the process to improve the effectiveness of the transplantation referral and waitlisting includes a comprehensive transplant education. In this issue of Transplantation, Waterman et al7 report on a survey of 1694 US dialysis centers, an extension of their prior work from 2015,8 on their educational practices and determined which are associated with increased waitlisting rates. The majority of the educators surveyed were female, Caucasian, and social workers. There were 12 transplant education practices and 8 reported barriers to providing transplant education assessed by the authors. Combined transplant education strategies such as distribution of print education and using >1 intensive education practice within dialysis centers were associated with higher waitlisting rates. This goes along with the Center for Medicare and Medicaid Services requirement for providers to inform patients of their transplant options within 45 days of initiating dialysis and a more recent Center for Medicare and Medicaid Service Technical Expert Panel requiring more specific metrics for transplant educational delivery in dialysis centers.9 The most important finding from this report is that a minority of centers used what is considered an intensive education approach which was associated with an increased odds ratio of waitlisting. The current study shows that a reduced odds ratio of using intensive education strategies is associated with centers having a greater percentage of uninsured patients, rural locations, for profit ownership, and dialysis patients >65 years old. Considering that the mortality rate of patients on dialysis at 5 years exceeds 60%,10 a timely referral and transplantation should be viewed with the same urgency perspective as for patients with other life threatening conditions. Perhaps we should review the process of mandatory information of transplant options and complement it with more intensive education practices and improved communication between dialysis and transplant centers. Perhaps the transplant community can encourage a change in the paradigm toward a form of mandatory referral of patients for a transplantation assessment. Transplant centers can help in the process of educating dialysis centers in better identifying eligibility of candidates and to rule out those with specific contraindications. Our patients certainly deserve to have every option to be able to make the best decision for their care. Increasing education of patients, patients' families, and general nephrologists about renal transplantation should harmonize practice and increase referral for renal transplantation. ACKNOWLEDGMENTs The authors wish to thank Andrea Herrera-Gayol, MD, MSc, PhD, for her critical review on the commentary.