Kidney Transplant Access in the Southeast: Middle View

Abstract

To the Editor: We commend the authors of the article “Kidney Transplant Access in the Southeast: View from the Bottom” (Patzer and Pastan) for their insightful findings 1. The impact of a geographical divide is certainly evident and we agree with the findings of the authors. We wanted to expand the conversation by mentioning additional barriers to renal transplant access. Selection criteria for renal transplantation across the various transplant centers tend to vary. Transplant centers may restrict their eligibility criteria in pursuit of achieving better outcomes. As mentioned by Schold et al, “Centers with a higher risk candidate pool are significantly more likely to be identified for poor performance and could potentially lose public funding. Pressures to enhance outcomes may lead centers to exclude high-risk but otherwise viable transplant candidates” (2, p. 1). Though transplant may improve the individual outcome, the relatively shorter survival compared with healthier candidates can negatively impact outcome statistics especially if the volume of transplant done is low. By creating a uniform selection criteria, renal transplant candidates may be better served since centers will be basing their decisions by using an already established criterion. Uniform selection criteria also allow other healthcare providers to begin addressing risk factors that can potentially limit a patient's eligibility before reaching the stage for renal transplantation. For example, uniform criteria for BMI will increase efforts to encourage transplant candidates to join weight loss programs prior to being evaluated for transplant. Last, common goals will improve the sharing of beneficial resources among the various centers, such as weight loss, diet and nutrition counseling, as well as social support networking. Cultural beliefs and personal perceptions continue to influence the rate of renal transplantation and should be addressed. For example, African Americans were less likely to believe that their quality of life will improve after renal transplantation 3. Cultural beliefs may also limit the number of kidney donors from minority groups. It is important to note that these perceptions exist among the physicians as well. Physician perception was directly correlated to the rate of referral for renal transplantation. Ayanian et al reported that “physicians were less likely to believe transplantation prolonged survival relative to dialysis for black patients than for white patients” (4, p. 354). Therefore, educating physicians about being cognizant of such perceptions will likely decrease another barrier to renal transplantation. The increasing prevalence of end-stage renal disease (ESRD), current fiscal climate and shortage of resources for patient education continues to be a significant concern among health-care providers 1. Incentives such as those implemented by the Centers for Medicare & Medicaid Services for predialysis educational sessions in Stage 4 chronic kidney disease patients, should be further promoted in these areas 5. Early patient education and awareness about renal transplant will tremendously benefit patients progressing toward ESRD. The involvement of primary care providers in such systematic educational activities will further complement the process. Foremost, health-care providers must be advocates for prevention of ESRD in this high-risk population. Reduction in risk factors will undoubtedly be the best way to improve the view from all angles. We would like to thank all the staff members at NSUH transplant program for their whole hearted support. P. Madhavan1,*, S. Jairath1, N. Sukumaran1, A. Sagar2, E. Molmenti1, B. Natarajan3, A. Basu1, N. Ali1 and M. Bhaskaran1 1North Shore LIJ Health System, Kidney Transplant Program, Manhasset, NY 2Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY 3NHLBI, NIH, Bethesda, MD Corresponding author: Parvathy Madhavan, madhavan.parvathy@gmail.com The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.