Kidney Transplantation Contraindications: Variation in Nephrologist Practice and Training Vintage

Abstract

IntroHealth system leaders aim to increase access to kidney transplantation in part by encouraging nephrologists to refer more patients for transplant evaluation. Little is known about nephrologists’ referral decisions and whether nephrologists with older training vintage weigh patient criteria differently (e.g., more restrictively). MethodsUsing a novel, iteratively validated survey of U.S.-based nephrologists, we examined how nephrologists assess adult patients’ suitability for transplant, focusing on established, important criteria: seven clinical (e.g., overweight) and seven psychosocial (e.g., insurance). We quantified variation in nephrologist restrictiveness—proportion of criteria interpreted as absolute or partial contraindications versus minor or negligible concerns—and tested associations between restrictiveness and nephrologist age (proxy for training vintage) in logistic regression models, controlling for nephrologist- and practice-level factors. ResultsOf nephrologists invited (n=144), 42 survey respondents (29% response rate) were 85% male and 54% non-Hispanic white, with mean age 52 years, and 67% spent ≥1 day/week in outpatient dialysis facilities. Nephrologists interpreted patient criteria inconsistently; consistency was lower for psychosocial criteria (intraclass correlation coefficient [ICC] 0.28) than for clinical criteria (ICC 0.43; p<0.01). With each additional 10 years of age, nephrologists’ odds of interpreting criteria restrictively (top tertile) doubled (adjusted odds ratio [aOR] 1.96, 95% CI 0.95-4.07), with marginal statistical significance. This relationship was significant when interpreting psychosocial criteria (aOR 3.18, 95% CI 1.16-8.71) but not when interpreting clinical criteria (aOR 1.12, 95% CI 0.52-2.38). ConclusionNephrologists interpret evaluation criteria variably when assessing patient suitability for transplant. Guideline-based educational interventions could influence nephrologists’ referral decision-making differentially by age.