A systems approach to kidney transplantation disappoints

The use of a province-wide, multisystem approach did not increase steps toward kidney transplantation. The COVID-19 pandemic may have disrupted implementation.

Advanced chronic kidney disease (CKD) is treated most effectively with kidney transplantation, which ultimately saves the healthcare system money from dialysis costs. Yet, due to access barriers, many kidney transplant-eligible patients will never receive a kidney transplant.

Dr Amit Garg (McMaster University, Canada) and colleagues designed a multicomponent intervention to address barriers that prevent kidney transplantation [1,2]. The components included administrative support, educational resources for healthcare professionals, patients, and donors, a patient support group called the ‘Transplant Ambassador Program,’ and reports on each patient’s progress. This was a “pragmatic, cluster-randomised trial to determine if renal programme-wide use of this multicomponent intervention was superior to usual care in helping eligible patients complete up to 4 key steps towards receiving a kidney transplant,” Dr Garg explained. The 4 steps were referral to a transplant centre, having a contact for living donor evaluation, addition to the donor waitlist, and receiving a transplant. All 26 CKD renal programmes in Ontario were randomly assigned to multicomponent intervention or usual care groups. Participants were 18 to 75 years old, had no recorded contraindication to transplantation, had an estimated glomerular flow rate <15 mL/min/1.73 m², and had a >25% 2-year chance of receiving renal replacement therapy.

Approximately 10,000 participants were included in each group, and they were followed for a median of 2.1 years. The number of steps completed did not differ between the multicomponent intervention or usual care groups (HR 1.00; 95% CI 0.87–1.15). Dr Garg reflected that, even though the intervention did increase access to transplantation or living donation, the COVID-19 pandemic played a significant role in patients’ access, and he “believes that several aspects of our systems approach remain sensible.”

1. Garg AX, et al. Effect of a Multi-Component Intervention to Improve Patient Access to Kidney Transplantation and Living Kidney Donation. FR-OR114, ASN Kidney Week 2023, 2–5 November, Philadelphia, PA, USA.
2. Garg AX, et al. JAMA. 2023;Nov 3. DOI:10.1001/jamainternmed.2023.5802.

 

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Posted on 28 November, 202329 February, 2024