Roadblocks need to be eliminated to improve access to transplants
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BOSTON — Transplant programs erect several bureaucratic roadblocks that can stall efforts by patients to obtain a kidney transplant, a speaker said at the National Kidney Foundation Spring Clinical Meetings.
“We need to get out of the rut created by the organ transplant system,” Eliot C. Heher, MD, founder of Square Knot Health Inc. and previously the medical director of kidney transplant at Massachusetts General Hospital, said in the presentation. “The 2020 KDIGO guideline recommendations for transplant eligibility indicate that all [chronic kidney disease stage] 4 [to] 5 patients expected to reach [end-stage renal disease] ESRD be informed about, educated about and considered for kidney transplantation.”
The challenge, Heher said, is that patients with CKD are initially given the “dialysis first” option. “These are patients who are never referred to a nephrologist; 30% have unplanned kidney failure and ‘crash’ onto dialysis,” Heher said. “Preemptive referral to transplant is rare, only occurring in 5% of incident dialysis patients.”
Ultimately, 30% to 75% of patients on dialysis are never referred for a transplant evaluation and 80% of the patients who are referred are neither transplanted nor put on a waitlist within 1 year of referral, he said.
Patients often deal with clinical deterioration during dialysis that eventually disqualifies them for a transplant, and “we often see minimal assistance with a live donor search,” Heher said. “Donor evaluations are often limited by transplant center capacity.”
Barriers to transplant
Heher said a “bottleneck” for patients getting a transplant occurs at the transplant center, where limitations on donor evaluation combine with limited capacity and personnel. “Only one donor can be evaluated at a time,” he said.
“Transplant centers often follow rules that lack clinical rationale,” Heher said. “Donor candidates are not evaluated until the recipient has been listed. Patients’ eGFR must fall below 20 mL/min 2 to qualify for a transplant evaluation,” he said. “This is done by the transplant centers, in part, to protect themselves from volume they struggle to manage.”
Underrepresented groups have a more difficult time getting a transplant, Heher said. “Black people on dialysis are less likely to be placed on the waiting list than white people and wait longer from dialysis start to transplant listing,” Heher said. “Black people with CKD are less likely to be referred for transplant. If they are referred, they are less likely to make it through the evaluation process.”
Improvements to care
Patients can help prepare themselves for the transplant process by engaging in better health behaviors, Heher said. Patients should maintain transplant readiness and awareness by optimizing diet, exercise and compliance. Recipients and donors can be better matched to centers where they will qualify, and an analysis of data related to successful live donor searches can be done to develop best practices for other live donor searches.
“We believe every patient facing kidney failure should be considered for kidney transplant. The living kidney donor supply can increase, and barriers to transplant or donation can be overcome,” Heher said.
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Heher EC. Paving the way to kidney transplantation. Presented at: National Kidney Foundation Spring Clinical Meetings; April 5-10, 2022; Boston.
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