Factors Associated with Completion of Pre–Kidney Transplant Evaluations

Abstract

This study sought to examine various factors that may prevent transplant candidates from completing their transplant workup prior to listing. We reviewed the records of 170 subjects (cases = 100, controls 70) who were either on dialysis or had less than 20 mL/min creatinine clearance and were therefore candidates for preemptive transplantation. Approximately, 56% of preemptive patients completed their workup, while only 36% of patients on dialysis completed their workup. Our data revealed that factors contributing toward completion of workup included intrinsic motivation (four times more likely), lack of specific medical comorbidities (three times more likely), and preemptive status (two times more likely). Among patients on dialysis, intrinsic motivation (five times more likely) and absence of cardiovascular complications (four times more likely) were associated with completion. When comparing patients on dialysis to patients not on dialysis, there were significant differences between the two groups in distance from home to the transplant center, level of education, and presence of medical comorbidities. We believe that targeted interventions such as timely referral, providing appropriate educational resources, and development of adequate support systems, have the potential to improve workup compliance of patients with advanced chronic kidney disease, including those on dialysis.

Kidney transplantation has been shown to have the greatest potential for improving survival and restoring a healthy productive life.^{1 2} The pretransplant workup includes but is not limited to financial, social, medical, surgical, and nutritional evaluation that must be completed prior to being considered a candidate and placed on the organ waiting list.³ Although many patients complete their workup within a specified time period, others fail to do so, resulting in eventual closure of their evaluation.

This study sought to examine different variables that may prevent patients from completing their workup, and to determine if any specific factors were more prevalent among this group.

Methods

We retrospectively analyzed the records of all kidney transplant candidates on dialysis and with creatinine clearance under 20 mL/min, whose charts were closed due to failure to complete the required workup evaluation between July 1, 2011 and June 30, 2012. All patients were initially evaluated by both a transplant nephrologist and a transplant surgeon. Each patient was fully evaluated and a list of recommended evaluations developed. All those with contraindications to transplantation based on the center's guidelines were not considered in the study.

Cases (n = 100) included all kidney transplant candidates during the time period of interest who did not complete their evaluation process. Controls (n = 70) included all kidney transplant candidates during the same time period, who completed their evaluation process and were listed. Patients who took more than 365 days to complete their workup were excluded. Variables considered included age, gender, evaluation start to end date (the time period from the start date of the initial evaluation to the date when the evaluation was completed by the patient, and the patient was put on the waiting list), duration of the evaluation process (in days), dialysis status (whether the patient was on dialysis or not, at the time of evaluation), year when dialysis was first initiated, distance from the patient's home to the dialysis center in miles and minutes, distance from their home to the transplant center/hospital in minutes, employment status (whether the patient was a student, unemployed, retired, working part time or working full time at the time of evaluation), and educational level (whether the patient had no education, was in grade school, high school, some college, completed college, or was at a masters level at the time of evaluation). Medical comorbidities were also reviewed. These included hypertension, and anemia, as reported by their history, physical, laboratory and imaging studies). Patients who were noted to have cardiovascular comorbidities included those who had any reported coronary artery disease requiring cardiac catheterization or stenting prior to transplantation as reported by the cardiac evaluation on file. The reason for closure of the patient file at any point in time was assessed. If the patient failed to complete their workup in the allotted time period or if they moved to another transplant center for evaluation, their file was closed. Adequacy of social support system and intrinsic motivation were also assessed by a comprehensive psychosocial evaluation conducted by the transplant social worker. Support system was assessed by who the patient considers will provide support to them during the evaluation process, and who they state will be there to take care of them after the transplant. This may include their spouse, children, extended family members, who the patient lives with at home or who is accompanying them to appointments. Based on this assessment, the transplant social worker grades the patient as having an adequate support system, having a borderline support system which could possibly be enhanced, or having no support system.

Patients showed motivation by asking questions about the transplantation process, being actively involved in the recipient evaluation, coming to educational classes or attending support groups. In most cases, the patient has a reason for pursuing the transplant. The patients may state that they do not want to be on dialysis anymore or they may be an end-stage renal disease patient who does not want to start dialysis at all and therefore is considering transplantation preemptively. Based on this assessment the transplant social worker specifically describes the patient as “highly motivated” and includes the patient's reasons to support this factor. If these factors are not present, the patient is described “less motivated.” Social workers discussed motivation and reasons for failing to complete or delaying the workup with the patients themselves. These observations derived from direct interaction with the potential candidates were considered in the manuscript. General nephrologists were also contacted in the case of patients who did not fulfill their prescribed evaluations.

Univariate and multivariate analyses, chi-square test, and logistic regression models were used to interpret the data. Descriptive statistics and univariate analyses using the Mann-Whitney test, a nonparametric counterpart to the two sample t-test, were used to compare “cases” (noncompliant patients) and “controls” (compliant patients) for continuous variables. Chi-square test or Fisher exact test, as deemed appropriate, were used to compare the two groups for categorical data. Those factors associated with “completing workup” by univariate analysis (p < 0.10) were included in a logistic regression model. Backward selection was used to eliminate variables with no significant contribution.

Results

Our study reviewed 170 subjects. Fifty six percent (56%) of preemptive patients completed their workup, while 36% of patients on dialysis completed their workup. Factors for both groups associated with workup completion included intrinsic motivation (four times more likely), lack of medical comorbidities (three times more likely), and preemptive status (two times more likely). Among patients on dialysis, intrinsic motivation (five times more likely) and the absence of cardiovascular complications (four times more likely) were positive predictors. Distance from home to the transplant center, level of education, and presence of medical comorbidities were found to be significantly different when comparing the preemptive versus dialysis groups.

When comparing “cases” and “controls,” there were significant differences in miles to hospital, dialysis, support system, medical complications—hypertension, medical complications—anemia, medical complications—cardiovascular, and motivation. These variables were included in the logistic regression model for potential predictors associated with compliance or noncompliance (i.e., “completing workup”). Dialysis (p < 0.0489), medical complications-anemia (p < 0.0105), and motivation (p < 0.0002) were associated with compliance in the final logistic regression model (Tables 1 and 2).

Table 1. Patient characteristics (all subjects n = 170).

	Controls (n = 70)	Cases (n = 100)	p-Value
Age	55.97 ± 13.04 (median = 58.50)	57.52 ± 13.22 (median = 61.00)	0.44897
Start dialysis	2009.34 ± 2.28 (median = 2010.00)	2008.04 ± 3.35 (median = 2009.00)	0.00277
Miles to dialysis	5.68 ± 4.73 (median = 3.80)	6.28 ± 7.24 (median = 4.10)	0.87361
Minutes to dialysis	12.87 ± 7.63 (median = 12.00)	13.57 ± 10.64 (median = 12.00)	0.97850
Miles to hospital	11.59 ± 7.93 (median = 9.70)	14.10 ± 9.67 (median = 11.70)	0.04193
Gender  Females  Males	23 (32.86%) 47 (67.14%)	33 (33.00%) 67 (67.00%)	0.9844
Dialysis  Yes	47 (67.14%)	82 (82.00%)	0.0258
Education  No education  Grade school  High school  Some college  College completed  Masters level	2 (2.86%) 4 (5.71%) 24 (34.29%) 12 (17.14%) 19 (27.14%) 9 (28.6%)	2 (2.04%) 2 (2.04%) 45 (45.92%) 17 (17.35%) 27 (27.55%) 5 (5.10%)	0.3010a
Support system  Inadequate support  Adequate support	2 (2.86%) 68 (97.14%)	13 (13.00%) 87 (87.00%)	0.0218
Employment status  Student  Unemployed  Retired  Part-time  Full-time	2 (2.86%) 13 (18.57%) 39 (55.71%) 3 (4.29%) 13 (18.57%)	0 (0.00%) 20 (20.20%) 51 (51.52%) 4 (4.04%) 24 (24.24%)	0.5306a
Diabetes  Yes	29 (41.43%)	44 (44.00%)	0.7389
HTN  Yes	34 (48.57%)	62 (62.00%)	0.0822
Anemia  Yes	9 (12.86%)	30 (30.00%)	0.0089
Cardiovascular  Yes	7 (10.00%)	25 (25.00%)	0.0138
Cancer	0 (0.00%)	2 (2.00%)	0.5127a
Poor understanding from psychosocial perspective	7 (10.00%)	11 (11.00%)	0.8348
Motivated	33 (47.14%)	15 (15.00%)	< 0.0001

Abbreviation: HTN, hypertension.

^aFisher exact test.

Table 2. Logistic regression for all patients (n = 170) in predicting compliance.

Variable	β-Estimate	Odds ratio	95% Confidence interval	p-Value
Intercept	0.2322			0.3684
Dialysis status	0.4004	2.227	(1.004, 4.942)	0.0489
Medical complication—anemia	0.5982	3.308	(1.324, 8.266)	0.0105
Motivation	0.7210	4.229	(1.991, 8.984)	0.0002

• Preemptive patients were approximately two-times more likely to be compliant (odds ratio [OR] = 2.2, 95% confidence interval: 1.0–4.9) than those on dialysis.

• Patients without anemia were approximately three-times more likely to be compliant (OR = 3.3, 95% confidence interval: 1.3–8.3) than those with anemia.

• “Motivated” patients were approximately four-times more likely to be compliant (OR = 4.2, 95% confidence interval: 2.0–9.0) than those considered not “motivated.”

For dialysis patients only (n = 129), when comparing “cases” (n = 82) and “controls” (n = 47) for patients, there were significant differences in start dialysis, miles to hospital, support system, medical complications—anemia, medical complications—cardiovascular, and motivation. Medical complications—cardiovascular (p < 0.0282) and motivation (p < 0.0003) remained significant for compliance in the final logistic regression model (Tables 3 and 4).

Table 3. Characteristics for dialysis patient only (n = 129).

	Controls (n = 47)	Cases (n = 82)	p-Value
Age	54.13 ± 13.70 (median = 55.00)	57.88 ± 13.05 (median = 61.00)	0.1340
Start dialysis	2009.34 ± 2.28 (median = 2010.00)	2008.04 ± 3.35 (median = 2009.00)	0.0028
Miles to dialysis	5.68 ± 4.73 (median = 3.80)	6.28 ± 7.24 (median = 4.10)	0.8736
Minutes to dialysis	12.87 ± 7.63 (median = 12.00)	13.57 ± 10.64 (median = 12.00)	0.9785
Miles to hospital	10.93 ± 6.54 (median = 9.55)	13.66 ± 8.72 (median = 11.80)	0.0306
Gender  Females  Males	15 (31.91%) 32 (68.09%)	27 (32.93%) 55 (67.07%)	0.9060
Education  No education  Grade school  High school  Some college  College completed  Masters level	2 (4.26%) 3 (6.38%) 22 (46.81%) 6 (12.77%) 9 (19.15%) 5 (10.64%)	2 (2.50%) 2 (2.50%) 42 (52.50%) 12 (15.00%) 21 (26.25%) 1 (1.25%)	0.1568a
Support system  Inadequate support  Adequate support	2 (4.26%) 45 (95.74%)	13 (15.85%) 69 (84.15%)	0.0480
Employment status  Student  Unemployed  Retired  Part time  Full time	2 (4.26%) 12 (25.53%) 26 (55.32%) 3 (6.38%) 4 (8.51%)	0 (0.00%) 16 (19.75%) 44 (54.32%) 4 (4.94%) 17 (20.99%)	0.1405
Diabetes	20 (42.55%)	40 (48.78%)	0.4950
HTN	22 (46.81%)	50 (60.98%)	0.1189
Anemia	5 (10.64%)	22 (26.83%)	0.0296
Cardiovascular	4 (8.51%)	23 (28.05%)	0.0087
Cancer	0 (0.00%)	1 (1.22%)	1.0000a
Poor understanding from psychosocial perspective	6 (12.77%)	10 (12.20%)	0.9246
Motivated	22 (46.81%)	11 (13.41%)	< 0.0001

Abbreviation: HTN, hypertension.

^aFisher exact test.

Table 4. Logistic regression for dialysis patients only (n = 129) in predicting compliance.

Variable	β-Estimate	Odds ratio	95% Confidence interval	p-Value
Intercept	–0.6414			0.0425
Medical complication—cardiovascular	0.6616	3.755	(1.152, 12.242)	0.0282
Motivation	0.8077	5.030	(2.083, 12.143)	0.0003

• Patients without cardiovascular complications were approximately four-times more likely to be compliant (OR = 3.8, 95% confidence interval: 1.2–12.2) than those with cardiovascular complications.

• “Motivated” patients were approximately five times more likely to be compliant (OR = 5.0, 95% confidence interval: 2.1–12.1) than those not motivated.

Discussion

Patients who have started dialysis have less time, less energy and in general seem to be overwhelmed with the details of starting a transplant evaluation. The workup can be arduous. Even when the workup is completed patients may still face a daunting period of years on the waiting list, and transplantation may seem an unreachable goal. Having a live donor may make this time shorter and more fluid⁴; however, living donor interactions are often fraught with their own challenges. The recipient may not want to feel like they are causing any harm or risk to the donor, and may feel like they are accepting a gift they can never pay back.

Of the 100 cases, only three (3%) had a live donor present at the time of evaluation, and the remaining 97 (97%) did not. At the time of the initial transplant evaluation, most recipients are either in the process of finding a living donor or may not have a living donor available. Recipient candidates, who successfully complete their workup/evaluation, are placed on the waiting list for a deceased donor kidney. However, there may be a living donor available for the recipient at any point in time, as many recipients contact their family members, friends, coworkers and community in search for a living donor. Therefore, whether or not the recipient would receive a transplant from a cadaveric donor would only be determined if the recipient does not have a living donor, and as they move up on the waiting list. For this reason, only data regarding presence of a living donor at time of evaluation was collected. However, further analyses taking donor type (living and cadaveric transplants) into consideration will be invaluable.

Dialysis takes a physical and psychological toll on patients.⁵ This may be a potential factor that either limits their efforts or slows their progress toward completing a workup. Over time, complications on dialysis can also increase the number of hospitalizations and medical comorbidities⁶ preventing patients from getting the necessary clearance for a transplant. We analyzed many comorbidities including diabetes, hypertension, anemia, cardiovascular disease, as these were the ones most frequently encountered. Cardiovascular comorbidities and anemia were found to be significant predictors in our series.

Another phenomenon is the fact that patients on dialysis may not have the opportunity to meet those who have successfully undergone transplantation. The implementation and expansion of educational programs stressing the benefits of transplantation over dialysis would be of great use. Furthermore, transplant education and appraisal of transplant evaluation status is part of the dialysis nurse's clinical assessment. We have begun to implement these interventions in our own institutions with initial success. Transplant education is provided to all transplant recipient candidates at our center through weekly seminars where candidates are informed about the transplantation process. Candidates are encouraged to ask questions and participate in discussions with the nephrologists, surgeons, and transplant coordinators at these seminars and throughout the course of their evaluation. These interventions need to be further strengthened and enforced.

A national survey showed that while 81% of nephrologists felt that they should discuss kidney transplantation with their patients for 20 minutes during appointments, only 43% actually did so. This results in 30% of end-stage renal disease patients not being referred for transplantation.^{5 6 7} Patients with advanced chronic kidney disease should be advised of the option of preemptive transplantation through early referral by primary nephrologists to a transplant center. Preemptive transplantation has improved graft survival and overall mortality.^{7 8}

Potential recipients should be thoroughly evaluated by a multidisciplinary transplant team, educated with respect to the benefits of transplantation, and expedited in the necessary testing. This approach provides a solid support system, with all resources and information in one place to facilitate the evaluation. Coordinators should make all necessary information available to the patients from the outset, be in constant communication with them, and assist them throughout the process from initial evaluation to listing, to transplant and posttransplant care.

One point for improvement was that our evaluation of intrinsic motivation was a subjective binary assessment. Our results show that motivation was a significant factor to complete the transplant evaluation. Therefore, we are developing a thorough scoring system to better assess motivation gradations to correlate with prediction of evaluation completion.

Conclusion

The present study strongly supports lack of intrinsic motivation, dialysis dependence, and existence of medical comorbidities as the major predictors of failure to complete the pretransplant workup. The finding that patients on dialysis are less likely to complete their transplant evaluation differs from a previous study that could not discern a difference.⁹ We believe that through targeted interventions such as timely referral, providing appropriate educational resources, and the development of adequate support systems, all patients with advanced chronic kidney disease, including those on dialysis, will show an improvement in patient compliance in completing their transplant workup.