Kidney Transplant Clinicians' Perceptions of Palliative Care for Patients With Failing Allografts in the US: A Mixed Methods Study

Terminal Hospitalizations in Liver Transplant Recipients: Reducing Costs and High-Intensity Care Through Palliative Care

IntroductionEnd-of-life care for liver transplant recipients is often characterized by high utilization of invasive procedures, prolonged hospital stays, and elevated health care costs. Despite evidence demonstrating that palliative care can reduce aggressive interventions, improve patient-centered outcomes, and lower costs, its integration into transplant care remains inconsistent.MethodsA retrospective analysis was conducted using the National Inpatient Sample database (2016-2021). Hospitalizations ending in death for liver transplant recipients were compared to non-recipients regarding invasive procedures, health care costs, and the impact of palliative care consultations. Assessed procedures included: mechanical ventilation, tracheostomy, enteral and parenteral nutrition support, red blood cell transfusion, renal replacement therapy, central line placement, and cardiopulmonary resuscitation. Multivariable regression models adjusted for demographic and clinical covariates were utilized.ResultsAmong 4,582,658 terminal hospitalizations, liver transplant recipients (n = 5995) were younger (mean age: 66.0 vs 70.9 years, P < 0.001), had higher comorbidity burdens, and were more likely to have undergone one or more of the assessed procedures (74.7% vs 58.4%, P < .001) compared to non-recipients. Hospitalization costs were increased in transplant recipients ($62,630 vs $46,930, P < .001). Palliative care consultations were associated with reduced procedure utilization (69.9% vs 83.7%, P < .001), shorter hospital stays, and lower costs ($46,930 vs $62,630, P < .001).DiscussionLiver transplant recipients face unique end-of-life care challenges, including greater reliance on high-intensity interventions and associated costs. Palliative care is associated with less invasive procedures and lower costs, highlighting the need for its integration into transplant care pathways.

Pediatric Transplant Surgeons' Perspectives on Palliative Care for Children With Chronic Kidney Disease: A National Cross-Sectional Survey

BACKGROUND

Some adult transplant surgeons consider transplant to be contraindicated in patients receiving palliative care (PC). Little is known about pediatric transplant surgeons' attitudes toward PC. We sought to ascertain pediatric kidney transplant surgeons' perspectives regarding the routine integration of PC for children with chronic kidney disease.

METHOD

We administered a cross-sectional web-based survey to members of the American Society of Transplant Surgeons listserv in summer 2021. We adapted the survey from the previously validated Provider Survey about Palliative Care for Children with Heart Disease and pretested it with representative kidney transplant surgeons, nephrologists, and PC physicians; queries related to PC included institutional and personal experience, knowledge, and education. Data were summarized descriptively.

RESULTS

There were 21 participants. Over half of the respondents were white (57%) males (62%), practicing in urban, academic centers (94%). Although 67% of the participants practiced in an institution with a subspecialty PC team, 24% were unsure if such a team existed in their institution. A minority (19%) perceived PC consultation and kidney transplant to be mutually exclusive. Most surgeons (86%) believed that PC should not be restricted to when a child is dying, and 59% reported that PC consultation should happen at diagnosis for life-threatening conditions. However, surgeons indicated that PC consultation is rarely utilized for pediatric kidney transplant recipients. Transplant surgeons expressed a desire for additional PC-focused training and willingness to engage in additional education.

CONCLUSIONS

Although a minority of pediatric transplant surgeons perceived PC to be contraindicated for kidney transplant, most indicated openness to PC engagement for their patients.

Hospice Referral Rate Disparities of American Indian/Alaska Native Kidney Transplant Recipients with End-Stage Kidney Disease: A Retrospective Cohort Analysis

INTRODUCTION

American Indian/Alaska Native (AI/AN) persons disproportionately suffer from end-stage kidney disease caused by diabetes (ESKD-D). Kidney transplant is the most desirable option to treating ESKD-D, but remains unattainable for many AI/AN persons, especially in rural South Dakota (SD). Additionally, palliative and hospice care options for AI/AN with any serious illness in SD are largely inaccessible. Moreover, receiving kidney transplant potentially affects hospice referral because of the desire to prolong transplant function. Therefore, the purpose of this study was to compare hospice use rates among AI/AN and non-Hispanic White (NHW) persons with ESKD-D prior to death and determine if differences in referral rates are present for those with and without a prior kidney transplant.

METHODS

Retrospective cohort analysis of United States Renal Data System data from 2000-2021. Data for persons with hospice care, transplant status, place of death, and race were analyzed using chi-squared tests with Yates' continuity correction and the Cochran-Mantel-Haenszel test.

RESULTS

AI/AN persons with ESKD-D were less likely to receive hospice care prior to death compared to NHW persons in both transplant (P < 0.001) and non-transplant (P < 0.001) groups. When comparing transplant and non-transplant groups by hospice use, persons with no previous transplant were more likely to receive hospice care prior to death (P < 0.001).

CONCLUSION

These results confirm the assumptions of significant differences in hospice care use among AI/AN vs NHW who have ESKD-D, including differences between those with a prior transplant. There is a need to expand palliative/hospice care services for persons with a prior kidney transplant.

Perceptions of Palliative Care Among Patients With Kidney Allograft Dysfunction: A Qualitative Study

Rationale & Objective

Nearly half of kidney transplant recipients develop allograft failure within 10 years of transplantation and experience high mortality, significant symptom burden, and complex communication challenges. These patients may benefit from palliative care, but palliative care is infrequently provided in this population. This study explores palliative care perceptions and needs among patients with poorly functioning and declining kidney allografts.

Study Design

A qualitative study using semistructured interviews.

Setting & Participants

Adult kidney transplant recipients with a glomerular filtration rate of <20 mL/min/1.73m2 followed at a single transplant center were interviewed from April 2022 to November 2022.

Analytical Approach

An interdisciplinary team, including nephrology, palliative care, and surgery, conducted a thematic analysis.

Results

Twelve participants (3 women, 9 men; 9 White, 2 Black, and 1 Hispanic patient) were interviewed. The median age of participants was 59 (IQR 48-73). At 6 months postinterview, 7 participants had resumed dialysis, 1 participant had been retransplanted, and 1 participant was deceased. Most participants had not heard of palliative care and those who had equated it with end-of-life care. Participants reported that emotional distress, particularly pervasive concern about the worsening of their kidney disease, was their most significant priority related to unmet palliative care needs. They also desired more discussion with their care team about future quality of life and lifespan. Participants described high trust in their transplant teams, suggesting that palliative care integration with these teams would be well-received.

Limitations

Limitations include recruitment from a single institution, lack of subject familiarity with palliative care, and limited racial and ethnic diversity among participants.

Conclusions

Patients with declining kidney allografts have heterogeneous, unmet palliative care needs, including emotional symptoms and a desire for better prognostic awareness. Our results suggest that patients are largely unaware of palliative care and may benefit from practice models in which transplant teams integrate palliative care education and timely palliative care engagement.