Global Perspective on Kidney Transplantation: Australia

Cognitive decline related to chronic kidney disease as an exclusion factor from kidney transplantation: results from an international survey

Background and hypothesis

There seems to be a lack of consensus on the necessity and the modality of psychological and specifically cognitive assessment of candidates for kidney transplantation. Both points are often delegated to individual hospitals/centres, whereas international guidelines are inconsistent. We think it is essential to investigate professionals' opinions to advance towards a consistent clinical practice.

Methods

This paper presents the results of an international survey among clinical professionals, mainly nephrologists from the CONNECT (Cognitive decline in Nephro-Neurology: European Cooperative Target) network and beyond (i.e. from personal contacts of CONNECT members). The survey investigated their opinions about the question of whether cognitive decline in patients with chronic kidney disease may affect their eligibility for kidney transplantation.

Results

Our results show that most clinicians working with patients affected by chronic kidney disease think that cognitive decline may challenge their eligibility for transplantation despite data that suggest that, in some patients, cognitive problems improve after kidney transplantation.

Conclusion

We conclude that three needs emerge as particularly pressing: defining agreed-on standards for a multifaceted and multifactorial assessment (i.e. including both clinical/medical and psychosocial factors) of candidates with chronic kidney disease to kidney transplantation; further investigating empirically the causal connection between chronic kidney disease and cognition; and further investigating empirically the possible partial reversibility of cognitive decline after kidney transplantation.

Assessing survival post-kidney transplantation in Australia: A multivariable prediction model

AIM

Kidney transplantation remains the preferred standard of care for patients with kidney failure. Most patients do not access this treatment and wide variations exist in which patients access transplantation. We sought to develop a model to estimate post-kidney transplant survival to inform more accurate comparisons of access to kidney transplantation.

METHODS

Development and validation of prediction models using demographic and clinical data from the Australia and New Zealand Dialysis and Transplant Registry. Adult deceased donor kidney only transplant recipients between 2000 and 2020 were included. Cox proportional hazards regression methods were used with a primary outcome of patient survival. Models were evaluated using Harrell's C-statistic for discrimination, and calibration plots, predicted survival probabilities and Akaike Information Criterion for goodness-of-fit.

RESULTS

The model development and validation cohorts included 11 302 participants. Most participants were male (62.8%) and Caucasian (79.2%). Glomerulonephritis was the most common cause of kidney disease (45.6%). The final model included recipient, donor, and transplant related variables. The model had good discrimination (C-statistic, 0.72; 95% confidence interval (CI) 0.70-0.74 in the development cohort, 0.70; 95% CI 0.67-0.73 in the validation cohort and 0.72; 95% CI 0.69-0.75 in the temporal cohort) and was well calibrated.

CONCLUSION

We developed a statistical model that predicts post-kidney transplant survival in Australian kidney failure patients. This model will aid in assessing the suitability of kidney transplantation for patients with kidney failure. Survival estimates can be used to make more informed comparisons of access to transplantation between units to better measure equity of access to organ transplantation.

Identifying the barriers to kidney transplantation for patients in rural and remote areas: a scoping review

BACKGROUND

Populations in rural and remote areas have higher rates of chronic kidney disease and kidney failure than those in urban or metropolitan areas, and mortality rates for chronic kidney disease are almost twice as high in remote areas compared to major cities. Despite this, patients residing in regional, rural, or remote areas are less likely to be wait-listed for or receive a kidney transplant. The objective of this scoping review is to identify specific barriers to kidney transplantation for adult patients residing in rural and remote areas from the perspectives of health professionals and patients/carers.

METHODS

Studies were identified through database (MEDLINE, CINAHL, Emcare, Scopus) searches and assessed against inclusion criteria to determine eligibility. A descriptive content analysis was undertaken to identify and describe barriers as key themes.

RESULTS

The 24 selected studies included both quantitative (n = 5) and qualitative (n = 19) methodologies. In studies conducted in health professional populations (n = 10) the most prevalent themes identified were perceived social and cultural issues (80%), burden of travel and distance from treatment (60%), and system-level factors as barriers (60%). In patient/carer populations (n = 14), the most prevalent themes were limited understanding of illness and treatment options (71%), dislocation from family and support network (71%), and physical and psychosocial effects of treatment (71%).

CONCLUSIONS

Patients in regional, rural, and remote areas face many additional barriers to kidney transplantation, which are predominantly associated with the need to travel or relocate to access required medical testing and transplantation facilities.

Financial toxicity experienced by rural Australian families with chronic kidney disease

AIM

Chronic kidney disease (CKD) and its treatment places a financial burden on healthcare systems and households worldwide, yet little is known of its financial impact, on those who reside in rural settings. We aimed to quantify the financial impacts and out-of-pocket expenditure experienced by adult rural patients with CKD in Australia.

METHODS

A web based structured survey was completed between November 2020 and January 2021. English speaking participants over 18 years of age, diagnosed with CKD stages 3-5, those receiving dialysis or with a kidney transplant, who lived in a rural location in Australia.

RESULTS

In total 77 (69% completion rate) participated. The mean out of pocket expenses were 5056 AUD annually (excluding private health insurance costs), 78% of households experienced financial hardship with 54% classified as experiencing financial catastrophe (out-of-pocket expenditure greater than 10% of household income). Mean distances to access health services for all rural and remote classifications was greater than 50 kilometres for specialist nephrology services and greater than 300 kilometres for transplanting centres. Relocation for a period greater than 3 months to access care was experienced by 24% of participants.

CONCLUSION

Rural households experience considerable financial hardship due to out-of-pocket costs in accessing treatment for CKD and other health-related care, raising concerns about equity in Australia, a high-income country with universal healthcare.

Renal transplant anastomotic time-Every minute counts!

The impact of anastomotic time in renal transplant is under recognized and not well studied. It is one of the few controllable factors that affect the incidence of delayed graft function (DGF). Our study aimed at quantifying the impact of anastomotic time. We performed a retrospective review of 424 renal transplants between the years 2006 and 2020. A total of 247 deceased donor renal transplants formed the study cohort. Patients were divided into two groups based on the presence or absence of DGF. Variables with p < 0.3 were analyzed using the binary logistic regression test. The final analysis showed anastomotic time to be significantly associated with DGF with odds ratio of 1.04 per minute corresponding to 4% increase in DGF incidence with every minute increment in anastomotic time. Other variables that had significant impact on DGF were DCD donor (odds ratio - 8.7) and donor terminal creatinine. We concluded that anastomotic time had significant impact on the development of DGF and hence should be minimized.

Australian Rural Caregivers' Experiences in Supporting Patients With Kidney Failure to Access Dialysis and Kidney Transplantation: A Qualitative Study

RATIONALE & OBJECTIVE

Caregivers of patients with chronic kidney disease from rural communities play a crucial role in access to dialysis and transplantation, but they face many challenges including geographical distance, financial hardship, and limited support. This study aimed to inform strategies to overcome these challenges by describing the experiences of caregivers of patients with kidney failure from rural Australian communities in accessing kidney replacement therapy.

STUDY DESIGN

Qualitative study.

SETTING & PARTICIPANTS

18 adult caregivers of Australian rural patients with kidney failure treated with dialysis or kidney transplantation.

ANALYTICAL APPROACH

Semistructured interviews were conducted. Interview transcripts were thematically analyzed.

RESULTS

The 18 participants were aged 20 to 78 years; 13 (72%) were female, and 13 (72%) were the spouse/partner of the patient. We identified 5 themes: devastating social isolation (difficult periods of separation, exclusion from peers, forced relocation); financial dependency and sacrifice (burgeoning out-of-pocket costs, disruption to work life, foregoing autonomy); ongoing psychological trauma (concern for neglect and stress on children, long-term emotional distress); overwhelmed by multifaceted roles and expectations (patient advocacy, uncertainty in navigating multiple health systems); and persistent burden of responsibility (loss of self-identity, ongoing travel requirements, scarcity of psychosocial support, unpreparedness for treatment regime).

LIMITATIONS

The study was conducted in a high-income, English-speaking country with universal health insurance, which may limit the transferability of the findings.

CONCLUSIONS

Australian rural caregivers of people with kidney failure treated by maintenance dialysis or transplantation experience an exhausting physical, financial, and psychological burden. Strategies to address these profound challenges are needed.

PLAIN-LANGUAGE SUMMARY

This interview-based study elicited the challenges faced by people and family members who care for patients from rural towns who are receiving dialysis or kidney transplantation. The barriers and difficulties reported included traveling long distances, needing to move to larger towns and leaving their homes, feeling concerned for the long-term effects on their children, physical exhaustion, and financial issues. Additional efforts are needed to identify the means by which caregivers and their families in rural towns can obtain support to care for those with kidney failure.

Perspectives of a proposed patient navigator programme for people with chronic kidney disease in rural communities: Report from national workshops

AIMS

People who live in rural areas have reduced access to appropriate and timely healthcare, leading to poorer health outcomes than their metropolitan-based counterparts. The aims of the workshops were to ascertain participants' perspectives on barriers to access to dialysis and transplantation, to identify and prioritize the roles of a rural patient navigator, to discuss the acceptability and feasibility of implementing this role and identify possible outcomes that could be used to measure the success of the programme in a clinical trial.

METHODS

Rural patients (n = 19), their caregivers (n = 5) and health professionals (n = 18) from Australia participated in three workshops. We analysed the data using thematic analysis.

RESULTS

We identified four themes related to access to dialysis and transplantation: overwhelmed by separate and disconnected health systems, unprepared for emotional toll and isolation, lack of practical support and inability to develop trust and rapport. Four themes related to the role of the patient navigator programme: valuing lived experience, offering cultural expertise, requiring a conduit, and flexibility of the job description. The key roles prioritized by participants were psychological support and networking, provision/consolidation of education, and provision of practical support.

CONCLUSION

Rural patients, caregivers and health professionals believed that programmes that include navigators with lived experience of dialysis and kidney transplantation and cultural expertise, especially for Aboriginal Australians, may have the potential to improve patient experiences in accessing healthcare.

Clinicians' perspectives on equity of access to dialysis and kidney transplantation for rural people in Australia: a semistructured interview study

OBJECTIVES

People with chronic kidney disease requiring dialysis or kidney transplantation in rural areas have worse outcomes, including an increased risk of hospitalisation and mortality and encounter many barriers to accessing kidney replacement therapy. We aim to describe clinicians' perspectives of equity of access to dialysis and kidney transplantation in rural areas.

DESIGN

Qualitative study with semistructured interviews.

SETTING AND PARTICIPANTS

Twenty eight nephrologists, nurses and social workers from 19 centres across seven states in Australia.

RESULTS

We identified five themes: the tyranny of distance (with subthemes of overwhelming burden of travel, minimising relocation distress, limited transportation options and concerns for patient safety on the roads); supporting navigation of health systems (reliance on local champions, variability of health literacy, providing flexible models of care and frustrated by gatekeepers); disrupted care (without continuity of care, scarcity of specialist services and fluctuating capacity for dialysis); pervasive financial distress (crippling out of pocket expenditure and widespread socioeconomic disadvantage) and understanding local variability (lacking availability of safe and sustainable resources for dialysis, sensitivity to local needs and dependence on social support).

CONCLUSIONS

Clinicians identified geographical barriers, dislocation from homes and financial hardship to be major challenges for patients in accessing kidney replacement therapy. Strategies such as telehealth, outreach services, increased service provision and patient navigators were suggested to improve access.