Introduction:
Kidney transplantation (KTx) is the treatment of choice for patients (pts) with kidney failure and could be lifesaving in countries with limited access to dialysis. The referral rate in high-income countries (HIC) is 17-33% pre-emptively, or within 1-yr of the initiation of chronic dialysis, while data is lacking in low-income countries (LIC). We aimed to explore and compare barriers and patterns of referral of pts with kidney failure for KTx in lower vs higher-income countries.
Methods:
A working group of the International Society of Nephrology (ISN) and The Transplantation Society created a Knowledge, Attitude, and Practice survey sent to nephrologists globally via the ISN mailing list. In addition to demographic and health system questions, the survey included 37 case scenarios covering medical and social issues affecting referral rates for KTx. Responses were collected anonymously and sorted according to responder countries’ income levels based on the World Bank classification into HIC, upper middle income (UMIC), lower middle income (LMIC), and LIC.
Results:
Based on 237 responses, responders from 88 countries were 60.6% males, 60% 30-50 yrs, and 85% worked at academic centers. Living and/or deceased donor KTx is available in 92.5% of all countries, while LMIC and LIC represent 27.4% and 7.2% of responders, respectively. Lack of an active deceased donor KTx program was reported in 5% of HIC, 37.3% of UMIC, 64.6% of LMIC, and 82.3% of LIC (P<0.001).
Knowledge questions showed that practitioners from LIC and LMIC were less likely to refer pts >80 yrs (P=0.008), pts without social support (P<0.001), with no health insurance (P=0.014), mentally incapacitated (P<0.001), with substance abuse (P<0.001), with financial hurdles (P<0.001), incarcerated (P<0.001), or those who experienced graft loss secondary to nonadherence (P<0.001). Additionally, pts who required combined heart-kidney Tx (P=0.002), with two prior graft losses (P<0.001), with graft loss secondary to recurrent glomerulonephritis (P=0.002), or no identified living kidney donor (LKD) (P=0.001) were less likely to be referred for KTx in LIC and LMIC.
Consistent with knowledge questions, attitude questions showed that practitioners in LIC and LMIC were less comfortable referring pts mentally incapacitated (P<0.001); with no health insurance (P=0.002), with financial hurdles (P<0.001); with two prior graft losses (P<0.001), or no identified LKD (P<0.001).
Questions reflecting practice showed that practitioners in LIC and LMIC referred less pts with the following characteristics: >70 yrs (P=0.025), no social support (P=0.016), substance abuse (P=0.026), treated HBV (P=0.017), pts requiring combined kidney-pancreas Tx (P=0.002), elderly frail pts (P=0.022), smokers (P=0.026), and no identified LKD (P<0.001).
Conclusions:
Differences in KTx referral patterns between practitioners in LIC and LMIC vs those in higher-income countries are related to medical, social, and financial issues. Educational activities targeting practitioners’ gaps in knowledge, attitude, and practice may optimize referral process.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.