Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access
Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc
Journal website https://www.jocmr.org

Original Article

Volume 13, Number 1, January 2021, pages 1-8

Low Rates of Preemptive Kidney Transplantation: A Root Cause Analysis to Identify Opportunities for Improvement

Figures

Figure 1.
Figure 1. Recipient and donor evaluation process.
Figure 2.
Figure 2. Fishbone diagram illustrating potential barriers to preemptive kidney transplant. DSA: donor-specific antibody; KPD: kidney paired donation.
Figure 3.
Figure 3. Distribution of root causes amongst non-preemptive transplant recipients (n = 39). KPD: kidney paired donation.

Tables

Table 1. Demographics and Baseline Characteristics
 
CharacteristicsFailed to achieve a preemptive transplant, % (n = 39)Achieved a preemptive transplant, % (n = 11)P value
ESRD: end-stage renal disease.
Recipients
  Age, years, mean ± SD50 ± 1646 ± 15
  Male recipient69%55%0.12
  Cause of ESRD
    Diabetes18%18%1
    Hypertension5%9%0.53
    Cystic kidney disease18%18%0.67
    Glomerulonephritis38%45%1
    Others21%9%0.69
Donors
  Age, years, mean ± SD47 ± 1645 ± 8
  Male donor60%63%1
  Relationship to recipient
    Spouse18%27%0.4
    Related32%36%1
    Unrelated50%36%1
    First donor evaluated64%64%1
  Location of residence
    Out of province12%9%1
    Out of country2%0%1

 

Table 2. eGFR at Time of Referral for Recipients Referred Preemptively Only
 
eGFR (mL/min/1.73 m2)Failed to achieve a preemptive transplant, % (n = 39)Achieved a preemptive kidney transplant, % (n = 11)P value
eGFR: estimated glomerular filtration rate.
Less than 1577.3%36%0.052
15 to 2018.2%55%0.049
Greater than 204.5%9%1

 

Table 3. Logistic Regression Model of eGFR Values and Odds of Achieving Preemptive Transplant*
 
eGFR (mL/min/1.73 m2)UnadjustedAdjusted
Odds ratio95% confidence intervalP valueOdds ratio95% confidence intervalP value
LowerUpperLowerUpper
*Represent the odds of “preemptive kidney = achieved” vs. “preemptive kidney = failed”. Adjusted for age, sex and cause of ESRD. +Statistically significant. eGFR: estimated glomerular filtration rate.
Less than 15Reference
15 to 209.711.0887.310.042+10.690.92124.910.059
Greater than 200.140.020.840.032+0.03< 0.0010.340.005+

 

Table 4. Time to Complete Evaluation Milestones for Recipients and Donors
 
Median (days)Range
†Three polycystic kidney disease recipients had longer wait times between initial assessment and clearance due to delayed nephrectomies just prior to reaching end-stage renal disease and transplant. *The time interval between recipient referral and their donor completing the donor questionnaire. ∧The negative result in this range is due to five donors who contacted the program prior to their respective recipient’s referral. Also, the range is affected by whether multiple donors contacted the program at varying stages before a suitable donor was found.
Recipient milestones (n = 50)
  Referral to initial testing344 - 200
  Pre-referral testing to transplant nephrologist consultation3812 - 145
  Consultation to recipient clearance32463 - 1,945†
  Recipient clearance to transplantation9022 - 1,176†
  Recipient referral to clearance for transplant408149 - 2,014†
Donor milestones (n = 50)
  Questionnaire returned to initial testing445 - 403
  Initial testing completion to donor nephrologist consultation495 - 136
  Donor nephrologist consultation to donor clearance1207 - 255
  Donor questionnaire returned to donor clearance24161 - 506
  Recipient referral to donor questionnaire completion*106-183 - 1,611∧