A Process Model for Referral to Kidney Transplant Evaluation

By Victoria Socha - Last Updated: April 11, 2023

While the preferred modality for kidney failure treatment is kidney transplant, most patients initiate dialysis prior to receiving a transplant. Referral to a transplant center is a key early component of receipt of a transplant; however, according to Adam Wilk, PhD, and colleagues at Emory University, Atlanta, Georgia, only 34% of patients are referred to a transplant center within 1 year of dialysis initiation. The absence of a process model to characterize how dialysis clinics approach the decision of whether to refer patients for transplant impedes efforts to mitigate provider- and clinic-level barriers to early referral.

The researchers conducted 39 interviews during June to August 2022 with dialysis clinic providers in Georgia, North Carolina, and South Carolina to identify processes leading up to referral or nonreferral to a transplant center. Results were reported during a poster session at the National Kidney Foundation Spring Clinical Meetings 2023 in a poster titled How Dialysis Providers Assess and Refer Patients for Kidney Transplant Evaluation: A Process Model.

Interviews were conducted with dialysis social workers, nurse managers, nephrologists, and administrators. Recruitment was facilitated using purposive sampling to ensure diversity by participants’ role, years of experience, and county median household income level. The semistructured interviews were conducted via telephone and were recorded and transcribed. Key constructs, including discrete steps and decisions, were identified using a phenomenological approach. Multiple coders developed the codebook and interpreted the data.

Most participants described a four-step process preceding any transplant referral: (1) assessment of whether the patient has a nonmodifiable contraindication to transplant, in which case the referral does not proceed; (2) parallel dialogues with the patient, including education on transplant, and within the care team, leading to inquiring about the patient’s interest in transplant (step 2 is repeated if the patient does not express interest in transplant); (3) once the patient indicates interest in transplant, the lead provider (nephrologist) or the collective care team judges whether to make the referral at that time or to wait and intervene with the patient to improve chances of waitlisting; and (4) carry out the referral on the specified timeline.

“Qualitative interviews with dialysis providers revealed a four-step process for approaching transplant referral decisions,” the researchers said. “This model can be used to inform interventions on dialysis clinics’ assessment and referral processes.”

Source: Wilk A, McDonnell J, Urbanski M, et al. How dialysis providers assess and refer patients for kidney transplant evaluation: a process model. Poster #446. Abstract of a poster presented at the National Kidney Foundation Spring Clinical Meetings 2023; April 11-15, 2023; Austin, Texas.

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