Getting real about kidney transplant timelines

In this month's BMC Nephrology blog, Editor Dr. Sumeska Thavarajah explores the difficulty of predicting pretransplant hemodialysis duration for dialysis patients cleared for transplanation, and discusses associated potential complications and consequences of this process.

One of the biggest aspects in taking care of patients with advanced chronic kidney disease is planning for future renal replacement needs, either dialysis or transplant options. The benefits of transplantation over dialysis are widely accepted and if someone is a medically cleared, they should be encouraged to pursue transplantation. Dialysis counseling and education is individualized for patients depending on their other medical conditions, support systems, and transplant candidacy.   For those patients that are cleared medically and have potential live donors, discussions about home dialysis training and permanent dialysis access are curtailed. The assumption that the time on dialysis will be short and therefore effort towards arteriovenous access creation or home dialysis training seems wasted. But is the wait time really that short?

This week in BMC Nephrology, Dr. Slyvestre et al. report on 9300 incident dialysis patients listed and cleared for transplantation, and highlight the potential complications of catheter procedures or infections and associated increased risk of death during the wait time. Most striking was the median time to transplantation for both deceased donor recipients of 15 months and 9 months for those with live donors.

The potential year on dialysis therapy, even with potential donors, raises a few questions for nephrologists. Are we adequately preparing patients for that time on dialysis while they are waiting for workup and the potential delays? Should we be looking at the home dialysis options more? Are we putting patients at risk of a tunneled dialysis catheter infection that could have more significant complications such as disseminated infection requiring prolonged antibiotics or delay their surgery. The wait times also suggest perhaps a closer look at the process of workup for donors to see if there are ways to streamline.

Are we putting patients at risk of a tunneled dialysis catheter infection that could have more significant complications

Having a discussion with the patient’s transplant team to get a realistic time frame for the live donor surgery is going to be an important part of the decision making process. It will be a very different approach if a patient has a surgical date in 2 months versus a patient who has a potential donor but it is very early in the process. On the flip side, it would be important to share the information with patients so they are not getting discouraged with the wait times. Additionally, the decisions that they will make about dialysis options would be more informed.

This need is further amplified against the backdrop of the COVID-19 pandemic and it’s impact on transplantation. While healthcare systems around the world were overwhelmed by the influx of cases, there was a need to pause on “elective” procedures. Kidney transplantation rates fell as providers scrambled to balance the risk of immunosuppression and the risk of infection from COVID-19. The transplant evaluation process is further slowed by the inability to do in person visits for a multi-disclipinary team evaluation and delays in necessary testing for medical clearance as routine testing for things like mammograms and colonoscopy were on hold. Transplant centers are actively surveilling local rates of infections and mortality rates from COVID-19 and modifying evaluation and listing processes based on the resources available.

While there is desire to move forward with transplantation, it needs to be done in a way to maintain the safety of donors and recipients. Nephrologists need to recognize the fluid nature of the transplantation process and help guide their patients through this process.

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