Initiating maintenance dialysis prior to living kidney donor transplantation when a donor candidate evaluation is well underway

AbstractBackgroundPreemptive kidney transplants result in better outcomes and patient experiences than transplantation after dialysis onset. It is unknown how often a person initiates maintenance dialysis prior to living kidney donor transplantation when their donor candidate evaluation is well underway.MethodsUsing healthcare databases, we retrospectively studied 478 living donor kidney transplants from 2004-2014 across 5 transplant centres in Ontario, Canada where the recipients were not receiving dialysis when their donor's evaluation was well underway. We also explored some factors associated with a higher likelihood of dialysis initiation before transplant.ResultsA total 167/478 (35%) persons with kidney failure initiated dialysis a median 9.7 (25th-75th percentile 5.4-18.7) months after their donor candidate began their evaluation, and received dialysis for a median 8.8 (3.6-16.9) months before kidney transplantation. The total cohort's dialysis cost was $8.1 million and 44/167 (26%) recipients initiated their dialysis urgently in hospital. The median total donor evaluation time (time from evaluation start to donation) was 10.6 (6.4-21.6) months for preemptive transplants and 22.4 (13.1-38.7) months for donors whose recipients started dialysis prior to transplant. Recipients were more likely to start dialysis if their donor was female, nonwhite, lived in a lower-neighbourhood income, and if the transplant centre received the recipient referral later.ConclusionOne-third of persons initiated dialysis prior to receiving their living kidney donor transplant, despite their donor's evaluation being well underway. Future studies should consider whether some of these events can be prevented by addressing inappropriate delays to improve patient outcomes and reduce healthcare costs. Background Preemptive kidney transplants result in better outcomes and patient experiences than transplantation after dialysis onset. It is unknown how often a person initiates maintenance dialysis prior to living kidney donor transplantation when their donor candidate evaluation is well underway. Methods Using healthcare databases, we retrospectively studied 478 living donor kidney transplants from 2004-2014 across 5 transplant centres in Ontario, Canada where the recipients were not receiving dialysis when their donor's evaluation was well underway. We also explored some factors associated with a higher likelihood of dialysis initiation before transplant. Results A total 167/478 (35%) persons with kidney failure initiated dialysis a median 9.7 (25th-75th percentile 5.4-18.7) months after their donor candidate began their evaluation, and received dialysis for a median 8.8 (3.6-16.9) months before kidney transplantation. The total cohort's dialysis cost was $8.1 million and 44/167 (26%) recipients initiated their dialysis urgently in hospital. The median total donor evaluation time (time from evaluation start to donation) was 10.6 (6.4-21.6) months for preemptive transplants and 22.4 (13.1-38.7) months for donors whose recipients started dialysis prior to transplant. Recipients were more likely to start dialysis if their donor was female, nonwhite, lived in a lower-neighbourhood income, and if the transplant centre received the recipient referral later. Conclusion One-third of persons initiated dialysis prior to receiving their living kidney donor transplant, despite their donor's evaluation being well underway. Future studies should consider whether some of these events can be prevented by addressing inappropriate delays to improve patient outcomes and reduce healthcare costs. Corresponding author: Amit X Garg MD, PhD Institute for Clinical Evaluative Sciences Western facility (ICES Western) Victoria Hospital. 800 Commissioners Rd, Victoria Hospital, Room ELL-215. London, Ontario, Canada N6A 5W9 Tel: 519-685-8502. Email: amit.garg@lhsc.on.ca Authorship Participated in research design: Steven Habbous, Eric McArthur, Stephanie N. Dixon, Susan McKenzie, Carlos Garcia-Ochoa, Ngan N. Lam, Krista L. Lentine, Christine Dipchand, Kenneth Litchfield, Mehmet A. Begen, Sisira Sarma, Amit X. Garg Participated in the writing of the paper: Steven Habbous, Eric McArthur, Stephanie N. Dixon, Susan McKenzie, Carlos Garcia-Ochoa, Ngan N. Lam, Krista L. Lentine, Christine Dipchand, Kenneth Litchfield, Mehmet A. Begen, Sisira Sarma, Amit X. Garg Participated in the performance of the research: Steven Habbous, Eric McArthur, Stephanie N. Dixon, Susan McKenzie, Carlos Garcia-Ochoa, Sisira Sarma, Amit X. Garg Contributed new reagents or analytic tools: N/A Participated in data analysis: Steven Habbous, Eric McArthur, Stephanie N. Dixon, Carlos Garcia-Ochoa, Sisira Sarma, Amit X. Garg Disclosures Dr. Garg received partnership funding from Astellas for a research grant funded by the Canadian Institutes of Health Research. The other authors have no conflicts of interest to disclose. Funding Funding for this analysis was provided by Ontario's Trillium Gift of Life Network. Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (CAN-SOLVE CKD) is a patient-orientated research network to transform the care of people affected by kidney disease. It is led by Drs. Adeera Levin and Braden Manns. Patient partnerships in this project were supported by CAN-SOLVE. Steven Habbous is supported by the Canadian Institutes of Health Research Frederick Banting and Charles Best Canada Doctoral Scholarship. Dr. Ngan N. Lam was supported by a Kidney Research Scientist Core Education and National Training Program (KRESCENT) New Investigator Award. Dr. Amit Garg is supported by the Dr. Adam Linton Chair in Kidney Health Analytics, and a Canadian Institutes of Health Research Clinician Investigator Award. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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