A Retrospective Review of the Quality of Care in Patients with Failed Kidney Transplants: A Single Centre Experience

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Abstract

Background

The quality of care provided to patients with failing kidney transplants has been shown to be suboptimal in prior reports. Kidney transplant recipients (KTR) with poor graft function have been shown to have increased mortality and morbidity secondary to prolonged use of immunosuppression. This indicates the need for early preparation of these patients with pre-dialysis counseling, education, and planning. However, a more recent review of this issue in a contemporary Canadian cohort has not been undertaken.

Methods

We conducted a cross-sectional study of all adult KTR who received their first deceased or living donor transplants at Toronto General Hospital from January 1, 2000 and experienced kidney allograft failure by December 31, 2015. We excluded any patients age < 18 years, recipients of multiple organ transplants, transplants from outside centres, or kidney allografts that failed within 3 months of transplant. Suboptimal dialysis starts (SDS) were defined as dialysis initiation as inpatients while optimal dialysis starters were initiated as outpatients. SDS were further categorized as avoidable vs. unavoidable (i.e., patients with the rapid decline of eGFR (CKD-EPI) by more than 5 ml/min/1.73m2 within 30 days).

Results

A total of 303 KTR experienced kidney transplant failure over the study follow-up. The KTR with failed grafts were 65.0% white, and the median recipient age and BMI at graft failure were 53 years and 25.4 kg/m2, respectively. The prevalence of SDS was 58% (n = 104 of 178). The odds ratio was 1.03 in the logistic regression model for the effect of recipient age at graft failure on dialysis initiation in the SDS group [OR = 1.03 (1.00, 1.06), P value = 0.04]. Among SDS patients, 62 (60%) and 42 (40%) were unavoidable and avoidable, respectively. Half or more in each group of SDS (i.e., n = 21 avoidable starts and n = 41 unavoidable starts) were initiated on hemodialysis with a central venous catheter.

Conclusion

The majority of failed KTR were SDS in this single-centre study, with 40% of these SDS being potentially avoidable. Given the large proportion of avoidable SDS (especially with a central venous catheter), there appears to be an opportunity to improve the quality of care for these patients by ensuring more timely referral to kidney care clinics and better planning for chronic dialysis or re-transplantation.

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