An Environmental Scan of Canadian Kidney Transplant Programs for the Management of Patients With Graft Failure: A Research Letter

• Published in: Canadian journal of kidney health and disease 2024-01, Vol.11, p.20543581241274006
• Main Authors: Slominska, Anita, Gaudio, Kathleen, Shamseddin, M. Khaled, Lam, Ngan N., Ho, Julie, Vinson, Amanda, Mainra, Rahul, Hoar, Stephanie, Fortin, Marie-Chantal, Kim, S. Joseph, DeSerres, Sacha, Prasad, G. V. Ramesh, Weir, Matthew A., Cantarovich, Marcelo, Sandal, Shaifali
• Format: Article
• Language: English
• Subjects: Clinical medicine; Clinical Research Letter; Content analysis; Hemodialysis; Kidney diseases; Kidney transplants
• ISSN: 2054-3581; 2054-3581
• DOI: 10.1177/20543581241274006

Background: Kidney transplant recipients with graft failure (KTR-GF) and those with a failing graft are an increasingly prevalent group of patients. Their clinical management is complex, and outcomes are worse than transplant naïve patients on dialysis. In 2023, the Kidney Disease: Improving Global Outcomes (KDIGO) organization reported findings from a controversies conference and identified several clinical practice priorities for KTR-GF. Objective: As an exercise in needs assessment, we aimed to collate and summarize current practices in adult Canadian kidney transplant programs around these KDIGO-identified clinical practice priorities. Design: Environmental scan followed by content analysis. Setting: Canadian adult kidney transplant programs. Measurements: We categorized the themes of our content analysis around 7 clinical practice priorities: (1) determining prognosis and kidney failure trajectory; (2) immunosuppression management; (3) management of medical complications; (4) preparing for return to dialysis; (5) evaluation and listing for re-transplantation; (6) management of psychological effects; and (7) transition to supportive care. Methods: We solicited documents that identified each program’s current care practices for KTR-GF or patients with a failing graft, including policies, procedures, pathways, and protocols. A content analysis of documents and informal correspondence (email or telephone conversations) was done to extract information surrounding the 7 practice priorities. Results: Of the 18 programs contacted, 12 transplant programs participated in this study and a document from a provincial organization (where 2 non-responding programs are located) was procured and included in this analysis. Overall, practice gaps and discrepancies were noted. Many participants highlighted the lack of evidence or consensus to guide the management of KTR-GF as the key reason. Immunosuppression management was the most frequently addressed priority. Six programs and the provincial document recommended a nuanced approach to immunosuppressant management based on clinical factors and re-transplant candidacy. Two programs used the Kidney Failure Risk Equation and eGFR to determine referral trajectories and prepare patients for return to dialysis. Exact processes outlining medical management during the transition were not found except for nephrectomy indications and in 1 program that has a specific transition clinic for KTR-GF. All programs have a formal or info