The psychosocial factors influencing paediatric kidney transplantation access, their outcomes and the patient and family's perceived quality of life: a systematic review and meta-analysis.

Kidney transplantation is the gold standard treatment for children and young people (CYP) with stage 5 chronic kidney disease (CKD). However, psychosocial and structural factors including race, socioeconomic status and family context can delay or limit access to transplantation. This systematic review explores the breadth of psychological, social and societal factors influencing transplant access, outcomes and quality of life. We included peer-reviewed quantitative, qualitative and mixed-method studies with primary data. Medline, PsychInfo, CINAHL and Web of Science were searched for papers published in English between January 1964 and November 2022. A total of 66 studies (52 quantitative, 10 qualitative and 4 mixed-methods) were identified and analysed. A wide breadth of psychosocial factors were identified: mental health, adjustment to CKD, non-adherence, beliefs, motivation, cognitive status, family structure, family relationships, trust in or relationship with healthcare professionals, health insurance, infrastructure, education, geography, socioeconomic status (SES), social support, housing, religion or culture, national or regional wealth, migrant status-driven or racialised health inequities and kidney allocation policies. Among these studies, 13 qualified for meta-analysis regarding SES and race. CYP experiencing lower SES as a potential stressor were more likely to access deceased donor transplantation, less likely to access pre-emptive transplantation and more likely to experience allograft failure. CYP from racially minoritised groups had reduced access to living donor and pre-emptive transplantation, and higher rates of allograft loss. These inequities were often mediated by structural racism, implicit bias, allocation policies and overlapping systems of disadvantage. There is a wide breadth of psychosocial factors that influence the lived experience of CKD and access to and outcomes after transplantation. Race, as a proxy for racism, interacts with SES, geography and other social determinants through an intersectional process that deepens inequities. Some factors are modifiable at the clinical or family level, while others require systemic change. Addressing these inequities will require multi-tiered strategies, from clinician education on bias to reforms in allocation policy and broader social structures. Further studies are needed to better understand the complex relationship between these psychosocial factors and kidney transplantation outcomes. Prospero Registration. number CRD42020210506.