A Qualitative Study of Patients, Caregivers, and Providers on Barriers to Kidney Retransplantation following Graft Loss.

key pointsThis qualitative study explored patient, caregiver, and provider perceived barriers to retransplantation after kidney allograft loss. We identified four medical and nonmedical barriers to retransplantation and four additional barriers to pursuing living donor retransplantation. System-, transplant center-, provider-, and patient-level approaches to address these barriers are highlighted.

backgroundMany kidney transplant recipients experience graft loss, and retransplantation offers a significant survival benefit when compared with waitlisted patients. Yet, trends related to preemptive relisting/retransplantation are suboptimal. Little empirical evidence has explored barriers to kidney retransplantation. We aimed to identify the predominant barriers to retransplantation after graft loss and factors that hinder the pursuit of living kidney donor (LKD) retransplantation.

methodsThis was a qualitative study that used an interpretive descriptive design. Participants included patients with a history of graft loss, caregivers who supported them, and transplant nephrologists, recruited using purposive and snowball sampling techniques. Data collection entailed semistructured interviews that were coded, and an inductive thematic analysis was conducted.

resultsWe synthesized the perspectives of 23 patients, 23 caregivers, and 11 transplant nephrologists representing 11 Canadian transplant programs. Through our analysis, we identified four key barriers to retransplantation: high antibody sensitization resulting in scarcity of compatible donors; prevalence of comorbidities leading to ineligibility or wait list withdrawal; history of nonadherence among the recipients leading to ineligibility or delays in transplant referral and reevaluation; and delayed referrals and poor coordination of retransplant workup. Additional barriers to LKD retransplantation included patient preference for deceased donor transplantation that was unlikely to change after graft loss; perceived smaller pool of eligible LKDs felt to have been exhausted with the first transplant; the psychological burden of unresolved issues related to previous LKD transplant loss; and overall structural barriers to living kidney donation.

conclusionsThis analysis highlights both medical and nonmedical barriers to retransplantation and that the pursuit of retransplantation entails persistent as well as additional and compounding challenges. A list of implications that arise from these findings is presented. Given the well-established benefits of kidney transplantation and that graft loss remains a leading cause of dialysis initiation, these findings have important implications for the nephrology community.