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

Habbous S, McArthur E, Dixon SN, McKenzie S, Garcia-Ocha C, Lam NN, Lentine KL, Dipchand C, Litchfield K, Begen MA, Sarma S, Garg AX. Transplantation. 2018; 102(7):e345-53. Epub 2018 Mar 10.

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.