Addressing 3 Common Barriers to a Kidney Transplant

For most patients with end stage renal disease (ESRD), a kidney transplant can offer the best possible long-term treatment option. Transplanted patients typically have better life expectancy and overall quality of life than ESRD patients who remain on any modality of dialysis.

Pursuing a transplant is a multi-step and often-daunting task, and there are many factors along the way that can derail the process. The following three situations are common barriers to transplantation that we as health care professionals can help patients work through to join the active transplant list.

1. Disinterest in a transplant

While patients may have unmodifiable attributes or conditions (such as poor cardiac status or recent history of cancer) that make them less likely to pursue transplant, there are also psychosocial conditions that can be addressed to increase patients’ interest in receiving a transplant.

A study indicated the most-frequently identified reasons for lack of interest in a transplant were:

• Advanced age
• Perception of poor health
• Comfort with current modality
• Disinterest in further surgeries

The health care team can address these concerns through in-depth conversations to learn about patients’ fears and to provide additional education and/or supportive counseling. Social workers who are trained in cognitive-behavioral and mindfulness techniques, such as Melissa McCool’s symptom-targeted intervention (STI), may need to use these tools to address patients’ internal narratives on dialysis, disability status and other limiting beliefs. STI could help patients reevaluate the way they are thinking and feeling about themselves and what is possible—leading them to actively combat unhelpful ways of thinking and behaving and to be more open to receiving a kidney transplant.

2. Unemployment

Patients who are employed are more likely to be listed for transplant than those who are not employed. Many barriers to employment (access to transportation, depression and lack of motivation) are similar to reasons patients are not interested in pursuing transplant; conversely, it seems that many of the factors associated with employed patients (improved financial status and sufficient insurance coverage) may also help patients achieve a listed status for transplant.

A DaVita Clinical Research study on currently unemployed ESRD patients indicated the most frequently cited barriers to employment were:

• Lack of energy
• Feeling too ill to work
• Having a disability
• The perception of needing job training to return to employment

Stratification of patients by age revealed that, while lack of energy and feeling too ill were consistently reported as the leading barriers to employment across all age categories, other categories were age-dependent. Disability was more frequently identified as a barrier by older patients, while the need for job training and issues relating to child care and transportation were more frequently identified as barriers by younger patients.

Some aspects of employment, taken in isolation, can help patients be better candidates for transplant; in particular, access to good, comprehensive insurance coverage that covers post-transplant antirejection medications (coverage that won’t end after about three years post-transplant, which is the case for many patients on traditional Medicare plans). Employment can also provide a better financial situation, which helps with costs of transplant surgery, follow-up appointments and post-transplant medications.

There are also less-concrete aspects associated with employed patients that make them better candidates for transplant, such as improved quality of life, decreased incidence of depression and increased motivation. These are equally important to a patient who is trying to navigate the process from referral to listing to receipt of a kidney.

It is important for each member of the health care team to identify the underlying causes to employment and transplant barriers. When patients say they do not have enough energy or feel too ill, what does that really mean? Is it related to poor nutritional status, anemia, insufficient dialysis or uremia? Or could it be from lack of motivation, poor coping or depression? By asking the right questions and offering the right interventions, the health care team can help patients reach their goals, both vocationally and as it relates to transplant.

3. Lack of hope

Having a negative future outlook or dealing with depression can significantly affect dialysis patients’ receptivity to a transplant. From the very first contact, we as health care professionals have an opportunity to foster positive expectancy in all of our interactions we have with dialysis patients. When nephrologists meet with patients in the hospital or in their practices, they can convey to the patient that it is possible to lead a normal and fulfilling life that can include employment if the patient chooses to continue working. Surely patients who are not depressed and are hopeful about their present and future will be much better equipped to handle the unique challenges of working on dialysis and/or navigating the transplant process.

Conclusion

There are many barriers, both real and perceived, that can prevent dialysis patients from fully engaging in their lives. These barriers also make pursuit of a kidney transplant daunting and make patients less likely to want to do it. However, there are many ways health care team members and, in particular, social workers can intervene to help our patients overcome these barriers to have the best quality of life possible on dialysis and improve their chances of being able to receive a kidney transplant.