There is broad agreement among the US public, medical community, and policy community on a top priority to expand kidney transplantation to more patients while promoting quality and equity. How to achieve these goals within existing health systems is the key question. Essential to successful kidney transplantation is a proper pretransplant medical evaluation. However, an increasing body of evidence suggests that this process can be burdensome to patients and caregivers, resource-intensive for transplant programs and the healthcare system, and potentially perpetuate inequity in transplant access-all factors running counter to the objectives of improving transplant access. A strategy of systematically reducing the number or intensity of testing procedures-or de-escalation-that is supported by available medical evidence and clinical consensus holds promise as a potential avenue to improve transplant access. In this perspective, we outline the rationale for de-escalation of portions of the pretransplant medical evaluation for kidney transplantation, apply an implementation science framework to systematically examine the barriers and facilitators for de-escalation, and finally lay out a blueprint for how de-escalation may be achieved in an efficacious, safe, and sustainable manner.
Cheng et al. (Sun,) studied this question.