A Qualitative Study of Patients, Caregivers, and Providers on Barriers to Kidney Re-Transplantation Following Graft Loss

Background: Many kidney transplant recipients experience graft loss, and re-transplantation offers a significant survival benefit when compared with waitlisted patients. Yet trends related to pre-emptive re-listing/re-transplantation are sub-optimal. Little empirical evidence has explored barriers to kidney re-transplantation. We aimed to identify the predominant barriers to re-transplantation after graft loss and factors that hinder the pursuit of living kidney donor (LKD) re-transplantation. Methods: This 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 semi-structured interviews that were coded, and an inductive thematic analysis was conducted. Results: We 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 re-transplantation: high antibody sensitization resulting in scarcity of compatible donors; prevalence of comorbidities leading to ineligibility or wait list withdrawal; history of non-adherence among the recipients leading to ineligibility or delays in transplant referral and re-evaluation; and delayed referrals and poor coordination of re-transplant workup. Additional barriers to LKD re-transplantation 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 prior LKD transplant loss; and overall structural barriers to living kidney donation. Conclusions: This analysis highlights both medical and non-medical barriers to re-transplantation and that the pursuit of re-transplantation 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.