Special Article
Nephrologists' Perspectives on Waitlisting and Allocation of Deceased Donor Kidneys for Transplant

https://doi.org/10.1053/j.ajkd.2011.05.029Get rights and content

Background

Deceased donor kidneys are a scarce resource and there is debate about how to maximize the benefit from each donated kidney while ensuring equity of access to transplants. Allocation of kidneys to waitlisted patients is determined by a computer algorithm, but the decision to waitlist patients or accept the kidneys offered is largely at the discretion of nephrologists. This study aims to elicit nephrologists' perspectives on waitlisting patients for kidney transplant and the allocation of deceased kidneys.

Methods

We conducted semistructured face-to-face interviews with adult and pediatric nephrologists from 15 Australian nephrology or transplant centers. Transcripts were analyzed for descriptive and analytical themes.

Results

25 nephrologists participated. 5 major themes on waitlisting and deceased donor kidney allocation were identified: patient advocacy (championing their own patients, empowering patients, giving hope, individualizing judgments, patient preferences, and limited autonomy), professional and moral integrity (transparency, avoiding value judgments, and eliminating bias), protecting center reputation (gatekeeping), achieving equity (uniformity, avoiding discrimination, and fairness for specific populations), and maximizing societal benefit (prioritizing best use of kidney, resource implications, favoring social contribution, and improving efficiency of the allocation process). In making individual patient assessments, estimates about outcomes for a patient had to be resolved with whether it was reasonable from a broader societal perspective.

Conclusion

Nephrologists expressed their primary responsibility in terms of giving their own patients access to a transplant and upholding professional integrity by maintaining transparency and avoiding value judgments and bias. However, nephrologists perceived an obligation to protect their center's reputation through the selection of “good” patients, and this caused some frustration. Despite having personal preferences for optimizing the balance between societal benefit and equity, nephrologists did not want direct responsibility for ensuring societal benefit in clinical practice. Rather, they placed the onus on policy makers and the community to reconcile such tensions and advocate for societal benefit.

Section snippets

Context

In Australia, the nephrologist makes a recommendation about patient suitability for transplant based on medical and psychosocial considerations. Potential transplant candidates also are reviewed independently by a transplant assessment team that includes nephrologists, allied health staff, anesthetists, and surgeons. Allocation of deceased donor kidneys is determined by a computer program called the National Organ Matching System.9 The major criteria used in the algorithm are time on waiting

Results

Of 28 invited nephrologists, 25 (89%) participated in the study. Nonparticipation was due to travel and clinical commitments. Participant characteristics are listed in Table 1. On average, each interview lasted 30-90 minutes. Participants were from New South Wales (n = 12), Queensland (n = 2), South Australia (n = 6), Victoria (n = 3), and Western Australia (n = 2). Most participants were men (n = 20). Twenty practiced in a transplant center; 3, in a nephrology (nontransplant) center; and 2, in

Discussion

Nephrologists viewed their primary responsibility as being to their own patients, in which they empowered patients to achieve the required threshold for waitlist suitability based on adherence, weight, and cessation of smoking. Nephrologists made decisions to waitlist and accept a donated kidney mainly based on medical status, potential for improved health outcomes, psychological factors, and patient preferences. They also sought to uphold professional integrity by maintaining transparency in

Acknowledgements

We thank all the nephrologists for taking the time to share their thoughtful and insightful perspectives on waitlisting patients for transplant and on organ allocation.

Support: This project is supported by the Australian Research Council Discovery Project Grant DP 0985187. Dr Tong is supported by the National Health and Medical Research Council (NHMRC) Capacity Building Grant in Population Health ID 457281. The study sponsor had no role in study design; collection, analysis, and interpretation

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    Originally published online August 24, 2011.

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