Solving the Kidney Transplant Conundrum Through Systems Thinking

Abstract

Kidney transplant is the optimum treatment for individuals with kidney failure because it provides significantly improved quality and length of life compared with dialysis. Live donor kidney transplants offer the best outcomes compared with deceased donor kidney transplants and dialysis. 1 Despite this, kidney transplants are underutilized-not only because of a shortage of deceased donor kidneys, but also because of the lack of access to and underutilization of live donor kidneys. 2 The process to obtain kidney transplant is complex and involves multiple actors, presenting a conundrum regarding how best to optimize outcomes. Multiple steps in the process (including recognizing when patients are eligible for kidney transplant based on kidney function decline, referring potentially eligible patients to kidney transplant centers, completion of multiple tests and evaluations to demonstrate patients' fitness to receive kidney transplants, patients' placement on the deceased donor kidney transplant waiting list, and identifying willing and suitable live kidney donors) rely on consistent action of primary care physicians, community nephrologists, dialysis units, and kidney transplant centers. These groups have traditionally worked in disjointed and poorly coordinated ways to move patients through the process, leading to completely missed or delayed opportunities for patients to be waitlisted or receive live donor kidney transplants. Calls for coordinated care models to improve access to kidney transplant have set admirable goals to improve kidney transplant rates, yet little progress to improve kidney transplant access, particularly for live kidney transplants has been achieved. 3,4 In this issue, Garg et al 5 report on the EnAKT LKD Trial, a pragmatic cluster randomized clinical trial representing one of the first and largest-scale studies in North America to evaluate the effectiveness of a complex systems-based community intervention to improve kidney transplant access compared with usual care. The EnAKT LKD Trial was conducted among all 26 chronic kidney disease (CKD) programs in Ontario, Canada, including 26 specialized kidney clinics, 26 home dialysis programs, and 97 hemodialysis units. The EnAKT LKD trial intervention targeted key systems-level barriers to kidney transplant including lack of administrative infrastructure to ensure quality improvement for transplant access processes in CKD clinics; a greater need to educate health care staff members, patients, and potential donors about transplant; patients' needs for peer support and motivation to seek and complete the transplant process; and a need to provide clinical program administrators with data streams to support their oversight and accountability for transplant access outcomes. The EnAKT LKD Trial 5 outcomes measured enrolled patients' achievement of 4 key steps to achieving kidney transplants, including referrals to kidney transplant centers; live kidney donors' contacts to transplant centers; being wait-

Randomized Clinical Trials That Advance Health and Health Equity

“…In another example, the recent EnAKT LKD cluster RCT evaluated the effectiveness of a complex community– and health system–partnered intervention to improve access to kidney transplant. As stated in the Invited Commentary, the “intervention components and implementation strategies were informed by a robust community-informed stakeholder panel, ensuring interventions were tailored to regional needs. Stakeholder codeveloped interventions yielded novel strategies to bolster administrative health delivery system infrastructure, data streams, and program accountability” and “demonstrated how a comprehensive intervention simultaneously targeting numerous barriers to [kidney] transplant could be developed and implemented to serve residents across a large geographic region.”…”