Dedicated transplant coordinators may be able to improve access to kidney transplantation for disadvantaged patients but more needs to be done to address disparities.
While the optimal treatment for kidney failure is transplant, in the USA just 13% of patients are ever placed on the waiting list.1
The literature shows that racial and socioeconomic disparities play a role in this disparity. Black people make up 31% of end-stage kidney disease sufferers but are less likely to make it onto the waiting list or to receive a transplant than their white counterparts.2
In 2017 alone, 2,710 black people with kidney failure died or were removed from the waiting list because they were too ill for the transplant.2
Several interventions designed to address this disparity have been tested over the last decade. These have included initiatives to reduce financial barriers, implement community-based education, establish transplant liaison and developing a research strategy to better understand the inequities.
Between January 2013 and August 2014, a single-center randomized controlled trial examined the effectiveness of a trained navigator among high-risk kidney failure patients referred for transplant evaluation.
Those who did not receive the intervention were given standard care, which involved meeting with the transplant nurse coordinator, social worker, financial coordinator and physician’s assistant on the first day of evaluation.
Of the 401 people included in the study, 196 were given additional support from the transplant navigator who had a master’s degree in social work.
Their duties included transplant education with an emphasis on living donor transplant, as well as assisting with scheduling, appointment reminders, financial aid and transplantation. They also helped non-English speakers with interpretation and providing social support by signposting to support and community groups. What’s more, the navigator acted as a liaison point between the patient, their care team, the transplant center and other health and care services.
After evaluation, the navigator attended a multidisciplinary selection meeting to discuss the patient and make a decision as to whether they would be placed on the waitlist.
At the end of the study, 32% of intervention and 26% of standard care patients had been placed on the waiting list. The difference was not statistically significant.
Time from referral to being placed on the waiting list was 126 days longer among those who were assigned the navigator.
However, after 500 days post-referral, those who had received the additional care were 3.3 times more likely to be waitlisted. 18% of people in the intervention group had living donor inquires compared to 10% of those in the standard care group.
While the intervention improved the number of high-risk patients being waitlisted, this was not noticed until after 500 days of follow up and the absolute effect was relatively small.
Authors suggest those included in the study may not have been waitlisted at all without a patient navigator. Their high needs level meant it would take more time to complete the required medical tests and follow-ups than those who waitlisted in the first 500 days.
“Although a navigator did not reduce time to waitlisting, the intervention could potentially still help a high-needs population successfully access the waitlist after 500 days by addressing frequently encountered barriers that may delay waitlisting.
“In addition, we found that patients assigned to a patient navigator had a higher number of living donor inquiries,” said the study.
In an accompanying editorial, Dr. Amy Waterman of the David Geffen School of Medicine at UCLA and Dr. Jennifer Beaumont of the Terasaki Research Institute, said more work was needed to effectively tackle the disparity of kidney transplant waiting times.2
“The stakes for high-risk patients are too great to give up on the search for solutions to education and ensure them equal access to treatment,” the editorial concluded.
Basu M, Petgrave-Nelson L, Smith KD, Perryman JP, Clark K, Pastan SO, Pearson TC, Larsen CP, Paul S, Patzer RE. Transplant Center Patient Navigator and Access to Transplantation among High-Risk Population: A Randomized, Controlled Trial. Clin J Am Soc Nephrol 2018; 13:620-627.
- American Society of Nephrology (2018). Press release: Trained navigators may improve access to transplantation for disadvantaged patients. Available from: https://www.eurekalert.org/pub_releases/2018-03/ason-tnm032018.php (accessed April 2018)
- Waterman AD, Beaumont JL. What Else Can We Do to Ensure Transplant Equity for High-Risk Patients? Clin J Am Soc Nephrol 2018; 13:529-530.