Introduction: Kidney transplantation is considered the optimal form of renal replacement therapy. However, in the Netherlands, about sixty percent of patients on dialysis are not actively considered for transplantation, which is difficult to explain based on basic medical variables only. Indeed, various (non-) medical barriers to optimal access to transplantation have been mentioned in literature. Remarkably, no systematic inventory exists on these multiple (non-)medical barriers and the different perspectives on these barriers by these multiple stakeholders’ perspectives. Hence, the present qualitative study presents the various (non-)medical barriers to optimal access to transplantation from different perspectives of multiple stakeholders.

Method: Stakeholders involved in renal care are interviewed in two different phases about attitudes (phase 1) and integrative perspective of the different stakeholders (phase 2) regarding barriers to optimal access to transplantation. The topic list for the interviews contains six themes: psychological, policy, medical, ethical, social, and economic. The interview method followed grounded theory principles.

Results: A total of 117 participants were involved: patients (21), donors (10), social workers (25), nephrologists (22), surgeons (5), nurses (6), policy officers (24) and representatives of insurance companies (4). The following major barriers are typical for the six themes:

1. psychological: fear for transplantation relates to delay kidney transplantation;
2. policy-based: health care providers experience a lack of or unclarity regarding treatment guidelines;
3. medical: no consensus on criteria for acceptance for transplantation, e.g. age, BMI, comorbidity;
4. ethical: lack or insufficient use of programs/interventions that could help patients reach equal access to transplantation;
5. social: lack of an effective social network or lack of skills to activate social support system;
6. economic: differences in purchasing agreements and following reimbursements for dialysis and transplantation could provide an economic incentive for choosing one or the other therapy.

Conclusion: According to participants, access to transplantation rely heavily on a well-informed and acting patients, donors and health professionals. Despite the existence of national clinical guidelines, participants report ambiguity about their existence. Decision making by patients and donors is hampered by a lack of information about the different options, fears and difficulty to the complex decision-making process with multiple stakeholders. Financial incentives can influence access as they are not always aimed at encouraging early referral to kidney transplantation. Stakeholders state that access to kidney transplantation could be improved when these issues would be addressed. Next to the results of phase 1, the results of phase 2 (integrative perspective of stakeholders) will be presented.