Variability in workup and eligibility criteria for adult kidney transplantation among Canadian transplant centres
Faissal Tallaa1, Lakshman Gunaratnam2, Marcelo Cantarovich1, Héloise Cardinal3, Stephanie Hoar4, Olwyn Johnston5, Martin Karpinski6, Tammy Keough-Ryan7, Joseph Kim8, Caroline Lamarche9, Khaled Lotfy2, Jeff Ma10, Rahul Mainra11, Mélanie Masse12, Shaifali Sandal1, M. Khaled Shamseddin13, Kevin Wen14, Rita S. Suri1.
1McGill University, Montreal, Canada; 2Western University, London, Canada; 3Centre Hospitalier de l’université de Montréal , Montreal, Canada; 4University of Ottawa, Ottawa, Canada; 5University of British Columbia, Vancouver, Canada; 6University of Manitoba, Winnipeg, Canada; 7Dalhousie University, Halifax, Canada; 8University of Toronto, Toronto, Canada; 9L’hôpital Maisonneuve-Rosemont de l’université de Montréal , Montreal, Canada; 10University of Calgary, Calgary, Canada; 11University of Saskatchewan, Saskatoon, Canada; 12Université de Sherbrooke , Sherbrooke, Canada; 13Queen's University, Kingston, Canada; 14University of Alberta, Edmonton, Canada
Introduction: All potential kidney transplant recipients undergo rigorous evaluation to rule out or ensure appropriate treatment of conditions that may increase risk of post-transplant complications, but specific recommendations regarding workup and kidney transplant candidacy vary across published guidelines. We assessed current pre-transplant evaluation practices and eligibility criteria for adult kidney transplantation across Canada to elucidate differences in guideline interpretation and identify areas of most uncertainty.
Methods: We compared published guidelines on kidney transplant workup and eligibility in order to create a focused digital survey that included both undisputed and controversial domains. The survey was divided into: referral process, history/physical exam, multidisciplinary assessments, laboratory/imaging, and contraindications. Given the many cancers and different staging for each, malignancy-related inquiries were simplified. The medical directors of all 18 Canadian adult kidney transplant programs were invited to complete the survey. We defined consensus and uncertainty, respectively, as >90% and <65% agreement between centers.
Results: Survey completion rate was 78% (14/18). There was consensus on mandatory pre-transplant viral serology testing, tuberculosis screening, and dental evaluation, while cardiac evaluation protocols varied considerably. Of 28 questioned conditions, 6 were considered absolute contraindications by >90% of centers (active bacterial infection/malignancy, non-healing ulcer, COVID-19, severe lung/liver disease). Moderate uncertainty existed for: medication non-adherence (57%), symptomatic heart failure (50%), recent myocardial infarction (57%), and frailty (35%). Other parameters demonstrating wide variability included latent tuberculosis treatment protocols, and exclusion thresholds for parathyroid hormone, body mass index, left ventricular ejection fraction, and blood pressure. Centers used several guidelines to determine eligibility for patients with treated cancer.
Conclusion: There is marked variability in evaluation requirements and eligibility criteria for kidney transplantation across Canada. National harmonization of evaluation processes and eligibility criteria may help to ensure more equitable and transparent access to kidney transplantation for Canadian patients with end-stage kidney disease.
