Multicomponent Intervention Fails to Improve Access to Kidney Transplantation

Amit Garg, MD, PhD

Credit: ICES

Results from the Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) trial showed evidence of intervention uptake but no difference in steps completed toward kidney transplantation between the intervention and usual-care groups.

Presented at the American Society of Nephrology Kidney Week 2023, the study failed to show intervention increased access to kidney transplantation and living donation, which investigators attributed to disruptions from the COVID-19 pandemic during the study period.¹

“Whenever someone receives a kidney transplant, they live longer, they live healthier, and they save the healthcare system substantial amounts of money. And there are many people who are eligible to receive a transplant but will never receive one. This is a major problem in renal care, and we're committed to fixing it,” said Amit Garg, MD, PhD, professor at Schulich School of Medicine and Dentistry at Western University, in an interview with HCPLive.

A pragmatic, 2-arm, parallel-group, cluster-randomized trial, EnAKT LKD included 20,375 potentially transplant-eligible patients with advanced chronic kidney disease (CKD) at 26 CKD programs in Ontario, Canada, and offered a multi-component intervention designed to target several barriers thought to prevent kidney transplantation and living donation.¹

Kidney transplants are necessary for patients with CKD or end-stage renal failure whose kidneys can no longer filter waste properly. An estimated 2 million patients worldwide are affected by kidney failure, a figure continually increasing at a rate of 5-7% per year. Although dialysis offers a short-term solution for these patients, a transplant will eventually be needed.²

Using covariate-constrained randomization, investigators randomly assigned the CKD programs in a 1:1 ratio to provide the intervention or usual care for 4.2 years. The intervention had 4 main components: administrative support to establish local quality improvement teams, transplant educational resources, an initiative for transplant recipients and living donors to share stories and experiences, and program-level performance reports and oversight by administrative leaders.¹

The primary outcome of interest was a composite of all completed steps toward receiving a kidney transplant. Each patient could complete up to 4 steps, which included being referred to a transplant center for evaluation, having a potential living donor contact a transplant center for evaluation, being added to the deceased donor waitlist, and receiving a transplant from a living or deceased donor.¹

Among the 26 CKD programs included in the study, 13 (n = 9780 patients) were assigned to intervention and 13 (n = 10 595 patients) were assigned to usual care. Upon analysis, the step completion rate did not significantly differ between the intervention and usual care groups (5334 vs 5638 steps; 24.8 vs. 24.1 steps per 100 patient-years; adjusted hazard ratio, 1.00 (95% confidence interval, 0.87–1.15).¹

“Even though we didn't see the quantitative data in no uncertain terms, we heard so many stories about how patients were really affected positively by being able to talk to someone else, to the point that some of them then became transplant ambassadors themselves. So there were definitely stories of the impact, even though we didn't see it in the ultimate results,” said Garg. “We have some thoughts on on what we believe still seem sensible in our approach, and also some opportunities to perhaps improve it.”

References:

1. Garg AX, Yohanna S, Naylor KL, et al. Effect of a multicomponent intervention to improve patient access to kidney transplant and living kidney donation. Paper Presented at: American Society of Nephrology Kidney Week 2023. November 1-5, 2023.
2. University of California San Francisco. The Kidney Project. Accessed November 3, 2023. https://pharm.ucsf.edu/kidney/need/statistics