KDIGO guidelines advise health care providers to refer patients on dialysis with past non-adherence to transplant centers for evaluation as possible kidney transplant candidates, yet not all qualified patients are referred, investigators reported at the 2023 American Transplant Congress in San Diego, California. In some cases, providers delay referral or opt not to refer based on their idiosyncratic and subjective beliefs about patients’ non-adherence.

“We believe most providers at dialysis centers and at transplant centers want all eligible patients referred for kidney transplantation,” Adam S. Wilk, PhD, and Jenny McDonnell, PhD/MPH candidate, of Emory University’s Rollins School of Public Health in Atlanta, Georgia, said in a joint statement to Renal & Urology News. “The problem is that there is no clear or universal understanding of what ‘eligible’ means in this context.”

To better understand how providers respond to patient non-adherence and make transplant referral decisions, Dr Wilk and his team conducted a qualitative study including 39 in-depth interviews with dialysis clinic providers in Georgia, North Carolina, and South Carolina. The investigators interviewed 24 social workers, 6 nurses and nurse managers, 4 clinic managers, 3 dietitians/nutritionists, and 2 nephrologists/medical directors.

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“Providers often organically brought up patient non-adherence as a barrier to transplant candidacy,” McDonnell explained. “How dialysis providers responded to patient non-adherence was affected by how they made meaning of non-adherence, based on their beliefs about its causes and implications. Their beliefs ultimately informed their decisions about referring patients for transplant evaluation.”

The investigators identified 3 themes from provider interviews. First, nonadherence to dialysis treatments, medical appointments, dietary advice, medications, weight loss regimens, wound care, or communication signaled to some providers that a patient was a “risky” rather than “good” candidate for transplant. Perceived reasons for patient nonadherence included socioeconomic factors, comorbidities, and lack of motivation. Second, providers considered the implications of non-adherence. They were concerned about wasting their limited time and resources, their emotional expenditure, a possible negative response from the transplant center, and the potential loss of a valuable and scarce kidney to a “risky” patient. Third, providers’ beliefs about whether a patient would be invested in the transplant process affected their decision to delay, deny, or proceed with transplant referral. Providers’ responses were highly individual.

“Dialysis providers have varying understandings of their role in assessing patients,” McDonnell explained. “Where there is any gap between providers’ perceptions of the reasons and implications of non-adherence and the true reasons and implications, patients’ access to kidney transplantation may be impeded.”

Researchers can provide useful information to fill the gap, she said, by linking clearly defined and internally valid measures of non-adherence to transplant outcomes and sharing these measures with the dialysis and transplant provider communities for decision-making.

Addressing providers’ misperceptions and apprehension may also help, McDonnell added. She noted that previous studies on implicit bias in medical decision-making have shown that racial and ethnic minorities, low-income patients, and other marginalized patients are less likely to receive preferred medical treatments.

McDonnell acknowledged dialysis providers’ limited time and resources.

“Affording social workers and other dialysis providers the time and resources needed to support these patients may require reallocating tasks and providing for additional time and staff resources, prioritizing interventions that uncover and address the real reasons for patient non-adherence. Such efforts and interventions could help improve adherence among patients, and in the long term, increase rates of patient referral, waitlisting, and transplant receipt.”


McDonnell J, Urbanski MA, Pastan SO, Lea JP, Arriola KJ, Escoffery C, Patzer RE, and Wilk AS. A grounded theory approach to understanding dialysis providers’ transplant referral decisions for patients with past non-adherence. Presented at: ATC 2023, San Diego, California, June 3-7. Poster A147.