Time on Dialysis Prior to Kidney Transplant Evaluation and Patient Uncertainty of Treatment Options Open Access

Abstract

Objective: There are two primary treatment options for end stage renal disease (ESRD): dialysis and kidney transplant. Although kidney transplantation provides a significant survival benefit over long-term dialysis, many ESRD patients are uncertain, i.e., conflicted, about their decision to pursue kidney transplantation or remain on dialysis. ESRD patients' uncertainty about treatment of their kidney disease may be affected by cumulative time spent on dialysis prior to a kidney transplant evaluation. We aimed to investigate the association of time from dialysis start to kidney transplant evaluation with decisional conflict.

Methods: In a cross-sectional study using data from a clinical trial measuring effectiveness of a decision tool at three U.S. transplant centers, 464 patients were asked 10 questions, using a standardized question tool, assessing decisional conflict related to kidney transplant vs. dialysis. Scores could range from 0 to 100 (high) and patients were dichotomized as having (score >0) or not having (score=0) decisional conflict. Time on dialysis at evaluation start was abstracted from electronic medical records and categorized as never, <1 year, ≥1 year. Logistic regression was used to investigate associations of decisional conflict with time on dialysis prior to kidney transplant evaluation.

Results: Of 464 surveyed patients, 62% were male and 48% were African American; the average age was 51 years. Nearly half (49%) of patients had some decisional conflict about treatment options at the transplant evaluation. Those with decisional conflict were more likely to be male, African American, and publically insured, and less likely to be married, highly educated, and state a preference for transplant vs. dialysis at the time of evaluation compared to patients without decisional conflict. In the adjusted logistic analyses, time on dialysis was not statistically significantly associated with decisional conflict.

Conclusions: These results suggest that decisional conflict may be highly prevalent among ESRD patients being evaluated for transplant at a transplant center. Male, minority race, uninsured, uneducated, and patients with no social support are more likely to have decisional conflict. Identifying conflicted patients could inform intervention efforts to improve patients' abilities to make treatment decisions about their kidney disease before being evaluated by a transplant nephrologist.

Table of Contents

Chapter 1: Background…………………………………………………………...................……….1

The Significance of Chronic and End Stage Renal Disease…………………....……….......….1

Chronic and End Stage Renal Disease Clinical Risk Factors……………………...……..........2

Disparities in Chronic and End Stage Renal Disease…………………………………..............2

End Stage Renal Disease Treatment Options…………………………………………...............4

Disparities in Access to Kidney Transplantation……………………………………….............4

iChoose Kidney Clinical Trial……………………………………………………...................…...7

Decisional Conflict Scale………………………………………………………………...................8

Importance of Evaluating ESRD Patients' Treatment Option Uncertainty……..…...........9

Chapter 2: Manuscript………………………………………………………...................………...12

Abstract……………………………………………………………...……………...........................12

Introduction……………………………………………………………………….….......................13

Methods………………………………………………………………………………........................16

Data Collection Procedures - iChoose Kidney Clinical Trial………………………..............16

Study Protocol and Population……………………………………………………......................16

Study Variables……………………………………………………………………..........................17

Data Cleaning and Quality Control Assessment Activities………………………….............20

Analyses……………………………………………………………………….................................20

Results………………………………………………………………………………...........................21

Patient Characteristics………………………………………………………………......................21

Association Between Patient Time on Dialysis and Decisional Conflict Score……...........23

Treatment Preferences by Decisional Conflict Score……………………………..........….......24

Discussion…………………………………………………………………………….........................24

Study Strengths and Limitations……………………………………………………....................29

Conclusions……………………………………………………………………….............................30

References………………………………………………………………………………......................32

Tables and Figures…………………………………………………………………….......................39

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Medicine and Surgery Health Sciences, Epidemiology
Keyword	decisional conflict kidney transplant dialysis
Committee Chair / Thesis Advisor	Patzer, Rachel Elizabeth, Emory University

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