Clinical and Socioeconomic Aspects of Kidney Transplantation

For patients that require renal replacement therapy, kidney transplantation is the best option in terms of outcomes and quality of life. However, not all patients have equal access to transplantation, as for various reasons some are not even referred for transplantation. Though not always obvious, a spectrum of reasons may be responsible for non-referral, e.g. insufficient condition to undergo surgery or inadequate mastering of the language to understand and communicate the transplantation process. Other patients are highly sensitized which complicates finding a match. Once transplanted, graft survival may be hampered by various factors causing a fall back on less favorable options for renal replacement therapy. The aims of this thesis were to investigate what factors influence access to living or deceased donor kidney transplantation and what factors influence graft and patient survival once transplantation is carried out. The retrospective cohort studies described in this thesis showed that older patients and patients with unfavorable socioeconomic factors have a decreased chance to receive a living donor kidney transplant. Moreover, age has a negative influence on the chance to receive a deceased donor kidney transplant. Only half of the patients above 55 years that are dependent on the waiting list for deceased donor kidney transplantation will be transplanted. Graft and patient survival were studied using multivariable analyses. While various clinical factors were found to influence graft and patient survival, socioeconomic factors did not influence survival. The combined influence of donor age and donor type showed that the results of living donor kidney transplantation are better than the results of living donor kidney transplantation, independent of donor age. This applied to the number of HLA mismatches between recipient and donor as well. To study the influence of comorbidities on survival a new comorbidity score was developed, the Rotterdam Comorbidity in Kidney Transplantation (RoCKeT) score. Though a higher comorbidity score did influence patient survival, patient survival after transplantation was still remarkably good. The main conclusion is that survival after living donor kidney transplantation is superior to deceased donor kidney transplantation. Living donor kidney transplantation should be accessible for all patients, also for elderly patients with extensive comorbidity and for patients with unfavorable socioeconomic factors. They should be referred for transplantation as early as possible to prevent dialysis, even when they present without a potential living donor. As home based education was added to our standard care for these patients, their chance to become transplanted increases