Increasing the Rate of Living Donor Kidney Transplantation in New Zealand: Developing an Evidence Base

Increasing numbers of New Zealanders are experiencing end-stage renal failure, requiring kidney transplantation or dialysis. A transplant from a living kidney donor is the preferred treatment, offering better quality of life than dialysis, and greater life expectancy and cost-effectiveness than dialysis and deceased donor transplantation. Living donor transplant rates in New Zealand have plateaued and may even be declining at a time when many comparable countries are experiencing sustained increases. Viewing this issue as a complex policy problem, this research aimed to identify how rates of living donor kidney transplantation could be increased in New Zealand. Based on Walt and Gilson’s health policy triangle, which suggests that understanding policy issues requires attention not only to content (policy options) but also processes, contextual issues and actors, this research asked firstly, what the barriers are for patients in the journey to living donor transplantation, and secondly, why greater attention has not been paid to how to increase current rates, given evidence of better outcomes for patients and cost-effectiveness. The research took a patient-centred, systems perspective and used a pragmatic, interdisciplinary, mixed-methods research design. Methods included a survey of kidney transplant waiting-list patients; interviews with patients, renal health professionals and key informants; document analysis; and a survey of health managers. A Five-Stage Model of the living donor kidney transplant process was developed to map specific barriers in the journey to transplantation and Kingdon’s multiple streams agenda-setting model was used to examine the issue of why so little attention had been paid to living donor kidney transplantation in New Zealand. The research found that, in common with patients elsewhere, New Zealand patients are not systematically informed about living donor transplantation, would like to receive a transplant but have concerns about health and financial impacts on donors, and face challenges in approaching people in their networks about living donation. Incompatibility and medical unsuitability are major barriers for potential donors who do come forward. Issues with existing service models, configuration of key roles in transplant services, and delays in donor work-up processes are all evident. Perceived ethical constraints may limit how willing health professionals are to promote living donation, requiring both potential recipients and donors to be very proactive to successfully navigate the living donation process. There has been political will to address organ shortages in the past but there has been little focus specifically on live donation. An absence of feasible and acceptable options for decision-makers to consider, crowding-out by demand for dialysis services, lack of leadership, absence of an effective advocate, and issues in funding and accountability arrangements may all have contributed to why live kidney transplantation has not had more prominence on the policy agenda in New Zealand in recent years. Overall, the research concludes that policy and practice in the wider system are not adequately oriented to supporting living donor kidney transplantation as the preferred treatment for end-stage renal failure. A comprehensive national strategy for increasing New Zealand’s rate is recommended.