Protocol of a cluster randomized trial of an educational intervention to increase knowledge of living donor kidney transplant among potential transplant candidates

BackgroundThe best treatment option for end-stage renal disease is usually a transplant, preferably a live donor kidney transplant (LDKT). The most effective ways to educate kidney transplant candidates about the risks, benefits, and process of LDKT remain unknown.Methods/designWe report the protocol of the Enhancing Living Donor Kidney Transplant Education (ELITE) Study, a cluster randomized trial of an educational intervention to be implemented during initial transplant evaluation at a large, suburban U.S. transplant center. Five hundred potential transplant candidates are cluster randomized (by date of visit) to receive either: (1) standard-of-care ("usual") transplant education, or (2) intensive education that is based upon the Explore Transplant series of educational materials. Intensive transplant education includes viewing an educational video about LDKT, receiving print education, and meeting with a transplant educator. The primary outcome consists of knowledge of the benefits, risks, and process of LDKT, assessed one week after the transplant evaluation. As a secondary outcome, knowledge and understanding of LDKT are assessed 3 months after the evaluation. Additional secondary outcomes, assessed one week and 3 months after the evaluation, include readiness, self-efficacy, and decisional balance regarding transplant and LDKT, with differences assessed by race. Although the unit of randomization is the date of the transplant evaluation visit, the unit of analysis will be the individual potential transplant candidate.DiscussionThe ELITE Study will help to determine how education in a transplant center can best be designed to help Black and non-Black patients learn about the option of LDKT.Trial registrationClinicaltrials.gov number NCT01261910

Kidney Patients’ Intention to Receive a Deceased Donor Transplant: Development of Stage of Change, Decisional Balance and Self-efficacy Measures

In order to sustain life, patients whose kidneys fail must receive dialysis or obtain a transplant. This study reports on the development and validation of measures of Stage of Change, Decisional Balance and Self-efficacy based on the Transtheoretical Model (TTM) to assess patients’ readiness to receive a deceased donor transplant. We surveyed 293 transplant-eligible kidney patients about their deceased donation readiness. Exploratory and confirmatory analyses for all measures demonstrated factor structures similar to previous application of the TTM to other health behaviors, excellent model fit and good internal and external validity. These brief, reliable instruments with good psychometric properties can guide the development of improved, individually-tailored transplant education for patients

Application of the Transtheoretical Model in Hispanic and African American Populations to Assess Deceased Kidney Donor Noncompliance

Given existing health disparities such as financial barriers, lack of education and inadequate health care in minority communities, the rates of deceased kidney donation continues to decline. The transtheoretical model (TTM) assesses the patients’ willingness to pursue deceased kidney donation through application of a stage structured curriculum. Patients are evaluated into five different stage groups; pre-contemplation, contemplation, preparation, action, and maintenance. This assessment of behavior change as applied to the willingness of a patient to pursue a deceased kidney donor transplant can be tracked over time and used to help determine what stage of change a patient is in during their kidney transplant evaluation process. Self-reported reasons why members from these communities opt out of deceased donation or who don’t complete their transplant evaluation process will be examined as well as possible solutions to alleviate some of the barriers that preclude these patients from completing evaluation will be proposed. Research is continuing and results are not final

Living Donor Kidney Transplantation: A Focus on the Socioecological Model to Determine Why Hispanics/Latinos Have a Disproportionate Amount of Kidney Transplants When Compared to Other Ethnic Groups

Health disparities, especially kidney transplantation disparities, are prevalent in the Hispanic/Latino community. In order to decrease existing kidney transplantation disparities in the Hispanic/Latino community, culturally tailored education surrounding living donor kidney transplants needs to be improved. The socioecological model depicts factors that affect a patient’s decision making when deciding on obtaining a living kidney donor transplant. These factors often act as barriers, which are categorized as patient-level factors, provider factors, and system factors. Patient-level factors include family and social networks, provider factors include physician and/or health care provider relationships, and system level factors include health care organization efficiency. Developing patient education tools (i.e. videos, pamphlets, brochures, factsheets) that address these potential barriers would alleviate some of the patient concerns and perceived hindrances to kidney transplantation. The methodology requires patient interaction in the form of interviews and data retrieval from online sysmtems. Although the results of this study are not concluded it is expected that Hispanics/Latinos have a disproportionate amount of kidney transplants when compared to other ethnic groups due to factors such as familism and lack of living donor kidney transplantation knowledge

Invariance of measures to understand decision-making for pursuing living donor kidney transplant

Living donor kidney transplant is the ideal treatment option for end-stage renal disease; however, the decision to pursue living donor kidney transplant is complex and challenging. Measurement invariance of living donor kidney transplant Decisional Balance and Self-Efficacy across gender (male/female), race (Black/White), and education level (no college/college or higher) were examined using a sequential approach. Full strict invariance was found for Decisional Balance and Self-Efficacy for gender and partial strict invariance was found for Decisional Balance and Self-Efficacy across race and education level. This information will inform tailored feedback based on these constructs in future intervention studies targeting behavior change among specific demographic subgroups

Explore Transplant at Home: A randomized control trial of an educational intervention to increase transplant knowledge for Black and White socioeconomically disadvantaged dialysis patients

BackgroundCompared to others, dialysis patients who are socioeconomically disadvantaged or Black are less likely to receive education about deceased donor kidney transplant (DDKT) and living donor kidney transplant (LDKT) before they reach transplant centers, often due to limited availability of transplant education within dialysis centers. Since these patients are often less knowledgeable or ready to pursue transplant, educational content must be simplified, made culturally sensitive, and presented gradually across multiple sessions to increase learning and honor where they are in their decision-making about transplant. The Explore Transplant at Home (ETH) program was developed to help patients learn more about DDKT and LDKT at home, with and without telephone conversations with an educator.Methods and study designIn this randomized controlled trial (RCT), 540 low-income Black and White dialysis patients with household incomes at or below 250 % of the federal poverty line, some of whom receive financial assistance from the Missouri Kidney Program, will be randomly assigned to one of three education conditions: (1) standard-of-care transplant education provided by the dialysis center, (2) patient-guided ETH (ETH-PG), and (3) health educator-guided ETH (ETH-EG). Patients in the standard-of-care condition will only receive education provided in their dialysis centers. Those in the two ETH conditions will receive four video and print modules delivered over an 8 month period by mail, with the option of receiving supplementary text messages weekly. In addition, patients in the ETH-EG condition will participate in multiple telephonic educational sessions with a health educator. Changes in transplant knowledge, decisional balance, self-efficacy, and informed decision making will be captured with surveys administered before and after the ETH education.DiscussionAt the conclusion of this RCT, we will have determined whether an education program administered to socioeconomically disadvantaged dialysis patients, over several months directly in their homes, can help more individuals learn about the options of DDKT and LDKT. We also will be able to examine the efficacy of different educational delivery approaches to further understand whether the addition of a telephone educator is necessary for increasing transplant knowledge.Trial registrationClinicalTrials.gov, NCT02268682

Development and Validation of a Socioeconomic Kidney Transplant Derailers Index

Background: Socioeconomic barriers can prevent successful kidney transplant (KT) but are difficult to measure efficiently in clinical settings. We created and validated an individual-level, single score Kidney Transplant Derailers Index (KTDI) and assessed its association with waitlisting and living donor KT (LDKT) rates. Methods: The dataset included 733 patients presenting for KT evaluation in a transplant center in California. Exploratory factor analysis was used to identify socioeconomic barriers to KT (derailers) to include in the index. Potential KT derailers included health insurance, employment, financial insecurity, educational attainment, perception of neighborhood safety, access to a vehicle, having a washer/dryer, and quality of social support. Validity was tested with associations between KTDI scores and the following: (1) the Area Deprivation Index (ADI) and (2) time to KT waitlisting and LDKT. Results: Nine derailers were retained, omitting only social support level from the original set. The KTDI was scored by summing the number of derailers endorsed (mean: 3.0; range: 0–9). Black patients had higher estimated KTDI scores than other patient groups (versus White patients, 3.8 versus 2.1; P \u3c 0.001, effect size = 0.81). In addition, the KTDI was associated with the ADI (γ = 0.70, SE = 0.07; P \u3c 0.001). Finally, in comparison to the lower tertile, patients in the upper and middle KTDI tertiles had lower hazard of waitlisting (upper tertile hazard ratio [HR]: 0.34, 95% confidence interval [CI]: 0.25-0.45; middle tertile HR: 0.54, 95% CI: 0.40-0.72) and receiving an LDKT (upper tertile HR: 0.15, 95% CI: 0.08-0.30; middle tertile HR: 0.35, 95% CI: 0.20-0.62). These associations remained significant when adjusting for the ADI and other patient characteristics. Conclusions: The KTDI is a valid indicator of socioeconomic barriers to KT for individual patients that can be used to identify patients at risk for not receiving a KT

Risk aversion in the use of complex kidneys in paired exchange programs: Opportunities for even more transplants?

This retrospective review of the largest United States kidney exchange reports characteristics, utilization, and recipient outcomes of kidneys with simple compared to complex anatomy and extrapolates reluctance to accept these kidneys. Of 3105 transplants performed, only 12.8% were right kidneys and 23.1% had multiple renal arteries. 59.3% of centers used fewer right kidneys than expected and 12.1% transplanted zero right kidneys or kidneys with more than 1 artery. Five centers transplanted a third of these kidneys (35.8% of right kidneys and 36.7% of kidneys with multiple renal arteries). 22.5% and 25.5% of centers currently will not entertain a match offer for a left or right kidney with more than one artery, respectively. There were no significant differences in all-cause graft failure or death-censored graft loss for kidneys with multiple arteries, and a very small increased risk of graft failure for right kidneys versus left of limited clinical relevance for most recipients. Kidneys with complex anatomy can be used with excellent outcomes at many centers. Variation in use (lack of demand) for these kidneys reduces the number of transplants, so systems to facilitate use could increase demand. We cannot know how many donors are turned away because perceived demand is limited.Wiley Read-and-Publish Agreemen

Global patterns of diapycnal mixing from measurements of the turbulent dissipation rate

The authors present inferences of diapycnal diffusivity from a compilation of over 5200 microstructure profiles. As microstructure observations are sparse, these are supplemented with indirect measurements of mixing obtained from (i) Thorpe-scale overturns from moored profilers, a finescale parameterization applied to (ii) shipboard observations of upper-ocean shear, (iii) strain as measured by profiling floats, and (iv) shear and strain from full-depth lowered acoustic Doppler current profilers (LADCP) and CTD profiles. Vertical profiles of the turbulent dissipation rate are bottom enhanced over rough topography and abrupt, isolated ridges. The geography of depth-integrated dissipation rate shows spatial variability related to internal wave generation, suggesting one direct energy pathway to turbulence. The global-averaged diapycnal diffusivity below 1000-m depth is O(10?4) m2 s?1 and above 1000-m depth is O(10?5) m2 s?1. The compiled microstructure observations sample a wide range of internal wave power inputs and topographic roughness, providing a dataset with which to estimate a representative global-averaged dissipation rate and diffusivity. However, there is strong regional variability in the ratio between local internal wave generation and local dissipation. In some regions, the depth-integrated dissipation rate is comparable to the estimated power input into the local internal wave field. In a few cases, more internal wave power is dissipated than locally generated, suggesting remote internal wave sources. However, at most locations the total power lost through turbulent dissipation is less than the input into the local internal wave field. This suggests dissipation elsewhere, such as continental margins