Robert S. Gaston
Must Health Literacy Be a Prerequisite for Kidney Transplantation?
University of Alabama at Birmingham
patients esrd want kidney transplants study impact health literacy access dialysis patients transplantation issue cjasn found 90 favoring transplantation preferred modality therapy 1 regardless original kidney disease age gender ethnicity educational status income level dialysis provider health literacy patients perspective transplantation best option yet fewer 25 patients esrd functioning transplants 20 dialysis patients populate transplant waiting lists despite estimates perhaps many half would live longer transplant dialysis 24 delivery renal replacement therapy rrt united states offered medicareeligible patients entitlement accompanied mandate provide optimal services deviate markedly expressed preferences 5 perhaps patients studied grubbs et al 1 represent dialysis patients ayanian et al 6 found fewer 40 patients began dialysis aware transplantation option education regarding treatment modalities patients studied alabama southern california michigan midatlantic area expressed sentiments remarkably similar bay area patients article grubbs et al 1 80 wanted transplants must also pointed studies design excluded 50 kidney transplant recipients successfully navigated system enabling transplantation either preemptively within first year rrt 7 intense preference transplantation increasing number americans recognizing roadblocks current system travel abroad seeking transplants often unsavory circumstances 8 response castigation fines potentially criminal penalties 9 circumstance punish desperately ill patients search healing perhaps patients wrong perceived health benefits transplantation illusory indeed recent study documented patients awaiting transplantation overestimate relative qualityoflife benefit associated transplantation 10 likewise dialysis patients transplant candidates however ongoing attempt better allocate available kidneys deceased donors united states documents longevity benefit transplantation dialysis virtually every definable category patient esrd estimates quality life among dialysis patients 20 less functioning transplant 11 among 350000 dialysis patients united states many 120000 might benefit listed transplantation 2 also true perhaps 30 waiting list inactive given time statistic used evidence waiting list overestimates demand 1213 however inactive result either selflimited illness original stated purpose creating inactive category bureaucratic delays although arbitrary policies shift posttransplantation financial responsibilities patient thirdparty payers know transplantation least expensive modality therapy 7 face objective data available difficult contend patients misguided expressed preferences many us would choose years dialysis loved ones equally challenging circumstances problem patient perceptions lie fear rests esrd program evolved time dialysis viable option vast majority patients transplantation thought cure esrd almost afterthought 14 today dichotomous view longer relevant centers medicare medicaid services guidelines mandate teamoriented approach dialysis transplantation ensure optimal care 15 longer anyone involved process view kidney transplant delivered estimated gfr 50 60 mlmin cure rather transplantation provides best outcomes available rrt modalities given practicing nephrologists seek offer effective treatment options patients must one health literate access optimal care system study grubbs et al 1 adds new dimension debate confirming importance accurate education delivering optimal rrt unfortunately conclusions study may generalizable first authors acknowledge response rate low perhaps patients inclined favor transplantation ones willing interviewed second sample size admittedly small finally evaluation process bay areas largest program different waiting list exceeds 3000 patients allocation system based primarily waiting time many patients placed waiting list without completing traditional evaluation process vincenti f university california san francisco ca personal communication october 21 2008 16 thus conclusions grubbs et al 1 biggest barrier placement waiting list referral may true bay area elsewhere centers access transplantation follows complex algorithm described alexander sehgal 17 disadvantaged patients fail progress multiple steps process transplantation default position rrt changing current paradigm one major challenges facing transplant community ability deliver promise kidney transplantation would clearly benefit require multifaceted effort 18 begins routine identification impending kidney failure early enough allow early education feasible best alternatives preemptive transplantation current regulations mandating education referral dialysis patients transplantation remain loosely defined erratically monitored transplant centers repository uptodate information regarding risks benefits candidacy kidney transplantation must given resources ramp educational evaluation efforts meet latent demand defined study finally although much accomplished much must done increase availability kidneys especially living donors 1219 improving health literacy among patients esrd without commensurate improvements overall access transplantation fear prove hollow achievement indeed disclosures none