Clinical practice guidelines on wait-listing for kidney transplantation: consistent and equitable?

Abstract

Background: Apparent variability in wait-listing criteria globally has raised concern about inequitable access to kidney transplantation. This study aimed to compare the quality, the scope, and the consistency of international guidelines on wait-listing for kidney transplantation.

Methods: Electronic databases and guideline registries were searched to December 2011. The Appraisal of Guidelines for Research and Evaluation II instrument and textual synthesis was used to assess and compare recommendations.

Results: Fifteen guidelines published from 2001 to 2011 were included. Methodological rigor and scope were variable. We identified 4 major criteria across guidelines: recipient age and life expectancy, medical criteria, social and lifestyle circumstances, and psychosocial considerations. Whereas some recommendations were consistent, there were differences in age cutoffs, estimated life expectancy (2-5 years), and glomerular filtration rate at listing (15-20 mL/min/1.73 m). Cardiovascular contraindications were broadly defined. Recommended cancer-free periods also varied substantially, and whereas uncontrolled infections were universally contraindicated, human immunodeficiency virus thresholds and adherence to highly active antiretroviral therapy were inconsistent. Most guidelines recommended psychological screening but were not augmented with specific clinical assessment tools.

Conclusions: Wait-listing recommendations in current guidelines are based on life expectancy, comorbidities, lifestyle, and psychosocial factors. Some recommendations are different across guidelines or broadly defined. There is a case for developing comprehensive, methodologically robust, and regularly updated guidelines on wait-listing for kidney transplantation.