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Table 2 Forward momentum (Theme 1)

From: Thematic analysis of the medical records of patients evaluated for kidney transplant who did not receive a kidney

Subtheme

Illustrative Quotations (source)

The evaluation process proceeds reflexively

Debilitated man who is blind, deaf, and requires a wheel chair … His creatinine today is 4.0, so I think he should be referred for fistula evaluation … We also discussed the possibility of transplant, which seems unlikely, but I will mention him to the transplant team. (nephrologist)

[The patient] was declined as a kidney transplant candidate … However, they also said that “If he is able to resolve his peripheral vascular disease issues you could re refer him to [the transplant center] again at a later date.” (nephrologist)

Kidney transplant was “DECLINED” because the team felt patient was high risk candidate [due to] co-morbid conditions … If Medicare supplement insurance is available we could refer this patient on to [a second transplant center]. (transplant coordinator)

[The patient] is undecided about transplant saying he needs to think about it. Worried that he would be “taking a kidney away” from a younger person … I currently see no contraindication to transplant for this Veteran. (transplant coordinator)

I have left a number of phone messages for [the patient] regarding completion of his pre-transplant evaluation. To date he has not returned any of my calls. (transplant coordinator)

A step-wise and piecemeal approach to testing and treatment

I spent 40 min talking with [the patient] about his declining health (… poor functional capacity) in the context of his candidacy for renal transplant. Nonetheless, [the patient] is determined to move forward with cardiac catheterization as recommended by cardiologist. (transplant coordinator)

Our plan of attack will be to start the evaluation with the issues most likely to represent a barrier to transplant. (transplant coordinator)

Cigarette smoking is an absolute barrier to transplant. You will need to be smoke free for at least a few months before we could consider starting a pre-transplant evaluation. (transplant coordinator)

There is scintigraphic evidence of a small area of mild myocardial ischemia … a consult has been placed to cardiology. (nuclear medicine physician) … [Seen cardiology and now] post stent … and request that patient be further evaluated via myoperfusion study. Additionally a left “cervical” bruit was noted and thus a carotid duplex was requested. (transplant coordinator)

He understands it takes time/is a slow process, but he said “tests keep being forgotten, and when I’m just about ready to get on the list, they remember they forgot another test.” (social worker)

Uncertainty about what to expect from the evaluation process

Patient states that he may have been placed on the renal transplant list, but unable to clarify status at this time … States that he has an appointment coming up next week. I also asked the patient to clarify his renal transplant status at this time. I will have him come back to the clinic in four weeks with this updated information and make plans for possible knee replacement. (orthopedic surgeon)

He wanted to know when he’ll be having surgery (kidney transplant). I reminded [the patient] that his referral was deferred by [the transplant center] and that he must FIRST be seen at his transplant center and accepted as a patient before he will be listed for [deceased donor] renal transplant. (transplant coordinator)

The patient also continues metoprolol 25 mg twice a day and atorvastatin 20 mg a day for hypercholesterolemia. He also asked me how this would affect his ability to get back on the renal transplant list. I told him I really did not know and he should address this with his nephrologist. (cardiologist)

Gentleman with chronic hepatitis C … liver biopsy would be indicated to sort this out as it might change plans in terms of renal transplant. The couple wanted to know more about this and I asked them to talk to their Nephrologist or [transplant coordinator] about in the event that we find cirrhosis would that disqualify him for a renal transplant, as I was not clear on the answer. (hepatologist)

  1. Non-standard medical abbreviations have been expanded and typographical errors corrected to improve clarity and readability