Table 3 Potential for transplant shapes other medical decisions (Theme 2)

Exposing and treating subclinical conditions

Patient has no symptoms referable to angina and has a good functional capacity … does not have a good clinical indication for PCI. However, if his transplant work-up deems it absolutely necessary, then PCI could be considered. (cardiologist)

Recommend extraction of [tooth] #1 due to gross decay. There is a low risk of tooth becoming abscessed due to level of decay... Patient did not want extraction at this time. Patient advised dental clearance [for transplant] will not be given until tooth is removed. (dentist)

As part of the [transplant] work up he was noted to have new elevated left hemidiaphragm for which a CT scan of the chest was performed. He was noted to have dilated pancreatic duct with multiple pancreatic calcifications and was sent here for further work up. (gastroenterologist) … He underwent endoscopic ultrasound and endoscopic retrograde ERCP to further evaluate for evidence of cancer. Approximately 1 h after the procedure, he started to report right upper-quadrant pain...consistent with post-ERCP pancreatitis. (hospitalization discharge summary)

Decisions about dialysis and transplant are interdependent

His goal to “avoid” dialysis may become his stimulus to learn more [about transplant]. (psychiatrist)

Patient adamant that he does not want dialysis, discussed that given his rate of decline in GFR he may need renal replacement therapy soon, hopefully as a bridge to transplant. (nephrologist)

[The patient’s wife] tells me that [the patient] is still working as well as going for HD 3 times per week. The family is feeling overwhelmed “we’re doing the best we can”. (transplant coordinator, calling to inquire about the reason for delayed transplant clinic visits)

Request that he have cardiac catheterization prior to [transplant center] approval/denial for transplant. [The patient] understands that this procedure may negatively impact his kidneys and force him to begin dialysis. (transplant coordinator)

Transplant evaluation shapes other aspects of care

Recommend repeating vaccination series. Patient skeptical of this as he doesn’t want it to affect his upcoming transplant. (gastroenterologist)

[The patient’s wife] reports that he had significant hesitation to seek treatment for his depression because he believed that he would be removed from the kidney transplant list if they found out he was being treated. (psychiatrist)

The Veteran … has a long history of left knee osteoarthritis, which is debilitating to him (transplant center note) … It doesn’t seem that it would be best for him to have a knee replacement now when he is high priority for a kidney and this may disrupt his place on the waiting list. (orthopedic surgeon)

Lymphadenopathy was incidental finding on non-contrast MRI completed [years ago] … In light of this patient’s interest and desire for kidney transplant this issue must be fully explored and malignancy ruled out … He told me “I don’t want to do any more tests’ … he understands the possible consequences (progression of a yet to be diagnosed disease/cancer), “I don’t want to know if there’s something wrong.” (transplant coordinator)

The transplant team told him that he would not be a candidate for transplant because he was using a wheelchair for his mobility … he said that he was determined to walk so he could be considered for transplant. (psychiatrist)

[Primary nephrologist] felt that by being motivated by potential transplant he may be more compliant...He needs to show compliance with weight modifications and blood pressure. Will make sure he is controlled before placement on list. (transplant center note)