🎗Barriers to Kidney Transplantation Among Dialysis Patients in a Low-Middle Income Country: A Large Patient-Reported Survey

Background: Kidney transplantation offers superior survival and quality of life compared with dialysis; however, access to transplantation in low and middle-income countries (LMICs) remains limited. Patient-reported barriers to transplantation in LMIC settings are poorly characterized. We aimed to identify key barriers to kidney transplantation among patients receiving maintenance dialysis in India.
Methods: We conducted a cross-sectional survey of adult patients undergoing maintenance dialysis across multiple dialysis centres. Data collected included demographics, socioeconomic status, dialysis characteristics, transplant awareness, willingness for transplantation, donor availability, and perceived barriers to both living and deceased donor kidney transplantation. Descriptive analyses were performed.
Results: A total of 4,363 dialysis patients were included (mean age 46.5 ± SD years; 67.3% male). Although 49.1% of patients expressed willingness to undergo kidney transplantation, only 6% reported having an identified potential living donor with 49.3% of the patients not having given a serious thought regarding it. The most frequently reported barrier to transplantation was financial constraints (49.8%), despite provision of government schemes/insurances subsidising transplant reflecting a significant knowledge gap. 49.4% respondents reported having inadequate knowledge regarding transplantation and an additional 17.7% felt unsure regarding their knowledge reflecting significant gaps in transplant awareness and donor availability. Only 23% patients felt that the allocation for deceased kidneys was fair and transparent.
Willingness for transplantation did not translate into access, highlighting a substantial mismatch between intent and feasibility. Our study highlights that prevailing misconceptions like risk to donor health and future after trasnplant, the lack of awareness about government subsidies and insurance coverages and physician and patient inertia contributes to the continuation of dialysis.
Conclusions: In this large LMIC dialysis cohort, nearly half of patients were willing to undergo kidney transplantation, yet actual donor availability and conversion to transplantation was exceedingly low. Financial limitations, knowledge gap, doctor-patient inertia and social barriers remain the dominant obstacles to transplantation. Targeted patient education and donor counselling are essential to maximise the utliziation of already available policy-level financial support and improve equitable access to kidney transplantation in a resource limited settings.