PHOENIX — Successful transition from chronic kidney disease to either home dialysis or transplantation requires a thorough evaluation of a patient’s psychosocial and economic status, speakers said at the Southwest Nephrology Conference.

“The role of the social worker is vital to the stability of a patient on a home modality,” Lauren Pelletier, MSW, CCM, a social worker for patients on peritoneal dialysis at DaVita Inc. “Psychosocial status impacts a patient’s ability to adhere to treatment,” she said. “As social workers, we can assist patients with emotionally adjusting to dialysis,” Pelletier said.

Choosing a home modality, whether it is PD or home hemodialysis, starts with a patient’s desire to do self-care, Pelletier said. She uses a decision-making tool called Method to Assess Treatment Choices for Home Dialysis, or Match D, offered by the Medical Education Institute, that helps patients navigate through the requirements of home dialysis.

Some of the reasons to consider home dialysis include being employed full time, living far from a dialysis clinic and being independent. “It’s of value to the patient if they have a strong caregiver/support system at home,” Pelletier said.

Similar to choosing home dialysis, patients considering transplantation must be vigilant in adhering to a care plan, Julie LaMantia, LCSW, CCTSW, a social worker at Banner University in Phoenix in the division of transplantation, told attendees.

“Patients will need to adapt to challenges as they come up,” LaMantia said. “That can include additional testing as needed. Good communication is also important, as well as collaborating with the transplant team.”

Support at home after the transplant is helpful. She noted that 10% to 20% of denials for surgery made by the transplant team are because the patient does not have a good support system at home. “It’s vital for the elderly, patients with complex medical history, those with language barriers and mental or physician impairments,” LaMantia said.

A psychosocial evaluation can also help the transplant team determine whether a patient will have success after transplant. “Non-adherence post-transplant is highly prevalent and increases with time after the transplant,” LaMantia said. “Medication non-adherence is estimated to be responsible for 15% of graft failures and 50% of late acute rejection.”

A transplant team also needs to evaluate a patient’s physical status. For older patients who are interested in a transplant, assessment for frailty includes testing a patient for gait speed, conducting the stop-and-stand test, and a test for hand grip strength is of value to the transplant team, Mantis said. “Obesity – with a BMI of greater than 35 – is a contraindication to transplant. Such patients should be referred to dietary counseling or bariatric surgery,” she said.

Likewise, a history of substance abuse or sign of mental health conditions can often go unnoticed. “Marijuana is now legal in 30 states,” LaMantia said. “We want to be able to restrict use of [such] drugs due to concern of post-transplant interaction with immunosuppressive medications.

“Social workers need to look for cannabis use disorder, because of the higher risk of graft failure, often taking place in the first year of the transplant,” LaMantia said. “Smokers also have a high risk of post-surgical respiratory complications.”

Finally, a patient’s ability to make a strong financial commitment to the transplant is important. “Medicare covers the transplant for eligible patients, but immunosuppressive drugs are only covered at 80%, and currently that coverage only goes for 36 months,” LaMantia said. “That will change next January, when patients will have lifetime immunosuppressive drug coverage.”

Reference: LaMantia J, Pelletier L. What makes a good candidate for referral to transplant and home therapies? Presented at: the Southwest Nephrology Conference; March 17-18, 2022; Phoenix.

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