Systems analysis of the renal transplant process

A successful renal transplant requires a wide range of factors to interact in a positive manner. Research on renal transplant outcomes has tended to have a fairly narrowly defined scope that has resulted in conclusions that are limited in the degree to which they have provided guidance that would improve outcomes [1]. Factors ranging from donor match / wait time, medical history, hereditary, patient / physician interaction, etc., all impact the eventual transplant outcome. One particularly interesting factor that needs further study is that of the impact of patient appointment diligence on medical outcome [2]. In addition, a key question in assessing transplant outcome is how "success" is measured. Many function and quality of life metrics have been developed and some have been shown to be effective for patients with end stage renal disease, yet there remain other issues that need to be incorporated to obtain an overall systems view of transplant outcome. This presentation presents results of an ongoing systemic analysis of the factors contributing to successful renal transplants that lead to high patient quality of life. First, an IDEFO diagram will be presented of the care process from identification of a patient as a potential transplant candidate to post-op period with respect to procedures, communication, information, and material flow in order to show the boundaries of the study. Second, the results of a multivariate statistical analysis of patient chart data conducted to determine significant factors that affect both patient performance status and creatinine levels in the 12 months after transplant surgery will be given. Factors considered within the analysis include: performance status (at discharge, IM, 6M, 12M), age, gender, race, smoker, etiology of end stage renal disease, HLA match, cytomegalovirus (CMV), coagulation disorders, number of prior transplants, preexisting conditions, donor type/gender/age/CMV, cold ischemia time, white blood count at transplant, platelet count at transplant, serum creatinine levels (at discharge, 1M, 3M, 6M, 12M post transplant), rejection management, transplant complications, time between first dialysis and transplant evaluation, time between transplant evaluation and transplant, pre/post transplant appointment attendance, hereditary influences, related procedures before and after transplant. Hypothesis tested with respect to the impact on patient outcome include: high incidence of non-attendance of appointments, time between transplant evaluation and surgery, number of related procedures before and after transplant surgery, number of other medical issues, different hereditary influences. Factor interactions were also examined in order to explore new relationships between patient outcomes and both patient controlled decisions and transplant characteristics. The primary objective of this research is to determine the contribution of various environmental, procedural and medical factors so that root causes can be identified that impact overall patient health and outcome when undergoing a renal transplant. The results of the multivariate analysis will be used as the basis of recommendations that are presented concerning how to improve renal transplant protocols from both patient and clinical perspectives.