Introduction: Numerous studies worldwide have focused on the determinants affecting access to kidney transplantation from deceased donors (KTDD) among waitlisted patients. However, as of present, no such investigation has been undertaken in Tunisia to identify the factors influencing access to transplantation from the national waiting list (WL). Hence, this study aimed to evaluate these factors among patients enlisted from the department of Internal Medicine "A" at Charles Nicolle Hospital in Tunis.
Method: This cohort study focused on patients who were monitored in the department of Internal Medicine "A" and placed on the national WL. The data were collected retrospectively over a period of 22 years, from January 1, 2001, to December 31, 2022. Patients were observed from the date of registration on the WL until either removal from the WL or last follow-up available or the end of the study period. Patients who underwent kidney transplantation (KT) at other centers in Tunisia or abroad were excluded from the analysis. Access to KT was evaluated using the Kaplan-Meier method in the univariate analysis and Cox model in the multivariate analysis.
Results: Throughout the study period, a total of 787 patients were listed, with 42.6% being female and the mean age recorded at WL registration being 38.9± 11.4 years. Among these patients, 65.4% had hypertension, 5.7% were diabetic and 83.5% were undergoing hemodialysis (HD). KTDD was performed for 12.5% of the patients with a mean waiting time of 4.23 ± 3.8 years.
In the univariate analysis, several factors showed significant association with access to KTDD. These included younger age (p=0.017), peritoneal dialysis (p=0.049), precarious vascular access (p<0.01), hemoglobin levels below 10 g/dl (p=0.02), AB blood type (p=0.018), negative cytotoxic antibodies (p=0.016), registration on the WL between 2001 and 2011 (p=0.015), and absence of complications after registration (p<0.01).
In the multivariate analysis, factors associated with lower access to KT were HD (HR=0.38 [CI: 0.19-0.76]), WL registration between 2012 and 2022 (HR=0.40 [CI: 0.2-0.83]), and complications occurring after registration (HR=0.18 [CI: 0.09-0.36]). Notably, gender, cause of end stage renal disease (ESRD), diabetes, and body mass index were not found to be associated with access to KT.
Conclusion: Our study sheds light on factors affecting KTDD access in Tunisia. These findings highlight the importance of optimizing patient care pathways, ensuring timely pre-transplant assessments, and addressing complications effectively to improve KTDD access and outcomes for ESRD patients in Tunisia. Future studies can delve deeper into the specific mechanisms underlying these associations and explore interventions to enhance access to KTDD.