Abstract
Introduction: Mental illness is highly prevalent among people with chronic kidney disease, yet its impact on access to kidney transplantation remains poorly understood. We aimed to examine the association between mental health service use and access to kidney transplantation among adults with kidney failure across three universal healthcare systems.
Methods: Population-based observational cohort study of adults with incident kidney failure between April 2011 and December 2020 in New South Wales (NSW, Australia), New Zealand (NZ), and Scotland, using linked registry and administrative healthcare data. Participants were followed from dialysis initiation until transplantation, death before transplantation, loss to follow-up, or December 2020. We classified mental health service use (MHSU) prior to kidney failure as none/mild, moderate, or severe based on psychotropic medication dispensing, community mental health contacts, and hospital admissions. The primary outcome was receipt of a kidney transplant. We used cause-specific Cox regression to estimate adjusted hazards ratios (aHRs) accounting for the competing risk of pre-transplant death, stratifying by sex and adjusting for age, ethnicity, BMI, remoteness, socio-economic disadvantage, and comorbidities. We estimated adjusted cumulative incidence of transplant using direct standardization. The secondary outcome was odds of receiving a living donor transplant (among all transplant recipients).
Results: We included 18,692 individuals (New South Wales 8,334; New Zealand 4,939; Scotland 5,303). Severe MHSU ranged from 2% to 5% and was associated with lower transplantation rates in NSW (aHR 0.41, 95%CI 0.23-0.72, p=0.007) and Scotland (aHR 0.59, 95%CI 0.39-0.88, p<0.001), with a similar but non-significant trend in NZ (aHR 0.70, 95%CI 0.49-1.01, p=0.1). Moderate MHSU was associated with reduced transplantation only in Scotland (aHR 0.76, 95%CI 0.64-0.90, p<0.001). Adjusted cumulative incidence of transplant is presented in Figure 1. Odds of receiving a living donor transplant did not differ by MHSU.
Conclusions: Severe mental illness was associated with reduced access to kidney transplantation across three universal healthcare systems. These findings suggest that mental illness may represent an under-recognized structural barrier to transplantation and highlight the need for integration of mental health assessment and support within transplant pathways to improve equitable access.
Oral presentation.