Hospitalization and Hospitalized Delirium Are Associated With Decreased Access to Kidney Transplantation and Increased Risk of Waitlist Mortality

Background

Kidney transplant (KT) candidates often experience hospitalizations, increasing their delirium risk. Hospitalizations and delirium are associated with worse post-KT outcomes, yet their relationship with pre-KT outcomes is less clear. Pre-KT delirium may worsen access to KT due to its negative impact on cognition and ability to maintain overall health.

Methods

Using a prospective cohort of 2374 KT candidates evaluated at a single center (2009–2020), we abstracted hospitalizations and associated delirium records after listing via chart review. We evaluated associations between waitlist mortality and likelihood of KT with hospitalizations and hospitalized delirium using competing risk models and tested whether associations differed by gerontologic factors.

Results

During a median of 1.8 years after listing, 735 (31.0%) candidates had ≥1 hospitalizations. Candidates with less education, frailty, depressive symptoms, and lower extremity function impairment were more likely to be hospitalized. Hospitalization was associated with higher waitlist mortality (aSHR = 3.65, 95% CI: 2.99–4.45) and a lower likelihood of KT (aSHR = 0.74, 95% CI: 0.66–0.84). Among candidates who were hospitalized, 80 (11%) had ≥1 delirium episodes. Candidates who were older, frail, and impaired in lower extremity function were more likely to have delirium, which was associated with higher waitlist mortality (aSHR = 4.87, 95% CI: 3.42–6.93) and a lower likelihood of KT (aSHR = 0.45, 95% CI: 0.27–0.74). The association between hospitalization and KT differed by candidate age (p_interaction < 0.001), with those aged ≥65 having a 61% lower likelihood of KT.

Conclusion

Hospitalization and delirium are associated with worse pre-KT outcomes and have serious implications on candidates’ access to KT. Providers should work to reduce preventable instances of delirium.