Are we disadvantaging smokers by excluding them from kidney transplantation? A single-centre experience and survey of kidney transplantation units.

Background: Smoking has been shown to have detrimental effects on KT outcomes and survival. Most units and guidelines advocate for the cessation of smoking prior to a kidney transplant and consider it a general contraindication to listing. Smoking prevalence is higher in disadvantaged groups. Smoking cessation is complex and often takes many years. For those suffering from the burden of chronic kidney disease, a delay in transplantation with a longer dialysis time may result in worse outcomes and accentuate the difficulty of cessation.

Aim: The objective of this study was to describe the cohort of excluded smokers for kidney transplantation (KT) and further examine the current practices regarding smoking and KT waitlisting.

Methods: We undertook a retrospective observational study of dialysis patients in Hunter New England Local Health District 2013-2023 <65 years old and assessed but not listed for KT. We examined the reasons for non-transplant listing and divided them into two categories, smoking versus others (comorbidities, patient preference and cancer). We compared the categories in terms of demography, comorbidities and dialysis modality. We also conducted a survey of KT units across Australia and New Zealand regarding their policies towards smoking.

Results: We reviewed the records of 333 patients (142 female), 89 of whom were smokers. Patients not listed due to smoking were less comorbid than those rejected for another reason (83% vs 40% having ≤1 comorbid condition, P < 0.001). Patients rejected due to smoking were younger than those rejected for other reasons (47.8 vs 52.1, P = 0.007). There was no difference between the two groups in terms of sex or dialysis modality. All the acute KT units were surveyed (response rate 100%); 72% of units do not list current smokers for KT.

Conclusion: Patients not listed for KT due to smoking are generally younger and less comorbid than those not listed for other reasons. Our survey shows variation in practice between units. As smoking is more prevalent in marginalised communities, not listing these patients for KT may be an equity-of-access-to-treatment issue.