Should Adherence to Medical Recommendations Be a Requirement for Kidney Transplant Candidacy?

To be considered a candidate for transplant, patients with advanced kidney disease must demonstrate their ability to adhere to medical recommendations. An adherence criterion is intended to ensure effective use of deceased donor kidneys by selecting candidates who are able to engage in complicated post-transplant clinical care. However, evidence that pre-transplant assessment of adherence predicts meaningful post-transplant outcomes is equivocal. Further, this criterion risks exacerbating existing inequities in access to transplant and rigid definitions of what constitutes adherent behavior may impede opportunities to tailor treatment plans to individual preferences and circumstances. It is also unclear that an adherence criterion supports ethical standards for a fair process of resource allocation including transparency, relevance to affected groups, regulation, and opportunity for revision. We offer several strategies to revise the current approach to evaluating transplant candidates for adherence to better align with ethical principles guiding allocation of a scarce societal resource.