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Scand J Public Health. 2013 Mar;41(2):206-15. doi: 10.1177/1403494812470399. Epub 2013 Jan 3.

Priority setting in kidney transplantation: a qualitative study evaluating Swedish practices.

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Department of Medical and Health Sciences Linköping University, Sweden.



Transplantation is the treatment of choice for end-stage renal disease; it increases survival and quality of life, while being more cost-effective than dialysis. It is, however, limited by the scarcity of kidneys. The aim of this paper is to investigate the fairness of the priority setting process underpinning Swedish kidney transplantation in reference to the Accountability for Reasonableness (A4R) framework.


Fifteen semi-structured interviews were carried out with transplant surgeons (7), nephrologists (6) and coordinators (2) representing centers nationwide. Collected data was analysed using thematic analysis. To assess fairness in the priority setting process, identified factors were assessed in the reference to the four conditions (publicity, relevance, revision and appeal, enforcement) forming the accountability for reasonableness framework.


Decision-making in assessment and allocation is based on clusters of factors. The factors appeal to various values, which are balanced against each other throughout the kidney allocation process: maximizing benefit, priority to the worst off and equality. The factors described by subjects and the values on which they rest satisfy the relevance condition of the accountability for reasonableness framework. However, two potential sources for unfair inequalities in access to treatment are identified: clinical judgment and institutional policies.


The development of national guidelines both for assessing transplant candidacy, and for the allocation of kidneys from deceased donors, would contribute to standardize practices across centres; it will also help to better meet the conditions of fairness in reference to Accountability for Reasonableness. The benefits of this policy proposal in Swedish kidney transplantation merits consideration.

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