Clinical trial NCT04999436: APOL1 Genetic Testing Program for Living Donors, Part 2
Official title: APOL1 Genetic Testing Program for Living Donors, Part 2
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Chronic Kidney Diseases
Genetic Predisposition
Keywords: Implementation science
Ethics
African continental ancestry group
Culturally competent care
Shared decision making
Genetic couseling
Informed consent
Nephrology
Educational intervention
Surveys and questionnaires
Apolipoprotein L1
Lead sponsor: Northwestern University
Sponsor class: OTHER
Collaborators: name: Georgetown University
First posted: 2021-08-10
Enrollment: 35
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NA
Intervention model: SINGLE_GROUP
Intervention model description: We will collect observational data to assess the impact of the training program on clinical practice. We will collect pre-test data before the intervention, and post-test data after the intervention.
Primary purpose: SCREENING

Brief summary: Living donor (LD) kidney transplantation is the optimal treatment for patients with end-stage kidney disease (ESKD). However, LDs take on a higher risk of future ESKD themselves. African American (AA) LDs have an even greater, 3.3-fold, risk of ESKD than white LDs post-donation. Because evidence suggests that Apolipoprotein L1 (APOL1) risk variants contribute to this greater risk, transplant nephrologists are increasingly using APOL1 testing to evaluate LD candidates of African ancestry. However, nephrologists do not consistently perform genetic counseling with LD candidates about APOL1 due to a lack of knowledge and skill in counseling about APOL1. Without proper counseling, APOL1 testing will magnify LD candidates' decisional conflict about donating, jeopardizing their informed consent. Given their elevated risk of ESRD post-donation, and AAs' widely-held cultural concerns about genetic testing, it is ethically critical to protect AA LD candidates' safety through APOL1 testing in a culturally competent manner to improve informed decisions about donating.

No transplant programs have integrated APOL1 testing into LD evaluation in a culturally competent manner. Clinical "chatbots," mobile apps that use artificial intelligence to provide genetic information to patients and relieve constraints on clinicians' time, can improve informed treatment decisions and reduce decisional conflict. The chatbot "Gia," created by a medical genetics company, can be adapted to any condition. However, no chatbot on APOL1is currently available. No counseling training programs are available for nephrologists to counsel AA LDs about APOL1 and donation in a culturally competent manner. Given the shortage of genetic counselors, increasing nephrologists' genetic literacy is critical to integrating genetic testing into practice.

The objective of this study is to culturally adapt and evaluate the effectiveness of an APOL1testing program for AA LDs at two transplant centers serving large AA LD populations (Chicago, IL, and Washington, DC). The APOL1 testing program will evaluate the effect of the culturally competent testing, chatbot, and counseling on AA LD candidates' decisional conflict about donating, preparedness for decision-making, willingness to donate, and satisfaction with informed consent. The specific aims are to:

1. Adapt Gia and transplant counseling to APOL1 for use in routine clinical practice
2. Evaluate the effectiveness of this intervention on decisional conflict, preparedness, and willingness to donate in a pre-post design
3. Evaluate the implementation of this intervention into clinical practice by using the RE-AIM framework to longitudinally evaluate nephrologist counseling practices and LDs' satisfaction with informed consent.

The impact of this study will be the creation of a model for APOL1 testing of AA LDs, which can then be implemented nationally via implementation science approaches. APOL1 will serve as a model for integrating culturally competent genetic testing into transplant and other practices to improve patient informed consent.

Detailed description: Clinical practice guidelines advise "...considering APOL1 genotyping in live kidney donor candidates with sub-Saharan African ancestors" and using shared decision making until the NIH APOLLO study of APOL1 outcomes in living donors provides population-level data. Transplant physicians are increasingly adopting APOL1 testing. However, physicians do not consistently inform live donor candidates about APOL1, perform genetic counseling, or practice shared decision making with live donor candidates. Our prior research has shown that this variation results from lack of knowledge and skill in counseling about APOL1, and fear that APOL1 testing will deter live donor candidates from donating. It is unknown if they address African American live donor candidates' cultural concerns about genetic testing while counseling.

Effective counseling about APOL1 test results is critical especially because genetic information can magnify live kidney donor candidates' decisional conflict about donating. The consequences of such decisional conflict may be reduced donation rates, which could exacerbate disparities in African Americans patients' access to living donor kidney transplants and health outcomes. Therefore, effective culturally competent counseling is ethically essential to reduce live donor candidates' decisional conflict and enable informed decisions about donation.

This project will entail adapting established genetic counseling discussions for transplant nephrologists to counsel donor candidates about APOL1 test results and engage in shared decision making to improve live donor candidates' informed consent for living donation. The APOL1 counseling training program will address nephrologists' practical knowledge and counseling skill deficits about APOL1 as identified in our prior work. The specific duration and format of the counseling training program will be finalized through a final nephrologist needs assessment early in Year 1. Our preliminary needs assessment revealed a preference for a 2-4 hour educational program delivered by a genetics counselor through a live webinar format. The investigators plan to enroll all transplant nephrologists who evaluate live kidney donor candidates (n=6) across both sites for participation in the counseling training program.

The effectiveness of the nephrologist counseling training program will be assessed primarily by assessing increases in nephrologists' skill in delivering counseling for APOL1 by comparing the number and quality of prescribed counseling behaviors observed between nephrologists counseling live donor candidates in the control group (year 1) versus intervention group (years 2-5). Secondarily, we will evaluate the counseling training program via paired tests of pre-post scores of validated surveys assessing practical knowledge and skills in counseling. Additionally, we will qualitatively analyze nephrologists' perceptions of their APOL1 counseling over time.

Training materials will be updated after two years of implementing the APOL1 intervention based on lessons learned, and will be available for future dissemination. The findings generated from this research have the potential to meaningfully protect donor candidate safety by providing culturally competent counseling and shared decision making to improve candidates' informed consent. As such, we believe this proposal is both timely and responsive to the NIDDK Program Announcement (PA-18-330) "Investigator-Initiated Clinical Trials Targeting Diseases within the Mission of NIDDK."

Eligibility criteria: Inclusion Criteria:

* Adults (age 18 years and older)
* English-speaking
* Transplant nephrologists evaluating live kidney donor candidates practicing at the study sites
* Not vision impaired
* Not cognitively impaired

Exclusion Criteria:

* Not a nephrologist

Primary outcomes:
measure: Number and quality of prescribed Pre-Test counseling practices
timeFrame: Post-intervention, up to 5 years
measure: Number and quality of prescribed Post-Test counseling practices
timeFrame: Post-intervention, up to 5 years
Secondary outcomes:
measure: Practical Knowledge and Self-Efficacy in Genetic Counseling
timeFrame: Day 1
measure: Practical Knowledge and Self-Efficacy in Genetic Counseling
timeFrame: Approximately Day 14
measure: Acceptability of Intervention Measure (AIM)
timeFrame: Approximately Day 21
measure: Acceptability of Intervention Measure (AIM)
timeFrame: Approximately Month 2
measure: Acceptability of Intervention Measure (AIM)
timeFrame: Approximately Month 12
measure: Intervention Appropriateness Measure (IAM)
timeFrame: Approximately Day 21
measure: Intervention Appropriateness Measure (IAM)
timeFrame: Approximately Month 2
measure: Intervention Appropriateness Measure (IAM)
timeFrame: Approximately Month 12
measure: Feasibility of Intervention Measure (FIM)
timeFrame: Approximately Day 21
measure: Feasibility of Intervention Measure (FIM)
timeFrame: Approximately Month 2
measure: Feasibility of Intervention Measure (FIM)
timeFrame: Approximately Month 12
measure: Clinical Sustainability Assessment Tool (CSAT)
timeFrame: Approximately Month 36
Other outcomes:
measure: Racial attributes in clinical evaluation (RACE) scale
timeFrame: Day 1
measure: Racial attributes in clinical evaluation (RACE) scale
timeFrame: Approximately Day 14
measure: Genetic variation knowledge assessment index (GKAI)
timeFrame: Day 1
measure: Genetic variation knowledge assessment index (GKAI)
timeFrame: Approximately Day 14
measure: Health Professionals Beliefs about Race (HPBR) scale
timeFrame: Day 1
measure: Health Professionals Beliefs about Race (HPBR) scale
timeFrame: Approximately Day 14
measure: Barriers and Facilitators to APOL1 testing Implementation
timeFrame: Approximately Day 21
measure: Barriers and Facilitators to APOL1 testing Implementation
timeFrame: Approximately Month 3
measure: Barriers and Facilitators to APOL1 testing Implementation
timeFrame: Approximately Month 25
Locations:
city: Washington
country: United States
facility: Medstar Georgetown Transplant Institute
state: District of Columbia
city: Chicago
country: United States
facility: Northwestern University Feinberg School of Medicine
state: Illinois
Study officials:
affiliation: Northwestern University
name: Elisa J Gordon, PhD, MPH
role: PRINCIPAL_INVESTIGATOR
References: