51 DISCUSSION Evidence on patient- and system-level mediating factors and effectiveness of interventions is generally weak, which impairs the identification of promising intervention targets and strategies. We found strong evidence for an association of LHL with a suboptimal transplant process and smoking. We retrieved only weak evidence for a variety of other factors that potentially mediate the relation between LHL and health outcomes. Moreover, we found weak evidence that HL tailored intervention strategies were effective in improving knowledge, decisionmaking and health behaviors. We retrieved strong evidence for an association of LHL with having a suboptimal transplant process[35–39] and smoking[7,33,34]. Since both factors relate to behaviors that have a negative effect on health outcomes in the general CKD population[78,82], we consider them important targets for interventions. Our review adds LHL as an important factor negatively influencing the chance to receive a kidney transplant, next to the patients’ knowledge and beliefs, which were known to cause disparities in transplant access[83]. Our findings also support the results in other organ transplant settings that patients with LHL use care differently. For example, they need more emergency care[84], make less use of preventive services[85] and miss follow-up appointments more often[86]. Our review also strengthens the evidence from non-CKD studies, which show that LHL is associated with current smoking[87,88], less knowledge about smoking, lower risk perceptions[89] and difficulties in stopping with smoking[90]. In the general CKD population, patients are often unaware that smoking is a risk factor for kidney deterioration[91]. Our findings suggest that patients with LHL have reduced knowledge or lower ability to change behavior. Customized interventions, particularly to support the transplantation process and stopping with smoking, are needed to improve the outcomes of patients with LHL. We found only weak evidence for a variety of factors that potentially mediate the relation between LHL and health outcomes. This impedes to draw strong conclusions on targets for interventions in CKD. Even though studies on HL in other diseases like diabetes and cardiovascular disease showed strong associations of LHL with mediating factors, such as knowledge, patient-provider communication, medication adherence, and self-care behaviors[92,93].
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