*Purpose: To understand the barriers and facilitators to care for patients with failed kidney transplants from the perspective of providers.

*Methods: Qualitative study employed focus groups to examine the perspectives of surgeons, nephrologists, transplant center staff, and dialysis facility staff who care for patients with failed kidney transplants. Thematic analysis of focus group transcripts using the constant comparative approach was used to identify themes and sub-themes. The thematic coding scheme was refined iteratively during the analysis process.

*Results: 30 providers participated in 4 focus groups. 40% of them worked in dialysis facilities and 47% in transplant centers, and 73% were female. On average, participants had worked 10 years at their current job. Providers discussed facilitators and barriers across system-, provider-, and patient- levels of care. Notably, at the system level, fragmented care among multiple providers across a variety of clinical settings with ill-defined provider roles act as barriers to care. Lack of expectation-setting between providers and patients about transplant failure outcomes was also noted. Providers perceived that patients were often unprepared for the physical and emotional sequelae of a failing kidney transplant and thus experienced denial throughout the transition. Key facilitators were similarly identified at each level and included maintaining long-term relationships centered on trust and clear communication between patient and providers, and aligning care by multidisciplinary providers in a shared clinical setting. Focusing on empathetic interactions to guide incremental acceptance of a failed transplant eased the emotional aspect of this transition. Patients’ prior experiential insight of dialysis and strong interpersonal support systems helped to facilitate the transition back to dialysis.

*Conclusions: Based on provider-identified barriers and facilitators, core practices for improving care and outcomes of patients with failed kidney transplants need to recognize that the physical and emotional influence of failed transplants can be severe. Care gaps are created by the lack of coordination between medical care specialties with behavioral and social interventions. Importantly, promoting trust and team member communication can support transitions for patients with failed kidney transplants.

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