*Purpose: Despite that various barriers to optimal access to transplantation are described in literature,there is no research combining the perspectives of all stakeholders in renal care. The aim ofthis project is to qualitatively explore the various barriers to optimal access to kidneytransplantation as describe by different stakeholders.

*Methods: Stakeholders involved in renal care are interviewed in two different phases about attitudes (phase 1) and opinions (phase 2) regarding barriers to optimal access to transplantation. The topic list for the interviews contains six themes: psychological, policy, medical, ethical, social, and economic. The interview method followed grounded theory principles.

*Results: A total of 117 participants were involved: patients (21), donors (10), social workers (25),nephrologists (22), surgeons (5), nurses (6), policy officers (24) and representatives ofinsurance companies (4). The following major barriers are typical for the six themes: 1.Psychological: fear for transplantation relates to delay kidney transplantation; 2. Policy-based: health care providers experience a lack of or unclarity regarding treatment guidelines; 3. Medical: no consensus on criteria for acceptance for transplantation, e.g. age, BMI,comorbidity. 4. Ethical: lack or insufficient use of programs/interventions that could helppatients reach equal access to transplantation; 5. Social: lack of an effective social network or lack of skills to activate social support system; 6. Economic: differences in purchasing agreements and following reimbursements for dialysis and transplantation could provide an economic incentive for choosing one or the other therapy.

*Conclusions: According to participants, access to transplantation rely heavily on a well-informed and acting patients, donors and health professionals. Despite the existence of national clinical guidelines, participants report ambiguity about their existence. Decision making by patients and donors is hampered by a lack of information about the different options, fears and difficulty to the complex decision-making process with multiple stakeholders. Financial incentives can influence access as they are not always aimed at encouraging early referral to kidney transplantation. Stakeholders state that access to kidney transplantation could be improved when these issues would be addressed.

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