Dialysis facility referral and start of evaluation for kidney transplantation among patients treated with dialysis in the Southeastern United States

Abstract

followed through February 2018 and linked data to referral and evaluation data from nine transplant centers in Georgia, North Carolina, and South Carolina. Multivariableadjusted competing risk analysis examined each outcome. The median within-facility cumulative percentage of patients referred for kidney transplantation within 1 year of dialysis at the 690 dialysis facilities in Network 6 was 33.7% (interquartile range [IQR]: 25.3%-43.1%). Only 48.3% of referred patients started the transplant evaluation within 6 months of referral. In multivariable analyses, factors associated with referral vs evaluation start among those referred at any time differed. For example, black, non-Hispanic patients had a higher rate of referral (hazard ratio [HR]: 1.22; 95% confidence interval [CI]: 1.18-1.27), but lower evaluation start among those referred (HR: 0.93; 95% CI: 0.88-0.98), vs white non-Hispanic patients. Barriers to transplant varied by step, and national surveillance data should be collected on early transplant steps to improve transplant access.

An opt-out model for kidney transplant referral: The time has come

“…Highly prevalent racial ethnic gender geographic and socioeconomic disparities affect equitable access in kidney transplant. In addition evidence from the United States and Canada has documented substantial variability in referral rates for kidney transplantation among dialysis facilities (from 0%‐100%) and higher rates of wait listing among those facilities with higher referral suggesting there are many end‐stage kidney disease (ESKD) patients who may be eligible for kidney transplantation but have not yet been referred 6,7 . Improving access to the kidney transplant waiting list remains a prominent challenge for the nephrology and transplant communities 8‐10 …”

Kidney transplant program waitlisting rate as a metric to assess transplant access

“…Referral was defined as the date at which the transplant program received a transplant referral form from a dialysis facility or referring provider. The referral data were collected from transplant referral forms and electronic medical records in the transplant programs and linked to the USRDS data as described previously 16,20 . Patients <18 or >80 years of age and those waitlisted, transplanted, or died before referral were excluded (Figure 1).…”

“…The referral data were collected from transplant referral forms and electronic medical records in the transplant programs and linked to the USRDS data as described previously. 16,20 Patients <18 or >80 years of age and those waitlisted, transplanted, or died before referral were excluded ( Figure 1). The waitlisting rate metric was calculated as the number of patients who were waitlisted at the transplant program (numerator) divided by the total number of person-years after referral to that program (denominator).…”

“…Prior research has shown that, for ESRD patients, variation in multiple early transplant steps, including waitlisting, is often a culmination of multilevel factors such as a patient’s age, race, sex, comorbidities, geographical location, insurance status, and profit status of the dialysis provider, and that these barriers may differ depending on the transplant step 13,14 . For example, barriers to referral from a dialysis facility to a transplant center may be different from barriers to waitlisting after referral 15,16 . Lack of specific nationally standardized transplant eligibility criteria and regulations focused on posttransplant outcomes have resulted in increased transplant program patient selection and variability in waitlisting practices across center 17,18 .…”

“…13,14 For example, barriers to referral from a dialysis facility to a transplant center may be different from barriers to waitlisting after referral. 15,16 Lack of specific nationally standardized transplant eligibility criteria and regulations focused on posttransplant outcomes have resulted in increased transplant program patient selection and variability in waitlisting practices across center. 17,18 All patients who want a kidney transplant, including those who get a living donor transplant, have to first be placed on the kidney transplant waitlist.…”