Study finds low rate of dialysis facility referral for kidney transplantation evaluation

For most of the more than 600,000 patients in the United States with end-stage renal disease (ESRD), kidney transplantation represents the optimal treatment, providing longer survival, better quality of life, and substantial cost savings compared with dialysis. Dialysis facilities in the United States are required to educate patients with ESRD about all treatment options, including kidney transplantation. Patients receiving dialysis typically require a referral for kidney transplant evaluation at a transplant center to begin the transplantation process, but the proportion of dialysis patients referred for transplantation has been unknown, according to background information in the article.

Rachel E. Patzer, Ph.D., M.P.H., of the Emory University School of Medicine, Atlanta, and colleagues examined variation in dialysis facility-level referral for kidney transplant evaluation and factors associated with referral among patients initiating dialysis in Georgia, the U.S. state with the lowest kidney transplantation rates. The study included data from the United States Renal Data System for 15,279 adult (18-69 years) patients with ESRD from 308 Georgia dialysis facilities from January 2005 to September 2011, followed up through September 2012, and linked to kidney transplant referral data collected from adult transplant centers in Georgia in the same period.

The median within-facility percentage of patients referred within 1 year of starting dialysis at 308 Georgia dialysis facilities was 24 percent. There were 15 facilities (5 percent) that referred zero patients within 1 year of starting dialysis; the maximum referral in a year was 75 percent. Facilities in the lowest tertile of referral (<19 percent) were more likely to treat patients living in high-poverty neighborhoods, had a higher patient to social worker ratio, and were more likely nonprofit compared with facilities in the highest tertile of referral (>31 percent).

Factors associated with lower referral for transplantation, such as white race, older age, and nonprofit facility status, were not necessarily the same as those associated with lower waitlisting, the researchers write. "Results of this study suggest that referral for transplantation among Georgia dialysis facilities is not uniform and that national surveillance data measuring waitlisting and transplantation, but not referral, may be inadequate to assess and intervene on disparities in access to kidney transplantation."

"These findings may have implications for health policy makers, researchers, clinicians, and patients. Low facility-level referral for transplantation, as well as the variability in referral across Georgia facilities, suggests that standardized guidelines are needed for the content and duration of a patient-clinician educational discussion regarding treatment options at start of dialysis. Socioeconomic status factors were significant barriers to both referral and waitlisting in this study; national policies, such as Medicaid expansion, could help to alleviate disparities," the authors write.

"Researchers should continue to develop, test, and implement pragmatic interventions to improve knowledge of transplantation among both clinicians and patients. In Georgia, such interventions could focus on those dialysis facilities with the lowest proportions of patients with ESRD referred for kidney transplantation."

Editorial: Improving Access to Kidney Transplantation

"In summary, this important report by Patzer et al has established that major barriers in access to transplantation exist even after a patient has been referred to a transplant center, with 80 percent of referred patients not joining the transplant waitlist within 1 year of referral," writes Dorry L. Segev, M.D., Ph.D., and colleagues with the Johns Hopkins University School of Medicine, Baltimore, in an accompanying editorial.

"Furthermore, the initial rates of referral were likely low and varied widely between dialysis centers, suggesting that some facilities may have been underreferring patients. Future research to better understand and target post-referral barriers, as well as interventions to identify and improve referral rates in the context of comprehensive transplant education, will be crucial for improving access to kidney transplantation for patients with ESRD."