Low Rate of Dialysis Facility Referral for Kidney Transplantation Evaluation

Low Rate of Dialysis Facility Referral for Kidney Transplantation Evaluation

Results from a recent study published in the journal JAMA showed that in the state of Georgia only a limited portion of patients treated with dialysis were referred for kidney transplant evaluation between 2005 and 2011, but there was considerable variability in referral among facilities that provide dialysis.

In the United States more than 600,000 patients suffer with end-stage renal disease (ESRD). End-stage kidney disease is the last stage of chronic kidney disease, when kidneys can no longer support bodily needs. Kidney transplantation is the ideal treatment for the condition with the procedure providing better quality of life, longer survival, and substantial cost savings in comparison to dialysis.

To describe the variation in dialysis facilities – level of referral for kidney transplant evaluation and which factors were associated with the referral in a cohort of patients initiating dialysis in Georgia – in the study titled “Variation in Dialysis Facility Referral for Kidney Transplantation Among Patients With End-Stage Renal Disease in Georgia, Rachel E. Patzer, Ph.D., M.P.H., of the Emory University School of Medicine, Atlanta, and colleagues analyzed data from the United States Renal Data System from a total of 15,279 ESRD patients from 308 Georgia dialysis facilities between 2005 and 2011, followed up through 2012. This information was linked to kidney transplant referral data gathered from adult transplant centers in Georgia in the same period of time.

The study primary outcome was the referral for kidney transplant evaluation within 1 year of starting dialysis at any of the 3 Georgia transplant centers. The researchers also assessed placement on the deceased donor waiting list.

Results revealed that the median within-facility percentage of patients referred within 1 year of starting dialysis was 24.4% and varied from 0% to 75.0%. Facilities in the lowest tertile of referral (<19.2%) 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 (>31.3%).

According to the researchers, the factors associated with a lower referral for kidney transplantation such as older age, nonprofit facility status and white race, were not associated with lower waitlisting. “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”, the researchers explained in a news release. “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,” they added.

“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.”

In a supplement editorial Dorry L. Segev, M.D., Ph.D., and colleagues with the Johns Hopkins University School of Medicine, Baltimore, commented, “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.”

“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”, they concluded.

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Daniela holds a PhD in Clinical Psychology from The University of Edinburgh, United Kingdom, a MSc in Health Psychology and a BSc in Clinical Psychology. Her work has been focused on vulnerability to psychopathology and early identification and intervention in psychosis.

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