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www.medscape.com
|August 12, 2015
Only 28.0% of patients with end-stage renal disease (ESRD) are referred for transplant evaluation within a year of starting dialysis
in Georgia, the US state with the lowest transplantation rate, new research shows. The study, published in the August 11 issue of
JAMA, also found that individual facility referral rates varied substantially, ranging from 0% to 75%.
"For most of the more than 600 000 patients in the United States with [ESRD], kidney transplantation represents the optimal
treatment, providing longer survival, better quality of life, and substantial cost savings compared with dialysis," write Rachel E.
Patzer, PhD, MPH, assistant professor of surgery in Emory University School of Medicine and Rollins School of Public Health in
Atlanta, Georgia, and colleagues.
Although there are numerous barriers to transplants, including a scarcity of available organs, the researchers hypothesize that
evaluating earlier steps in the transplant process may ultimately help improve equity in transplants.
Therefore, in an effort to evaluate factors involved in the state’s low transplant rate, researchers analyzed data reported by the US
Renal Data System for a cohort of 15,279 adults aged 18 to 69 years at 308 Georgia dialysis facilities from January 2005 to
September 2011 and followed up through September 2012.
The median within-facility percentage of patients referred within a year of starting dialysis was 24.4%. Fifteen facilities (4.9%) had
referral rates of 0%; the highest referral rate was 75.0%.
Factors associated with the lowest vs highest tertile of facility referral rates (0.0% - 19.2% vs 31.3% - 75.0%) included treatment of
patients from high-poverty neighborhoods (difference, 21.8%; 95% confidence interval [CI], 14.1% - 29.4%), a higher patient-to-
social-worker ratio (difference, 22.5%; 95% CI, 9.7% - 35.2%), and nonprofit status (difference, 17.6%; 95% CI, 7.7% - 27.4%).
"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," the authors write.
Referral Rates Not the Only Factor in Low Transplant Rates
"Although referral to a transplant center is a critical step in the path to transplantation, it is only the beginning of a long process,"
write Lauren M. Kucirka, PhD, from Johns Hopkins University School of Medicine in Baltimore, Maryland, and colleagues in an
accompanying editorial.
Indeed, study data showed that only 21.5% of referred patients were subsequently waitlisted within 1 year. Significantly, factors
associated with a lower likelihood of referral did not always match those associated with a lower likelihood of being waitlisted.
"Because referral data has thus far been unknown and unmeasured, many researchers, including us, assumed that the racial
disparities we observed in Georgia and elsewhere were likely due to racial disparities in referral at the dialysis facility level," Dr
Patzer commented in a JAMA interview.
The authors found, however, that blacks had a higher rate of referral than whites (odds ratio [OR], 1.22; 95% CI, 1.10 - 1.35), but
were less likely to be waitlisted (OR, 0.77; 95% CI, 0.64 - 0.93).
Another factor, increasing age, was found to be a negative predictor of referral, but did not significantly affect waitlisting rates.
Compared with patients aged 18 to 29 years, those aged 60 to 69 years had a referral OR of 0.19 (95% CI, 0.15 - 0.23), but a
waitlist OR of 0.83 (95% CI, 0.57 - 1.20). "This may reflect a difference in the perception of the dialysis facility vs transplant center
that older age is a contraindication to transplantation," the authors comment.
The data also challenge the assumption that low transplantation rates in for-profit dialysis facilities are financially motivated. For-
profit centers were actually more likely to refer patients for transplant evaluation than nonprofits (OR, 1.51; 95% CI, 1.20 - 1.91),
but waitlisting rates were similar (OR, 1.09; 95% CI, 0.83 - 1.44).
Dialysis: Only 28% in Georgia Referred for Transplant
Yael Waknine

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"This new study makes it clear that disparities in access are not primarily driven by patients' inability to 'get into the system' via the
initial referral, but may largely result from difficulty navigating the complexities of the process of kidney transplant evaluation and
waitlisting," the editorialists write.
"Future research to better understand and target postreferral 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 conclude.
This study was supported by a grant from the National Institute on Minority Health and Health Disparities. One coauthor reports
being a minority shareholder in Fresenius Dialysis. The other authors have disclosed no relevant financial relationships. The
editorialists are supported in part by grants from the National Institute of Diabetes and Digestive and Kidney Diseases of the
National Institutes of Health.
JAMA. 2015;314:565-567, 582-594. Article abstract, Editorial extract
Medscape Medical News © 2015 WebMD, LLC
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Cite this article: Dialysis: Only 28% in Georgia Referred for Transplant. Medscape. Aug 12, 2015.