Dialysis and Transplant Access: Kidney Capitalism at a Crossroads?

Kidney transplantation is the preferred treatment modality for kidney failure as it improves quality of life and reduces mortality. The adjusted prevalence of kidney failure in the United States is 2242 cases per million, and at the end of 2018, over 550,000 patients with kidney failure were receiving dialysis, whereas approximately 230,000 (29%) had functioning kidney transplants (1). Kidney transplants are a scarce resource, indicating the need for transparency and equity in organ allocation policy. Given the overall benefits of transplantation, however, it is also important to understand the factors that affect patient access to this treatment option. In recent decades, notable steps have been taken to promote equity in access to transplant. For example, the Organ Procurement and Transplantation Network implemented a new kidney allocation system in 2014 (2), which increased access to transplantation for historically disadvantaged candidates, such as highly sensitized patients, blood group B candidates, and those with longer dialysis times prior to waitlisting. Another important yet potentially controversial factor that may influence access to kidney transplantation is the for-profit status of dialysis centers that initially refer patients with kidney failure for transplant evaluation.

In one of the earliest published studies to evaluate the potential influence of dialysis facility for-profit status on patient outcomes and transplant access, Garg et al. (3) noted that patients at for-profit facilities in the early 1990s had an adjusted 20% higher risk of death and an adjusted 26% lower likelihood of kidney transplant waitlisting. They hypothesized that lower staffing levels at for-profit facilities could contribute to poorer dialysis outcomes as well as hinder patient education and initial steps in transplant evaluation.

In a larger study of over 15,000 patients limited to new dialysis starts at facilities in Georgia between 2005 and 2011, Patzer et al. (4) found that the facilities in the lowest tertile of referral (in which <19% of the facility’s new patients were referred for evaluation at one of the three transplant centers in Georgia within 1 year of starting dialysis) were more likely to be nonprofit compared with facilities in the highest tertile of referral (>31% of new patients referred for transplant in the first year of dialysis). The authors considered the possibility that for-profit centers in Georgia could have increased referrals in response to criticism about low transplantation rates. Members of the same research group subsequently performed a 1.58 million–patient national database study that was republished with corrected data in 2020 (5). The investigators noted that compared with nonprofit facilities, patients dialyzed at for-profit facilities had significantly lower 5-year cumulative incidence for deceased donor waitlisting (−3%), receipt of deceased donor transplants (−1%), and receipt of living donor transplants (−0.9%). With the expansion of their Georgia cohort to also include patients from North Carolina and South Carolina (6), the investigators subsequently showed that transplant center–specific characteristics were associated with waitlisting and transplantation rates, whereas the earlier steps involved in transplant access, such as educating patients about transplantation as well as referral for transplant evaluation, were more strongly associated with dialysis facility attributes. They found that patient-social worker ratio, neighborhood poverty, patient age, and comorbidities, like congestive heart failure, were associated with a lower likelihood for referral and starting transplant evaluation. They also found that compared with patients from nonprofit dialysis centers, those from for-profit facilities were 14% less likely to be referred for evaluation at transplant centers.

Although causation cannot be established by observational evidence alone and not all published results have been consistent, there seems to be at least some cause for concern that for-profit facilities may be incentivized to aggressively control costs and maintain patients on dialysis volumes to maximize financial returns to investors. Providers and patients may be troubled by the idea that such a strategy does not provide adequate incentives to refer patients for transplant evaluation. To further explore the potential link between dialysis center for-profit status and referral for kidney transplant, McPherson et al. (7) performed additional analyses in the three-state cohort of over 33,000 patients who initiated dialysis in 2012–2016 in Georgia, North Carolina, and South Carolina. As reported in this issue of CJASN (7), the investigators found that for-profit facilities had a significantly lower absolute difference (−5%) in cumulative incidence for referral within 1 year of dialysis. In adjusted analyses, patients dialyzed at for-profit facilities had a 16% lower likelihood for referral (adjusted hazard ratio, 0.84; 95% confidence interval, 0.80 to 0.88). For those who were referred, they found no significant difference by dialysis center for-profit status in evaluation start at a transplant center. Similarly, there was no difference in kidney transplant waitlisting by for-profit status for those who started evaluation.

The investigators for this latest analysis list several important limitations, including the geographic restriction to the three specific states in the Southeastern United States, limited follow-up time, and the relative lack of information about patients with advanced kidney disease not yet requiring dialysis as well as potential differences in transplant center criteria for waitlisting eligibility. Although dialysis facilities play a major role in the early steps of access to transplant, such as patient education and referral for evaluation, transplant center policies may influence decisions by dialysis facilities to refer certain patients.

Given current economic and other drivers that affect dialysis center operations, it seems likely that the proportion of for-profit facilities could continue to increase. Reflecting on the growing body of evidence to suggest that dialysis center for-profit status influences kidney transplant referral rates while being cognizant of the epidemiologic limitations of all of the studies to date, it is important to consider possible mitigation strategies. McPherson et al. (7) noted recent policy initiatives that may lead to increased transplant referrals, including new Centers for Medicare & Medicaid Services payment models as of January 1, 2021 that reward dialysis centers and providers for increasing home dialysis modalities as well as kidney transplants (8). A different potential solution recently proposed by Huml et al. (9) calls for patients initiating dialysis to be automatically referred for transplant if they meet certain basic criteria. With such an approach, in which patients could opt out if desired, referrals for transplant evaluation would almost certainly increase without having to identify all of the reasons that currently limit referrals from dialysis facilities. However, this could potentially inundate transplant centers with many more candidates who ultimately do not meet medical eligibility criteria for waitlisting, thereby tying up transplant center resources and delaying evaluation and waitlisting of eligible candidates. In this situation, the principles of equity and utility could be at odds.

It is important to ensure that every eligible patient has the ability or help to navigate the necessary steps toward transplantation (education about the option, referral, starting evaluation, waitlisting, and surgery) with minimal delays. The early steps in transplant access remain frustratingly opaque, indicating the ongoing need to address long-standing disparities and ensure equity in treatment options for patients with kidney failure. The work by McPherson et al. (7) involves a voluntary data registry to track early steps in transplantation, and their findings lend credence to the idea that the medical community and regulatory agencies should be systematically collecting information about these steps at the national level. Further research in this area is necessary and could enable more targeted approaches to improve equity without diminishing utility by overwhelming individual transplant systems.

Disclosures

I.E. Hall reports employment with the University of Utah and serving as a United Network for Organ Sharing Donor Management Goals Advisory Board member and a Donor Connect Organ Procurement Research Oversight Committee member. D. Raghavan reports that her husband previously held Livongo (16 shares, total worth $1774.40), Moderna (seven shares, total worth $564.06), and CRISPR Therapeutics AG (3.23867 shares, total worth $281.77) shares; they no longer have these shares.

Funding

None.