Why do many kidney patients stay on dialysis rather than getting a transplant?

August 31, 2015

Despite widespread acceptance that kidney transplants are the best treatment for patients with end-stage kidney disease, many of these patients do not get transplants and are given long-term dialysis instead.

Looking into the possible reasons why, a study of Georgia’s three transplant centers in a recent issue of the Journal of the American Medical Association found only 28 percent of adult patients starting dialysis were referred for kidney transplant evaluation within a year, and there were a variety of differences — in regard to race, socioeconomics and geography — in referral rates among dialysis facilities.

"I don’t expect much difference in other parts of the country," said Kalathil K. Sureshkumar, medical director of the kidney and pancreas transplant program at Pittsburgh’s Allegheny General Hospital. He added that this may be one of the first studies on the topic. "It’s a lot about educating the patient … maybe they’re not wholly aware of the options."

Dr. Sureshkumar explained that a referral is the first step for patients to get a transplant: At the transplant center, they would be evaluated to see if they are a good candidate for a new kidney, and ultimately they would be put on a waiting list for a transplant.

With a transplant, he said, "It turns out to be cheaper than keeping people on dialysis. And they have a better quality of life, a longer life."

However, the need for kidney donations and various disparities continue to block access to a transplant for many.

The Georgia study analyzed the cases of a group of 15,279 patients, ages 18-69, at 308 Georgia dialysis facilities.

Among the findings were: Facilities with the lowest likelihood of referral for a transplant within one year of starting dialysis were more likely to be nonprofit, hospital-based, have more patients, treat patients in high-poverty neighborhoods and have a higher ratio of patients for every social worker.

Researchers found referrals varied from zero percent to 75 percent in the dialysis facilities. They concluded that prevailing methods of gauging the quality of dialysis facilities — measuring the length of time patients wait for a transplant and how well they do after a kidney transplant — may not be good enough. How long patients are "wait-listed" had racial disparities, for example, but the referral rates didn’t.

The reason for the findings were not clear, and the researchers called for further study into how health policy could alleviate disparities, how poorly performing dialysis centers could be improved and what factors influence a patient’s eligibility for a transplant at dialysis facilities and what factors at transplant centers influence wait listing.

The study also called for researchers to "continue to develop, test and implement pragmatic interventions" to improve an understanding among health care professionals and patients of what a kidney transplant involves.

In the U.S., about 100,000 people are on a waitlist, Dr. Sureshkumar said, but only about 16,000 kidneys are transplanted each year.

"I really want people to get transplants," he said, adding that the best results come with "preemptive" transplants, before a patient goes on dialysis.

That can happen when a patient with kidney disease is under the care of a nephrologist, who can refer the patient for a transplant, usually when kidney function is about 15 percent, he said.

"If they’re not going to improve, they’re eligible. People don’t need dialysis before they are 10 percent or below."

Waiting times for a transplant can be three to four years in Pittsburgh, he said. "In New York, it’s six or seven years; it’s longer in California."

"Preemptive transplants do the best long-term. The kidney function lasts the longest. (In contrast) the longer you stay on dialysis, the outcomes after a transplant are worse than if you were never on dialysis."

Commenting on the recent study, he said, "Maybe we need more guidelines to make sure staff and patients make the most of their options."



McClatchy-Tribune Information Services