Regional Variation in Early Kidney Transplant Access Across Dialysis Facilities in 4 US Regions

Abstract

Introduction: Pretransplant access varies, but whether pretransplant steps vary regionally across dialysis facilities remains unclear. Methods: We identified 62,467 adults (aged 18-80 years) referred from 2471 dialysis facilities and 27,171 initiating transplant evaluation from 2188 facilities in New England, New York, Southeast, and Ohio River Valley within the Early Steps to Transplant Access Registry (E-STAR) (January 1, 2015-December 31, 2023), linked with US Renal Data System (USRDS) and the Scientific Registry of Transplant Recipients data, followed-up through March 2, 2024. We examined dialysis facility-level proportions of evaluation start within 6 months of referral and waitlisting within 1 year of evaluation start. Descriptive statistics using analysis of variance and chi-square tests summarized outcome distributions and baseline characteristics within tertiles of outcome proportions, overall and by region. Results: Evaluation start within 6 months across 2471 facilities varied from 0% to 100%; median within-facility proportion was 50% (interquartile range: 33.3%-64.3%), ranging from 33.3% (18.2%-50%) in the Ohio River Valley to 66.7% (50%-76.7%) in New York. Waitlisting within 1 year of evaluation start varied from 0% to 100% across 2188 facilities; median within-facility proportion was 41.2% (26.0%-60%), lowest in the Southeast (31.9% [20%-43.8%]) and similar across other regions (50%). Facilities in the lowest tertile of evaluation start proportions (< 39.13%) more often treated patients from high-poverty neighborhoods (36.8% vs. 29.2%) and were for-profit (82.4% vs. 73.5%) than the highest tertile (> 58.33%). These characteristics varied by region. Facility-level clustering explained 12.2% (95% confidence interval [CI]: 10.5%-13.5%) of variation in evaluation and 8.2% (6.7%-9.2%) in waitlisting. Conclusion: Substantial regional variation in pretransplant access across dialysis facilities reinforces the need for region-specific strategies to improve access.