Dialysis Preparedness and Access to the Transplant Waitlist: Evidence From a National United States Cohort Study

Individuals who initiate dialysis for kidney failure do so with different levels of preparedness. Whether this has downstream effects for access to kidney transplant is unknown.

We identified adults (aged ≥ 18 years) initiating dialysis between 2015 and 2019 from the United States Renal Data System and followed-up with them until waitlisting, death, or end of follow-up (December 31, 2021), whichever occurred first. We grouped dialysis initiation context as follows: group 1 initiated peritoneal dialysis (PD) or hemodialysis (HD) with mature arteriovenous access (AVA), group 2 initiated HD with a catheter and maturing AVA, group 3 initiated HD with a catheter and without a maturing AVA, and group 4 lacked predialysis nephrology care. Fine-Gray subdistribution hazard models were used to assess the association between dialysis initiation context and waitlisting, adjusted for clinical and nonclinical factors, and stratified by age, sex, race, and insurance status.

Among 541,861 adults initiating dialysis, 26.9%, 14.9%, 29.8%, and 28.4% were in groups 1, 2, 3, and 4, respectively. Compared with group 1, individuals in groups 2, 3, and 4 were 40% (adjusted hazard ratio [aHR]: 0.60; 95% confidence interval [CI]: 0.59-0.62), 45% (aHR: 0.55 [95% CI: 0.54-0.56]) and 58% (aHR: 0.42 [95% CI: 0.41-0.43]) less likely to be waitlisted. The relative impact of no predialysis nephrology care was most pronounced among older, Black, female, and Medicare insured patients.

A large proportion (∼60%) of adults in the US initiate dialysis with no AVA or predialysis nephrology care, with detrimental consequences for downstream transplant access.