Barriers Limiting Equity in Access to Pretransplant Evaluation Among Predialysis Patients: A Cohort Study

Kidney transplantation is the optimal treatment for end-stage renal disease; however, referral for pretransplant evaluation remains inconsistent. We aimed to compare patients deemed eligible for pretransplant evaluation with those whose eligibility status was undetermined.

We conducted a single-center retrospective cohort study of patients aged ≤80 y, followed-up in a chronic kidney disease (CKD) clinic as of June 2021. We compared demographic, clinical characteristics, and survival prognosis scores between these groups.

Of the 572 patients followed in the clinic, 395 were aged ≤80 y. Among them, 203 had progressive disease, defined as CKD stage V or CKD stage IV with an estimated glomerular filtration rate (eGFR) projected to fall below 15 mL/min/1.73 m² within 5 y. These 203 patients were classified by the CKD clinic medical team as follows: 46 (23%) were considered eligible for pretransplant evaluation, 78 (38%) were deemed unsuitable, and 79 (39%) had an undetermined status. There were no significant differences in sex, body mass index, ethnicity, or distance from the transplant center between eligible and undetermined patients. However, undetermined patients were older (66 ± 11 versus 58 ± 13 y, P < 0.01), had a higher eGFR (15 ± 5 versus 12 ± 4 mL/min/1.73 m², P < 0.01), a greater number of cardiovascular and metabolic comorbidities (2.4 ± 1.6 versus 1.6 ± 1.3, P < 0.01), and a higher 3-y mortality risk score (5.9 ± 3.7 versus 3.2 ± 3.0, P < 0.01). Nonetheless, 43 (54%) of 79 undetermined patients were in the acceptable prognosis risk category for kidney transplantation, with a predicted 3-y dialysis mortality of ≤30%.

A substantial proportion of patients theoretically eligible for pretransplant evaluation had an undetermined referral status. Our findings suggest that several of these patients share similar age, comorbidity profiles, and survival prospects with those already deemed eligible for pretransplant evaluation.