Pre-dialysis care and access type are associated with transplant referral, evaluation, and waitlisting

Suboptimal dialysis initiation is associated with adverse patient outcomes. Whether it is also associated with access to downstream transplant care is unknown.

Adults initiating dialysis treatment for kidney failure in the Southeast U.S., from 1/1/2015 to 12/31/2019 were identified from the United States Renal Data System, linked to the Early Steps to Transplant Access Registry, and followed through 12/31/2021. The primary exposure was pre-dialysis care and categorized as highly, moderately, minimally, or non-optimal based on presence of nephrology care, dialysis type (in-center or home hemodialysis, peritoneal dialysis), and vascular access vs. catheter. Primary outcomes were referral to a transplant center within 12-months of dialysis initiation and evaluation start at a transplant center within 6 months of first referral. Multivariable competing risk models quantified the association between pre-dialysis care context and referral and evaluation.

Among 49,057 patients initiating dialysis, 28.8%, 15.5%, 31.0%, and 24.8% are highly, moderately, minimally, and non-optimal start, respectively. Patients initiating dialysis in moderately, minimally, and non-optimal ways are 28% (adjusted hazard ratio: 0.72, [95% CI: 0.69 - 0.72], 31% (0.69, [0.66 - 0.71], and 57% (0.43, [0.41 - 0.44]) less likely to be referred as compared with highly optimal starters. Those who had a non-optimal start are also 37% less likely to start the evaluation after being referred (0.63, [0.59 - 0.66]) as compared with highly optimal dialysis starters, while all other groups have a similar likelihood.

More than half of U.S. adults with kidney failure initiate dialysis in a minimal or non-optimal way leading to reduced likelihood of transplant referral and evaluation.