Age and sex disparities in discussions about kidney transplantation in adults undergoing dialysis

Abstract

Objectives: To explore whether disparities in age and sex in access to kidney transplantation (KT) originate at the time of prereferral discussions about KT.

Design: Cross-sectional survey.

Setting: Outpatient dialysis centers in Maryland (n = 26).

Participants: Individuals who had recently initiated hemodialysis treatment (N = 416).

Measurements: Participants reported whether medical professionals (nephrologist, primary medical doctor, dialysis staff) and social group members (significant other, family member, friend) discussed KT with them and, when applicable, rated the tone of discussions. Relative risks were estimated using modified Poisson regression.

Results: Participants aged 65 and older were much less likely than those who were younger to have had discussions with medical professionals (44.5% vs 74.8%, P < .001) or social group members (47.3% vs 63.1%, P = .005). Irrespective of sex and independent of race, health-related factors, and dialysis-related characteristics, older adults were more likely not to have had discussions with medical professionals (relative risk (RR) = 1.13, 95% confidence interval (CI) = 1.03-1.24, for each 5-year increase in age through 65; RR = 1.28, 95% CI = 1.14-1.42, for each 5-year increase in age beyond 65). Irrespective of age, women were more likely (RR = 1.45, 95% CI = 1.12-1.89) not to have had discussions with medical professionals. For each 5-year increase in age, men (RR = 1.04, 95% CI = 0.99-1.10) and women (RR = 1.17, 95% CI = 1.10-1.24) were more likely not to have discussions with social group members. Of those who had discussions with medical professionals or social group members, older participants described these discussions as less encouraging (all P < .01).

Conclusion: Older adults and women undergoing hemodialysis are less likely than younger adults and men to have discussions about KT as a treatment option, supporting a need for better clinical guidelines and education for these individuals, their social network, and their providers.

Keywords: access to transplantation; age disparities; dialysis; kidney transplantation; sex disparities.

Figure 1. Percent of participants who discussed kidney transplantation with different categories of discussants

Bars show the percent of participants who had discussed kidney transplantation with different categories of discussants. Medical Professionals include any or all of the following: nephrologist(s), PMD(s), dialysis staff. Social Group Members include any or all of the following: significant other(s), family member(s), friend(s). The percentage of those in the aged ≥65 yrs category who had discussed KT was significantly lower (Fisher's exact test p<0.05) for all 6 categories of potential discussants. Abbreviations: PMD = primary medical doctor

Figure 2. Discussion occurrence and tone, by discussant category and participant age

Stacked bars illustrate whether discussion about kidney transplantation occurred and the rated tone (encouraging, neutral, discouraging) among those discussions that did occur with categories of medical professionals (nephrologist, PMD, dialysis staff) and categories of social group members (significant other, family member, friend). P-values were calculated using ordered logistic regression. Abbreviations: PMD = primary medical doctor, Sig. Other = significant other

Figure 3. Predicted probability of discussion about kidney transplantation with medical professionals or social group members, by participant age

Plot lines show the predicted probability of having had discussion about kidney transplantation (KT) with a medical professional or a social group member, based on a linear regression with a spline (knot at 65 years). The lines show that the spline term is unnecessary for discussion with social group members, but is needed for discussion with medical professionals. The lines also illustrate effect modification of the association between being less likely to have had discussions about KT and age by the discussant group (medical professional vs. social group member) for participants aged ≥65 years (p-value for the interaction term =0.010). While the age-wise decrease in predicted probability of discussion about KT with medical professionals and social group members occurred for participants of all ages, the age-wise decrease in predicted probability of discussion about KT was more pronounced with medical professionals than with social group members for participants aged ≥65. No effect modification of the association between discussion and older age by discussant group was observed for those aged <65 years (p-value for the interaction 0.55