Referral for Kidney Transplantation in Canadian Provinces

Abstract

Background: Patient referral to a transplant facility, a prerequisite for dialysis-treated patients to access kidney transplantation in Canada, is a subjective process that is not recorded in national dialysis or transplant registries. Patients who may benefit from transplant may not be referred.

Methods: In this observational study, we prospectively identified referrals for kidney transplant in adult patients between June 2010 and May 2013 in 12 transplant centers, and linked these data to information on incident dialysis patients in a national registry.

Results: Among 13,184 patients initiating chronic dialysis, the cumulative incidence of referral for transplant was 17.3%, 24.0%, and 26.8% at 1, 2, and 3 years after dialysis initiation, respectively; the rate of transplant referral was 15.8 per 100 patient-years (95% confidence interval, 15.1 to 16.4). Transplant referral varied more than three-fold between provinces, but it was not associated with the rate of deceased organ donation or median waiting time for transplant in individual provinces. In a multivariable model, factors associated with a lower likelihood of referral included older patient age, female sex, diabetes-related ESKD, higher comorbid disease burden, longer durations (>12.0 months) of predialysis care, and receiving dialysis at a location >100 km from a transplant center. Median household income and non-Caucasian race were not associated with a lower likelihood of referral.

Conclusions: Referral rates for transplantation varied widely between Canadian provinces but were not lower among patients of non-Caucasian race or with lower socioeconomic status. Standardization of transplantation referral practices and ongoing national reporting of referral may decrease disparities in patient access to kidney transplant.

Keywords: clinical epidemiology; kidney donation; kidney transplantation.

Figure 1.

Referral for kidney transplantation in Canadian Regions. The referral rate per hundred patient-years of dialysis is shown for each region. B.C., British Columbia; Sask, Saskatchewan.

Figure 2.

Cumulative incidence of referral for kidney transplantation among incident patients on dialysis in Canada.

Figure 3.

Cumulative incidence of referral for kidney transplantation by province of residence.

Figure 4.

Association of deceased donor rate per million (A) and median waiting time for transplantation (B) with patient referral for transplantation. Provinces with a lower deceased donor rate had a higher rate of referral (referral rate = 48.6–2.3 [deceased donor rate]; 95% CI for slope, −3.7 to −0.9; P=0.01). There was no significant association between the median waiting time in provinces and referral (referral rate = −8.9+0.02 [median waiting time]; 95% CI for slope, 0.01 to 0.05; P=0.17).