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Referral for Kidney Transplantation in Canadian Provinces

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Referral for Kidney Transplantation in Canadian Provinces CLINICAL EPIDEMIOLOGY www.jasn.org Referral for Kidney Transplantation in Canadian Provinces S. Joseph Kim,1,a John S. Gill,2,3,a Greg Knoll,4,5 Patricia Campbell,6 Marcelo Cantarovich,7 Edward Cole ,1 and Bryce Kiberd8 1University Health Network, University of Toronto, Toronto, Canada; 2University of British Columbia, Vancouver, Canada; 3Division of Nephrology, Center for Health Evaluation and Outcome Sciences, Vancouver, Canada; 4University of Ottawa, Ottawa, Canada; 5Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Canada; 6University of Alberta, Edmonton, Canada; 7McGill University, Montreal, Canada; and 8Dalhousie University, Halifax, Canada 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 trans- plant 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 trans- plant 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 re- ferral 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 trans- plantation referral practices and ongoing national reporting of referral may decrease disparities in patient access to kidney transplant. JASN 30: 1708–1721, 2019. doi: https://doi.org/10.1681/ASN.2019020127 Among patients with ESKD, transplantation is asso- ciated with longer survival, better quality of life, and Received February 8, 2019. Accepted May 20, 2019. cost savings compared with treatment with chronic aS.J.K. and J.S.G. are cofirst authors. dialysis.1,2 Remarkably, the benefits of transplanta- tion are applicable to most patients with ESKD,2 Published online ahead of print. Publication date available at www.jasn.org. and only a minority of patients with ESKD have ab- solute contraindications to transplantation such as Correspondence: Dr. John S. Gill, Professor of Medicine, Di- vision of Nephrology, University of British Columbia, St. Paul’s active malignancy, uncontrolled infection, active sub- Hospital, Providence Building Ward 6a, 1081 Burrard Street, stance abuse, or habitual nonadherence.3,4 An insuf- Vancouver, BC V6Z 1Y6, Canada. E-mail: jgill@providencehealth. ficient supply of organs is the primary factor limiting bc.ca treatment with transplantation, and patients Copyright © 2019 by the American Society of Nephrology 1708 ISSN : 1046-6673/3009-1708 JASN 30: 1708–1721, 2019 www.jasn.org CLINICAL EPIDEMIOLOGY routinely wait on dialysis for 5 or more years for a deceased Significance Statement donor transplant.5 Given these conditions, minimizing dispar- ities in patient access to transplantation has been a challenge for In Canada, access to kidney transplantation requires referral to a transplant programs worldwide. Implementation of scientifi- transplant center, and selection of patients for transplant is in part a cally grounded organ distribution policies on the basis of clinical subjective process. The authors determined the incidence of transplant referral among incident patients with ESKD in Canada. criteria and ethical norms are essential features of national trans- Only 17% of incident patients with ESKD were referred within 12 plant systems to ensure fairness in access to transplantation months of starting dialysis, and transplant referral varied more than among wait-listed patients.6 three-fold between provinces. Factors associated with a lower Referral to a transplant center is a prerequisite for patients likelihood of referral included older age, female sex, and receiving . treated with dialysis to gain access to the deceased donor trans- dialysis 100 km from a transplant center, but not median house- hold income or nonwhite race. The findings highlight the need to plant waiting list and to access living donor transplantation. In educate health care providers about the medical criteria for kidney contrast to the strict rules governing the distribution of organs transplantation and implement standards for referral, as well as the to patients on the waiting list, the referral of patients on dialysis need for ongoing reporting of referral for transplantation in national for transplantation is a partially subjective process and there are registries. few safeguards to ensure that patients who will benefitare referred for transplantation. Previous work has documented June 1, 2010 and May 31, 2013. Data elements collected in- geographic variation in wait-listing and kidney transplanta- clude date of referral, patient demographics, and the date of 7,8 tion. However, relatively few studies of patient referral for initial transplant consultation. A listing of the 12 Canadian transplantation have been undertaken and understanding is transplant centers contributing data to the study is included in limited by the fact that information about referrals for trans- Supplemental Table 1. plantation is not currently collected in national dialysis or Data on patients referred for transplantation were linked to 9–11 transplant registries. The available information suggests data for all incident patients on chronic dialysis captured in fi signi cant variability in referral for transplantation related CORR fromJune 1, 2010to May31, 2013 usinga unique patient to factors such as age, sex, ethnicity, comorbid disease burden, identifier. CORR is a pan-Canadian information system man- and socio-economic status. Moreover, the likelihood of refer- aged by the Canadian Institute for Health Information.15,16 ral for transplantation may be dependent on physician knowl- CORR collects data from hospital dialysis programs, trans- 9–13 edge, beliefs, and attitudes about transplantation. Notably, plant programs, organ procurement organizations, and the association of measures of organ supply such as organ independent health facilities to track patients from their first donation rates and waiting times for transplantation with re- treatment for end-stage organ failure (dialysis or transplanta- ferral practices has not been studied. tion) to their death. The registry’s data quality and complete- Deceased donor kidneys are not routinely shared between ness of coverage have been previously reported.16 Canadian provinces and deceased donor rates and waiting times Patients referred for transplantation during the study pe- fi for transplantation are known to vary signi cantly between prov- riod before initiation of chronic dialysis treatment (i.e., pre- 14 inces. The objective of this study was to determine the association emptive transplant referrals) were excluded from the main ’ of a patient s province of residence with referral for transplantation. analysis, because these patients are not captured as incident We hypothesized that physician referral practices for transplanta- patients receiving dialysis in CORR before their transplant re- fl tion would be in uenced by the organ donation rate and waiting ferral. Although referrals for transplantation were collected fi times in their province. Speci cally, we hypothesized that referrals for Quebec residents, patients in the province of Quebec for transplantation would be lower in provinces with lower organ were also excluded from the analysis because Quebec privacy donation rates and longer waiting times for transplantation be- laws precluded the submission of patient-level data for inci- cause primary nephrologists, who are responsible for transplant dent patients on dialysis to CORR. referral, may believe their patients have limited opportunities for transplantation in these provinces. Definition of Transplant Referral The date of transplant referral was defined as the date when a METHODS kidney transplant center first received a mailed, faxed, or elec- tronic request for consultation to assess a patient’s candidacy The study was approved by the University Health Network for kidney transplantation. Research Ethics Board. Deceased Organ Donation Rates, Waiting Times, and Data Sources and Study Population ESKD Treatment Rates The Canadian Society of Transplantation kidney work group, Data on deceased organ donation rates (per million popula- in collaboration with the Canadian Organ Replacement Reg- tion), median waiting times of dialysis treatment before trans- ister (CORR), undertook a national study of adult patients plantation, and the rate of treated ESKD in Canadian provinces
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