Lower Dialysis Availability Linked to Lower Kidney Transplant Rates

By Will Boggs MD

June 05, 2014

NEW YORK (Reuters Health) - Lower kidney transplant rates in the Southeastern U.S. are associated with lower dialysis center staffing, fewer transplant centers per capita and more patients in groups that are historically undertreated, researchers have found.

"It is quite unfortunate, but we continue to see that the Southeastern US ranks towards the bottom or at the very bottom among many health care measures and diseases," said Dr. Rachel E. Patzer from Emory University School of Medicine in Atlanta.

"For example, rates of stroke, hypertension, diabetes, obesity, low birth weight, infant mortality rate, and hospitalization rates for chronic conditions are all higher in the South and Southeast compared to other regions of the country," she told Reuters Health by email. "Having the lowest kidney transplant rate in the nation in part reflects some of the same causes for disparities in these other conditions: primarily issues related to access to health care."

In response to a lack of studies examining whether transplant rates vary across End-Stage Renal Disease (ESRD) Network regions, Dr. Patzer and colleagues examined dialysis- and ESRD Network-level factors associated with reduced transplant rates.

The primary outcome was the four-year average standardized transplant ratio (STR), the total number of first transplants divided by the total number of expected first transplants within a center.

These average STRs ranged from 0.69 in the Southeastern Kidney Council to 1.61 in New England. Georgia had the lowest STR of all states, followed by Mississippi, Alabama, Louisiana, and South Carolina.

Dialysis facility-level factors associated with lower transplant rates included longer time on dialysis, a higher percentage of African-American or Native American patients, a higher percentage of patients with diabetes, a higher percentage of patients with no health insurance at the time of ESRD, and for-profit status of the facility, the researchers report May 29 in the American Journal of Transplantation.

Factors tied to a higher STR included a higher percentage of patients classified as employed, peritoneal dialysis as the dialysis modality, a higher percentage of patients with arteriovenous fistula, a higher percentage of patients with a history of using erythropoietin-stimulating agents, and more staff per facility.

At the ESRD Network level, only a higher number of transplant centers per 10,000 ESRD patients was significantly associated with higher transplant rates.

"While modifiable, these factors most likely are associated with improved access to care prior to the onset of ESRD," the researchers say.

"I think it is not a coincidence that the states that chose not to expand Medicaid are also states that have these poorer health outcomes," Dr. Patzer said. "Lack of preventive care and public health services has both an immediate and long-term impact on people, and I think it's important for policymakers to really acknowledge the causes of some of these disparities so that something can be done to reduce the disparities."

"For nephrologists and primary care physicians who treat patients with kidney disease, or even patients with risk factors for kidney disease (such as hypertension and diabetes), I think it's important for the physician to take the extra steps needed to ensuring that patients receive optimal care," she added.

"Yes, it may be more difficult for a patient who has less social support or fewer financial resources to take the steps necessary to obtain this optimal treatment, but the physician can help encourage the patients and seek additional assistance to help the patient achieve these goals," said Dr. Patzer. "For a treatment like transplant, which is truly life-saving, it is important to take additional steps to help patients."

SOURCE: http://bit.ly/1jLI02G

Am J Transplant 2014.

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