Dialysis Facility Profit Status and Early Steps in Kidney Transplantation in the Southeastern United States

Clin J Am Soc Nephrol. 2021 Jun;16(6):926-936. doi: 10.2215/CJN.17691120. Epub 2021 May 26.


Background and objectives: Dialysis facilities in the United States play a key role in access to kidney transplantation. Previous studies reported that patients treated at for-profit facilities are less likely to be waitlisted and receive a transplant, but their effect on early steps in the transplant process is unknown. The study's objective was to determine the association between dialysis facility profit status and critical steps in the transplantation process in Georgia, North Carolina, and South Carolina.

Design, setting, participants, & measurements: In this retrospective cohort study, we linked referral and evaluation data from all nine transplant centers in the Southeast with United States Renal Data System surveillance data. The cohort study included 33,651 patients with kidney failure initiating dialysis from January 1, 2012 to August 31, 2016. Patients were censored for event (date of referral, evaluation, or waitlisting), death, or end of study (August 31, 2017 for referral and March 1, 2018 for evaluation and waitlisting). The primary exposure was dialysis facility profit status: for profit versus nonprofit. The primary outcome was referral for evaluation at a transplant center after dialysis initiation. Secondary outcomes were start of evaluation at a transplant center after referral and waitlisting.

Results: Of the 33,651 patients with incident kidney failure, most received dialysis treatment at a for-profit facility (85%). For-profit (versus nonprofit) facilities had a lower cumulative incidence difference for referral within 1 year of dialysis (-4.5%; 95% confidence interval, -6.0% to -3.2%). In adjusted analyses, for-profit versus nonprofit facilities had lower referral (hazard ratio, 0.84; 95% confidence interval, 0.80 to 0.88). Start of evaluation within 6 months of referral (-1.0%; 95% confidence interval, -3.1% to 1.3%) and waitlisting within 6 months of evaluation (1.0%; 95% confidence interval, -1.2 to 3.3) did not meaningfully differ between groups.

Conclusions: Findings suggest lower access to referral among patients dialyzing in for-profit facilities in the Southeast United States, but no difference in starting the evaluation and waitlisting by facility profit status.

Keywords: United States Renal Data System; dialysis; end stage kidney disease; epidemiology and outcomes; kidney transplantation; transplantation.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Ambulatory Care Facilities / economics*
  • Cohort Studies
  • Female
  • Georgia
  • Humans
  • Kidney Failure, Chronic / surgery
  • Kidney Failure, Chronic / therapy*
  • Kidney Transplantation / statistics & numerical data*
  • Male
  • Middle Aged
  • North Carolina
  • Referral and Consultation / statistics & numerical data
  • Renal Dialysis*
  • Retrospective Studies
  • South Carolina
  • Time Factors
  • Young Adult