Kids Treated at For-Profit Dialysis Centers Less Likely to Receive Transplant

Children receiving dialysis at a for-profit facility were less likely to be put on the waitlist for — and ultimately receive — a kidney transplant, according to a retrospective cohort study.

Among over 13,000 pediatric patients, those receiving dialysis at a profit center had a 21% lower chance of being put on the waitlist for a kidney versus those receiving care at nonprofit facilities (adjusted HR 0.79, 95% CI 0.75-0.83), reported Sandra Amaral, MD, MHS, of the Children’s Hospital of Philadelphia, and colleagues.

During a median 0.87-year follow-up, the incidence rate of being put on a waitlist was 36.2 per 100 person-years for profit facilities versus 49.8 per 100 person-years for nonprofit facilities, the group noted in JAMA.

Furthermore, once pediatric patients at profit facilities were able to nab a spot on the waitlist, there was still a far lower chance that they actually received the transplant (adjusted HR 0.71, 95% CI 0.67-0.74), with an incidence rate of 21.5 versus 31.3 per 100 person-years, respectively, over a median follow-up of 1.52 years.

In unadjusted analyses, Amaral’s group found that the HR of transplants from deceased donors was 0.62 (95% CI 0.58-0.65) when comparing patients receiving care at profit and nonprofit facilities, while the HR for transplants from a living donor was 0.71 (95% CI 0.66-0.77).

Older age groups also saw larger discrepancies when it came to profit status and receiving a transplant:

• Ages 0 to 5: HR 0.84 (95% CI 0.75-0.94)
• 6 to 11 years: HR 0.82 (95% CI 0.73-0.93)
• 12 to 17 years: HR 0.73 (95% CI 0.68-0.78)

Interestingly, wait-listing and kidney transplant rates were lower among both profit and nonprofit facilities that were free-standing, rather than based in a hospital system.

This finding in particular “is consistent with diminished access to pediatric interdisciplinary expertise in freestanding facilities,” noted Mary B. Leonard, MD, MSCE, and Paul C. Grimm, MD, both of Stanford University School of Medicine in California, in an accompanying editorial.

Amaral’s group pointed out that while these trends have also been seen in adults with end-stage kidney disease, one difference is that more pediatric patients tend to be treated at nonprofit centers, where more pediatric nephrologists practice. Here, only 27% of pediatric patients were treated at profit facilities versus 88% of adults in a prior study.

“The substantial association between nonprofit dialysis facility ownership and greater access to transplants among pediatric patients likely reflects greater clinician experience with the special needs of pediatric patients with [end-stage kidney disease] and their families, as well as more robust facility-level processes and structures needed to care for these vulnerable patients,” Leonard and Grimm wrote.

They pointed out that Amaral and colleagues failed to include data on a few relevant factors — socioeconomic status beyond insurance, familial support system, clinician expertise, and facility characteristics related to pediatric experience or proximity to a pediatric transplant center — which may have provided greater insight into the differences reported.

Amaral and team looked at 13,333 pediatric patients who initiated dialysis from 2000 to 2018. Median age was 12, 45% were female, and 25% were Black. The most common cause of end-stage kidney disease was glomerulonephritis, followed by “other” causes, urological causes, hypertension, diabetes, and cystic kidney disease.

More patients at profit centers received hemodialysis versus peritoneal dialysis, while modality was evenly split at nonprofit centers. In addition, more patients living in the Northeast received dialysis at nonprofit centers compared with other areas of the country.