Why Nephrologists Exclude Patients from Referral for Kidney Transplant: A Survey

A recent anonymous survey among nephrologists suggests that patients' social support, ability to understand the transplant process, and age are the most important factors influencing nephrologists' decisions to exclude them from kidney transplant referral. Practice location and makeup and general patient population characteristics drive the provider's perceptions about the importance of these reasons.

Ankita Tandon, MD, resident physician in the Department of Medicine of Pennsylvania State University College of Medicine in Hershey, PA, and colleagues reported their findings at Kidney Week 2013, the American Society of Nephrology's annual meeting in Atlanta, GA, on November 9, 2013.

The researchers acknowledged that how suitable the providers perceive their patients to be for kidney transplant may contribute significantly to disparities in who receives kidneys. In the survey, they examined how nephrologists perceive the factors they consider to be important when deciding against referring patients for transplant, and they analyzed the associations between these perceptions and nephrologists’ demographic and practice characteristics.

They sent invitations to take part in the survey to 3,180 nephrologists in the mid-Atlantic and southeast United States. Of the 822 who were willing to participate and whose practices included 20 or more end-stage renal disease patients, the authors randomly invited 250 to complete a questionnaire about demographics, practice characteristics, and their perceptions of the importance of various reasons nephrologists might give for declining to refer a patient for kidney transplant. They performed chi-square and stepwise logistic regression on the 216 complete responses they received. Variables included age, gender, race, location, distance to transplant center, number of transplant centers within a 50 mile radius, transplant training, attendance at national meetings, and patients who have completed high school.

They found that the three most common reasons the nephrologists regarded as important for excluding patients were “patient’s inadequate social support” (70% of respondents), “limited understanding of the transplant process due to patient's inadequate education” (56%), and “patient's age above 65” (53%). Physicians with 2 or fewer transplant centers within a 50 mile radius were more likely to exclude patients due to inadequate social support (OR: 3.15; p=0.001) and age greater than 65 years (1.88; p=0.04).

Nephrologists whose majority of patients did not complete high school were more likely to consider “limited understanding due to patient's education” (OR: 3.31; 95% CI: 1.60-6.86; p=0.001) important.

Other reasons for non-referral included “extent of the pre-transplant workup” (25%); “patient is not yet on dialysis” (22%); “limited clinical and administrative support” (20%); “financial disincentive to provide care to post-transplant patients” (15%); “complexities of caring for the post-transplant patient” (13%); “scarcity of transplant centers in the area” (13%); and “concern that the transplant center may take over patients’ care” (12%).

Demographics of the participating nephrologists included that their average age was 44 years and that they followed more than 50 patients with end-stage renal disease (74.5%); practiced in an urban setting (70.4%); practiced in an academic center (56.5%); practiced in groups of more than 10 nephrologists (23.6%); were female (15%); and (9.7%) were transplant nephrologists.