Pre-dialysis care and access type are associated with transplant referral, evaluation, and waitlisting

BACKGROUND: Suboptimal dialysis initiation is associated with adverse patient outcomes. Whether it is also associated with access to downstream transplant care is unknown. METHODS: Adults initiating dialysis treatment for kidney failure in the Southeast U.S., from 1/1/2015 to 12/31/2019 were identified from the United States Renal Data System, linked to the Early Steps to Transplant Access Registry, and followed through 12/31/2021. The primary exposure was pre-dialysis care and categorized as highly, moderately, minimally, or non-optimal based on presence of nephrology care, dialysis type (in-center or home hemodialysis, peritoneal dialysis), and vascular access vs. catheter. Primary outcomes were referral to a transplant center within 12-months of dialysis initiation and evaluation start at a transplant center within 6 months of first referral. Multivariable competing risk models quantified the association between pre-dialysis care context and referral and evaluation. RESULTS: Among 49,057 patients initiating dialysis, 28.8%, 15.5%, 31.0%, and 24.8% are highly, moderately, minimally, and non-optimal start, respectively. Patients initiating dialysis in moderately, minimally, and non-optimal ways are 28% (adjusted hazard ratio: 0.72, [95% CI: 0.69 - 0.72], 31% (0.69, [0.66 - 0.71], and 57% (0.43, [0.41 - 0.44]) less likely to be referred as compared with highly optimal starters. Those who had a non-optimal start are also 37% less likely to start the evaluation after being referred (0.63, [0.59 - 0.66]) as compared with highly optimal dialysis starters, while all other groups have a similar likelihood. CONCLUSIONS: More than half of U.S. adults with kidney failure initiate dialysis in a minimal or non-optimal way leading to reduced likelihood of transplant referral and evaluation.