A report on the research appears online in the American Journal of Transplantation.
“Transplantation is not for everyone, but it is important that every dialysis patient be assessed and informed about the risks and benefits of getting atransplant,” says study leader Dorry L. Segev, M.D., Ph.D., an associate professor of surgery at the Johns Hopkins University School of Medicine. “For many patients, transplant is a more effective, life-extending and less costly treatment modality than dialysis. But in order to be transplanted, you need to be referred by your dialysis center and in many cases that just isn’t happening.”
Older, obese, uninsured and Medicaid patients were also less likely to be given all of their options, the research showed, and overall, the uninformed were 53 percent less likely to be placed on a waiting list for a new organ or to receive a kidney from a living donor.
Mechanical cleansing of the bloodstream at dialysis centers becomes necessary when the kidneys can no longer filter the blood and rid the body of harmful waste and fluids. Many patients require dialysis hours a day for several days a week, treatment that can wreak havoc on quality of life. Kidney transplants, when successful, eliminate the need for dialysis.
For their study, Segev and his colleagues examined the Centers for Medicare and Medicaid Services Form 2728, recently modified to require reporting of transplant education in the hopes of encouraging physicians to at least evaluate and consider every patient for transplantation. On the form, nephrologists are asked if they informed patients about transplant options, and, if not, to select a reason. The team examined data collected by the United States Renal Data System and found that of the 236,079 adults in the United States who developed end-stage kidney disease between Jan. 1, 2005 and Sept. 24, 2007, more than 30 percent had not been informed about transplantation at the time the form was filled out. The primary reason, given by 42 percent of providers, was that they had not yet assessed whether the patient was even a candidate for transplant.
“Given long waiting times and high death rates on dialysis, a delay in kidney transplant education for appropriate candidates leads to later referral and likely worse outcomes,” says Lauren M. Kucirka, Sc.M., a Johns Hopkins epidemiologist who co-authored the study.
Patients at for-profit centers and those with Medicaid or no insurance were more likely to be unassessed, suggesting that financial pressures to keep patients on dialysis at the centers could be driving the disparity, Segev says. For-profit centers are also less likely to be affiliated with transplant hospitals, and many lack personnel trained specifically to conduct transplant education.
Because transplantation for those who qualify is the less costly therapy in the long run and leads to an improved quality of life, Segev says policy makers should consider ways to ensure that there are incentives for assessing all patients for possible transplant.
Other Johns Hopkins researchers involved in the study include Lauren M. Kucirka, Sc.M.; Morgan E. Grams, M.D., M.H.S.; Kamna S. Balhara, M.A.; and Bernard G. Jaar, M.D., M.P.H.
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