News Release

Lower rates of kidney transplant referrals at for- vs. non-profit dialysis facilities

Additional research is needed to uncover the reasons for this disparity

Peer-Reviewed Publication

American Society of Nephrology


  • Among patients receiving dialysis in the Southeastern United States, those at for-profit dialysis facilities were less likely to be referred for kidney transplantation than those at non-profit facilities.
  • Rates of starting medical evaluations soon after referral and placing patients on a waitlist after evaluations were similar between the groups.

Washington, DC (May 26, 2021) -- New research indicates that patients with kidney failure who receive care at for-profit dialysis facilities are less likely to be referred for kidney transplants that those receiving care at non-profit facilities. The findings will appear in an upcoming issue of CJASN.

Kidney transplantation is the optimal therapy for most patients with kidney failure. Many patients first initiate dialysis and are referred for a transplant by kidney specialists through dialysis facilities. Previous studies have reported that patients treated at for-profit dialysis facilities are less likely than those treated at non-profit facilities to be placed on a transplant waitlist and to receive a transplant. Little information is available concerning earlier steps in the process, however--namely, referrals and medical evaluations for transplantation.

To investigate, a team led by Rachel E. Patzer, PhD and Laura J. McPherson, MPH (Emory University) examined referral and evaluation data from all 9 transplant centers in the Southeastern United States (Georgia, North Carolina, and South Carolina), as well as information from the United States Renal Data System.

The analysis included 33,651 patients with kidney failure who initiated dialysis in the Southeast from 2012 to 2016. Eighty-five percent of patients received dialysis treatments at for-profit facilities, and 15% were treated at non-profit facilities. A total of 44% of patients were referred for transplant during the 4-year study period. After adjustments, patients at for-profit facilities were 16% less likely to receive a referral than patients at non-profit facilities. Rates of starting medical evaluations within 6 months of referral and placing patients on a waitlist within 6 months of evaluations did not meaningfully differ between the groups.

"Our study offers insight into the practice patterns related to referral for transplantation, start of the transplant evaluation at the transplant center, and placement on the national deceased donor waiting list, but our study does not have detailed information about the mechanisms and reasons for these differences in referral between for profit and non-profit facilities," said Dr. Patzer. "The reasons for these differences in referral could be due to differences in patients' health status that are not measured in our dataset, or they could be due to other unmeasured factors such as limited time to educate or refer patients for transplant, or unconscious bias. Future research is still needed to better understand these mechanisms, such as through focus groups and interviews with patients and care provider team members."

An accompanying editorial notes that "the early steps in transplant access remain frustratingly opaque, indicating the ongoing need to address long-standing disparities and ensure equity in treatment options for patients with kidney failure."


Study co-authors include Elizabeth R. Walker, MD, Yi-Ting Hana Lee, MPH, Jennifer C. Gander, PhD, Zhensheng Wang, PhD, Amber M. Reeves-Daniel, DO, Teri Browne, PhD, Matthew J. Ellis, MD, Ana P. Rossi, MD, and Stephen O. Pastan, MD.

Disclosures: The authors reported no financial disclosures.

The article, titled "Dialysis Facility Profit Status and Early Steps in Kidney Transplantation in the Southeastern United States," will appear online at on May 26, 2021, doi: 10.2215/CJN.17691120.

The editorial, titled "Dialysis and transplant access: Kidney capitalism at a crossroads?" will appear online at on May 26, 2021, doi: 10.2215/CJN.04680421.

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