Among patients receiving dialysis in the Southeastern United States, those at for-profit dialysis facilities may be less likely to be referred for kidney transplantation than those at non-profit facilities, according to a new study published in Clinical Journal of the American Society of Nephrology. The findings suggest there is an urgent need for national surveillance data on transplant referral and evaluation.  

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 data exist, however, on the earlier steps in the process, such as referrals and medical evaluations.

“The main strength of the study is that it is the first study to look at for-profit status of a facility and transplant referral and evaluation start, as these 2 steps of the transplant process are not measured in national surveillance data,” said study investigator Laura McPherson, MPH, a PhD student in epidemiology at Emory University’s Rollins School of Public Health in Atlanta, Georgia. “This provides a more detailed look at where attrition is occurring in the steps to transplant.”

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The researchers examined referral and evaluation data from all 9 transplant centers in Georgia, North Carolina, and South Carolina as well as information from the US Renal Data System. The analysis included 33,651 patients who initiated dialysis in the Southeast from 2012 to 2016. In this study, 85% of patients received dialysis treatments at for-profit facilities and 15% at non-profit facilities. Patients had a mean age of 60 years, and 55% were male. There were no significant differences between for-profit and non-profit in terms of age, sex, or race/ethnicity. Patients treated at non-profit facilities had significantly higher proportions of all 11 assessed comorbidities with the exception of body mass index compared with those treated at for-profit facilities.

A high proportion of kidney failure cases were attributed to hypertension at for-profit facilities compared with non-profit facilities (38% vs. 33%). Those treated at for-profit facilities were more likely to have employer-based insurance (18% vs 15%), and Medicaid (25% vs 24%). More patients at non-profit facilities lacked coverage at kidney failure start (12% vs 10%).

Of the 33,651 patients, 14,729 (44%) were referred for a kidney 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, McPherson’s team reported. Rates of starting medical evaluations within 6 months of referral and placing patients on a waitlist within 6 months of evaluations were similar in both groups. The median time from dialysis initiation to referral was 4.4 months, with a significantly longer median time to referral for patients treated at for-profit (4.6 months) compared with non-profit facilities (3.8 months).

“It is unclear whether this means that for-profit facilities are doing a better job of selecting more appropriate candidates for transplantation, or if they are missing some patients that should have been referred but were not,” McPherson said.

It is possible the differences found in this study may be due to the patients’ health status, which was not included in this dataset, or other unmeasured factors such as unconscious bias. “One surprising finding in our study was that while we found that referral was lower among for-profit facilities, the rate of wait listing was not significantly lower,” McPherson said. 

The investigators found no differences in the numbers of patients educated about transplant as a treatment option when they compared profit and non-profit dialysis facilities. “These results do shed some light on the steps prior to wait listing and suggest a need to consider the nuances of each step in the transplant process before making a conclusion that for-profit dialysis facilities are inappropriately managing patients with respect to transplant access,” McPherson said.

She and her colleagues acknowledged that their findings are not generalizable to other areas outside of the Southeast. The study potentially missed information about referrals that may occur outside of the three states. For example, less than 10% of referrals are estimated to occur to transplant centers outside of the Southeast region. If for-profit facilities have a higher proportion of referrals outside of the region, this could partially explain why referrals are lower among for-profit compared with non-profit facilities.

“We need to really understand barriers to transplant access and to inform health system interventions to improve equity in transplant access. It is concerning that there are lower rates of referral among for-profit facilities, and we need better data to understand why this is occurring,” McPherson said.

In an accompanying editorial, Diya Raghavan, MD, and Isaac E. Hall, MD, of the University of Utah School of Medicine in Salt Lake City, noted that the early steps in transplant access remain frustratingly opaque. Much greater attention may be warranted to address long-standing disparities and ensure equity in treatment options for all patients with kidney failure, according to the authors. Even though causation cannot be established by this observational study, “there appears to be at least some cause for concern that for-profit facilities may be incentivized to aggressively control costs and maintain dialysis patient volumes to maximize financial returns to investors,” Drs Raghavan and Hall wrote.

Matthew B. Rivara, MD, an assistant professor of medicine in the Division of Nephrology at the University of Washington in Seattle, said while there is concern about profit status affecting referrals, these new data do not support the argument that for-profits are trying to maximize financial returns.

“The number of for-profit facilities compared with non-profit facilities varies significantly in some parts of the country. What is occurring in the Southeastern part of the country may be significantly different from other regions in terms of referrals,” Dr Rivara said. “The majority of dialysis centers in Seattle are non-profit. Other cities have a majority of for-profit [facilities],” Dr Rivara said. “You may not find the same thing if you studied referral rates in the Pacific Northwest or East Coast.”

Prospective studies are warranted to look at the factors influencing referral. “Something not covered in this article is who is the person making the transplant referral. I think one of the things that needs to be understood is what factors affect nephrologists’ referral patterns. Some nephrologists may not have implemented early transplant referral as part of their practice,” Dr Rivara said.


McPherson LJ, Walker ER, Hana Lee YT et al. Dialysis facility profit status and early steps in kidney transplantation in the Southeastern United StatesClin J Am Soc Nephrol. Published online May 26, 2021. doi:10.2215/CJN.17691120

Raghavan D, Hall IE. Dialysis and transplant access: Kidney capitalism at a crossroads? Clin J Am Soc Nephrol. Published online May 26, 2021. doi:10.2215/CJN.04680421