Children receiving maintenance dialysis have lower rates of pediatric transplant waitlisting and kidney transplantation at facilities that are for-profit rather than nonprofit, according to an analysis of data from the US Renal Data System.

Among 13,333 pediatric patients with end-stage kidney disease (ESKD) who initiated dialysis during 2000-2018, 3618 (27%) attended for-profit facilities, 7907 (59%) attended nonprofit facilities, and 1748 (13%) switched profit status.

Over a median 0.87 years of follow-up, the pediatric waitlisting rate was lower at profit than nonprofit facilities: 36.2 vs 49.8 per 100 person-years, Sandra Amaral, MD, MHS, of The Children’s Hospital of Philadelphia in Pennsylvania, and colleagues reported in JAMA. In adjusted analyses, children at profit vs nonprofit centers had a significant 21% lower rate of waitlisting.

Continue Reading

Over a median 1.52 years, the kidney transplantation rate (per 100 person-years) also was lower at profit than nonprofit facilities (21.5 vs 31.3), including living donor (7.6 vs 10.8) and particularly deceased donor (13.9 vs 20.4) transplantations. In adjusted analyses, pediatric patients treated at for-profit centers had a significant 29% lower likelihood of undergoing kidney transplantation compared with those treated at nonprofit facilities, the investigators reported.

The effect of profit vs nonprofit status on the likelihood of receiving a kidney transplant was most pronounced among patients aged 12-17 years. Patients in this age group treated at for-profit vs nonprofit facilities were 27% less likely to receive a transplant, in adjusted analyses. By comparison, children aged 6-11 and 0-5 years treated at for-profit facilities were 18% and 16% less likely to receive a transplant. Patients aged 12-17 years treated at for-profit vs nonprofit facilities also were less likely than those in the other groups to receive a living donor transplant.

“The association between profit status and longer time to waiting list registration and transplant, especially from deceased donors, raises concerns that pediatric patients with ESKD may be disadvantaged for transplant access when they receive care at profit facilities,” Dr Amaral’s team wrote. The investigators suggested that less transplant education and discussions occur at profit centers.

Pediatric kidney transplant waitlisting and transplantation rates were lowest at freestanding dialysis facilities compared with hospital settings, presumably because fewer pediatric nephrologists work at freestanding facilities, according to the investigators. By US region, the Northeast had the most pediatricians certified in pediatric nephrology.

In an accompanying editorial, Mary Leonard, MD, MSCE, and Paul Grimm, MD, of Stanford University School of Medicine in California, highlighted the tremendous cost of delayed pediatric kidney transplant waitlisting and surgery:

“The estimated life expectancy is 30 to 40 years greater in prevalent pediatric transplant recipients than in prevalent pediatric dialysis patients, highlighting the clinical significance of these differences.”

Of the pediatric cohort, 25% were Black. A previous study, published in the Journal of the American Society of Nephrology, concluded that excess mortality among Black pediatric patients can be reduced with kidney transplantation equity.


Amaral S, McCulloch CE, Lin F, et al. Association between dialysis facility ownership and access to the waiting list and transplant in pediatric patients with end-stage kidney disease in the US. JAMA 328(5):451-459. Published online August 2, 2022. doi:10.1001/jama.2022.11231

Leonard MB, Grimm PC. Improving quality of care and outcomes for pediatric patients with end-stage kidney disease: the importance of pediatric nephrology expertise. JAMA 328(5):427-429. Published online August 2, 2022. doi:10.1001/jama.2022.11603