Disparities in access to the kidney transplant wait list have been described for women, African Americans (AAs), and the elderly. However, few data are available regarding transplant referrals from outpatient dialysis facilities and the characteristics of patients who refuse such referrals.

Transplant referral information completed within 60 days of entry into the Wake Forest Outpatient Dialysis Program (WFOPD) was retrospectively reviewed starting in 2009. A total of 3845 dialysis patients treated in 16 outpatient facilities were evaluated. Standardized transplant ratios (STRs) for first transplant from 2010-2013 were >1.0 in 13 of 16 WFOPD facilities, and 4 of 16 facilities had higher than expected STRs. We identified 1393 individuals who refused transplant referral, compared with 2452 individuals who agreed to referral. Individuals who refused were older, with mean±SD age 71.1±12.7 years, compared with 61.4±16.1 years (p<0.0001). European Americans (EAs) were more likely to refuse referral (40%) than AAs (36%; p=0.003). Among race and gender groups, EA women (43.5%) were most likely to refuse referral compared with EA men (37.6%), AA women (35.9%), and AA men (36.2%), p=0.0018. Individuals with diabetes (DM) as cause of ESRD were more likely to refuse referral than those without DM as cause of ESRD (39% vs. 35%, p=0.01). Of the 2220 who consented to a transplant referral, 338 received a transplant, including 141 AAs (14%), 20 individuals of other ethnicities (27%), and 177 EAs (15.4%), p=0.01. Significant differences in frequency of transplant among gender or race/gender groups were not observed. Among individuals with DM as cause of ESRD, 12% received transplants, compared with 17% without DM as cause of ESRD, p=0.0009. Transplanted patients were younger, mean 52.8±16.5 vs. 62.9±15.6 years (p<0.0001) in the group consenting to evaluation but not receiving a transplant during the study.

In conclusion, we found significant differences in rates of patient refusal for transplant referral at a large, independent academically-owned dialysis program with a university-associated transplant center. We were encouraged to find that AAs were not more likely to refuse transplant referrals compared to EAs. Increased use of patient navigators in dialysis units may help educate patients and reduce current high rates of patient refusal for kidney transplantation.

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