Most patients with end-stage kidney disease (ESKD) who are on dialysis will need to be referred from a dialysis facility to a kidney transplant center for a medical evaluation to potentially begin the transplant process. Currently, the United States has slightly more than 250 adult transplant centers, but there are well over 7,000 dialysis facilities throughout the country. As such, transplant centers may be less accessible to referred dialysis patients. Studies have suggested the average one-way driving distance from a patient’s home to the nearest dialysis facility is about 8 miles, but the mean distance between a transplant patient’s home and the nearest transplant center is 23 miles.

“In previous literature, patients and nephrologists—particularly in rural locations—viewed distance and access to transportation as a barrier to kidney transplant,” explains Laura J. McPherson, MPH. “However, the early steps in the kidney transplant process, like referral and initiation of an evaluation at a transplant center, are not routinely studied because they are not currently collected in national surveillance data.”

Taking a Closer Look

For a study published in the Clinical Journal of the American Society of Nephrology, McPherson and colleagues assessed the association of distance to transplant center with timely transplant center referral and evaluation initiation among patients with ESKD in the southeastern United States, a region that has historically had the lowest transplant rates in the U.S. The authors identified more than 27,000 adults who began treatment for ESKD at any Georgia, North Carolina, or South Carolina dialysis facility and assessed the impact of distance from the patient’s residential zip code to the nearest transplant center.

According to the results, investigators did not find an association between distance from a patient’s residential zip code to the nearest transplant and referral for kidney transplant evaluation or evaluation initiation at a transplant center (Table). “However, our results suggested that distance to a transplant center may be a barrier for a subset of patients living more than 90 miles from the nearest transplant center in this region of the country,” says McPherson.

In addition, the study examined associations among patient subgroups that may be more vulnerable to traveling far distances to a transplant center. “We still did not find an association between distance and access to early steps in the transplant process when we considered specific factors like race/ethnicity, socioeconomic status, neighborhood poverty, or urban/rural residential location,” McPherson says.

Assessing Implications

Based on the findings, distance to the nearest transplant center does not appear to be the primary driving force in accessing kidney transplant in the southeastern U.S., according to McPherson. “Patients who live the farthest away from the nearest transplant center—those more than 90 miles away and/or from rural areas—may benefit from additional transplant-center associated satellite clinic locations or a more streamlined evaluation process that reduces the number of visits patients need to make to a center to complete the evaluation,” she says. “Other factors in the same genre as distance, like travel time or lack of transportation, may have a larger impact on these early steps in the kidney transplant process.”

McPherson says their analysis was limited to dialysis patients in Georgia, North Carolina, and South Carolina because referral and evaluation initiation data is currently only available in that region. “Our research team is currently working to collect these data in the Northeast and Ohio River Valley,” she says. “We also intend to examine if there is homogeneity in our results in the southeastern U.S. across other geographic regions. In addition, we need studies to explore the role of other factors, including travel time, public transportation availability, or inability to find a caretaker for children or elderly relatives, to better understand geographic-based factors that can impact access to these early steps in the kidney transplant process.”

References

McPherson LJ, Barry V, Yackley J, et al; Southeastern Kidney Transplant Coalition. Distance to kidney transplant center and access to early steps in the kidney transplantation process in the southeastern United States. Clin J Am Soc Nephrol. 2020 Mar 24 [Epub ahead of print]. Available at: https://cjasn.asnjournals.org/content/early/2020/03/23/CJN.08530719?rss=1.

Patzer RE, McPherson L, Wang Z, et al. Dialysis facility referral and start of evaluation for kidney transplantation among patients treated with dialysis in the Southeastern United States. Am J Transplant. 2020 Jan 25 [Epub ahead of print]. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/ajt.15791.

Patzer RE, Plantinga LC, Paul S, et al. Variation in dialysis facility referral for kidney transplantation among patients with end-stage renal disease in Georgia. JAMA. 2015;314:582-594.

Patzer RE, Gander J, Sauls L, et al; Southeastern Kidney Transplant Coalition. The RaDIANT community study protocol: Community-based participatory research for reducing disparities in access to kidney transplantation. BMC Nephrol. 2014;15: 171.

Stephens JM, Brotherton S, Dunning SC, et al. Geographic disparities in patient travel for dialysis in the United States. J Rural Health. 2013;29:339-348.