Variation in kidney transplant referral, living donor contacts, waitlisting, and kidney transplant across regional renal programs in Ontario, Canada: a population-based cohort study

Background — Previous studies conducted in publicly and privately funded health care systems suggest that access to kidney transplants may vary depending on where a patient receives their kidney care. It is poorly understood whether variability exists across the key steps required to receive a kidney transplant in a publicly funded health care system.

Objective — To determine whether there is variation across Ontario’s regional renal programs (RRPs) in key steps completed toward receiving a kidney transplant.

Design — Population-based cohort study from November 1, 2017, to December 31, 2021, using linked administrative health care databases with a maximum follow-up of March 31, 2023.

Setting — This study includes 27 RRPs and independent health facilities in Ontario, Canada.

Patients — Patients approaching the need for dialysis and patients receiving maintenance dialysis with no recorded contraindication to kidney transplant.

Measurements — Key steps toward receiving a kidney transplant, including (1) referred to a transplant center for an evaluation; (2) had a potential living donor contact a transplant center to be evaluated; (3) deceased donor waitlist activation; and (4) received a transplant from a living or deceased donor.

Methods — For each step toward receiving a kidney transplant, we reported a unique incidence rate per 100 person-years with a 95% confidence interval (95% CI), presented by Ontario’s RRPs, including the 27 RRPs and independent health facilities. We also presented results by 5 Ontario geographic regions. In an additional analysis, we examined the time to complete specific transplant steps.

Results — We included 8319 individuals approaching the need for dialysis and 4869 individuals receiving maintenance dialysis. During follow-up, 2870 (34.5%) individuals approaching the need for dialysis initiated maintenance dialysis. In individuals approaching the need for dialysis, we found the rate of a potential living kidney donor contacting a transplant center to be evaluated varied more than 17-fold across RRPs from 0.67 (95% CI = 0.1, 4.8) to 11.7 (95% CI = 9.2, 14.9). In the dialysis cohort, the average number of steps completed toward receiving a kidney transplant varied almost 4-fold across RRPs from 11.7 (95% CI = 9.3, 14.8) to 44.0 (95% CI = 38.6, 50.1) steps per 100 person-years. The average rate of each step measured separately also varied widely, with the rate of referral to a transplant center for an evaluation (per 100 person-years) varying across RRPs from 6.0 (95% CI = 4.2, 8.5) to 47.9 (95% CI = 42.6, 53.8), the rate of a potential living kidney donor contacting a transplant center to be evaluated from 1.5 (95% CI = 0.78, 2.9) to 10.7 (95% CI = 7.9, 14.5), the rate of deceased donor waitlisting from 2.9 (95% CI = 1.9, 4.4) to 13.2 (95% CI = 11.0, 15.8), and the rate of kidney transplant from 2.0 (95% CI = 1.1, 3.4) to 12.6 (95% CI = 10.8, 14.8). When examining the results by 5 Ontario geographic regions, we found patients receiving maintenance dialysis in Northern Ontario had substantially lower rates of completing key steps toward receiving a kidney transplant. For example, the rate of transplant referral (per 100 person-years) was almost 3-fold lower in Northern Ontario (10.0, 95% CI = 8.3, 12.0) compared to Toronto (28.7, 95% CI = 25.7, 32.1).

Limitations — We did not examine the reason for differences in access to kidney transplant across RRPs (eg, differences in physician practices and staff-to-patient ratio).

Conclusions — Despite operating in a publicly funded health care system, there is substantial variability across the 4 key steps required to receive a kidney transplant.