Yohanna Seychelle, Naylor Kyla L, Luo Bin, Dixon Stephanie N, Bota Sarah E, Kim S Joseph, Blake Peter G, Elliott Lori, Cooper Rebecca, Knoll Gregory A, Treleaven Darin, Wang Carol, Garg Amit X
Division of Nephrology, McMaster University, Hamilton, ON, Canada.
ICES, London, ON, Canada.
Can J Kidney Health Dis. 2023 Jun 14;10:20543581231169608. doi: 10.1177/20543581231169608. eCollection 2023.
Eligible patients with kidney failure should have equal access to kidney transplantation. Transplant referral is the first crucial step toward receiving a kidney transplant; however, studies suggest substantial variation in the rate of kidney transplant referral across regions. The province of Ontario, Canada, has a public, single-payer health care system with 27 regional chronic kidney disease (CKD) programs. The probability of being referred for kidney transplant may not be equal across CKD programs.
To determine whether there is variability in kidney transplant referral rates across Ontario's CKD programs.
Population-based cohort study using linked administrative health care databases from January 1, 2013, to November 1, 2016.
Twenty-seven regional CKD programs in the province of Ontario, Canada.
Patients approaching the need for dialysis (advanced CKD) and patients receiving maintenance dialysis (maximum follow-up: November 1, 2017).
Kidney transplant referral.
We calculated the 1-year unadjusted cumulative probability of kidney transplant referral for Ontario's 27 CKD programs using the complement of Kaplan-Meier estimator. We calculated standardized referral ratios (SRRs) for each CKD program, using expected referrals from a 2-staged Cox proportional hazards model, adjusting for patient characteristics in the first stage. Standardized referral ratios with a value less than 1 were below the provincial average (maximum possible follow-up of 4 years 10 months). In an additional analysis, we grouped CKD programs according to 5 geographic regions.
Among 8641 patients with advanced CKD, the 1-year cumulative probability of kidney transplant referral ranged from 0.9% (95% confidence interval [CI]: 0.2%-3.7%) to 21.0% (95% CI: 17.5%-25.2%) across the 27 CKD programs. The adjusted SRR ranged from 0.2 (95% CI: 0.1-0.4) to 4.2 (95% CI: 2.1-7.5). Among 6852 patients receiving maintenance dialysis, the 1-year cumulative probability of transplant referral ranged from 6.4% (95% CI: 4.0%-10.2%) to 34.5% (95% CI: 29.5%-40.1%) across CKD programs. The adjusted SRR ranged from 0.2 (95% CI: 0.1-0.3) to 1.8 (95% CI: 1.6-2.1). When we grouped CKD programs according to geographic region, we found that patients residing in Northern regions had a substantially lower 1-year cumulative probability of transplant referral.
Our cumulative probability estimates only captured referrals within the first year of advanced CKD or maintenance dialysis initiation.
There is marked variability in the probability of kidney transplant referral across CKD programs operating in a publicly funded health care system.
符合条件的肾衰竭患者应能平等地获得肾移植机会。移植转诊是接受肾移植的关键第一步；然而，研究表明各地区的肾移植转诊率存在很大差异。加拿大安大略省拥有一个公共的单一支付者医疗保健系统，设有27个地区慢性肾脏病（CKD）项目。在这些CKD项目中，被转诊进行肾移植的概率可能并不相等。
确定安大略省各CKD项目的肾移植转诊率是否存在差异。
基于人群的队列研究，使用2013年1月1日至2016年11月1日期间相链接的行政医疗保健数据库。
加拿大安大略省的27个地区CKD项目。
接近需要透析的患者（晚期CKD）以及接受维持性透析的患者（最长随访时间：2017年11月1日）。
肾移植转诊。
我们使用Kaplan-Meier估计值的互补值计算了安大略省27个CKD项目的1年未调整肾移植转诊累积概率。我们使用两阶段Cox比例风险模型的预期转诊数为每个CKD项目计算标准化转诊率（SRR），在第一阶段对患者特征进行了调整。标准化转诊率小于1表示低于省级平均水平（最长可能随访时间为4年10个月）。在另一项分析中，我们根据5个地理区域对CKD项目进行了分组。
在8641例晚期CKD患者中，27个CKD项目的1年肾移植转诊累积概率范围为0.9%（95%置信区间[CI]：0.2%-3.7%）至21.0%（95%CI：17.5%-25.2%）。调整后的SRR范围为0.2（95%CI：0.1-0.4）至4.2（95%CI：2.1-7.5）。在6852例接受维持性透析的患者中，各CKD项目的1年移植转诊累积概率范围为6.4%（95%CI：4.0%-10.2%）至34.5%（95%CI：29.5%-40.1%）。调整后的SRR范围为0.2（95%CI：0.1-0.3）至1.8（95%CI：1.6-2.1）。当我们根据地理区域对CKD项目进行分组时，我们发现居住在北部地区的患者1年移植转诊累积概率显著较低。
我们的累积概率估计仅涵盖了晚期CKD或维持性透析开始后第一年内的转诊情况。
在公共资助的医疗保健系统中运作的各CKD项目，其肾移植转诊概率存在显著差异。
