Access to Kidney Transplantation: Is There a Potential Conflict of Interest?

ESRD network for this research effort (Network 6), which covers the southeastern region of the United States and serves the states of North Carolina, South Carolina, and Georgia, has the lowest standardized transplant ratio of all networks in the country. Thus, this study specifically examines the network that regulates the dialysis centers that were least likely to refer their patients for transplantation. It is therefore not surprising that fewer than 25% of these facilities reported transplantation as their first option of consideration. This low transplantation referral rate is likely related to the fact that this region serves more African-Americans who may have less health insurance and more socioeconomic disadvantage, and they may be cared for by for-profit dialysis centers. The lower standardized transplant ratio in Network 6 may be less prevalent in other ESRD networks serving other demographic populations or may have more nonprofit dialysis facilities. Since profit depends, in part, on a larger number of patients in any center, it may not be surprising that dialysis staff who are paid by the centers, would be less likely to refer their patients for transplantation. Additionally, physician compensation for posttransplant care is far less than the capitated rate for supervising these patients on dialysis. Moreover, the time commitment for supervising immunosuppression and many of the medical comorbidities associated with posttransplantation care requires additional infrastructural Kidney transplantation has been demonstrated to be the optimal treatment for many, if not most, patients with end-stage renal disease (ESRD), providing both a better quality of life, as well as duration of life, compared to continuing dialysis as a method of treatment [1, 2] . However, there exists a vast difference with regards to referral for kidney transplantation and kidney transplantation rates in the United States [3–5] . In the study by Gander et al. [6] , it is quite evident that the dialysis facility transplant philosophy for referral varies considerably, and those dialysis centers whose staff have a more positive attitude toward transplantation demonstrate a much higher referral rate for kidney transplantation. Prior work by these same authors [7] has demonstrated that factors associated with a lower standardized transplant ratio in the United States ESRD networks include a for-profit status of the dialysis facility, facilities with a higher percentage of African American or diabetic patients, as well as patients with no health insurance. On the other hand, dialysis facilities with a larger number of staff, ESRD network regions with a higher number of transplant centers, as well as facilities with more patients who were employed, or on peritoneal dialysis had higher standardized transplant ratios. The observations of Gander et al. [6] , although important, must be tempered by the understanding that their Published online: August 6, 2015 Nephrology American Journal of