Individual and center level determinants of progression from kidney transplant referral to kidney transplantation in the United States: A national EHR study

Purpose: Most patients with kidney failure never receive a kidney transplant (KT). We study barriers to KT among patients referred for KT using Epic Cosmos, a national electronic health record database.
Methods: Using Cosmos patients referred for KT 2014-2024, we assessed the stage-specific progression and attrition in the process of evaluation, waitlisting, and kidney transplantation. Center-level and individual (socioeconomic, geographic, and insurance status) factors associated with access to evaluation, waitlisting, and KT were characterized using modified Poisson regression.
Results: Among 415,505 referred candidates median age 58 years [IQR: 48, 67] at 87 transplant centers participating in Epic Cosmos, 43% of patients were white and 60% were male. Only 56% of referred candidates were evaluated, 27% were waitlisted, and 14% were ultimately transplanted (Figure 1). Among patients who were evaluated, median (IQR) time was 1.8 (0.9-3.3) months post-referral; among patients who were waitlisted, median (IQR) time was 4.2 (1.8-8.0) months after the beginning of evaluation. Patients who were Black (RR= 0.73; 95% CI, 0.71-0.75; P < .001), never married (0.60; 95% CI, 0.59-0.62; P < .001), or obese (0.93; 95% CI, 0.90-0.95; P < .001) were less likely to be evaluated. Very low relative rates (<0.7 times national average) of evaluation and waitlisting, respectively, were observed at 9% of transplant centers (evaluation), and 6% of transplant centers (waitlisting) (Figure 2). Low-volume centers had lower relative rates of evaluation initiation (0.86; 95% CI 0.73-0.99; P = .048) and waitlisting (0.86; 95% CI 0.74-0.97, P = .02). Candidates referred in the Northeast had a higher relative rate of evaluation initiation than the South (1.20; 95% CI 0.99-1.40; P = .04).
Conclusions: Our study shows substantial attrition before patients reach the KT waitlist, especially between the referral and evaluation stages. Interventions that reduce barriers to transplant evaluation among referred patients may increase access to transplantation for patients with kidney disease.