美国凯撒医疗集团、埃默里大学等机构的医学专家探讨了透析机构所有权与肾移植机会之间的关系。2019年9月10日，国际知名医学期刊《美国医学会杂志》发表了这一成果。

营利性透析机构与非营利性机构相比，其肾移植率一直较低，目前尚不清楚活体供肾和死者供肾移植的机会是否因机构所有权不同而有所不同。

这项回顾性队列研究分析了美国肾脏数据系统2000-2016年间的数据，包括在6511家美国透析机构进行治疗的1478564名患者，他们的中位年龄为66岁，男性占55.3％，28.1％为非西班牙裔黑人。

共有87%的患者在营利性透析机构接受治疗。其中109030名患者（7.4%）在435家非营利性小型连锁机构接受治疗，78287名（5.3%）在324家非营利性独立机构接受治疗，96677名（65.3%）在4321家大型营利性连锁机构进行治疗，225890名（15.3%）在997家营利性小型连锁机构接受治疗，98680名（6.7%）在434家营利性独立机构接受治疗。

在研究期间，121680名患者（8.2％）进入已故捐献者等候名单，23762名患者（1.6％）接受了活体捐献肾脏移植，49290名患者（3.3％）接受了已故捐献肾脏移植。营利性透析机构5年中进入已故捐赠者名单、接受活体供肾移植和接受死者供肾移植的患者所占比率均显著低于非营利性机构。

总之，对于美国终末期肾病患者，与非营利性机构相比，在营利性机构进行透析的患者获得肾移植的可能性较低。作者表示，仍需进一步研究以了解这种关联背后的机制。

附：英文原文

Title: Association Between Dialysis Facility Ownership and Access to Kidney Transplantation

Author: Jennifer C. Gander, Xingyu Zhang, Katherine Ross, Adam S. Wilk, Laura McPherson, Teri Browne, Stephen O. Pastan, Elizabeth Walker, Zhensheng Wang, Rachel E. Patzer

Issue&Volume: Vol 322 No 10

Abstract: 

Importance  For-profit (vs nonprofit) dialysis facilities have historically had lower kidney transplantation rates, but it is unknown if the pattern holds for living donor and deceased donor kidney transplantation, varies by facility ownership, or has persisted over time in a nationally representative population.

Objective  To determine the association between dialysis facility ownership and placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant.

Design, Setting, and Participants  Retrospective cohort study that included 1?478?564 patients treated at 6511 US dialysis facilities. Adult patients with incident end-stage kidney disease from the US Renal Data System (2000-2016) were linked with facility ownership (Dialysis Facility Compare) and characteristics (Dialysis Facility Report).

Exposures  The primary exposure was dialysis facility ownership, which was categorized as nonprofit small chains, nonprofit independent facilities, for-profit large chains (>1000 facilities), for-profit small chains (<1000 facilities), and for-profit independent facilities.

Main Outcomes and Measures  Access to kidney transplantation was defined as time from initiation of dialysis to placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant. Cumulative incidence differences and multivariable Cox models assessed the association between dialysis facility ownership and each outcome.

Results  Among 1?478?564 patients, the median age was 66 years (interquartile range, 55-76 years), with 55.3% male, and 28.1% non-Hispanic black patients. Eighty-seven percent of patients received care at a for-profit dialysis facility. A total of 109?030 patients (7.4%) received care at 435 nonprofit small chain facilities; 78?287 (5.3%) at 324 nonprofit independent facilities; 483?988 (32.7%) at 2239 facilities of large for-profit chain 1; 482?689 (32.6%) at 2082 facilities of large for-profit chain 2; 225?890 (15.3%) at 997 for-profit small chain facilities; and 98?680 (6.7%) at 434 for-profit independent facilities. During the study period, 121?680 patients (8.2%) were placed on the deceased donor waiting list, 23?762 (1.6%) received a living donor kidney transplant, and 49?290 (3.3%) received a deceased donor kidney transplant. For-profit facilities had lower 5-year cumulative incidence differences for each outcome vs nonprofit facilities (deceased donor waiting list: −13.2% [95% CI, −13.4% to −13.0%]; receipt of a living donor kidney transplant: −2.3% [95% CI, −2.4% to −2.3%]; and receipt of a deceased donor kidney transplant: −4.3% [95% CI, −4.4% to −4.2%]). Adjusted Cox analyses showed lower relative rates for each outcome among patients treated at all for-profit vs all nonprofit dialysis facilities: deceased donor waiting list (hazard ratio [HR], 0.36 [95% CI, 0.35 to 0.36]); receipt of a living donor kidney transplant (HR, 0.52 [95% CI, 0.51 to 0.54]); and receipt of a deceased donor kidney transplant (HR, 0.44 [95% CI, 0.44 to 0.45]).

Conclusions and Relevance  Among US patients with end-stage kidney disease, receiving dialysis at for-profit facilities compared with nonprofit facilities was associated with a lower likelihood of accessing kidney transplantation. Further research is needed to understand the mechanisms behind this association.

DOI: 10.1001/jama.2019.12803

Source: https://jamanetwork.com/journals/jama/article-abstract/2749598