Background: There is wide variation in referral for kidney transplant and preemptive kidney transplant (PKT). Patient characteristics such as age, race, sex and geographic location have been cited as contributing factors to this disparity. We hypothesize that the characteristics of nephrologists interplay with the patients' characteristics to influence the referral decision. In this study, we used hypothetical case scenarios to assess nephrologists' decisions regarding transplant referral. Methods: A total of 3180 nephrologists were invited to participate. Among those interested, 252 were randomly selected to receive a survey in which nephrologistswere asked whether they would recommendtransplant for the 25 hypothetical patients. Logistic regression models with single covariates and multiple covariates were used to identify patient characteristics associated with likelihood of being referred for transplant and to identify nephrologists' characteristics associated with likelihood of referring for transplant. Results: Of the 252 potential participants, 216 completed the survey. A nephrologist's affiliation with an academic institution was associated with a higher likelihood of referral, and being '>10 years fromfellowship'was associated with lower likelihood of referring patients for transplant. Patient age <50 years was associated with higher likelihood of referral. Rural location and smoking history/chronic obstructive pulmonary diseasewere associated with lower likelihood of being referred for transplant. The nephrologist's affiliation with an academic institution was associated with higher likelihood of referring for preemptive transplant, and the patient having a rural residence was associated with lower likelihood of being referred for preemptive transplant. Conclusions: The variability in transplant referral is related to patients' age and geographic location as well as the nephrologists' affiliation with an academic institution and time since completion of training. Future educational interventions should emphasize the benefits of kidney transplant and PKT for all population groups regardless of geographic location and age and should target nephrologists in non-academic settings who are 10 or more years from their fellowship training.
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