Neighborhood Poverty and Racial Disparities in Kidney Transplant Waitlisting

Abstract

Racial disparities persist in the United States renal transplantation process. Previous studies suggest that the distance between a patient's residence and the transplant facility may associate with disparities in transplant waitlisting. We examined this possibility in a cohort study using data for incident, adult ESRD patients (1998 to 2002) from the ESRD Network 6, which includes Georgia, North Carolina, and South Carolina. We linked data with the United Network for Organ Sharing (UNOS) transplant registry through 2005 and with the 2000 U.S. Census geographic data. Of the 35,346 subjects included in the analysis, 12% were waitlisted, 57% were black, 50% were men, 20% were impoverished, 45% had diabetes as the primary etiology of ESRD, and 73% had two or more comorbidities. The median distance from patient residence to the nearest transplant center was 48 mi. After controlling for multiple covariates, distance from patient residence to transplant center did not predict placement on the transplant waitlist. In contrast, race, neighborhood poverty, gender, age, diabetes, hypertension, body mass index, albumin, and the use of erythropoietin at dialysis initiation was associated with waitlisting. As neighborhood poverty increased, the likelihood of waitlisting decreased for blacks compared with whites in each poverty category; in the poorest neighborhoods, blacks were 57% less likely to be waitlisted than whites. This study suggests that improving the allocation of kidneys may require a focus on poor communities.

Racial Ethnic Differences in Rates and Determinants of Deceased Donor Kidney Transplantation

“…11,32,33 The U.S. Census defines a "poverty area" as an area where at least 20% of residents are poor. 37 We further included a variable corresponding to the percentage of linguistically isolated households in each patient's zip code of residence (Ͻ1, 1 to 4, 5 to 9, 10 to 19, or Ն20% of the population).…”

“…5,9 -12 Most prior studies identifying determinants of low rates of waitlisting and deceased donor transplantation after waitlisting have been limited primarily to black Americans. 2,6,9,11,13,14 Relatively few U.S.-based studies have examined determinants of delayed transplantation among patients of other racial ethnic minority groups. 5,10,12 In addition, it is difficult to compare transplantrelated outcomes such as access to the waitlist and movement up the waitlist across racial ethnic groups because studies have not consistently reported results for discrete steps along the path to transplantation.…”

Impact of a Patient Education Program on Disparities in Kidney Transplant Evaluation

“…Despite strong evidence for improved quality of life and survival after transplantation, there is a large gap between the number of patients who need a kidney transplant and the number of available organs (2). Racial disparities in access to kidney transplantation have been documented in several steps in the renal transplant process, including referral, evaluation completion, and waitlisting (3)(4)(5)(6)(7)(8)(9). The reasons for the disparities are likely multifactorial, and they may not be entirely explained by clinical factors (10)(11)(12).…”

The Interplay of Socioeconomic Status, Distance to Center, and Interdonor Service Area Travel on Kidney Transplant Access and Outcomes

“…Patients with low SES often delay seeking medical care and lack access to specialty services, leading to delays in transplant referral, evaluation, and listing (10,11). Despite near-universal eligibility for Medicare coverage on the basis of ESRD provisions, insurance status continues to influence outcome and access to transplantation.…”