Racial disparities in pediatric access to kidney transplantation: does socioeconomic status play a role?

Abstract

Racial disparities persist in access to renal transplantation in the United States, but the degree to which patient and neighborhood socioeconomic status (SES) impacts racial disparities in deceased donor renal transplantation access has not been examined in the pediatric and adolescent end-stage renal disease (ESRD) population. We examined the interplay of race and SES in a population-based cohort of all incident pediatric ESRD patients <21 years from the United States Renal Data System from 2000 to 2008, followed through September 2009. Of 8452 patients included, 30.8% were black, 27.6% white-Hispanic, 44.3% female and 28.0% lived in poor neighborhoods. A total of 63.4% of the study population was placed on the waiting list and 32.5% received a deceased donor transplant. Racial disparities persisted in transplant even after adjustment for SES, where minorities were less likely to receive a transplant compared to whites, and this disparity was more pronounced among patients 18-20 years. Disparities in access to the waiting list were mitigated in Hispanic patients with private health insurance. Our study suggests that racial disparities in transplant access worsen as pediatric patients transition into young adulthood, and that SES does not explain all of the racial differences in access to kidney transplantation.

Figure 1. Kaplan–Meier estimates for time to waitlisting (step 1) and deceased donor renal transplantation (step 2) by race/ethnicity and age group

The rate of waitlisting (step 1) was lower among black versus white patients age 18–20 years (p < 0.0001) and the rate of transplant (step 2) was lower among blacks and Hispanics of all ages (p < 0.0001).

Figure 2. Step 1: Effect of race on time to waitlisting within strata of health insurance

Panel A shows the multivariable-adjusted effect of time to waitlisting among Hispanics versus whites (age 0–17 years) by health insurance coverage. Panel B shows the multivariable-adjusted effect of time to waitlisting among Hispanics versus whites (age 18–20) by health insurance coverage at the time of ESRD start.