The role of race and poverty on steps to kidney transplantation in the Southeastern United States

Abstract

Racial disparities in access to renal transplantation exist, but the effects of race and socioeconomic status (SES) on early steps of renal transplantation have not been well explored. Adult patients referred for renal transplant evaluation at a single transplant center in the Southeastern United States from 2005 to 2007, followed through May 2010, were examined. Demographic and clinical data were obtained from patient's medical records and then linked with United States Renal Data System and American Community Survey Census data. Cox models examined the effect of race on referral, evaluation, waitlisting and organ receipt. Of 2291 patients, 64.9% were black, the mean age was 49.4 years and 33.6% lived in poor neighborhoods. Racial disparities were observed in access to referral, transplant evaluation, waitlisting and organ receipt. SES explained almost one-third of the lower rate of transplant among black versus white patients, but even after adjustment for demographic, clinical and SES factors, blacks had a 59% lower rate of transplant than whites (hazard ratio = 0.41; 95% confidence interval: 0.28-0.58). Results suggest that improving access to healthcare may reduce some, but not all, of the racial disparities in access to kidney transplantation.

Figure 1

Flow diagram of study inclusion criteria and follow-up status.

Figure 2. Racial differences in transplant step completion and duration

Panel A shows the proportion of eligible patients completing each transplant step. Among all patients referred, 60.6% of whites and 51.5% of blacks started the evaluation; among all those who started the evaluation, 92% of white and 90.8% of blacks completed the evaluation process. Among patients who completed the evaluation requirements, 71.0% of white and 59.6% of black patients were placed on the deceased donor waiting list. Among waitlisted patients, 30.0% of whites and 18.1% of black patients received a deceased donor transplant during follow-up. Racial differences were also observed in the median time to completion for each step (panel B). Differences in the time to referral and time from referral to evaluation were evident. The greatest racial differences were observed in the final step, waitlisting to transplantation. *p < 0.001.