Racial and socioeconomic disparities in the allocation of expanded criteria donor kidneys

Abstract

Background and objectives: In carefully selected individuals, receiving expanded criteria donor (ECD) kidneys confer a survival advantage over remaining on dialysis. However, wait lists for ECD kidneys often include a significant proportion of young patients, who have no predictable survival benefit from ECD kidneys. This study hypothesized that educational and socioeconomic factors might influence a younger patient's decision to accept an ECD kidney.

Design, setting, participants, & measurements: This study was a retrospective analysis of all first single-kidney transplants in the Scientific Registry of Transplant Recipients database from 2000 to 2009 in patients aged 18-40 years and waitlisted <3 years. The primary outcome measured was the odds of receiving an ECD kidney compared with an standard criteria donor kidney in different demographic subgroups. Race, income, and education were analyzed in main-effect and two-way interaction models, corrected for candidate panel reactive antibodies and sex.

Results: Of 13,615 ECD transplants, 591 kidneys (4.3%) went to recipients aged between 18 and 40 years who were waitlisted <3 years. African Americans (odds ratio, 1.71; 95% confidence interval, 1.26 to 2.33) or those with low education (odds ratio, 2.32; 95% confidence interval, 1.38 to 3.89) were more likely to receive an ECD kidney than Caucasians or those with a college degree, respectively. However, African Americans with higher education levels did not have significantly higher odds of receiving an ECD kidney than Caucasians with a college degree.

Conclusions: In patients aged <40 years and waitlisted <3 years, African Americans and those with lower educational status and low income are more likely to receive an ECD kidney than Caucasians or those with higher education. It is important that health care providers and patients understand such disparities to facilitate a more rational use of ECD kidneys.

Figure 1.

The funnel plot of observed/expected ECD kidney transplants in the study population. The plot shows the observed/expected ratio and 95% confidence interval for each of the study centers transplanting ECDs in the study population. The intensity of gray indicates the amount of deviation from an observed/expected ratio of 1. Most of the centers are at or close to 1. ECD, expanded criteria donor.

Figure 2.

Kaplan–Meier curves for graft survival in ECD versus SCD kidneys in the study population. ECD kidneys have a reduced long-term graft survival (P=0.01). ECD, expanded criteria donor; SCD, standard criteria donor.