Geographic determinants of access to pediatric deceased donor kidney transplantation

Abstract

Children receive priority in the allocation of deceased donor kidneys for transplantation in the United States, but because allocation begins locally, geographic differences in population and organ supply may enable variation in pediatric access to transplantation. We assembled a cohort of 3764 individual listings for pediatric kidney transplantation in 2005-2010. For each donor service area, we assigned a category of short (<180 days), medium (181-270 days), or long (>270 days) median waiting time and calculated the ratio of pediatric-quality kidneys to pediatric candidates and the percentage of these kidneys locally diverted to adults. We used multivariable Cox regression analyses to examine the association between donor service area characteristics and time to deceased donor kidney transplantation. The Kaplan-Meier estimate of median waiting time to transplantation was 284 days (95% confidence interval, 263 to 300 days) and varied from 14 to 1313 days across donor service areas. Overall, 29% of pediatric-quality kidneys were locally diverted to adults. Compared with areas with short waiting times, areas with long waiting times had a lower ratio of pediatric-quality kidneys to candidates (3.1 versus 5.9; P<0.001) and more diversions to adults (31% versus 27%; P<0.001). In multivariable regression, a lower kidney to candidate ratio remained associated with longer waiting time (hazard ratio, 0.56 for areas with <2:1 versus reference areas with ≥5:1 kidneys/candidates; P<0.01). Large geographic variation in waiting time for pediatric deceased donor kidney transplantation exists and is highly associated with local supply and demand factors. Future organ allocation policy should address this geographic inequity.

Figure 1.

Variation across DSAs in waiting time (days) until 50% of pediatric candidates undergo deceased donor transplantation (September 2005 to September 2010). Kaplan–Meier estimates with censoring for death, delisting, and live donor transplantation.

Figure 2.

Variation in the ratio of pediatric-quality deceased donor kidneys to pediatric candidate wait-listings across DSAs (September 2005 to September 2010).

Figure 3.

Waiting time for pediatric DDKT and percentage of pediatric-quality deceased donor kidneys diverted to adults across DSAs (September 2005 to September 2010). Bubble size is proportional to the number of wait-listed candidates.