Disparities in Kidney Transplant Waitlisting Among Young Patients Without Medical Comorbidities

Abstract

Importance: Disparities in kidney transplant referral and waitlisting contribute to disparities in kidney disease outcomes. Whether these differences are rooted in population differences in comorbidity burden is unclear.

Objective: To examine whether disparities in kidney transplant waitlisting were present among a young, relatively healthy cohort of patients unlikely to have medical contraindications to kidney transplant.

Design, setting, and participants: This retrospective cohort study used the US Renal Data System Registry to identify patients with end-stage kidney disease who initiated dialysis between January 1, 2005, and December 31, 2019. Patients who were older than 40 years, received a preemptive transplant, were preemptively waitlisted, or had documented medical comorbidities other than hypertension or smoking were excluded, yielding an analytic cohort of 52 902 patients. Data were analyzed between March 1, 2022, and February 1, 2023.

Main outcome(s) and measure(s): Kidney transplant waitlisting after dialysis initiation.

Results: Of 52 902 patients (mean [SD] age, 31 [5] years; 31 132 [59%] male; 3547 [7%] Asian/Pacific Islander, 20 782 [39%] Black/African American, and 28 006 [53%] White) included in the analysis, 15 840 (30%) were waitlisted for a kidney transplant within 1 year of dialysis initiation, 11 122 (21%) were waitlisted between 1 and 5 years after dialysis initiation, and 25 940 (49%) were not waitlisted by 5 years. Patients waitlisted within 1 year of dialysis initiation were more likely to be male, to be White, to be employed full time, and to have had predialysis nephrology care. There were large state-level differences in the proportion of patients waitlisted within 1 year (median, 33%; range, 15%-58%). In competing risk regression, female sex (adjusted subhazard ratio [SHR], 0.92; 95% CI, 0.90-0.94), Hispanic ethnicity (SHR, 0.77; 95% CI, 0.75-0.80), and Black race (SHR, 0.66; 95% CI, 0.64-0.68) were all associated with lower waitlisting after dialysis initiation. Unemployment (SHR, 0.47; 95% CI, 0.45-0.48) and part-time employment (SHR, 0.74; 95% CI, 0.70-0.77) were associated with lower waitlisting compared with full-time employment, and more than 1 year of predialysis nephrology care, compared with none, was associated with greater waitlisting (SHR, 1.51; 95% CI, 1.46-1.56).

Conclusions and relevance: This retrospective cohort study found that fewer than one-third of patients without major medical comorbidities were waitlisted for a kidney transplant within 1 year of dialysis initiation, with sociodemographic disparities in waitlisting even in this cohort of young, relatively healthy patients unlikely to have a medical contraindication to transplantation. Transplant policy changes are needed to increase transparency and address structural barriers to waitlist access.

Figure 1.. Flowchart of US Renal Data System (USRDS) Records That Were Screened, Included, and Excluded in the Analysis

A total of 52 902 patients who initiated dialysis between 2005 and 2019 and were 40 years or younger without documented medical comorbidities or kidney transplant waitlisting before dialysis initiation were included in the analysis.

Figure 2.. Cumulative Incidence of Kidney Transplant Waitlisting After Dialysis Initiation by Demographic Characteristic Group

Female patients initiating dialysis had a lower cumulative incidence of waitlisting than male patients (A), and patients with Black race had the lowest cumulative incidence of waitlisting among all racial groups (B). Patients with full-time employment status had higher cumulative incidence of waitlisting compared with any other employment status, with unemployed and retired patients having the lowest cumulative incidence of waitlisting (C). Patients with a longer duration of predialysis nephrology care had a higher cumulative incidence of waitlisting (D). The other, multiracial, or unknown race group includes American Indian or Alaska Native, other or multiracial, Middle Eastern, or unknown.