Neighborhood Disadvantage and Inequities in Access to Preemptive and Living Kidney Transplantation

Abstract

Key Points:

1. Pediatric patients residing in low-resource neighborhoods experienced lower rates of preemptive and living donor kidney transplantation.

2. Household-level factors (single-parent, non-English primary language, and receiving government assistance) may also affect the type of transplant received.

3. Area Deprivation Index scores offer an objective way to quantify neighborhood-level disadvantage and can enhance pretransplant screening.

Background: Living donor kidney transplant (LDKT) generally results in better outcomes than deceased donor kidney transplant (DDKT). Preemptive kidney transplant (KT) allows patients to bypass undergoing maintenance dialysis and is associated with improved patient and graft survival. Studies in the US pediatric population have shown racial-ethnic disparities in KT listing and the type of transplant received, but have yet to assess the association between neighborhood disadvantage and transplant type (LDKT versus DDKT), access to preemptive KT, or waitlisting.

Methods: The aim of this study was to use geocoded data to quantify neighborhood disadvantage and analyze its effect on access to pediatric KT. A single-center retrospective chart review was conducted of all pediatric KT recipients at Texas Children's Hospital from 2000 to 2022. Patients with multiorgan transplantation, older than 18 years, and with retransplantation were excluded. Transplant type, listing date, and patient address were obtained from the Organ Procurement and Transplantation Network registry. Neighborhood-level disadvantage was categorized using the Area Deprivation Index (ADI) score. ADI scores were calculated on the basis of patient address and transplant year and then stratified into US-based quartiles (Q1=least disadvantaged, Q4=most disadvantaged). Differences in characteristics between groups were determined by chi-square or Fisher's exact test for categorical variables and Kruskal–Wallis test for continuous variables.

Results: There was a significant trend favoring DDKT as ADI quartile increased (Q1=59.1%, Q4=83.5%, P = 0.001). Concurrently, there was a significant decline in preemptive KT rates as ADI quartile increased (Q1=34.1%, Q4=10%, P = 0.001). No preemptive KT or LDKT occurred for Black patients in the most disadvantaged neighborhoods (Q3–4). There was no difference in the time from dialysis to transplant across ADI quartiles.

Conclusions: These findings suggest that pediatric KT recipients from disadvantaged households were less likely to receive a preemptive KT or a LDKT. Using geocoded data can provide an objective assessment of patients' neighborhood disadvantage that supplements subjective pretransplant screening tools.

Keywords: health equity, diversity, and inclusion; pediatric kidney transplantation; pediatric nephrology; social determinants of health.

Graphical abstract

Figure 1

Flow chart of the study population. ADI, Area Deprivation Index; TCH, Texas Children's Hospital.

Figure 2

Proportion of preemptive transplants by race and ADI quartiles. P values are of the comparisons between ADI Q1–2 and ADI Q3–4 in individual race and ethnicity categories. NH, non-Hispanic.

Figure 3

Proportion of living donor transplants stratified by race and ADI quartile. P values are of the comparisons between ADI Q1–2 and ADI Q3–4 in individual race and ethnicity categories.

Figure 4

Kaplan–Meier curves for time from first dialysis to waitlisting within 5 years, by ADI quartiles 1–2 versus 3–4 (in patients having dialysis before waitlisting and nonmissing time from first dialysis to waitlisting, N=234).