Race and socioeconomic factors influencing early placement on the kidney transplant waiting list

Abstract

This cohort study investigates whether there are inequities in the current system for listing patients for cadaveric renal transplantation, using univariate and multivariate analyses to identify factors associated with early registration before initiation of dialysis. It includes patient registrations for the kidney and kidney-pancreas waiting lists between April 1, 1994, and June 30, 1996 (n = 41,596) from all 238 United Network for Organ Sharing renal transplant centers. Patient and center factors predicting dialysis status (pre- or postdialysis initiation) at the time of registration were examined. Independent predictors of listing before dialysis (P < 0.001) included: female (odds ratio [OR] = 1.14, reference: male, i.e., listing before dialysis was 14% more likely in females than in males); age < or =17 and age 18 to 55 (OR = 1.91 and 1.14, respectively, reference: age >55); prior transplant (OR = 1.80, reference: no prior transplant); 0 to 8 yr education, attended college, and received a college degree (OR = 0.78, 1.18, and 1.37, respectively, reference: high school degree); black race, Hispanic, and Asian/other (OR = 0.47, 0.59, and 0.55, reference: white); full-time employment (OR = 1.98, reference: less than full time); payment with Medicare and private insurance (OR = 0.35 and 1.24, respectively, reference: other pay); receiving insulin (OR = 1.29, reference; not on insulin); listed for kidney-pancreas (OR = 1.43, reference: listed for kidney only); listed at a center with volume >400 (OR = 1.22, reference: volume <400). To remove possible bias for general access to health care and referral for transplantation, the analysis was limited to patients who had a previous transplant and found similar results. It is concluded that racial and ethnic minorities, those less well educated, and those with fewer financial resources are less likely than their counterparts to be listed for renal transplantation before dialysis. These results suggest there may be remediable inequities in the current system for registration for renal transplantation in the United States. Education efforts directed at patients and providers, as well as recently mandated uniform listing criteria for cadaveric organ transplantation, may help to reduce these inequities.