The Association Between Residential Segregation and Access to Kidney Transplantation - Evidence from a Multi-State Cohort Study.

Background: Individuals currently living in neighborhoods historically influenced by racial segregation have reduced access to healthcare. Whether this is true for individuals with end-stage kidney disease (ESKD) seeking transplant is unknown.

Methods: We identified Black or White adults (n = 42,401; 18-80 years) with ESKD initiating kidney replacement therapy (KRT) in three US States (Georgia, North Carolina, South Carolina) between January 2015 and December 2019, with follow-up through 2020, from the United States Renal Data System (USRDS). Residential segregation was defined using the racial Index of Concentration at the Extremes and classified into tertiles (predominantly Black, mixed, or predominantly White neighborhoods). Primary outcomes were referral within 12-months of KRT initiation (among patients initiating KRT) and evaluation within six-months of referral (among all referred patients), determined via linkage of USRDS to the Early-Steps to Transplant Access Registry. Secondary outcomes included waitlisting (among evaluated patients), and living or deceased donor transplant (among waitlisted patients). The association between residential segregation and each outcome was assessed using multivariable Cox models with robust sandwich variance estimators.

Results: In models adjusted for clinical factors, individuals living in predominantly Black or mixed (vs. predominantly White) neighborhoods were 8% (adjusted hazard ratio (aHR) 0.92 [0.88 - 0.96]) and 5% (aHR: 0.95 [0.91 - 0.99]) less likely to be referred for a kidney transplant, 18% (aHR: 0.82 [0.76 - 0.90]) and 9% (aHR: 0.91 [0.84 - 0.98]) less likely to be waitlisted among those who started evaluation, and 54% (aHR: 0.46 [0.36 - 0.58]) and 24% (aHR: 0.76 [0.63 - 0.93]) less likely to receive a living donor kidney transplant among those who were waitlisted, respectively. For other transplant steps, associations were non-significant.

Conclusion: Individuals with ESKD living in historically and currently marginalized communities in the Southeast US have reduced access to important steps along the transplant care continuum.