Neighborhood disadvantage and inequities in access to preemptive and living kidney transplantation

Authors: FAIRLESS, BRANDON - Baylor College Of Medicine; FAWOLE, OLUWATUNMISE - Baylor College Of Medicine; NGUYEN, DUC - Baylor College Of Medicine; BANERJEE, ANKONA - Baylor College Of Medicine; NOBLEZA, KENNETH - Baylor College Of Medicine; OLUYOMI, ABIODUN - Baylor College Of Medicine; ROSALES, OMAR - Baylor College Of Medicine; DAVE, JAYNA - Children'S Nutrition Research Center (CNRC); ONUGHA, ELIZABETH - Baylor College Of Medicine

Submitted to: Kidney360
Publication Type: Peer Reviewed Journal
Publication Acceptance Date: 1/27/2025
Publication Date: 3/21/2025
Citation: Fairless, B.M., Fawole, O., Nguyen, D.T., Banerjee, A., Nobleza, K.J., Oluyomi, A., Rosales, O., Dave, J.M., Onugha, E.A. 2025. Neighborhood disadvantage and inequities in access to preemptive and living kidney transplantation. Kidney360. https://doi.org/10.34067/KID.0000000724.
DOI: https://doi.org/10.34067/KID.0000000724

Interpretive Summary: Children from disadvantaged neighborhoods are less likely to receive a living donor kidney transplant or a transplant before needing dialysis (pre-emptive kidney transplant), both of which lead to better health outcomes. This study reviewed pediatric kidney transplant cases at Texas Children's Hospital from 2000 to 2022, using the Area Deprivation Index (ADI) to measure neighborhood disadvantage. The researchers found that as neighborhood disadvantage increased, the likelihood of receiving a deceased donor kidney transplant rose, while pre-emptive kidney transplant rates declined. Notably, no African-American children from the most disadvantaged neighborhoods received a pre-emptive kidney transplant or living donor kidney transplant. However, once dialysis began, the wait time for a transplant was similar across all groups. These results suggest that socioeconomic factors significantly impact access to optimal kidney transplant options, highlighting the need for better strategies to address these disparities.

Technical Abstract: Living donor kidney transplant (LDKT) generally results in better outcomes than deceased donor kidney transplant (DDKT). Pre-emptive 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 kidney transplant listing and the type of transplant received, but have yet to assess the association between neighborhood disadvantage and transplant type (LDKT vs DDKT), access to pre-emptive KT, or waitlisting. Geocoded data was utilized to quantify neighborhood disadvantage and analyze its impact on access to pediatric KT.  We conducted a single-center retrospective chart review of all pediatric kidney transplant recipients at Texas Children's Hospital from 2000 to 2022. Multi-organ transplantation, patients >18 years, and re-transplantation were excluded. Transplant type, listing date, and patient address were obtained from UNET transplant registry. Neighborhood-level disadvantage was categorized using the Area Deprivation Index (ADI) score. ADI scores were calculated based on 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 the chi-square or Fisher's exact tests for categorical variables and Kruskal Wallis test for continuous variables. 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 pre-emptive KT rates as ADI quartile increased (Q1=34.1%, Q4=10%, p=0.001). No pre-emptive KT or LDKT occurred for African-American patients in the most disadvantaged neighborhoods (Q3-4). There was no difference in the time from dialysis to transplant across ADI quartiles. These findings suggest that pediatric KT recipients from disadvantaged households were less likely to receive a pre-emptive KT or a LDKT. Utilizing geocoded data can provide an objective assessment of patients' neighborhood disadvantage that supplements subjective pre-transplant screening tools.