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

Key Points Residential segregation is associated with reduced access to several important steps on the kidney transplant care continuum. Residential segregation affects both Black and White individuals with ESKD seeking lifesaving transplant. Background Individuals currently living in neighborhoods historically influenced by racial segregation have reduced access to health care. Whether this is true for individuals with ESKD seeking transplant is unknown. Methods We identified Black or White adults ( N =42,401; 18–80 years) with ESKD initiating 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. 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 individuals initiating KRT) and evaluation within 6 months of referral (among all referred individuals), determined by linkage of the United States Renal Data System to the Early Steps to Transplant Access Registry. Secondary outcomes included waitlisting (among evaluated individuals) and living or deceased donor transplant (among waitlisted individuals). 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 (versus predominantly White) neighborhoods were 8% (adjusted hazard ratio aHR, 0.92 0.88 to 0.96) and 5% (aHR, 0.95 0.91 to 0.99) less likely to be referred for a kidney transplant, 18% (aHR, 0.82 0.76 to 0.90) and 9% (aHR, 0.91 0.84 to 0.98) less likely to be waitlisted among those who started evaluation, and 54% (aHR, 0.46 0.36 to 0.58) and 24% (aHR, 0.76 0.63 to 0.93) less likely to receive a living donor kidney transplant among those who were waitlisted, respectively. For other transplant steps, associations were nonsignificant. Conclusions Individuals with ESKD living in historically and currently marginalized communities in the Southeast United States have reduced access to important steps along the transplant care continuum.