Association between Area Deprivation Index, Kidney Transplant Waitlisting, and Reasons for Denial

Background and objectives: Neighborhood socioeconomic disadvantage may impact kidney transplant (KT) access and reasons for waitlist denial. We assessed (1) the association between Area Deprivation Index (ADI) and time-to-KT waitlisting and (2) whether evaluation outcomes differ by ADI quartile. Design, setting, participants, and measurements: We conducted a retrospective cohort study of 4,896 adults who were referred for KT evaluation from 1/2015 -12/2021 at the University of Washington, using data collected from the electronic medical record. We used Cox proportional hazards models to evaluate the association of ADI quartile and time to KT waitlisting, adjusting for individual medical and social variables. Multinomial logistic regression was used to assess if KT evaluation outcomes (including waitlist denial reason) differed across ADI quartiles. Results: Among the 3,638 patients who initiated evaluation, 1,381 (38%) were waitlisted. Residents in ADI quartile 4 (Q4) (most disadvantaged) required longer time and were 27% less likely to be waitlisted than residents in Q1 (least disadvantaged) in the adjusted analysis (adjusted odds ratio (aOR) 0.73, 95% confidence interval (CI) 0.62-0.87). Residents in Q4 were more likely to be denied for medical reasons (aOR 2.83, 95% CI 2.03-3.95), non-medical reasons (aOR 2.56, 95% CI 1.80-3.64), or for higher body mass index (BMI) (aOR 2.47, 95% CI 1.40-4.36) than residents in Q1. Conclusions: Residents in disadvantaged neighborhood required longer time and had lower likelihood of KT waitlisting, with variable reasons for denial (medical, psychosocial, and BMI), suggesting a need for individualized interventions to improve KT access. Further work, including qualitative methods, may better specify barriers and inform future interventions to address this disparity.