Association Between Rurality and Evaluation Start Among Referred Patients with End Stage Kidney Disease

Introduction: Rural residents with end-stage kidney disease have lower access to kidney transplantation, especially in later stages. We examined the impact of rurality on initiation of transplant evaluation and whether this varies by region. Methods: We conducted a retrospective cohort study of 86,839 adults (18–80 years) referred for kidney transplantation between 2015 and 2023 in the Early Steps to Transplant Access Registry, linked to United States Renal Data System (USRDS). Rurality was defined using the USRDS variable based on ZIP code using Rural–Urban Commuting Area codes. The primary outcome was evaluation initiation within six months of referral. Fine and Gray competing risks models estimated time to evaluation start, accounting for death as a competing event, with multivariable adjustment and interaction by geographic region; sub-analyses were stratified by ESRD Network. Results: Median time to evaluation was longer for rural patients (166 days) than urban patients (106 days), a pattern consistent across all ESRD Networks. The largest rural-urban time gaps were observed in New York and the Ohio River Valley. Rural residence was associated with an 11% lower likelihood of evaluation initiation (aSHR[95% CI], 0.89[0.86,0.92]). The strongest disparities were in New York (aSHR[95% CI], 0.56[0.50,0.62]) and New England (aSHR[95% CI], 0.76[0.69,0.83]). The Southeast (aSHR[95% CI], 0.90[0.87,0.94]) and Ohio River Valley (aSHR[95% CI], 0.92[0.85,0.99]) showed similar associations. Conclusions: Rural residents were less likely to initiate transplant evaluation compared to urban residents. These findings suggest that rural disparities exist in the early steps of the transplant process, highlighting the need for targeted interventions, especially in regions with lowest access.