Social Determinants of Health in Access to Repeat Kidney Transplantation

Background: The longevity of transplanted kidney grafts is limited, and more than half of kidney transplant patients need repeat transplants during their lifetimes. However, inequity in access to repeat kidney transplants, especially that resulting from social determinants of health, has not been studied. Methods: Using national data, this retrospective study analyzed kidney transplant recipients with failed kidney grafts (n=63,635) between October 1, 1987, and August 31, 2015, in the United States. Results: After controlling the clinical covariates (i.e., primary disease, panel reactive antibody), age, race, education level, insurance type, and job status significantly impacted access to the kidney transplant waiting list after kidney graft failure. Higher odds of waiting-list access were evident among patients who were younger, White, and fully employed and who had private insurance and a college degree. A Cox proportional hazard model indicated that age, race, and insurance type impacted how long patients waited until being listed. Compared with patients younger than 71 years, those 71 years or older had a shorter duration until being wait-listed, with a hazard ratio (HR) of 1.84 (95% confidence interval CI, 1.369–2.463; P<0.001). By contrast, Black patients waited longer to be wait-listed compared with White patients, with an HR of 0.75 (95% CI, 0.704–0.803; P<0.001). Moreover, of all insurance types, patients with public insurance (Medicare) experienced the longest duration to being re-listed. Conclusion: Efforts to alleviate the impact of social determinants of health should start earlier following the initial transplant. Improving access to repeat kidney transplants will build transparency and trust in our transplant community, ultimately helping to achieve the best health outcomes.