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The Extent and Predictors of Waiting Time Geographic Disparity in Kidney Transplantation in the United States

Davis, Ashley E.1,2; Mehrotra, Sanjay1,2,3,4; McElroy, Lisa M.2,3; Friedewald, John J.2,5; Skaro, Anton I.2; Lapin, Brittany2; Kang, Raymond2,3; Holl, Jane L.3; Abecassis, Michael M.2; Ladner, Daniela P.2,3,6

doi: 10.1097/01.tp.0000438623.89310.dc
Clinical and Translational Research

Background: Waiting time to deceased donor kidney transplant varies greatly across the United States. This variation violates the final rule, a federal mandate, which demands geographic equity in organ allocation for transplantation.

Methods: Retrospective analysis of the United States Renal Data System and United Network for Organ Sharing database from 2000 to 2009. Median waiting time was calculated for each of the 58 donor service areas (DSA) in the United States. Multivariate regression was performed to identify DSA predictors for long waiting times to kidney transplantation.

Results: The median waiting time varied between the 58 DSAs from 0.61 to 4.57 years, ranging from 0.59 to 5.17 years for standard criteria donor kidneys and 0.41 to 4.69 years for expanded criteria donor kidneys. The disparity in waiting time between the DSAs grew from 3.26 years (range, 0.41–3.67) in 2000 to 4.72 years (range, 0.50–5.22) in 2009. In DSAs with longer waiting times, there were significantly more patients suffering from end-stage renal disease and more patients listed for kidney transplant, lower kidney procurement rates, and higher transplant center competition. Patients were more likely black, sensitized, with lower educational attainment and less likely to waitlist outside of their DSA of residence. Donor organs used in DSAs with long waiting times were more likely hepatitis C positive and had a higher kidney donor profile index. Graft and patient survival at 5 years was worse for deceased donor kidney transplant, but rates for living donor kidney transplant were higher.

Conclusion: Our analysis demonstrates significant and worsening geographic disparity in waiting time for kidney transplant across the DSAs. Increase in living donor kidney transplant and use of marginal organs has not mitigated the disparity. Changes to the kidney allocation system might be required to resolve this extensive geographic disparity in kidney allocation.

1 Industrial Engineering and Management Sciences, Northwestern University, Evanston, IL.

2 Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL.

3 Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University, Chicago, IL.

4 Center for Engineering and Health, Northwestern University, Chicago, IL.

5 Division of Nephrology, Department of Medicine, Feinberg School of Medicine, Chicago, IL.

6 Address correspondence to: Daniela P. Ladner, M.D., M.P.H., Surgery, Division of Transplantation, Department of Surgery Director Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC) Feinberg School of Medicine, Northwestern University 676 N. St. Clair Street, Suite 1900 Chicago, IL 60611.

This work is funded by the National Science Foundation award CMMI-1131568, Agency for Healthcare Research and Quality Health Services Research Dissertation Award R36 HS021078-01, and the Northwestern Transplant Outcomes Research Collaboration (NUTORC).

A.E.D. is support by the National Science Foundation award CMMI-1131568, Agency for Healthcare Research and Quality Health Services Research Dissertation Award R36 HS021078-01. S.M. is funded by the National Science Foundation award CMMI-1131568. L.M. is supported by the Agency for Research Healthcare and Quality T32 Training Grant 5T32HS000078-15. J.J.F. is supported by the National Science Foundation award CMMI-1131568. D.P.L. is supported by the National Science Foundation award CMMI-1131568.

The content of this work is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government.

The authors declare no conflicts of interest.

E-mail: dladner@nmh.org

A.E.D. participated in research design, writing of the paper, performance of the research, and data analysis. S.M. participated in research design, writing of the paper, performance of the research, and data analysis. L.M. participated in writing of the paper. J.J.F. participated in research design and writing of the paper. A.I.S. participated in research design, performance of the research, and data analysis. B.L. participated in writing of the paper and data analysis. R.K. participated in data analysis. J.H. participated in research design and writing of the paper. M.M.A. participated in research design and writing of the paper. D.P.L. participated in research design, writing of the paper, performance of research, and data analysis.

Received 16 July 2013. Revision requested 7 August 2013.

Accepted 1 November 2013.

© 2014 by Lippincott Williams & Wilkins