Context.— Cadaveric renal transplantation rates differ greatly by race, sex, and
income. Previous efforts to lessen these differences have focused on the transplant
waiting list. However, the transplantation process involves a series of steps
related to medical suitability, interest in transplantation, pretransplant
workup, and movement up a waiting list to eventual transplantation.
Objective.— To determine the relative importance of each step in explaining differences
in cadaveric renal transplantation rates.
Design.— Prospective cohort study.
Setting and Patients.— A total of 7125 patients beginning long-term dialysis between January
1993 and December 1996 in Indiana, Kentucky, and Ohio.
Main Outcome Measures.— Completion of 4 separate steps during each patient-year of follow-up:
(A) being medically suitable and possibly interested in transplantation; (B)
being definitely interested in transplantation; (C) completing the pretransplant
workup; and (D) moving up a waiting list and receiving a transplant.
Results.— Compared with whites, blacks were less likely to complete steps B (odds
ratio [OR], 0.68; 95% confidence interval [CI], 0.61-0.76), C (OR, 0.56; 95%
CI, 0.48-0.65), and D (OR, 0.50; 95% CI, 0.40-0.62) after adjustment for age,
sex, cause of renal failure, years receiving dialysis, and median income of
patient ZIP code. Compared with men, women were less likely to complete each
of the 4 steps, with ORs of 0.90, 0.89, 0.80, and 0.82, respectively. Poor
individuals were less likely than wealthy individuals to complete steps A,
B, and C, with ORs of 0.67, 0.78, and 0.77, respectively.
Conclusions.— Barriers at several steps are responsible for sociodemographic differences
in access to cadaveric renal transplantation. Efforts to allocate kidneys
equitably must address each step of the transplant process.