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G. Caleb Alexander, MD; Ashwini R. Sehgal, MD

JAMA. 1998;280:1148-1152.

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.

From the School of Medicine (Dr Alexander), the Department of Medicine (Dr Sehgal), the Center for Biomedical Ethics (Dr Sehgal), and the Department of Epidemiology and Biostatistics (Dr Sehgal), Case Western Reserve University, and the Division of Nephrology, MetroHealth Medical Center (Dr Sehgal), Cleveland, Ohio. Dr Alexander is now with the Department of Medicine, University of Pennsylvania, Philadelphia.

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