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Marcello Tonelli, MD, SM; Scott Klarenbach, MD, MS; Caren Rose, MSc; Natasha Wiebe, MMath; John Gill, MD, MS

JAMA. 2009;301(16):1681-1690.

Context  US residents with end-stage renal disease (ESRD) may live far away from the closest transplant center, which could compromise their access to kidney transplantation.

Objective  To assess access to kidney transplantation as a function of distance from the closest transplant center or as a function of rural rather than urban residence.

Design, Setting, and Participants  Observational study of 699 751 adult patients with kidney failure who had initiated renal replacement in the United States between 1995 and 2007 and were thus placed on a prospective mandatory registry list.

Main Outcome Measures  Time to placement on the kidney transplant waiting list and time to kidney transplantation, both measured at the start of renal replacement.

Results  During a median follow-up of 2.0 years (range, 0.0-12.5 years), 122 785 (17.5%) patients received a kidney transplant. Median distance to the closest transplant center was 15 miles. Participants were classified into distance categories by miles from a transplant center with 0 to 15 miles serving as the referent category. Compared with the referent category, the adjusted hazard ratios of deceased or living donor transplantation within each category follows: 16 to 50 miles, 1.03 (95% CI, 1.02-1.05); 51 to 100 miles, 1.11 (95% CI, 1.09-1.12); 101 to 136 miles, 1.14 (95% CI, 1.11-1.17); 137 to 231 miles, 1.16 (95% CI, 1.13-1.20); 232 to 310 miles, 1.20 (95% CI, 1.12-1.28); and more than 310 miles, 1.16 (95% CI, 1.09-1.23). When residence location was classified using rural-urban commuter areas, 79.6% of patients lived in urban; 10.3%, micropolitan; and 10.0%, rural areas. Compared with those living in metropolitan areas, the adjusted hazard ratios of deceased or living donor transplantation among patients residing in micropolitan communities was 1.13 (95% CI, 1.11-1.15) and 1.15 (95% CI, 1.13-1.18) for rural areas. Results were similar for both deceased donor and living donor transplantation and were consistent in multiple sensitivity analyses.

Conclusion  Remote or rural residence was not associated with increased time to kidney transplantation among people treated for ESRD in the United States.

Author Affiliations: Department of Medicine (Drs Tonelli and Klarenbach and Ms Wiebe), Division of Critical Care Medicine, and Department of Public Health Sciences (Dr Tonelli), University of Alberta, Edmonton, and Institute of Health Economics (Drs Tonelli and Klarenbach), Edmonton, Alberta, Canada; Division of Nephrology, St Paul's Hospital, Vancouver, British Columbia, Canada (Dr Gill and Ms Rose); and Division of Nephrology, Tufts-New England Medical Center, Boston, Massachusetts (Dr Gill).

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