The goal of this study was to assess whether there are sociodemographic differences in the transplantation process and to identify which steps in this process are most important in explaining sociodemographic patterns.

Dialysis providers in three states in the United States are required to discuss treatment options with renal patients at least annually and to report this information to a regional agency that monitors the care of patients with renal failure – The Renal Network, Inc of Indianapolis, Indiana. Subjects of this study included patients reported to this Network who were 18-65 years of age and began long-term dialysis between 1993 and 1995. Patients with a prior transplant were excluded, and patients who received a transplant from a living relative at any time during the study were excluded.

The authors identified four key stages in the transplant process recorded in the Network data: (1) “medically suitable and possibly interested,” (2) “definitely interested,” (3) “pre-transplant work-up complete and on waiting list,” and (4) “received transplant.” Patients who had not yet reached the first stage at the beginning of the year were considered “at risk” for that stage; they were then assessed as to whether they achieved that stage during the year. Once one stage was reached, patients were then considered “at risk” for the next one. Sociodemographic differences in achieving each of these stages were assessed in this report. Given the large sample size, the statistical significance tests are difficult to interpret; however, the reported patterns were consistent across the different analytic approaches undertaken by the authors.

The authors found that, controlling for gender, SES, age, diagnosis, and time on dialysis, blacks were less likely than whites to express definite interest in transplantation (OR=0.68, 95% confidence interval=0.61 to 0.76), to be given a pre-transplant work-up and placed on the waiting list after expressing interest (OR=0.56, 95% confidence interval =0.48 to 0.65), and to be given a transplant after being placed on the waiting list (OR=0.50, 95% confidence interval =0.40 to 0.62). Additionally, the effect of low income as a barrier to being given a pre-transplant work-up and placed on a waiting list was more pronounced among whites than blacks (the interaction term was statistically significant).

A key finding of this study is that racial disparities exist at the pre-transplant work-up/waiting list stage. Tasks performed at this stage include referral to transplant surgeons, evaluation and treatment of medical conditions, and laboratory studies. For only 3% of patients, not completing this step in a given year was due to the patient being medically unsuitable or uninterested in transplantation. Possible reasons for this pattern were not detailed and investigated in this report.

The authors argue that this study points to the need for a national database with uniform transplant status codes that correspond directly to distinct steps in the transplant process.