Educational level as a determinant of access to and outcomes after kidney transplantation in the United States

Am J Kidney Dis. 2008 May;51(5):811-8. doi: 10.1053/j.ajkd.2008.01.019. Epub 2008 Apr 3.


Background: Disparities in access to kidney transplantation exist, yet few studies investigated educational level as a determinant of access to and outcomes after kidney transplantation.

Study design: Prospective cohort study.

Settings & participants: Nationally representative sample of incident US dialysis patients, in which 3,245 patients reported their educational level.

Predictor: Educational level, categorized as some high school, high school graduate, some college, and college graduate.

Outcomes & measurements: Access to kidney transplantation was defined as time from first dialysis treatment to: (1) the day of being wait-listed and (2) first kidney transplantation. Outcomes after kidney transplantation were: (3) all-cause mortality and graft failure ([4] all-cause and [5] death censored). Using Cox regression, we studied the relationship between predialysis educational level and access to and outcomes after kidney transplantation.

Results: During follow-up, 692 patients were wait-listed and 670 underwent kidney transplantation. Of those, 164 died and 241 lost their allograft (121 from nondeath causes). After multivariate adjustment, college graduates experienced 3 times greater rates of wait-listing (hazard ratio, 2.81; 95% confidence interval, 2.21 to 3.58) or kidney transplantation (hazard ratio, 3.06; 95% confidence interval, 2.38 to 3.92) compared with patients without a high school degree (P for trend across educational level for both outcomes < 0.001). Although mortality was not associated with educational level, increased rates of death-censored allograft loss were observed with less education (P for trend = 0.03).

Limitations: Not a randomized study.

Conclusion: The latter finding is novel and important and requires confirmation. Its possible mechanisms (eg, adherence to immunosuppressants) warrant additional study.

MeSH terms

  • Aged
  • Educational Status
  • Female
  • Health Services Accessibility / statistics & numerical data*
  • Healthcare Disparities / statistics & numerical data*
  • Humans
  • Kidney Failure, Chronic / surgery*
  • Kidney Failure, Chronic / therapy
  • Kidney Transplantation / statistics & numerical data*
  • Male
  • Middle Aged
  • Patient Selection
  • Prospective Studies
  • Treatment Outcome
  • United States / epidemiology
  • Waiting Lists