Access to kidney transplantation among remote- and rural-dwelling patients with kidney failure in the United States

JAMA. 2009 Apr 22;301(16):1681-90. doi: 10.1001/jama.2009.545.


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.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Female
  • Health Services Accessibility / statistics & numerical data*
  • Humans
  • Kidney Failure, Chronic / surgery*
  • Kidney Transplantation / statistics & numerical data*
  • Likelihood Functions
  • Male
  • Middle Aged
  • Proportional Hazards Models
  • Rural Population / statistics & numerical data*
  • Tissue and Organ Procurement / statistics & numerical data*
  • United States
  • Waiting Lists*
  • Young Adult