BARRIERS TO CADAVERIC RENAL-TRANSPLANTATION AMONG BLACKS, WOMEN, AND THE POOR

Context.-Cadaveric renal transplantation rates differ greatly by race, sex, and income. Previous efforts to lessen these differences have fo cused on the transplant waiting list. However, the transplantation pro cess involves a series of steps related to medical suitability, intere st in transplantation, pretransplant workup, and movement up a waiting list to eventual transplantation. Objective.-To determine the relativ e 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 betwee n January 1993 and December 1996 in Indiana, Kentucky, and Ohio. Main Outcome Measures.-Completion of 4 separate steps during each patient-y ear of follow-up: (A) being medically suitable and possibly interested in transplantation; (B) being definitely interested in transplantatio n; (C) completing the pretransplant workup; and (D) moving up a waitin g list and receiving a transplant. Results.-Compared with whites, blac ks were less likely to complete steps B (odds ratio [OR], 0.68; 95% co nfidence interval [CI], 0.61-0.76), C (OR, 0.56; 95% CI, 0.48-0.65), a nd D (OR, 0.50; 95% CI, 0.40-0.62) after adjustment for age, sex, caus e of renal failure, years receiving dialysis, and median income of pat ient ZIP code. Compared with men, women were less likely to complete e ach of the 4 steps, with ORs of 0.90, 0.89, 0.80, and 0.82, respective ly. Poor individuals were less likely than wealthy individuals to comp lete steps A, B, and C, with ORs of 0.67, 0.78, and 0.77, respectively . Conclusions.-Barriers at several steps are responsible for sociodemo graphic differences in access to cadaveric renal transplantation. Effo rts to allocate kidneys equitably must address each step of the transp lant process.