Department of Surgery, Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire, USA.
Clin J Am Soc Nephrol. 2010 Dec;5(12):2276-88. doi: 10.2215/CJN.04940610. Epub 2010 Aug 26.
Variation in kidney transplant access across the United States may motivate relocation of patients with ability to travel to better-supplied areas.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We examined national transplant registry and U.S. Census data for kidney transplant candidates listed in 1999 to 2009 with a reported residential zip code (n = 203,267). Cox's regression was used to assess associations of socioeconomic status (SES), distance from residence to transplant center, and relocation to a different donation service area (DSA) with transplant access and outcomes.
Patients in the highest SES quartile had increased access to transplant compared with those with lowest SES, driven strongly by 76% higher likelihood of living donor transplantation (adjusted hazard ratio [aHR] 1.76, 95% confidence interval [CI] 1.70 to 1.83). Waitlist death was reduced in high compared with low SES candidates (aHR 0.86, 95% CI 0.84 to 0.89). High SES patients also experienced lower mortality after living and deceased donor transplant. Patients living farther from the transplant center had reduced access to deceased donor transplant and increased risk of post-transplant death. Inter-DSA travel was associated with a dramatic increase in deceased donor transplant access (HR 1.94, 95% CI 1.88 to 2.00) and was predicted by high SES, white race, and longer deceased-donor allograft waiting time in initial DSA.
Ongoing disparities exist in kidney transplantation access and outcomes on the basis of geography and SES despite near-universal insurance coverage under Medicare. Inter-DSA travel improves access and is more common among high SES candidates.
美国各地肾移植机会的差异可能促使有能力旅行的患者迁往供应更好的地区。
设计、设置、参与者和测量方法：我们研究了国家移植登记处和美国人口普查数据，这些数据来自 1999 年至 2009 年报告居住地邮政编码的肾移植候选人（n=203267）。使用 Cox 回归评估社会经济地位（SES）、居住地到移植中心的距离以及迁往不同的供体服务区（DSA）与移植机会和结果的关系。
与 SES 最低的患者相比，SES 最高的患者具有更高的移植机会，这主要是由于活体供体移植的可能性增加了 76%（调整后的危险比[HR]1.76，95%置信区间[CI]1.70 至 1.83）。高 SES 候选者的候补名单死亡率低于低 SES 候选者（HR 0.86，95%CI 0.84 至 0.89）。高 SES 患者在接受活体和已故供体移植后也经历了较低的死亡率。离移植中心较远的患者接受已故供体移植的机会减少，移植后死亡的风险增加。跨 DSA 旅行与已故供体移植机会的显著增加相关（HR 1.94，95%CI 1.88 至 2.00），并受 SES 较高、白种人以及初始 DSA 中已故供体移植物等待时间较长的预测。
尽管医疗保险提供了近乎普遍的保险覆盖，但基于地理位置和 SES，肾移植机会和结果仍然存在持续的差异。跨 DSA 旅行可提高移植机会，并且在 SES 较高的候选者中更为常见。
