Remote or rural residence not associated with increased time to kidney transplantation

Contrary to what may be a common perception, researchers found no evidence that the likelihood of kidney transplantation is lower among remote- or rural-dwelling patients treated for kidney failure in the United States, according to a study in the April 22/29 issue of JAMA, the Journal of the American Medical Association.

Kidney transplantation is a life-saving medical procedure for which the demand far exceeds the supply of transplantable organs. A recent study suggested that rural location of residence within the United States was associated with lower rates of solid organ transplantation compared with those living in urban areas, a finding that is consistent with other work showing that rural dwellers have reduced access to health services, which raises the possibility that current organ allocation schemes may discriminate against people living farther away from transplant centers, according to background information in the article.

Marcello Tonelli, M.D., S.M., of the University of Alberta, Edmonton, and colleagues examined the association between distance from the closest transplant center and time to placement on the kidney transplantation waiting list or time to kidney transplantation. "Because the mandatory pretransplantation medical evaluation is more likely to be available in major medical centers, we hypothesized that people residing further from the nearest transplant center would be less likely to undergo transplantation," the authors write. The study included 699,751 adult patients with kidney failure who had initiated renal replacement in the United States between 1995 and 2007 and were on a prospective mandatory registry list.

During median (midpoint) follow-up of 2.0 years, 122,785 (17.5 percent) 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 0-15 miles serving as the referent category.

"In contrast to our a priori hypotheses, we found that the likelihood of receiving a kidney transplant from a deceased or living donor among patients living farther away was similar to or greater than those residing within 15 miles of kidney transplant centers. Similarly, and again in contrast to our hypotheses, the adjusted likelihood of kidney transplantation was slightly lower among rural dwellers."

The authors add that the findings were independent of demographic factors, co-existing illnesses and measured socioeconomic characteristics.

"Although unexpected, our findings are encouraging because determining eligibility for kidney transplantation is a logistically challenging process that requires sequential diagnostic tests and encounters with health care clinicians. The finding that time to transplantation is similar or even shorter among remote- and rural-dwelling patients with kidney failure suggests that disparities in access for remote- and rural-dwellers with other diseases could be reduced or eliminated," the researchers write.

"These data suggest that efforts to improve equitable access to transplantation should not focus on populations defined solely by residence location."

http://jama.ama-assn.org/