Racial and Ethnic Disparities in Outcomes following Preemptive Kidney Transplant Waitlisting in the United States from 2009 to 2024

Background: – Preemptive kidney transplantation (prior to dialysis initiation) is the optimal therapy for most transplant-eligible advanced CKD patients. While prior research has documented racial and ethnic disparities in preemptive referrals, less is known about distinct outcomes following preemptive waitlisting. This study examines the association between race and ethnicity and outcomes for preemptively waitlisted patients.Methods: – We conducted a secondary analysis of a prospectively maintained U.S. cohort using data from the Scientific Registry of Transplant Recipients (SRTR). The study population included 98, 863 adult first-time kidney transplant candidates who were preemptively waitlisted from January 1, 2009, to December 31, 2020, and followed through December 31, 2024. The exposure of interest was race and ethnicity. The primary outcome was three-year preemptive deceased donor kidney transplantation, living donor kidney transplantation, or dialysis initiation. We used competing risk models to estimate adjusted subdistribution hazard ratios (aSHRs). Data were stratified into three-year intervals (2009–2011, 2012–2014, 2015–2017, and 2018–2020).Results: – Black and Hispanic patients received preemptive deceased donor kidney transplants as often as White patients (era 2018–2020, aSHRs [95% CI]: 0.99 [0.92–1.07] and 1.02 [0.93–1.12], respectively), while Asian patients had lower rates (0.78 [0.69–0.88]). However, Asian, Black, and Hispanic patients were more likely to initiate dialysis (aSHRs: 1.50 [1.39–1.61]; 1.41 [1.34–1.49]; and 1.21 [1.14–1.29], respectively) and were less likely to receive preemptive living donor kidney transplants than White patients (era 2018–2020, aSHRs: 0.49 [0.44–0.54]; 0.31 [0.29–0.34]; and 0.61 [0.56–0.66], respectively).Conclusions: – Among waitlisted CKD patients in the U.S between 2009 and 2020, rates of preemptive deceased donor kidney transplantation improved for Black and Hispanic patients and became comparable to White patients. However, Asian, Black, and Hispanic patients experienced higher rates of dialysis initiation and lower rates of preemptive living donor kidney transplantation.