Residential Neighborhood Disadvantage May Lower Kidney Transplant Access

There is a distinct and disproportionate incidence between a neighborhood’s systematic disadvantage and its residents who have end-stage kidney disease (ESKD) access to kidney transplantation (KT) and waitlisting, according to new research.1

These findings connect racial and ethnic disparities in the management of chronic diseases with KT, highlighting limited equity and access to Asian, Black, and Hispanic and Western residents, even in less disadvantaged neighborhoods, compared to those who are White and from the North.1

“Addressing the impact of neighborhood disadvantage on access to waitlisting and KT will require multifaceted interventions at both the local and national levels,” wrote study investigator Mara A. McAdams-DeMarco, PhD, a professor at New York University Langone Health, and colleagues.1

The fundamental mechanisms and resources of neighborhoods affect access to food, safety, education, health behaviors, and stress levels. Inhabitants of disadvantaged neighborhoods are at an increased risk of diabetes, cardiovascular disease, increased utilization of health services, and earlier death.1,2

Established < 3 decades ago by the Health Resources and Services Administration, the area deprivation index (ADI) provides accessible data on adverse social exposome, utilizing 17 education, housing-quality, and poverty measures to quantify neighborhood disadvantage in accessible metrics. In 2018, the ADI was updated to incorporate American Community Survey (ACS) data and is aimed to be applied broadly to support research, policy, and health interventions.1,2

Applying neighborhood disadvantage scores to KT, McAdams-DeMarco and colleagues leveraged data from the United States Renal Data System (USRDS), the Centers for Medicare & Medicaid Services, and the United Network for Organ Sharing and Organ Procurement and Transplantation Network.1

Investigators identified 9 standardized domains, including built environment disadvantage, criminal injustice, education disadvantage, unemployment, housing instability, poverty, social fragmentation, transportation barrier, and wealth inequality. They aggregated scores to the Zip Code Tabulation Area (ZCTA) by taking population-weighted means of census tracts. They divided neighborhood scores into tertiles of low (≤ -0.116), medium (> -0.116 and ≤ 0.681), and high (> 0.681).1

The retrospective study consisted of 2 analytical cohorts. The first included 501,444 adults ≥ 18 years of age with ESKD initiating dialysis, and the other included 95,068 adults waitlisted for KT. Investigators assigned neighborhood disadvantage scores based on the patient’s 5-digit zip code at the time of dialysis initiation and of waitlisting, respectively.1

In the dialysis cohort, the 5-year unadjusted cumulative incidence of waitlisting was 20.3% (95% Confidence Interval [CI], 20.1% to 20.7%) for those residing in high-disadvantage neighborhoods compared to 23.5% (95% CI, 23.2% to 23.9%) in low-disadvantage neighborhoods. Investigators also observed Asian (Adjusted Hazard Ratio [AHR], 0.76; 95% CI, 0.70 to 0.84), Black (AHR, 0.76; 95% CI, 0.70 to 0.84), Hispanic (AHR, 0.79; 95% CI, 0.76 to 0.83), and White (AHR, 0.68; 95% CI, 0.66 to 0.71) adults in the high tertile had a reduced likelihood of waitlisting compared with low.1

In cross-race and ethnicity comparisons, compared with White adults in low-disadvantage neighborhoods, investigators found Asian (AHR, 0.87; 95% CI, 0.80 to 0.95), Black (AHR, 0.68; 95% CI, 0.66 to 0.70), and Hispanic (AHR, 0.89; 95% CI, 0.86 to 0.92) adults in high-disadvantage neighborhoods had a reduced likelihood of waitlisting (P < .001 for interaction).1

Investigators revealed that all domains of neighborhood disadvantage were associated with access to waitlisting, with the strongest associations observed for increasing disadvantage in built environment (AHR, 0.86; 95% CI, 0.85 to 0.87), education disadvantage (AHR, 0.85; 95% CI, 0.84 to 0.86), unemployment (AHR, 0.87; 95% CI, 0.86 to 0.88), housing instability (AHR, 0.85; 95% CI, 0.84 to 0.86), and wealth inequality (AHR, 0.83; 95% CI, 0.82 to 0.84).1

In the KT cohort, the 5-year unadjusted cumulative incidence of any KT was 62.5% (95% CI, 61.5% to 63.6%) for those residing in high-disadvantage neighborhoods compared to 70.1% (95% CI, 69.9% to 71.5%; log-rank P < .001) in low-disadvantage neighborhoods. After adjustment, high-disadvantage neighborhoods were associated with a reduced likelihood of any KT (AHR, 0.89; 95% CI, 0.87 to 0.92).1

In cross–race and ethnicity comparisons, compared with White candidates in low-disadvantage neighborhoods, Asian (AHR, 0.57; 95% CI, 0.51 to 0.64), Black (AHR, 0.60; 95% CI, 0.58 to 0.62), and Hispanic (AHR, 0.62; 95% CI, 0.59 to 0.65) candidates in high-disadvantage neighborhoods had a reduced likelihood of any KT (P = .04 for interaction). Investigators reported the strongest associations for increasing education disadvantage (AHR, 0.94; 95% CI, 0.93 to 0.95), housing instability (AHR, 0.91; 95% CI, 0.90 to 0.93), and poverty (AHR, 0.92; 95% CI, 0.91 to 0.93).1

Candidates residing in high-disadvantage neighborhoods had a decreased likelihood of living donor kidney transplantation (LDKT) (AHR, 0.65; 95% CI, 0.62 to 0.69) and preemptive KT (AHR, 0.62; 95% CI, 0.58 to 0.67), according to investigators. Specifically, compared with White candidates in low-disadvantage neighborhoods, Asian (AHR, 0.25; 95% CI, 0.18 to 0.34), Black (AHR, 0.23; 95% CI, 0.21 to 0.25), and Hispanic (AHR, 0.51; 95% CI, 0.47 to 0.56; P < .001 for interaction) candidates residing in high-disadvantage neighborhoods had a reduced likelihood of LDKT.1

Investigators also reported, in the dialysis and KT cohorts, candidates in high-disadvantage neighborhoods located in the western region of the US had a reduced likelihood of waitlisting or transplantation, compared to those in low-disadvantage neighborhoods in the northeast.1

“These findings further suggest that neighborhood disadvantage may contribute to persistent racial and ethnic disparities in access to LDKT and preemptive KT,” investigators concluded. “Urgent, multifaceted interventions are needed to dismantle the structural barriers that contribute to high levels of neighborhood disadvantage.”1

References

1. Li Y, Menon G, Kim B, et al. Residential Neighborhood Disadvantage and Access to Kidney Transplantation. JAMA Network Open. 2025;8(12):e2549679-e2549679. doi:https://doi.org/10.1001/jamanetworkopen.2025.49679

2. Kind AJH, Buckingham WR. Making Neighborhood-Disadvantage Metrics Accessible — The Neighborhood Atlas. New England Journal of Medicine. 2018;378(26):2456-2458. doi:https://doi.org/10.1056/nejmp1802313