Examining Disparities in Access to Kidney Transplant Listing Before and During the COVID-19 Pandemic

Despite high dialysis prevalence, access to kidney transplant waitlisting remains limited, with persistent socioeconomic and racial disparities. Prior studies have not captured patients evaluated but not listed for transplantation. During the COVID-19 pandemic, telemedicine-based evaluations may have further widened these gaps. We examined transplant evaluation and waitlisting before and during the pandemic at a large urban transplant center.

We hypothesized that the COVID-19 pandemic would adversely affect access to listing for kidney transplant (KT) for transplant candidates from minority ethnic groups. We evaluated differences in listing for kidney transplant between pre- and peri-pandemic eras, in-person (IPE) and telemedicine (TME) evaluations, and associations with race/ethnicity and other socioeconomic factors.

A retrospective chart review of 1061 KT evaluations included pre-pandemic (March 13, 2019, to March 13, 2020) and peri-pandemic (March 14, 2020, to March 14, 2021) eras. Categorical data are presented as proportions and frequencies, and continuous data as means ± standard deviation or medians ± interquartile range. Independent group t-tests and Fisher's exact tests were used for bivariate comparisons.

A total of 629 (59%) candidate evaluations were pre-pandemic, and 430 (41%) were peri-pandemic. Of these, 734 (72%) were IPE and 288 (28%) were TME. Overall, 553 (54%) candidates were denied listing for medical (310) and social (184) reasons. Peri-pandemic evaluations (p = 0.002), employment (p < 0.001), TME (p < 0.001), and mental health (p = 0.009) were associated with listing. Positive assessments of social support and overall social work assessment were associated with listing (p = 0.002; p < 0.001). Better social support was associated with listing pre-pandemic (p = 0.001) but not peri-pandemic (p = 0.769). Race/ethnicity (p = 0.951), employment (p = 0.202), and mental health (p = 0.742) were similar pre- and peri-pandemic. Race/ethnicity was not associated with listing (p = 0.809).

Overall, more candidates were listed for KT during the pandemic than before, despite fewer evaluations. This increase was associated with TME but not with race/ethnicity. Employment and mental health were similar in both eras despite pandemic stressors. Denial for social reasons mostly affected minority candidates, which warrants further study.