Multi-Listing Among Rural Kidney Transplant Recipients: A National Cohort Study

Rural patients who qualify for kidney transplantation are less likely to undergo transplant compared to urban patients. Multi-listing, or being added to the waiting list at more than two centers, has been shown to improve kidney transplantation rates, yet it remains a subject of debate and is understudied in rural populations. We sought to compare demographic, clinical, and donor characteristics among rural kidney transplant recipients who were on the waiting list at two or more centers (i.e., multi-listed) versus those who were on the waiting list at one center (i.e., single-listed) prior to transplant.

This retrospective, cohort study used the Scientific Registry of Transplant Recipients (SRTR) to identify adult, first-time, deceased-donor kidney transplant recipients between 2019 and 2023 who resided in rural areas, as defined by Rural-Urban Commuting Area (RUCA) Codes. Patients were divided into cohorts based on their listing status (single-listed vs. multi-listed) before transplant.

Of the 6246 rural kidney transplant recipients included, 829 (13.3%) were multi-listed. Compared to single-listed recipients, multi-listed recipients were more likely to be college-educated (54% vs. 44%, p < 0.001) and employed (26% vs. 23%, p = 0.02); they also had a shorter duration of dialysis before transplant (33 months [interquartile range, IQR = 18-50] vs. 35 months [15-62], p = 0.01). However, donors for multi-listed recipients had a higher median Kidney Donor Profile Index (50% [IQR = 25%-69%] vs. 44% [23%-66%], p = 0.006).

These findings suggest that while multi-listed rural patients possess characteristics favorable to long-term graft success, they may receive organs from donors with less favorable profiles. Future work should focus on understanding and addressing any trade-offs involved in multi-listing strategies.