Regional disparities in living donor kidney transplantation: An analysis of transplant referral networks

Living donor kidney transplantation (LDKT) is the preferred standard of care for most patients with kidney failure. We sought to quantify the variation in access to living donor transplantation across referral networks for patients in Australia and New Zealand. We included adults who initiated kidney replacement therapy between 2002 and 2022. Each patient was mapped to a transplant referral network. For each network, we calculated a standardized living donor transplant ratio by comparing the observed number of living donor transplants within 12 months with the expected number. The expected number was estimated using multivariable Poisson regression with a random effect for each referral network. Overall, 53 313 patients were included. The ratio of observed to expected living donor transplants ranged from 0.36 to 2.11. Of 21 networks, 4 (19%) performed below expected. Initiating treatment at a center with direct transplant unit affiliation, nonmetropolitan residence, and timely nephrology referral were associated with increased LDKT. Access to LDKT varies substantially across transplant referral networks in Australia and New Zealand. Identifying center-level barriers and facilitators underpinning this variation will be critical to developing targeted center-based strategies to enhance living donation rates.