Sex, Drugs, and the Language of Donor Narratives: Associations With Kidney Acceptance

Despite the shortage of donor kidneys, nonutilization remains common. We hypothesized that social history language in donor narratives influences acceptance. Using Natural Language Processing, we evaluated how language describing high-risk behaviors interacts with objective data (eg, hepatitis B virus [HBV]/hepatitis C virus [HCV] testing) to affect kidney acceptance.

We queried the Standard Transplant Analysis and Research file (2007-2023), analyzing 151 591 donor narratives with Natural Language Processing to identify 40 topics grouped as Templated Administrative Content and Free-Text Clinical Descriptors. Free-Text Clinical Descriptors were further subdivided into 4 communities, including Social History. Modified Poisson regression modeled associations with acceptance across 3 eras (2007-2014, 2015-2020, 2021-2023), including interactions with HBV/HCV serology.

Of 151 591 potential donors, 122 106 (80.55%) were accepted. Positive HBV/HCV testing reduced acceptance in era 1 (risk ratio [RR], 0.773; 95% confidence interval [CI], 0.744-0.802), with attenuation in era 2 (RR, 0.893; 95% CI, 0.878-0.908), and no effect in era 3 (RR, 1.006; 95% CI, 0.993-1.019). Interactions between HBV/HCV positivity and topics reflecting language related to illicit drug use or infectious risk evaluation were associated with reduced acceptance in era 1 only, with no significant interaction in era 2 or era 3. In era 1, interaction terms indicated reduced acceptance for language describing illicit drug use and/or sex in exchange for drugs (RR, 0.665; 95% CI, 0.549-0.805) and infectious risk evaluation (RR, 0.640; 95% CI, 0.452-0.905).

The association between high-risk behavioral language and lower kidney acceptance was present in earlier eras but not in the modern era. These findings suggest that the influence of subjective narrative language on decision-making has diminished over time, consistent with advances in antiviral therapy, policy changes, and increased utilization of higher-risk donors.