Variation in Living Donor Evaluation and Acceptance across the United States

Variability exists in acceptance of living kidney donor candidates across the US. This study sought to quantify the extent to which this variation is driven by donor candidate ancestry, transplant centers and providers.

Using a retrospective cohort study of living donor candidates who completed donor evaluation across nine US transplant centers, we examined the Kidney Failure Risk Projection (KFRP) model (estimating donor risk of ESKD at 15 years) as a proxy of the threshold for donor acceptance. Mixed linear models clustered by transplant center and provider were used to relate donor ancestry to center decisions.

Among 1888 living donor candidates (median age 42 years, 62% women), 39% Black candidates were accepted to donate versus 45% Hispanic and 56% White candidates (p<0.001). KFRP scores were extremely low, with median risk of 0.13% (IQR 0.06-0.27). Accounting for the 15-year KFRP score in adjusted models, the odds of donor acceptance were higher for White candidates (OR 1.46; 95% CI 1.13-1.88) compared with Hispanic (referent) and Black candidates (OR 0.74; 95% CI 0.53-1.04). White donor candidates declined for donation had a higher KFRP score by 0.08% versus Hispanic and Black candidates (p<0.05). In mixed models, residual variability in donor acceptance was observed at the transplant center (SD 0.08% in the KFRP score) and provider levels (SD 0.04%) for those accepted as donors, without variability by donor ancestry.

In this cohort, although fewer Black donor candidates were accepted for donation versus White and Hispanic candidates, accepted candidates had extremely low risk of developing ESKD within 15 years, regardless of ancestry. Variability across providers and transplant centers was observed, but absolute differences in their threshold of acceptance (or non-acceptance) were small. Our findings suggest that disparities in living donor access by donor ancestry are not explained by differences in system-level variations in practice.