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Background <p>Care coordination between primary care providers and nephrologists is crucial for preemptive kidney transplantation (KT), which confers health advantages over KT after dialysis. Residence in areas with limited primary care (Medically Underserved Areas [MUAs]/Health Professional Shortage Areas [HPSAs]) and nephrology access may differentially affect preemptive listing/KT.</p> Objective <p>To quantify access to preemptive KT by residence in limited primary care/nephrology access&#xa0;areas.</p> Design <p>Retrospective cohort study from the US national registry.</p> Participants <p>A total of 353,636 adult KT candidates (age ≥ 18) listed between 2005–2020.</p> Exposures <p>ZIP-code level MUA and HPSA information (HRSA), and distance to nearest nephrologist (CMS; urbanicity-specific thresholds for “far” from nephrologists: suburban, &gt; 5.8&#xa0;km; urban, &gt; 2.3&#xa0;km; small town, &gt; 19.4&#xa0;km; rural, &gt; 25.2&#xa0;km).</p> Main Measures <p>Poisson regression with robust variance estimator quantified adjusted prevalence ratios (aPRs) of preemptive listing, and cause-specific hazards models quantified adjusted hazard ratios (aHRs) of preemptive KT by MUAs/HPSAs/distance to nephrologists. Interaction terms quantified differences in the aforementioned associations by race and ethnicity/neighborhood urbanicity/socioeconomic determinants.</p> Key Results <p>31.2% of candidates lived in MUAs, 15.2% lived in HPSAs, and 41.9% lived far from nephrologists. Overall, a lower proportion of candidates living in primary care (MUA, 24.5%; non-MUA, 31.4%; HPSA, 24.2%; non-HPSA, 30.2%) and nephrology shortage areas (far, 31.9% vs near, 32.3%) were preemptively listed. After adjustment, candidates in MUAs were 6% less likely to be preemptively listed (aPR = 0.94; 95% confidence interval [CI], 0.93–0.95) and 13% less likely to obtain preemptive KT (aHR = 0.87; 95%CI, 0.85–0.90). Similarly, candidates in HPSAs were less likely to be preemptively listed (aPR = 0.95, 95%CI, 0.94–0.96) or obtain preemptive KT (aHR = 0.89, 95%CI, 0.86–0.93). Black candidates in MUAs/HPSAs and candidates in urban MUAs/HPSAs were less likely to be preemptively listed (except urban HPSAs) or obtain preemptive KT (all <i>P</i><sub>interactions</sub> &lt; 0.05). Lastly, there were no associations between distance to nephrologists and preemptive listing/KT.</p> Conclusions <p>Limited primary care access may impede KT access. Greater investment in primary care within MUAs/HPSAs, addressing geographic/linguistic barriers, and improved nephrology care coordination may increase transplant equity.</p> Clinical Trial Number <p>Not applicable.</p>

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Access to Primary Care and Nephrology: Implications for Preemptive Listing and Kidney Transplantation, A National Registry Study

  • 期刊论文

  • 发表日期：

    2026年8月4日

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  • Gayathri Menon,
  • Yiting Li,
  • Malika Wilson,
  • Maya N. Clark-Cutaia,
  • Mario P. DeMarco,
  • Sunjae Bae,
  • Byoungjun Kim,
  • Babak J. Orandi,
  • Roland J. Thorpe Jr.,
  • Dorry L. Segev,
  • Mara A. McAdams-DeMarco

摘要

Background

Care coordination between primary care providers and nephrologists is crucial for preemptive kidney transplantation (KT), which confers health advantages over KT after dialysis. Residence in areas with limited primary care (Medically Underserved Areas [MUAs]/Health Professional Shortage Areas [HPSAs]) and nephrology access may differentially affect preemptive listing/KT.

Objective

To quantify access to preemptive KT by residence in limited primary care/nephrology access areas.

Design

Retrospective cohort study from the US national registry.

Participants

A total of 353,636 adult KT candidates (age ≥ 18) listed between 2005–2020.

Exposures

ZIP-code level MUA and HPSA information (HRSA), and distance to nearest nephrologist (CMS; urbanicity-specific thresholds for “far” from nephrologists: suburban, > 5.8 km; urban, > 2.3 km; small town, > 19.4 km; rural, > 25.2 km).

Main Measures

Poisson regression with robust variance estimator quantified adjusted prevalence ratios (aPRs) of preemptive listing, and cause-specific hazards models quantified adjusted hazard ratios (aHRs) of preemptive KT by MUAs/HPSAs/distance to nephrologists. Interaction terms quantified differences in the aforementioned associations by race and ethnicity/neighborhood urbanicity/socioeconomic determinants.

Key Results

31.2% of candidates lived in MUAs, 15.2% lived in HPSAs, and 41.9% lived far from nephrologists. Overall, a lower proportion of candidates living in primary care (MUA, 24.5%; non-MUA, 31.4%; HPSA, 24.2%; non-HPSA, 30.2%) and nephrology shortage areas (far, 31.9% vs near, 32.3%) were preemptively listed. After adjustment, candidates in MUAs were 6% less likely to be preemptively listed (aPR = 0.94; 95% confidence interval [CI], 0.93–0.95) and 13% less likely to obtain preemptive KT (aHR = 0.87; 95%CI, 0.85–0.90). Similarly, candidates in HPSAs were less likely to be preemptively listed (aPR = 0.95, 95%CI, 0.94–0.96) or obtain preemptive KT (aHR = 0.89, 95%CI, 0.86–0.93). Black candidates in MUAs/HPSAs and candidates in urban MUAs/HPSAs were less likely to be preemptively listed (except urban HPSAs) or obtain preemptive KT (all Pinteractions < 0.05). Lastly, there were no associations between distance to nephrologists and preemptive listing/KT.

Conclusions

Limited primary care access may impede KT access. Greater investment in primary care within MUAs/HPSAs, addressing geographic/linguistic barriers, and improved nephrology care coordination may increase transplant equity.

Clinical Trial Number

Not applicable.