Educational level as a determinant of access to and outcomes after kidney transplantation in the United States.

ABSTRACT

BACKGROUND: Disparities in access to kidney transplantation exist, yet few studies investigated educational level as a determinant of access to and outcomes after kidney transplantation. STUDY DESIGN: Prospective cohort study. SETTINGS & PARTICIPANTS: Nationally representative sample of incident US dialysis patients, in which 3,245 patients reported their educational level. PREDICTOR Educational level, categorized as some high school, high school graduate, some college, and college graduate. OUTCOMES & MEASUREMENTS Access to kidney transplantation was defined as time from first dialysis treatment to (1) the day of being wait-listed and (2) first kidney transplantation. Outcomes after kidney transplantation were (3) all-cause mortality and graft failure ([4] all-cause and [5] death censored). Using Cox regression, we studied the relationship between predialysis educational level and access to and outcomes after kidney transplantation. RESULTS: During follow-up, 692 patients were wait-listed and 670 underwent kidney transplantation. Of those, 164 died and 241 lost their allograft (121 from nondeath causes). After multivariate adjustment, college graduates experienced 3 times greater rates of wait-listing (hazard ratio, 2.81; 95% confidence interval, 2.21 to 3.58) or kidney transplantation (hazard ratio, 3.06; 95% confidence interval, 2.38 to 3.92) compared with patients without a high school degree (P for trend across educational level for both outcomes < 0.001). Although mortality was not associated with educational level, increased rates of death-censored allograft loss were observed with less education (P for trend = 0.03). LIMITATIONS: Not a randomized study. CONCLUSION: The latter finding is novel and important and requires confirmation. Its possible mechanisms (eg, adherence to immunosuppressants) warrant additional study.