Purpose: Our objective was to examine racial/ethnic differences in determinants of live-donor kidney transplantation (LDKT) across all major US racial/ethnic groups.

Methods: We performed a retrospective cohort study to examine racial/ethnic differences in determinants of LDKT among 162,308 non-elderly patients who initiated dialysis in 2005-2008. We linked patient-level data from the USRDS and UNOS registries and area-level socioeconomic data from the 2000 US Census. The primary outcome was time from dialysis initiation to receipt of LDKT through Sept. 30, 2008. We analyzed associations of race/ethnicity and time to LDKT using Cox proportional hazards models, and we estimated racial/ethnic differences in the degree of delayed LDKT attributable to demographic, socioeconomic and clinical factors in bootstrap analyses.

Results: Overall, 6126 subjects received a first LDKT during 221,185 person-years. Mean crude rates of LDKT were lowest among blacks (1.05 per 100 person-years [95% CI: 0.1-1.1]), American Indians/Alaska Natives-AIANs (1.22 [0.9-1.7]) and Pacific Islanders (1.47 [1.1-2.0]), intermediate among Hispanics (2.23 [2.1-2.4]) and Asians (3.20 [2.8-3.6]), and highest among whites (4.77 [4.6-4.9]). Disparities in LDKT attenuated but remained clinically and statistically significant after adjustment for demographic, socioeconomic and clinical factors. The largest fraction (34%, 21% and 33%, respectively) of the disparity among blacks, Hispanics and AIANs compared with whites was attributed to adjustment for health insurance and zip code poverty. Measures of pre-dialysis care accounted for 5%, 7%, 4% and 6% of the disparity among blacks, Hispanics, AIANs and Pacific Islanders but none of the disparity among Asians.

Conclusions: In the US, rates of LDKT remain significantly lower among nonwhites relative to whites, but determinants of these disparities appear to vary according to race/ethnicity. Targeted efforts to address race/ethnicity-specific determinants of delays in LDKT may help mitigate these disparities.

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