*Purpose: We leveraged a novel data linkage of candidate-level indicators of social determinants of health (SDOH) among kidney waitlist candidates in the United States to study socioeconomic and health disparities contexts of pre-emptive listing.

*Methods: We supplemented Organ Procurement and Transplantation Network (OPTN) data on adult kidney candidates ever waiting in 2020 with address data and proprietary, person-level SDOH data obtained from a private data vendor. We further linked this dataset to sources of county-level health professional shortage areas, tract-level estimated life expectancy, and a block group-level index of neighborhood deprivation. We imputed missing values for key variables using a predictive mean matching methodology. Crude and adjusted logistic regression models using the pooled imputed data assessed odds of listing for transplant before the initiation of dialysis. Age at listing, race/ethnicity, sex, and history of prior transplant were included in the final model, in addition to eight candidate-level SDOH indicators and six measures capturing the SDOH of candidates’ local geographies.

*Results: Individual factors most strongly associated with decreased odds of pre-emptive listing in this cohort of 110,490 candidates included Medicare (aOR = 0.31, CI = 0.30-0.32) and being Black (aOR = 0.47, CI = 0.46-0.49), Hispanic (aOR = 0.50, CI = 0.48-0.52), or Asian/Pacific Islander (aOR = 0.50, CI = 0.48-0.53). Odds of pre-emptive listing also decreased with decreases in estimated income, with the lowest income group having the lowest odds (aOR = 0.65, CI = 0.57-0.74). Living in a rural county, older age, and previous transplant increased adjusted odds of pre-emptive listing, and for each one year increase in county life expectancy, the adjusted odds of pre-emptive listing increased by 1.5% (CI = 1.0-2.0%). Critically, after adjustment for an array of social determinants, the effect estimates for all non-White racial/ethnicity groups only partially attenuated.

*Conclusions: Access to transplant literature extensively discusses pre-emptive listing as a driver of kidney health disparities. This early analysis of SDOH data from a novel waitlist linkage confirms that even when accounting for individual-level socioeconomic factors and the profiles of candidates’ communities, racial/ethnic disparities persist in this critical part of the waitlisting pathway. Clinicians and policymakers should consider the root causes of this racial/ethnic disparity and the degree to which SDOH factors do not fully account for it.

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