Probability of Kidney Transplant in the Pediatric ESKD Population by Residence Type

Background: Rurality is a commonly cited barrier to care in pediatric nephrology. Utilization of healthcare by pediatric chronic kidney disease (CKD) patients has been shown to be largely centralized, with more than 86.6% of hospitalized pediatric CKD patients being cared for in urban teaching hospitals in one study. Access to care is a particular problem in CKD as it is a progressive disease that often leads to end-stage kidney disease (ESKD) requiring dialysis and/or kidney transplantation (KT). The goal of this study is to estimate the effect of rural or micropolitan residence, compared to urban residence, on probability of KT in patients with pediatric ESKD in the United States (US). Methods: We performed an observational cohort study using the US Renal Data System (USRDS) to identify pediatric (< 18 years) ESKD patients who have their first ESKD service between 2000 and 2019 and classify them using ZIP codes to rural, micropolitan, or urban residence at time of first ESKD service. Stabilized inverse probability of treatment weighting (IPTW) was used to balance rural, micropolitan, and urban groups based on their baseline covariates. Weighted Cox regression was used to calculate the hazard ratio of experiencing KT for rural and micropolitan patients compared to urban. Sensitivity analyses were run using time-varying residential status, mean and median imputation for missing calculated panel reactive antibody percentage and competing risks regression. Results: The final cohort of 14,404 pediatric (<18 years old) patients had 12,390 patients (86.0%) with urban residence, 1,095 patients (7.6%) with micropolitan residence, and 919 patients (6.4%) with rural residence. Of the cohort, 13,316 patients underwent kidney transplantation and 369 died prior to transplantation. Cox regression showed a non-significant decrease in probability of transplantation for patients who had rural (HR = 0.95, 95% CI = 0.86, 1.06) and micropolitan (HR = 0.99, 95% CI = 0.91, 1.07) residence compared to urban residence. Sensitivity analyses had similar results. Conclusion: Despite differences in healthcare resources between rural, micropolitan, urban areas in the US, once children receive their first ESKD service we did not identify a difference in probability of receiving KT based on rurality of residence.