Educational level and access to kidney transplantation: a 20-year cohort study in Italy

Abstract Background Kidney transplantation (KT) is the best treatment for chronic renal failure, providing improved quality of life, better clinical outcomes, and reduced healthcare costs. Access to KT is governed by strict criteria established in accordance with international guidelines. Aim To investigate the association between educational level (ED) and access to KT among incident dialysis patients in Lazio. Methods From the Lazio Regional Dialysis and Transplant, we selected incident dialysis patients during 2009-2020, aged 20-79 without prior transplants. Using health information systems, we followed-up patients for three years until transplantation or death. The socioeconomic indicator was ED (≤primary, secondary, ≥high school). We applied age-adjusted Cox regression model to explore the relationship between ED and access to KT. Sensitivity analysis using mortality as a competitive risk was applied. The interaction between ED and the period of dialysis incidence (2009-2012,2013-2016,2017-2020) was tested. Results The cohort counted 8,578 incident patients, 66.0% were male, the mean age was 63.0, and 41.4% had high ED. Over three years, 414 patients (4.8%) received a KT, while 2,256 (26.3%) died, with a mean follow-up of 2.6 years. Age-adjusted hazard ratios (HRs) were 1.98 (95%CI 1.34-2.93) for secondary and 3.56 (95%CI 2.49-5.10) for ≥high school vs. ≤primary. In the competing risk analysis, an interaction between ED and period was found; in the 1st period (2009-2012) HR of ≥high school vs. ≤primary was 2.38 (95%CI 1.44-3.93), the same measures in the 2nd and in the 3rd period were 9.34 (95%CI 4.07-21.45) and 3.30 (95%CI 1.59-6.87) respectively. Conclusions The evidence that the less educated have less chance of accessing a KT has been present in Lazio for over 20 years, despite the universal healthcare system. Policies to tackle inequalities in healthcare need to be intensified. Key messages • Higher levels of education significantly increase access to kidney transplantation among dialysis patients in Lazio. • Socioeconomic inequalities in access to transplantation persist over time, despite universal health care, requiring targeted policy actions.