How Far Is a Kidney Willing to Go? Kidney Transplant Outcomes Based on Distance Donor Kidney Travels to Transplant Centers

Rationale & Objectives: There are growing concerns over inequities and inequality in deceased-donor kidney access. The current allocation system emphasizes distance from the kidney donor, resulting in geographic disparities in kidney transplantation. Increasing the priority radius for deceased-donor kidneys may improve access; however, increasing the distance a kidney travels increases cold ischemia time and may result in worse allograft outcomes. We examined whether donor kidney travel distance is associated with posttransplant outcomes. Study Design: Retrospective cohort study. Setting & Participants: A total of 210,698 deceased-donor kidney transplants performed in the United States from 2000-2020 that were identified in the Organ Procurement and Transplantation Network/United Network for Organ Sharing database. Exposure: Distances were grouped ≤ 50, 50-200, 200-500, 500-1,000, 1,000-2,000, and >2,000 nautical miles from the transplant center. Outcomes: The primary outcome was death-censored graft survival. Secondary outcome measures were delayed graft function, primary nonfunction, and posttransplant serum creatinine levels. Analytical Approach: The Cox regression model with the Breslow method for ties was used to analyze survival data. Results: A total of 210,698 deceased-donor kidney transplants were used in our analysis, and 15,147 kidney transplant recipients were eligible for the multivariable proportional hazard model. In total, 3,488 kidney transplant recipients experienced graft failure at 10 years. Geographic distance demonstrated no significant association with death-censored graft survival (hazard ratios [HRs] of 1.05, 1.11, 1.14, 1.03, and 0.80). Higher kidney donor profile index scores, recipient age, and presence of diabetes were associated with increased graft failure (HR, 1.52, 1.01, and 1.46, respectively). Preemptive transplant was associated with a reduced risk of graft failure (HR, 0.83). Limitations: Our study lacked organ discard rates and a limited number of high-kidney donor profile index scores and donations after cardiac death at longer distances. Conclusions: Donor kidney travel distance was not associated with reduced long-term graft survival. Expanding allocation radius or implementing a national sharing system may improve equity in access without compromising outcomes. Plain-Language Summary: Where a patient lives determines how long they have to wait for a deceased-donor kidney transplant. Currently, deceased-donor kidneys are prioritized for patients listed within 250 nautical miles of the deceased donor’s location. Our research examined whether the distance a kidney is transported results in worse organ survival. Our analysis of 2 decades’ worth of national data showed that kidneys carried across longer distances fared as well as those transplanted shorter distances. This suggests that a broader sharing of donor kidneys could improve the time for kidney transplantation for patients who live in areas with a long waiting time without sacrificing transplant results.