Sex, Drugs, and the Language of Donor Narratives: Associations With Kidney Acceptance.

Background: Despite the shortage of donor kidneys, nonutilization remains common. We hypothesized that social history language in donor narratives influences acceptance. Using Natural Language Processing, we evaluated how language describing high-risk behaviors interacts with objective data (eg, hepatitis B virus [HBV]/hepatitis C virus [HCV] testing) to affect kidney acceptance. Methods: We queried the Standard Transplant Analysis and Research file (2007-2023), analyzing 151 591 donor narratives with Natural Language Processing to identify 40 topics grouped as Templated Administrative Content and Free-Text Clinical Descriptors. Free-Text Clinical Descriptors were further subdivided into 4 communities, including Social History. Modified Poisson regression modeled associations with acceptance across 3 eras (2007-2014, 2015-2020, 2021-2023), including interactions with HBV/HCV serology. Results: Of 151 591 potential donors, 122 106 (80.55%) were accepted. Positive HBV/HCV testing reduced acceptance in era 1 (risk ratio [RR], 0.773; 95% confidence interval [CI], 0.744-0.802), with attenuation in era 2 (RR, 0.893; 95% CI, 0.878-0.908), and no effect in era 3 (RR, 1.006; 95% CI, 0.993-1.019). Interactions between HBV/HCV positivity and topics reflecting language related to illicit drug use or infectious risk evaluation were associated with reduced acceptance in era 1 only, with no significant interaction in era 2 or era 3. In era 1, interaction terms indicated reduced acceptance for language describing illicit drug use and/or sex in exchange for drugs (RR, 0.665; 95% CI, 0.549-0.805) and infectious risk evaluation (RR, 0.640; 95% CI, 0.452-0.905). Conclusions: The association between high-risk behavioral language and lower kidney acceptance was present in earlier eras but not in the modern era. These findings suggest that the influence of subjective narrative language on decision-making has diminished over time, consistent with advances in antiviral therapy, policy changes, and increased utilization of higher-risk donors.