Educational level as a determinant of access to and outcomes after kidney transplantation in the United States

Background: Disparities in access to kidney transplantation exist, yet few studies investigated educational level as a determinant of access to and outcomes after kidney transplantation. Study Design: Prospective cohort study. Settings & Participants: Nationally representative sample of incident US dialysis patients, in which 3,245 patients reported their educational level. Predictor: Educational level, categorized as some high school, high school graduate, some college, and college graduate. Outcomes & Measurements: Access to kidney transplantation was defined as time from first dialysis treatment to: (1) the day of being wait-listed and (2) first kidney transplantation. Outcomes after kidney transplantation were: (3) all-cause mortality and graft failure ([4] all-cause and [5] death censored). Using Cox regression, we studied the relationship between predialysis educational level and access to and outcomes after kidney transplantation. Results: During follow-up, 692 patients were wait-listed and 670 underwent kidney transplantation. Of those, 164 died and 241 lost their allograft (121 from nondeath causes). After multivariate adjustment, college graduates experienced 3 times greater rates of wait-listing (hazard ratio, 2.81; 95% confidence interval, 2.21 to 3.58) or kidney transplantation (hazard ratio, 3.06; 95% confidence interval, 2.38 to 3.92) compared with patients without a high school degree (P for trend across educational level for both outcomes < 0.001). Although mortality was not associated with educational level, increased rates of death-censored allograft loss were observed with less education (Pfor trend = 0.03). Limitations: Not a randomized study. Conclusion: The latter finding is novel and important and requires confirmation. Its possible mechanisms (eg, adherence to immunosuppressants) warrant additional study.