Abstract
INTRODUCTION: Social determinants of health (SDOH) are associated with disparities in access to living donor kidney transplantation (LDKT). However, the separate and joint impact of individual- and area-level SDOH on the likelihood of LDKT versus deceased donor kidney transplantation (DDKT) is unclear. METHODS: This retrospective cohort study analyzed adult, kidney-alone recipients transplanted in 2020 or 2022, using data from the organ procurement and transplantation network (OPTN). Individual-level SDOH and patient address were obtained from LexisNexis; area-level SDOH were obtained from the American Community Survey and County Health Rankings. We fit 3 logistic regression models to estimate the effects of the following: (i) individual-level SDOH, (ii) area-level SDOH, and (iii) both individual- and area-level SDOH on the likelihood of LDKT, adjusting for clinical and demographic factors. RESULTS: This study included 38,964 adult kidney recipients; n = 9664 (25%) received a LDKT. In multilevel, multivariable analysis, adjusting for both individual- and area-level SDOH, higher individual income quartiles were associated with higher odds of LDKT (odds ratio[OR] [95% confidence interval, CI]: 1.35[1.23-1.47]; 1.48[1.35-1.63]; 2.07 [1.87-2.30], for quartiles Q2-Q4, respectively, compared with the Q1 [lowest income]). Although attenuated, the association between neighborhood median household income and likelihood of LDKT persisted after adjusting for individual-level income. The impact of insurance, education level, and county-level SDOH on likelihood of LDKT persisted in models adjusting for both individual- and area-level SDOH. CONCLUSION: Our findings suggest that individual- and area-level SDOH play overlapping but distinct roles contributing to disparities in LDKT. Addressing individual- and area-level SDOH is crucial, considering the accentuated effect of income at the individual- rather than area-level.