Regional Disparities in Living Donor Kidney Transplantation: An Analysis of Transplant Referral Networks.

Living donor kidney transplantation is the preferred standard of care for most patients with kidney failure. We sought to quantify variation in access to living donor transplantation across referral networks for patients in Australia & New Zealand. We included adults who initiated kidney replacement therapy between 2002-2022. Each patient was mapped to a transplant referral network. For each network, we calculated a standardized living donor transplant ratio by comparing the observed number of living donor transplants within 12 months with the expected number. The expected number was estimated using multivariate Poisson regression with a random effect for each referral network. Overall, 53,313 patients were included. The ratio of observed to expected living donor transplants ranged from 0.36 to 2.11. Of 21 networks, 4 (19%) performed below expected. Initiating treatment at a center with direct transplant unit affiliation, non-metropolitan residence and timely nephrology referral were associated with increased living kidney donor transplantation. Access to living donor kidney transplantation varies substantially across transplant referral networks in Australia & New Zealand. Identifying center-level barriers and facilitators underpinning this variation will be critical to developing targeted center-based strategies to enhance living donation rates.