Structural disparities in deceased donor kidney transplantation: A nationwide analysis of Mexico's decentralized organ distribution and allocation system.

Although disparities in access to kidney transplantation are well-documented, the impact of decentralized, institution-specific allocation systems remains understudied. This study evaluates how structural fragmentation shapes access to deceased donor kidney transplantation among candidates who remained alive and active on the waitlist in Mexico. We conducted a period-prevalent time-to-event analysis using National Transplant Registry data (2014-2024) encompassing 24 698 deceased donor kidney transplant candidates. Access disparities were evaluated across health care sectors (social security, public health, and private) and states using rate-based metrics, Kaplan-Meier, and time-stratified Cox proportional hazards models. Overall, 34.1% of candidates were transplanted. The median waiting time for social security candidates was statistically not reached (<50% transplanted), compared with 21.6 months for public health and 15.4 months for private candidates (P < .001). Time-stratified multivariable analysis revealed substantially higher early transplant hazards for private (adjusted hazard ratio, 6.95; 95% confidence interval, 6.29-7.68) and public health candidates (adjusted hazard ratio, 3.47; 95% confidence interval, 3.22-3.75) versus social security. Organ flow analysis exposed institutional segmentation. Access to deceased donor kidney transplantation in Mexico is profoundly shaped by a decentralized allocation framework that enforces institutional segmentation. These findings underscore the need for standardized national allocation and distribution criteria and enhanced systemic coordination to ensure medical utility and distributive justice.