Educational Level as a Determinant of Access to and Outcomes After Kidney Transplantation in the United States
Received 20 August 2007; accepted 16 January 2008. published online 04 April 2008.
Refers to article:
Do You Need to Stay in School to Get a Kidney Transplant?
Jeffrey C. Fink
American Journal of Kidney Diseases
May 2008 (Vol. 51, Issue 5, Pages 717-718) Full Text |
Full-Text PDF (51 KB)
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 (P for 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.
1Department of Medicine, Charité Campus Virchow, Berlin, Germany
2Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
3Department of Medicine, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Address correspondence to Wolfgang C. Winkelmayer, MD, ScD, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, 1620 Tremont St, Ste 3030, Boston, MA 02120.
Because an author of this manuscript is an editor for AJKD, the peer-review and decision-making processes were handled entirely by an Associate Editor (Donald Hricik, MD, University Hospitals of Cleveland) who served as Acting Editor-in-Chief. Details of the journal's procedures for potential editor conflicts are given in the Editorial Policies section of the AJKD website.
ABSTRACT