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https://doi.org/10.1159/000552281

Association Between Rurality and Evaluation Start Among Referred Patients with End Stage Kidney Disease.

May 6, 2026
American journal of nephrology
Angelitta M Britt-Spells +8 more

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Rural residents with end-stage kidney disease have lower access to kidney transplantation, especially in later stages. We examined the impact of rurality on initiation of transplant evaluation and whether this varies by region. We conducted a retrospective cohort study of 86,839 adults (18-80 years) referred for kidney transplantation between 2015 and 2023 in the Early Steps to Transplant Access Registry, linked to United States Renal Data System (USRDS). Rurality was defined using the USRDS variable based on ZIP code using Rural-Urban Commuting Area codes. The primary outcome was evaluation initiation within six months of referral. Fine and Gray competing risks models estimated time to evaluation start, accounting for death as a competing event, with multivariable adjustment and interaction by geographic region; sub-analyses were stratified by ESRD Network. Median time to evaluation was longer for rural patients (166 days) than urban patients (106 days), a pattern consistent across all ESRD Networks. The largest rural-urban time gaps were observed in New York and the Ohio River Valley. Rural residence was associated with an 11% lower likelihood of evaluation initiation (aSHR[95% CI], 0.89[0.86,0.92]). The strongest disparities were in New York (aSHR[95% CI], 0.56[0.50,0.62]) and New England (aSHR[95% CI], 0.76[0.69,0.83]). The Southeast (aSHR[95% CI], 0.90[0.87,0.94]) and Ohio River Valley (aSHR[95% CI], 0.92[0.85,0.99]) showed similar associations. Rural residents were less likely to initiate transplant evaluation compared to urban residents. These findings suggest that rural disparities exist in the early steps of the transplant process, highlighting the need for targeted interventions, especially in regions with lowest access.

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ABSTRACTBackgroundEfforts to identify barriers and improve access to kidney transplantation in the United States are limited by a lack of population‐level data on early steps in the transplant evaluation process.MethodsWe used a rule‐based natural language processing (NLP) approach with clinical notes in the US Veterans Affairs Healthcare System (VA) electronic health record (EHR) and linkage with the United States Renal Data System registry to characterize sequential steps in the kidney transplant evaluation process. Adults with advanced kidney disease (estimated glomerular filtration rate ≤20 mL/min/1.73m2) from 1/1/2012–12/31/2019 who were receiving care within the VA were followed through 12/31/2021.ResultsAmong 45,174 cohort members, the median age was 71 (IQR 64, 80) years, and 97.2% were men. There was documentation of kidney transplant being mentioned as a treatment option for 46.3% of cohort members, 28.2% engaged in some type of evaluation for transplant, and 8.4% were referred to and 5.4% evaluated at a VA kidney transplant center. 6.9% of cohort members were added to the national deceased donor waitlist and 3.1% received a kidney transplant. Compared with events identified through EHR chart search and manual review by two clinicians, NLP identified events within 90 days with a precision of 0.82–0.94 and recall of 0.56–0.89.ConclusionThese results illuminate the substantial proportion of patients who engage in early steps in the kidney transplant evaluation process. The work also demonstrates that NLP can accurately identify these key steps in the process as documented in patients’ EHRs.