Social Risk Factors and Kidney Transplant Waitlisting Among Patients Receiving Dialysis: A National Cohort Study

Rationale: Social risk factors (SRFs) include potentially intervenable individual-level social and economic conditions that impact health. Limited data exist on the prevalence of SRFs and their impact on transplantation among individuals receiving dialysis. Study Design: A cross-sectional cohort study. Exposures: The SRF data (housing, food security, utilities, transportation & personal safety) were collected from maintenance dialysis patients at Dialysis Clinic, Inc. from May 2023 to March 2025 using questions from the Accountable Health Communities Health-Related Social Needs Screening Tool. Outcome: Most recent transplant status, defined as neither being waitlisted nor having received a transplant through March 2025. Analytical Approach: A total SRF burden score was assigned to each patient, categorized as screening positive for none (0), one (1), or more than one (>1) SRF. We evaluated the association of SRF burden score and transplant status using logistic regression. Models were adjusted for age, sex, race/ethnicity, dialysis vintage, modality, clinic location, financial status, insurance coverage, and comorbid conditions. Supplementary analyses examined the association between each SRF domain and the outcome. Results: Among 12,994 patients with SRF data, 1,360 (10.5%) had a score of 1 and 445 (3.4%) had a score of >1. In an adjusted model, having one or more SRF was associated with increased odds of not being transplanted or waitlisted for transplant (odds ratio 1.19 [0.99-1.43] and 1.65 [1.14-2.38] for 1 and >1 SRF). Other associated SRFs included being financially uncomfortable (1.54 [1.33-1.78]) and dialyzing in a rural clinic (1.26 [1.11-1.44]). In supplementary analyses, transportation insecurity (2.59 [1.74, 3.87]) had the strongest association with the outcome. Limitations: Residual confounding and exposure misclassification. Conclusions: In a national cohort of maintenance dialysis patients, more than 10% had one or more SRF; this was associated with increased odds of not being transplanted or actively waitlisted. Addressing SRFs, including transportation barriers, may improve access to kidney transplants.