Ethnocultural Barriers to Pre-Emptive Kidney Transplantation: A Single Centre Retrospective Cohort Study

Aarushi Bansal1, Michelle Kwok1, Shen Cao1, Olusegun Famure1, S. Joseph Kim1, Istvan Mucsi1

1Multiorgan Transplant Program, University Health Network, Toronto, Ontario, Canada


Pre-emptive kidney transplant (PKT) may offer better outcomes compared to kidney transplant (KT) after starting dialysis. There is a well-documented disparity in access to PKT between Caucasians, African Americans and Hispanics in the United States. We assess the association between ethnicity and access to PKT in a large Canadian transplant centre.


Single-centre retrospective cohort study of 1,697 adult patients referred for KT between 2003 and 2012. Information about ethnicity was extracted from medical records, and was categorized (Caucasian; African Canadian; East Asian; South Asian; Other  [Middle Eastern, Pacific Islander, First Nations] or  Unknown). The primary outcome was pre-emptive referral for KT, which was defined as referral preceding the date of dialysis initiation. The secondary outcome was time from referral to receipt of any PKT (deceased or living donor). Univariable associations were assessed using chi-squared test with; the association between ethnicity and pre-emptive referral was adjusted for potential confounders in  multivariable logistic regression models. Multivariable adjusted association between ethnicity and PKT was assessed using Cox proportional hazards regression.


The mean (±SD) age was 49 (±14) years, 60% were male. Forty-three percent of the patients were Caucasian, 10% African Canadian, 9% East Asian, 8% South Asian. Twenty eight percent of patients were referred pre-emptively. Compared to Caucasians, other ethnicities had lower odds ratio (95% CI) of being pre-emptively referred for transplant assessment: African Canadian 0.21(0.13-0.35) East Asian 0.39 (0.25-0.59), South Asian 0.42 (0.27-0.65). Similarly, ethnic minorities were less likely to receive a pre-emptive transplant: African Canadian 0.23 (0.11-0.45), East Asian 0.27 (0.13-0.54), South Asian 0.31 (0.16-0.59). The associations remained significant (p<0.01) after adjusting for age, sex, marital status, language barrier, socioeconomic status, employment status, psychiatric diagnosis, and chronic medical comorbidities.


Our results suggest that significant ethnocultural inequities exist in access to pre-emptive kidney transplant in Canada. Further studies are needed to understand the specific ethnocultural barriers to pre-emptive kidney transplant.


  • Non-organ specific: disparities to outcome & access to healthcare
  • Non-organ specific: economics, public policy, allocation, ethics


 Figure 1 Cumulative probability of receiving pre-emptive kidney transplant by ethnicity.