title: The impact of socioeconomic status and geographic remoteness on access to pre-emptive kidney transplantation and transplant outcomes among children.
abstract: BACKGROUND
  Low socioeconomic status (SES) and geographic disparity have been associated with worse outcomes and poorer access to pre-emptive transplantation in the adult end-stage kidney disease (ESKD) population, but little is known about their impact in children with ESKD. The aim of our study was to determine whether access to pre-emptive transplantation and transplant outcomes differ according to SES and geographic remoteness in Australia.
  
  
  METHODS
  Using data from the Australia and New Zealand Dialysis and Transplant Registry (1993-2012), we compared access to pre-emptive transplantation, the risk of acute rejection and graft failure, based on SES and geographic remoteness among Australian children with ESKD (≤ 18 years), using adjusted logistic and Cox proportional hazard modelling.
  
  
  RESULTS
  Of the 768 children who commenced renal replacement therapy, 389 (50.5%) received living donor kidney transplants and 28.5% of these (111/389) were pre-emptive. There was no significant association between SES quintiles and access to pre-emptive transplantation, acute rejection or allograft failure. Children residing in regional or remote areas were 35% less likely to receive a pre-emptive transplant compared to those living in major cities [adjusted odds ratio (OR) 0.65, 95% confidence interval (CI) 0.45-1.0]. There was no significant association between geographic disparity and acute rejection (adjusted OR 1.03, 95% CI 0.68-1.57) or graft loss (adjusted hazard ratio 1.05, 95% CI 0.74-1.41).
  
  
  CONCLUSIONS
  In Australia, children from regional or remote regions are much less likely to receive pre-emptive kidney transplantation. Strategies such as improved access to nephrology services through expanding the scope of outreach clinics, and support for regional paediatricians to promote early referral may ameliorate this inequity.
authors.affiliation: Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia, 2006.
authors.forename: Anna
authors.initials: A
authors.lastname: Francis
authors.affiliation: Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia, 2006.
authors.forename: Madeleine
authors.initials: M
authors.lastname: Didsbury
authors.affiliation: Sir Charles Gairdner Hospital, Nedlands, WA, Australia.
authors.forename: Wai H
authors.initials: WH
authors.lastname: Lim
authors.affiliation: Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia, 2006.
authors.forename: Siah
authors.initials: S
authors.lastname: Kim
authors.affiliation: Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia, 2006.
authors.forename: Sarah
authors.initials: S
authors.lastname: White
authors.affiliation: Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia, 2006.
authors.forename: Jonathan C
authors.initials: JC
authors.lastname: Craig
authors.affiliation: Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia, 2006. germaine.wong@health.nsw.gov.au.
authors.forename: Germaine
authors.initials: G
authors.lastname: Wong
mesh_terms: D000293:Adolescent; D001315:Australia / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D005260:Female; D006084:Graft Rejection / Q000453:epidemiology; D006297:Health Services Accessibility; D054625:Healthcare Disparities / Q000191:economics*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007676:Kidney Failure, Chronic / Q000601:surgery*; D016030:Kidney Transplantation / Q000191:economics / Q000379:methods*; D019520:Living Donors; D008297:Male; D012042:Registries; D006435:Renal Dialysis; D019035:Rural Health Services; D012923:Social Class; D013997:Time Factors; D016896:Treatment Outcome
keywords: Geographic remoteness; Kidney transplantation; Paediatrics; Pre-emptive living donor transplantation; Socioeconomic factors; Survival analyses