Socioeconomic, demographic, and lifestyle factors associated with living kidney donation among individuals exploring the possibility of donating

Introduction: Since 2007, the U.S. National Kidney Registry (NKR) has facilitated over 12,000 living kidney donor transplants through paired exchanges and non-directed donor chains. In 2017, the NKR launched the Donor Automated Screening & History (DASH) system, an online portal that annually prescreens thousands of individuals exploring the possibility of donating a kidney. We aimed to identify socioeconomic, demographic, and lifestyle variables associated with donation and profiles of individuals who may need additional support in navigating the complex pathway to donation.
Methods: This IRB-approved, retrospective study included all potential living donors (PLD) who began the online screening process in DASH, the largest U.S. repository of data on PLDs, from 2019-2023. Donation was ascertained by probabilistic linkage to the Scientific Registry of Transplant Recipients. For PLDs who completed the 100+ question medical history survey, we used modified Poisson regression to predict the probability of donation within 12 months of registering based on self-reported socioeconomic, demographic, and lifestyle factors, adjusting for blood type and medical/psychosocial factors. 1.8% of cases had a missing covariate and were imputed using chained equations. Area under the receiver operator curve (AUC) was calculated on PLDs who registered in Q4 of 2023, which served as a validation cohort.
Results: From 2019-2023, 221,112 (44,222 per year) PLDs began exploring donation in DASH: 113,409 (51%) completed the medical history survey; 90,686 (41%) were referred to a center for evaluation; and 7,783 (4%) donated, as of 3/25. Of the 113,409, 27% were considering donating to a stranger, 25% to a friend; 25%, immediate family; 16%, extended family/other; 7%, acquaintance. Attributes associated with a lower chance of donation within 12 months included being an acquaintance (vs. parent) of the kidney patient (adjusted relative risk, aRR: 0.32); being unemployed (aRR: 0.59); currently using tobacco (aRR: 0.56); being African American (aRR: 0.51); and having concerns about non-reimbursed wages (aRR: 0.64) (Figure). 

The model’s validation AUC was 0.79. Simultaneously accounting for 14 of the most predictive factors, the predicted probability of donation varied from <1% to 41% across 15 LDC profiles (Table).

Conclusion: Over 1,500 individuals donate a kidney each year after being pre-screened through the DASH system. With over 40,000 PLDs considering donation annually, the DASH portal represents an enormous opportunity to increase living donation by ensuring that socioeconomic, lifestyle, and other barriers do not preclude medically eligible, genuinely committed individuals from helping someone in need. Peer mentoring, as well as targeted interventions to address financial hardships, have been implemented by the NKR. Enhancing PLD education and iteratively improving these programs may unlock this online screening system’s full potential.