J Am

Race and Socioeconomic

on the Kidney
Transplant
BERTRAM

L. KASISKE,*

*Dit,ision

of Nephrology,

Minnesota;

Abstract.

This

inequities

in the

eric

renal

and

cohort

Factors
Waiting

Department

study

current

whether

for

listing

patients

univariate

and

using

analyses
to identify
factors
before
initiation
of dialysis.

LONDON,t

of Medicine,

of Research,

investigates

system

transplantation,

WENDY

Department

associated
It includes

United

there
for

Influencing
List

are

cadav-

Network

ance

with early registration

patient
registrations
for

Sharing,

full-time
time);

receiving

(OR

for kidney-pancreas

center

ysis

sis

initiation)

pendent
cluded:

at the

before

males);

dialysis

age

b7

respectively,

was

and

respectively,

The United

States

organs
OPTN

is currently

Sharing

(UNOS).

part in organ
for allocating

exceeded
times

the
have

are

more

equal

(2).

to

UNOS
cadaveric

and

and efficient.
who
the

need

the

system

time,
likely

for

so that

allocating
individuals

to receive

It is understandable

a kidney,
that

once

pin

County

to Dr.
Medical

Bertram

Center,

L. Kasiske.
701

Park

Avenue,

Department
Minneapolis,

1046-6673/0901 1-2 142$03.00/()

Journal of the American
Society of Nephrology
Copyright
0 1998 by the American
Society of Nephrology

made that
physicians

possible,

racial

inequities

directed

at patients

uniform
help

with

fewer

those

counterparts

dialysis.

listing

to be

These

results

the

current

in

in the

and

United

providers,

criteria

to reduce

and

ethnic

and

transplantation

anal-

and

their

renal

may

transplantation
will want

to begin

advantage

as

for cadaveric

these

inequities.

waiting
more

have

waited

regard

all other

factors

there

a decision

has

Henne55415.

is usually

before
before

indicator

possible

who

register

care

no

dialysis
renal

may

be advantageous

who
after

transplanta-

to determine
did

in

or did

patients

in the allocation

with
whether

not
who

initiating

Thus,
practical

initiation

cadaveric

differences

inequities

who

dialysis,

kidney.

offers

we sought

in patients

those

and

patients

for

dialysis

accrual,

Major

to health

Materials
All

time

potential

be an
main-

theoretically

initiating

a cadaveric
usually

listing

before

differences

versus

indicate
access

of early

dialysis.

may

before

waiting
time accrual.
before
maintenance

listing

were

it may
initiating

dialysis

with

transplantation

to waiting

Indeed,
before

a transplant

patients
and
as soon
as

the need for permanent

dialysis
access.
bong waiting
time, preemptive
transplan-

not

before

Because

time.

before

to receive

advantage
other than
We used registration
tion.

waiting

for transplantation

Registering

patients

registering

is an option,
both
registration
to occur

accruing

to register
dialysis.

allow

awards

MN

transplantation,

than
before

mandated

the
transplant

that

remediable

efforts

tation

has

is now

of Medicine,

transplantation,

educated,

likely

for

in recent

kidneys
who

be

and thereby
obviate
However,
given the

Received
February
3, 1998. Accepted
May 9, 1998.
The statements
contained
in this report are solely those of the authors and do
not necessarily
reflect the views of the United Network
for Organ
Sharing.
Correspondence

been
their

as an

point

may

registration

as recently

tenance

take

transplant

time

there

organ

well

pay);

listed
kidney

(OR
=
1.22,
bias for general

a previous

It is concluded

transplantation

a system
that is

As a result,

waiting

Education

Organ

who

However,

a kidney

of organs.
median

States.

programs,

has established
transplantation

had

are less

renal

for

allocate

others

for

who

less

insur-

other

refer-

for

up of transplant

for

system

administer

Network

patients,

supply
and

for waiting

longer

United

is made
workers,

available

being

contract

the

equitable

increased,

than 2 yr (1).
The
UNOS
points

The
by

listed

with
volume
>400
To remove
possible
referral

resources

reference:

private

reference;
not on insulin):
1 .43, reference:
listed for

and

those

financial

and
reference:

to patients

results.

suggest

Procurement
and

similar

minorities,

well

care

limited

1.80,

race,

0.55,

to health
was

1.14,

black

and

to retrieve

of patients

in

attended
1 1 8, and

degree);
0.59,

the Organ

transplantation.
kidneys
for

and

(OR

(OPTN)

UNOS

to be both

school
0.47,

ini.e.,

than

1.91

transplant

created

care

the number

(OR

Network
held

health

designed

(OR

transplantation.

individual

in females

Congress

Transplantation

for

high

Asian/other

0.001)
male,

access

found

Inde-

0 to 8 yr education,
degree
(OR = 0.78,

reference:

and

examined.

likely

prior

>55);

or postdialy-

dialysis
(P <
1.14, reference:

18 to 55

age

(pre-

were

more

no prior transplant);
and received
a college

Hispanic,

years

14%

age

reference:

reference:
college,

and

of registration

predictors
of listing
before
female
(odds ratio [OR] =

listing

I .37,

time

status

1.98,

Medicare

respectively,

(OR

and

dialysis

Virginia.

(OR

with

1 .29,

only);
listed
at a center
reference:
volume
<400).

predicting

Richmond,

1 .24,

the kidney
and kidney-pancreas
waiting
lists between
April 1,
1994, and June 30, 1996 (n
41,596)
from all 238 United
Network
for Organ
Sharing
renal transplant
centers.
Patient
factors

Minneapolis,

employment

and

insulin

Center,

payment

0.35

Placement

D. ELLISONt

Organ

full

(OR

MARY
Medical

white);
than

Early

County
for

ence:
less

multivariate

and

Hennepin

Nephrol 9: 2142-2147, 1998

Soc

dialysis
system,

register
register

could
and/or

in

in general.

Methods
registered

with

UNOS

on

the

national

OPTN

1 , I 994,

and
June 30, 1996, were included in this analysis if their dialysis status at
the time of registration
was known (95.4% of all registrations).
Data
kidney

and

kidney-pancreas

waiting

lists

between

April

J Am Soc Nephrol

were
using

from
the

9: 2142-2147,

238 centers.
The
UNOS
Transplant

included

the

kidney

transplant,

following

400

variables:

period

versus

projected
a center

and

the

across

univariate

(I 994,

out both
we

responses
logistic

we

used

registration

after

dependent

or

this

kidney

status

at registration,

1996).

performed

carried

out

we

was that
registration
individuals

listing

in the final

logistic

per patient.
selected

after

versus

care.

subgroup

of patients

who

analysis

there

one
that

initiating

to health

regression

When

possibility

in access

that
6.12.

including

patients

again.

The

could

than

and

was

one

excluded

differences

dialysis
did

this

had

a previous

by

center

included

than

one

the

others.

in patients

who

may reflect

We

bias

The former
Therefore,

that

more

general

assistance,

or unable

out

only

registraWe

also

registered

differences

separately

analyzing

the

transplant,

reasoning

that

predialysis

versus

those

not be explained

by other

that could

variables.

Multivariate

were
dialysis.

were

Analysis
a total

multiple

of 41 ,596

listings.

A number

registrations

Of all registrants,
of characteristics

of which

1 8.4%
were

different

those not yet on dialysis

listing.
Although
59.3%

and those on dialysis

of all registrations
were

not yet on dialysis,

57.7%

yet on dialysis
prior
transplant.
often

white.

only

were younger
They
were
Patients

were
and
better

not on dialysis

male

were

(Table

1 1.9%

maintenance

defined

of daily

with

been

with

living

a slight

listed

as:

living

was also similar

with-

for those

tendency

for

rather

than

in 1996

the odds of being listed

dialysis

91%,

and

listed

before

times

those

18 to 55

dialysis.

as likely.

47,

The

59, and 55%

Individuals
ment status
dialysis

more

had a
more

of registration

greater

were

before

under-

for females

com-

with individuals
17 yr or younger

who
were

14%

with

years

more

a prior

likely

to be

transplant

of schooling

as likely

were

with

to patients

primary

source

likely,

whereas

likely
volume

to be listed
before
center
were 22%

Patients
istered

those

were

before

obtained

was

prior

kidney

cant

predictors

(Table

whole

3),

only

one

there

of patients

were

population.

similar

Of

(logistic)

those

5944).

to

those

note,

patients

before

with

a greater

likelihood

with

a reduced

likelihood

of patients
was analyzed
(Table
absence
of age as an independent

reglikely

due

found

used

registrations
same.
When
who

dialysis

In general,

had

or
the
had

signifi-

was

reinitiated

to a much
the independent

in part

in the

analysis

of

the

0 to 8 yr of education
of listing
when

before

the larger

2). It is possible
predictor
in this

a surrogate

results
was

statistically

are

however,

compared

became

at a high-

regression

fewer

predictors
=

as

more

predialysis.

per patient

of whether
were the

were

correlated

8 yr of schooling

34%

21%

2).

listed

fewer
(n

time.
whose

only

were

Patients
listed
to be listed

likely

regardless
the results
to only

size

full
those

were

registration

restricted

although

than

insurance

(Table

transplant,

sample

Medicare

multivariate

when

the

dialysis.

required
insulin,
and patients
transplant
were also more

dialysis

identical,

less

dialysis.

with diabetes
who
for a kidney-pancreas

before

sources,

private
more

had,

or whose
employto be listed before

payment

was

with

time,
likely

working

other

of payment

a patient

to be listed

full
more

those

with

those
than 3

been listed before

dialysis.
races
were,
respectively,

as whites

who were employed

was unknown,
were

compared

Compared

correlates

not

yr old

Individuals

more likely the patient

was to have
Blacks,
Hispanics,
and Asian/other

between

I). Those

14%

80% more likely

to be listed
before
dialysis,
whereas
whose
prior transplant
status was unknown
were more

smaller

at the time of
male, of those

were

with males
(Table
2). Compared
more than 55 yr old at listing,
those

not yet on

more likely
to have
educated
and were
at the time

also

Analysis

analysis

Results
Univariate
There

were

of daily

activities

to have

(data not shown).

Thus,
patients
were analyzed,

dialysis

to require

They

status

activities

on dialysis,

not yet on dialysis

the frequency

were listed before

if diabetic,

Functional

The year of listing

assistance.

to be listed
Virtually

patents

to have

of payment.

to be listed at a
at registration.

on dialysis.

performs
to perform

these patients
likely had fewer
barriers
to health
care, at least with
respect
to transplantation.
Finally,
we carried
out logistic
regression
to
determine
the extent to which there were center-specific
differences
in

with which

and,

not

on dialysis.

For all registrations,

model.

version

in more

those

likely

source

was

and those

1994 or 1995.

charac-

listings

more

more likely
on dialysis

to be diabetic

with

limitations,

pared
were

multiple

likely

no activity

I) or

we did not need to make arbitrary

to use for those with more than

that including

more

compared

were

primary

dialysis

predictors).

and registered

and

as a projected

2143

transplant
than
across
categothose
not on

grouped
patients
as
Model
building
was

for all registrations,

to be working

Transplantation

more likely to be listed for a kidney-pancreas

patients
on dialysis.
The distribution
of patients
ries of functional
status
was similar
between

going

kept

for Kidney

yet on dialysis
were
center
than patients

were

insulin

were those used on the

software,

lost the graft,

They

Listing

as the

or center
(the

likely

insurance

anal-

than one center.

Also included
were patients
than one transplant,
i.e. , patients
who regis-

out a second

the

before

(0)

from individuals
who registered
only once.
more weight
than the latter in the analysis.

randomly

more

private

those

and only the variables

were

SAS/STAT

the results

it is possible

registration

addressed

0.05)

<

using

if, for example,

we carried

patient
variables

manner,

(P

a transplant,

were different
would
receive

the

the

across

dialysis

dialysis

for each variable

of this approach
regarding
which

the results

and

in

dialysis

the multivariate
before

on maintenance

stepwise

were listed at more

registered
for more

one. However,

For

For the

differences
after

form. For age, we arbitrarily

41 to 55, and >55 yr old.

We first analyzed

advantage
decisions

test

listing

as the independent

significant

received

to

analyses.

versus

variable.
with

response),

in a forward
was

test
before

placed

the categories

statistically

Analysis

for each

above

registration
18 to 40,

and multivariate

regression
(the

described

In most cases,

tion,

1995,

used

being

variable

teristics

one

during

were

Patients
not
high-volume

race/ethnicity,

of registrations

functional

registering

ysis,

tered,

of previous

achieved,

diabetes/insulin-dependent,

univariate

of patients

all categorical

who
who

number

registration,

analysis,

proportions

were

history

collected
(3). We

Analyses

We carried

UNOS
17,

age,

level

was
Form

payment
source,
registered
at a highwith more than 400 registrations,
where

all centers),

of listing

Statistical

gender,

median

kidney-pancreas
the year

in the database
Registration

education

, at

is approximately

time

information
Candidate

highest

employment
status,
volume
center (i.e.

Early

1998

for

younger

dialysis,
population
that in the
model,
0 to
age.

2 144

Table

Journal

of the American

1. Characteristics

Society

of registrants

who

were

pre-

versus

Overall

(%)

P Value

57.7

59.3

<0.001

yr

3.8

2.7

Male
Age
18 to 40 yr

39.4

36.1

41 to 55 yr

37.5

35.9

>55

yr

14.3

20.2

not reported
Previous
transplant

4.9

5.1

17.6

14.4

Highest
none

education

attended

college

associate

or bachelor

post-college

degree

degree

unknown
Race/ethnicity

0.9

1.1

3.8
27.6

5.8
34.6

20. 1

1 8. 1

14.8

10.5

6.9

4.0

25.9

25.9

white

73.9

56.9

black

13.7

26.1

Hispanic

8.4

1 1.8

Asian

2.7

3.4

other

1.4

1.9

Employment
full time
not
not

53.4

time
working
working

unable

by choice
due to disease

to find

not working
retired
employment
Source

<0.001

<0.001

bevel

Oto8yr
9 to 12 yr

part

9: 2142-2147,

postdiabysis
Predialysis
(%)

Characteristic

l7

J Am Soc Nephrol

of Nephrology

work
for

unknown

status

unknown

reasons

<0.001

<0.001

34.5

6.5

8.2

2.6
19.2

3.8
31.7

0.6

0.8

2.8
4.7
10.0

4.2
7.7
9.0

<0.001

of payment

Medicare
Medicaid

23.2
7.3

other government
private
insurance

65.2

2.2

self
donation
other

or free

care

High-volume

center

50.1
7.6
2.0

<0.001

38.9

1.0

0.8

0.2
0.9

0.2
0.5

40.6

34.3

Diabetic

42.1

36.3

<0.001

Requiring
insulin
Kidney-pancreas

89.6
12.7

82.3
7.1

<0.001
<0.001

8 1 .7

81.9

8.8
0.6

10.4
0.7

9.0

7.0

Functional
no activity

listing

<0.001

status
limits

activities
with assistance
needs total assistance
not applicable/unknown
Listing
in (year)
1994

30.8

31.7

1995

45.6

45.6

1996

23.6

22.7

>0.05

<0.05

1998

J Am Soc Nephrol

Table

9:

The

2.

2142-2147,

odds

of being

initiating

Early

1998

placed

maintenance

on the United

dialysis

for

Network

41,596

Reference

waiting

Transplantation

list before

2145

after

versus

Group

Odds

Ratio

P Value

0.0001

1.136

Age

>55

yr

1.914

0.0001

Age

>55

yr

1.142

0.0001

First

transplant

1 .798

0.0001

First

transplant

3.250

0.0001

0 to 8 yr of schooling

High

school

degree

0.775

0.0004

Attended

High

school

degree

1 176

0.0001

degree

1 .363

0.0001

Age

l7

yr

Age

18 to 55

Prior

transplant

Prior

transplant

yr

unknown

college

Received

a college

degree

High

school

Black

White

0.465

0.0001

Hispanic

White

0.588

0.0001

White

0.548

0.0001

0.0001
0.0001
0.0001

Asian

or other

Full-time

employment

Employment

Medicare
Private

unknown

insurance

From

high-volume

Receiving

centerb

Less

than

full-time

1 .988

Less

than

full-time

1 .496

Other

pay

Other

pay

Low-volume
Not

insulin

Kidney-pancreas

on

0.343
1 .209
1 .222

centerb

0.0001
0.0001

insulin

1.283

0.0001

only

1 .426

0.0001

Kidney

Includes
patients
listed at more than one center.
High volume
is a center
with more than 400 listings.

Table

The odds
for Organ

3.

versus

of being
Sharing

after

prior

graft

renal

placed
(UNOS)
failure

frequently

on the United
Network
waiting
list before
5944

for

patients

only

with

than

0 to 8 yr of

High

schooling

Group

school

Odds .

P Value

1 .384

0.0 153

Ratio

degree

Black

White

0.715

0.0001

Hispanic

White

0.736

0.0048

0.626

0.0114

1.834
1.397

0.0001
0.0012

Otherpay
Other
pay

0.751
1 .579

Non-diabetic

1 .740

0.0135
0.0002
0.0001

Asian

or other

Full-time
Employment

White

Less
Less

employment
unknown

Medicare
Private

insurance

Diabetic
Excludes

multiple

these

suggested
Reference

than
than

full-time
full-time

of the

Superimposing

transplantr

Variable

expected.

12 (5%)
that

centers

(UNOS)

Male

Female

Sharing

for Kidney

registrationsa

Variable

for Organ

Listing

that

there

By chance,
to have

centers

on a map

was

differed

we would

centers

a random

from

the

Renal
Function
at the
Patients
Transplanted

have

entered

into

of the

geographical

norm

(not

expected
the

model.

United

States

distribution

of

shown).

Time of Transplantation
before
Dialysis

for

Of the 7654 registrants

not on dialysis
at the time of listing,
received
a kidney
transplant.
Of these, 1460 had complete

3172

data

(age,

gender,

UNOS
Kidney
tion of creatinine
(4).

body

weight,

Transplant
clearance

Estimated

creatinine

listed

before

dialysis

(mean

at the

SD)

and

serum

creatinine)

from

Registration
Form to allow
using the Cockcroft-Gault
clearance

in

initiation
time

this

was

subset

16.7

the

estimaformula

of

patients

10.2

mb/mm

of transplantation.

listings.

Discussion
Center-Specific

Differences

at

transplant
(after

into
centers

patients

an

centers.

or

for

the model
(36.

in these

less

age,

model

found

indicator

If registrants

more

adjusting

enter

regression

variables

listing)

significantly

86

in a logistic

independent

status

before

In this
of listing

Dialysis

waiting

Initiation
We included
other

in Listing

to correlate
for

from

a particular

likely
gender,

to

centers

entered

were

be

into

listed

each

then

before
that

center

predictor.
the

model,

before

of
center

listed

etc.),

with

with

variable

as an independent

1 %)

(along

the

dialysis
the

238
were

dialysis
would

Surprisingly,
suggesting

dialysis

more

that

or less

tion

study,
could
list earlier

of patients

for

were

prediabysis
at the time
of placement
on the

of renal

already

disease

on dialysis.

than

of

being

on dialysis

subset

of patients,

reasons.
these

was

were

with
that

renal

clearance

transplanted

this

assumption.

function

that

symptoms,
and not for

of creatinine

who

compatible

it is likely

to decline
with time)
placed
on the waiting

Estimates

patients

registra-

We assumed

placed
on dialysis
because
of signs,
indicators
of end-stage
renal disease,

nonmedical
a subset

in the course

who

patients
were
and laboratory
other,

we assumed
that being
be used as an indicator

(which

before

In this
tends

was even better

at the time of being
list than at the time of transplantation

2146

Journal

when

it was

not

be

of the American

measured.

Although

representative

before

of

dialysis,

Society

all

this

patients

it nevertheless

subset

had better

renal

function,

on

in their

course

renal

disease

the

and were

as possible,

UNOS
may

point
wait

likely

patient

as possible

many

American

Society

centers,
least

patients

who

waiting

time

listing

criteria,

study,

a logistic

30,

often

influenced

listing.

educated,

white,

working

coverage

were

with

patients

ethnic

others,
not

may

be

alter

nomically

before

effects

who

care

before

who

relisted

before

had

likely

rest

both

have

suboptimal

to keep
concerns
are

not

barriers

center

coverage.

Indeed,

coverage

for

were

socioeconomic

even

when

there

still

if they

and

There

do not

have
to

of patients
delayed

Even

inequities
ties

to be

employed

ized

and
care

the

is
vast

not

are

to under-

may

services.

is adequate

be more

the transplant
(even

when

overcoming
simply

these

have

influence

health

insurance

coverage

to

of
in this

listing

found

care

race

some

of

steps

system,

major

can
the

very

organ
appear

and

and

allocation

threatens

of altruistic
there
do

trans-

are

of organ

inequity

system
reasons,

there

donato be

these

inequi-

Secretary

things,

these

AM,
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rules

of Health

governing

mandate

criteria

on the
listing

Department

set of rules

listing

bevel

of

that

for

UNOS

could

be

held

criteria

for renal

list.

be

an

current

transplanUNOS
and
to require
filtration

soon.

important

first

disparities

that

The

a consensus

glomerular

implemented

the
UNOS

determining

waiting

Physicians

estimated

likely

of the

donor

of the

a new

Standardstep

appear

toward

to exist

in

system.

Rosendale

JD:

The

1988-1996.

UNOS

In: Clinical

OPTN

waiting

Transplants

list and

1996,

edited

2.
3.

ofCadaveric
Kidneys,
Richmond,
VA, August
1, 1997, Internet
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Network
for Organ
Sharing:
1996 Annual
Report
of the
Scientific

4.

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Transplant

Procurement

and

Transplantation

1988-1995,

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plantation,

utilization
(5).

been
and

to renal

barriers

the system

be placed

criteria

Harper

U.S.

that

waiting

has also
nonwhites,

by Cecka
JM, Terasaki
P1, Los Angeles,
Laboratory,
1997, pp 69-90
United
Network
for Organ Sharing:
UNOS

insurance
had

to affect

However,

that

issued

will

allocation

concerns

study

waiting

30, 1997, in conjunction

with
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Recommendations

some

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due

socioeconomic

a matter

of patients
Others

likely
center,

shown

until

of Transplant

correcting

1.

bevel

transplant

overcome

standardized

can

a threshold

References

who

likely

to

on standardized

Patients

be less

the

Society

caregivers.

majority

factors

uniform,

organ

been

allocation

other

patients

our

payment
However,

Among

(Table
3).
in early listing

coverage
with

Services

listing

and education

cadaveric

addressed.

4, 1998,

before

of steps

(9).

perception

tation
on January
National
Institutes
rate

status,

the

at large.

Human

conference

pa-

number

that

socioeconomic

difficult

On April

American

may

disadvantaged

Identificais influ-

income

organ

and

socioeconomic
factors.
for renal transplantation

have

to ensure

be

in other

others,

time to first renal transplant

for older individuals,
men,
and

transworkers

patients

than

of

to be influ-

on

gender

delay
care

to a growing

employment

placed

in the

coverage
discrepancies
may

gender,

the

should

reaching

Indeed,

likely

white,

is fair.

when
i.e.,

more

were

gender,
and
candidates

be

have

seem

foundation
upon which
our
tion is built.
For whatever

establish

early,

reason.

be taken

OPTN.

socioeco-

that

transplantation

in society

should

of listing
early, and, as a result,
may not
for themselves.
In addition,
patients
who

transplant

and

patients

may

and

centers

and do not get referred

transplant
initiation

earlier

listing.

listed

is not the only

patients

cost

health

these

list

that

suggests

well-founded).
to

early
likely
be

less

to differences

between

on

or

had

that

the analysis

appointments

about

(compared

is due

may

that

insurance

and

plantation

also

socioeconomically
be added

racial

that

who

health

sooner

to renal

a lower

of the

changes

better

of a racial

with

Many

could
manage

listed

can now

and

patients

that

dialysis.

been
age,

patients

dialfactors

better

However,

insurance

initial

did

(before

by race,

for

time (1 ,8). Finally,

shown
to be longer

present

effect

younger,

centers

it less

in general,

disadvantaged

stand the advantages

be good advocates

In the

center

time,

this

factors

had better
insurance
for socioeconomic

with

for

on standardized

a transplant

a prior

socioeconomically

race,

dialysis.

dialysis

full-time,
and
The reasons

list,

list

points

received

to the transplant

patients

Having

dialysis

by

individuals

had previously

referral

that

make

It is possible

nephrobogists

before

(7).

for differences

that

to health

to

This

before

road

enced

had

full

served

of these

disadvantaged

access

a recent

listing
the

trans-

educated,

than

adjusting

reasons

dialysis.

good

less

well

Early
along

center

were

before

less

It is unlikely

the

several

wish

In

their

sooner

and

listed

of patients

because

to be listed

to be

likely

that

for

who
time,

older,

working

populations

than

full

often

coverage).

in the

tients

and socioeconomic

Patients

were

minority,

insurance

did

more
who

the more

(6).

unconsciously,

some

in populations

and

it is possible

or

allow

it less

may

waiting

adherence

consciously,
that

common

may be asked to undergo

a period
they may be asked
to demonstrate

addition,

poll of UNOS

patients

that race

In

make

centers.

found

early

ways

as

is more

to care
which

medical

enced by race,
tion of potential

MD).

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other

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the

Bethesda,

may

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model

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than

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Listing

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on

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