Where Do We Go From Here: The Enduring Harms of Poverty on Transplant Outcomes

In his 1968 sermon, “Remaining Awake Through a Great Revolution,” Rev. Dr. Martin Luther King Jr asserted, “There is nothing new about poverty. What is new is that we now have the techniques and the resources to get rid of poverty. The real question is whether we have the will.”1 This assertion remains true, even now in 2025, within the field of transplantation. The enduring promise of transplantation is that it delivers substantial survival benefit and improved quality of life for patients with end stage organ failure.2 However, as we continue to advance surgical and immunological techniques, a persistent and sobering reality remains—poverty and other adverse social determinants of health continue to shape transplant outcomes.3–5 In this issue of Transplantation, Mupfudze et al6 examined the associations between individual- and neighborhood-level income with 3-y all-cause graft survival, patient survival, and death-censored graft survival among adult deceased donor kidney transplant (DDKT) and living donor kidney transplant (LDKT) recipients transplanted in the United States. The authors sought to measure the direct and indirect associations between individual- and neighborhood-level income and kidney transplant outcomes by linking data from the Organ Procurement and Transplantation Network registry with estimated individual annual income from LexisNexis and neighborhood median annual household income from the American Community Surveys. The authors also conducted analyses censoring COVID-19-attributed deaths to assess the extent to which the pandemic impacted the relationships between income and transplant outcomes. They hypothesized that individual- versus neighborhood-level income provides distinct contributions to post-kidney transplant disparities; thus, it is essential for transplant professionals to better understand these unique contributions to inform efforts to redress disparities in patient outcomes. Within the study, Mupfudze et al6 analyzed data from 14 091 DDKT recipients and 4565 LDKT recipients in 2020. They found that, as compared with DDKT recipients, LDKT recipients were younger at listing, had both higher median neighborhood and median estimated individual annual incomes, and were more likely to be non-Hispanic White. A total of 12.2% of DDKT recipients (versus 5.2% of LDKT recipients) died within 3 y of receiving a transplant. Among DDKT recipients, those with lower estimated individual annual income had a higher risk of death and 3-y all-cause graft failure compared with those in the highest individual income quartile. DDKT recipients in the lowest neighborhood median annual household income had a higher risk of 3-y all-cause graft failure and death (but similar risk of death-censored graft failure) as compared with recipients in the highest neighborhood income quartile. Censoring for COVID-19-related deaths did not meaningfully change these associations for DDKT recipients. Among LDKT recipients, neither estimated individual annual income nor neighborhood median annual household income was significantly associated with all-cause graft survival, patient survival, or death-censored graft survival at 3 y posttransplant. Censoring for COVID-19 related deaths did not meaningfully change these associations for LDKT recipients. Overall, results from this study suggest that lower estimated individual annual income was strongly associated with a higher risk of all-cause graft failure, largely explained by a higher risk of death, among DDKT recipients (but not LDKT recipients) during the COVID-19 pandemic. Additionally, study authors found that neighborhood-level income had a weaker association with overall graft failure and death than estimated individual-level income. Why should readers care about the finding that estimated individual-level patient income correlates more strongly than aggregated neighborhood-level income with all-cause graft survival and patient survival (but not death-censored graft survival) among DDKT recipients? First, the finding that lower income was not associated with death-censored graft survival (but with all-cause graft survival and patient survival) shifts the conversation from one centered primarily on immunological rejection or organ preservation techniques to broader conversations about modifiable pathways between lower income and higher overall patient mortality rates. This distinction was especially important in 2020, as national data demonstrated substantially higher mortality among lower income groups nationwide. Second, these study results suggest that while neighborhood-level income is often used in biomedical research as a proxy for individual patient income, it may not fully reflect individual socioeconomic circumstances faced by transplant patients; thus, reinforcing an ecological fallacy. For instance, neighborhood-level income does not fully capture individual-level posttransplant comorbidities, access to and quality of follow-up care, abilities to adhere to a complex posttransplant medication regimen, social support, food and housing stability, and other health-influencing social needs.7 This finding also underscores a glaring failure in our field to address a longstanding limitation of national transplant registries—the absence of individual-level income and wealth data. Third, the finding that neither estimated individual-level annual income nor neighborhood median annual household income was significantly associated with all-cause graft survival, patient survival, or death-censored graft survival at 3 y posttransplant for LDKT recipients is noteworthy. The study authors observed a higher average income among LDKT versus DDKT recipients. Ensuring more equitable access to LDKT remains an important goal and will require multilevel interventions to address national declines in living donation and widening racial and income-related disparities in LDKT.8 Where do we go from here? The association of poverty with transplant outcomes is unfortunately not a new observation. What is new is that we now have a growing and robust body of evidence from within and outside of our field to inform strategies to mitigate the harmful effects of poverty on transplantation. The real question is whether we have the will to perform the work needed to better understand and disrupt the deleterious link between poverty, structural inequities, and transplant access and outcomes. This requires building thoughtful and trustworthy relationships with patients, families, and community representatives to better inform health system strategies to address the social determinants of transplant access and outcomes. Transplant and nephrology professionals must also bolster policy changes through meaningful patient advocacy and sustained efforts9,10 to capture more granular, individual-level measures of socioeconomic adversity, which greatly influences transplant access and outcomes.