Invited commentary: Focusing upstream to improve equity in living donor transplantation: From theory to practice in kidney disease

Abstract

The U.S. Department of Health and Human Services in its most recent public health initiative established eliminating health disparities as a priority area with addressing the social determinants of health (SDOH) as an objective to advance health equity. 1 National Academies of Sciences Engineering and Medicine (U.S.)Leading Health Indicators 2030 : Advancing Health, Equity, and Well-Being. National Academies Press, Atlanta2020 Google Scholar Significant disparities based on race and ethnicity exist for patients with end-stage renal disease (ESRD) throughout their disease process. 2 Norton J.M. Moxey-Mims M.M. Eggers P.W. et al. Social determinants of racial disparities in CKD. J Am Soc Nephrol. 2016; 27: 2576-2595https://doi.org/10.1681/ASN.2016010027 Crossref PubMed Scopus (116) Google Scholar In particular, the optimal treatment for ESRD, living donor kidney transplantation, has seen significant disparities increase over the last 2 decades. 3 Purnell T.S. Luo X. Cooper L.A. et al. Association of race and ethnicity with live donor kidney transplantation in the United States from 1995 to 2014. JAMA. 2018; 319: 49-61https://doi.org/10.1001/jama.2017.19152 Crossref PubMed Scopus (131) Google Scholar While national policy has focused on improving equity in the deceased donor allocation system with the New Kidney Allocation System and broader sharing, fewer national policy interventions have been effective at increasing living donation for minority patients. 3 Purnell T.S. Luo X. Cooper L.A. et al. Association of race and ethnicity with live donor kidney transplantation in the United States from 1995 to 2014. JAMA. 2018; 319: 49-61https://doi.org/10.1001/jama.2017.19152 Crossref PubMed Scopus (131) Google Scholar ,4 Klarman S.E. Formica Jr., R.N. The broader sharing of deceased donor kidneys is an ethical and legal imperative. J Am Soc Nephrol. 2020; 31: 1174-1176https://doi.org/10.1681/ASN.2020020121 Crossref PubMed Scopus (6) Google Scholar One effective single-center mechanism for increasing living donation rates among minority patients has been instituting an advocacy program for potential recipients; however, recent work has shown this may not be as beneficial for self-advocates. 5 Locke J.E. Reed R.D. Kumar V. et al. Enhanced advocacy and health systems training through patient navigation increases access to living-donor kidney transplantation. Transplantation. 2020; 104: 122-129https://doi.org/10.1097/TP.0000000000002732 Crossref PubMed Scopus (12) Google Scholar Greater community vulnerability is associated with poor living donor navigator program fidelitySurgeryVol. 172Issue 3PreviewCommunity-level factors contribute to living donor kidney transplantation disparities but may also influence the interventions aimed to mitigate these disparities. The Living Donor Navigator Program was designed to separate the advocacy role from the patient in need of transplantation—friends/family are encouraged to participate as the patients’ advocates to identify living donors, though some of the patients participate alone as self-advocates. Self-advocates have a lower living donor kidney transplantation likelihood compared to the patients with an advocate. Full-Text PDF