Disparities In Kidney Transplantation Research Articles

Pharmacist-Led, Technology-Assisted Study to Improve Medication Safety, Cardiovascular Risk Factor Control, and Racial Disparities in Kidney Transplant Recipients.

Health disparities in African-American (AA) kidney transplant recipients compared with non-AA recipients are well established. Cardiovascular disease (CVD) risk control is a significant mediator of this disparity. To assess the efficacy of improved medication safety, CVD risk control, and racial disparities in kidney transplant recipients. Prospective, pharmacist-led, technology-aided, 6-month interventional clinical trial. A total of 60 kidney recipients with diabetes and hypertension were enrolled. Patients had to be at least one-year post transplant with stable graft function. Primary outcome measured included hypertension, diabetes, and lipid control using intent-to-treat analyses, with differences assessed between AA and non-AA recipients. The participants mean age was 59 years, with 42% being female and 68% being AA. Overall, patients demonstrated improvements in blood pressure <140/90 mmHg (baseline 50% vs. end of study 68%, p=0.054) and hemoglobin A1c <7% (baseline 33% vs. end of study 47%, p=0.061). AAs demonstrated a significant reduction from baseline in systolic blood pressure (-0.86 mmHg per month, p=0.026), which was not evident in non-AAs (-0.13 mmHg per month, p=0.865). Mean HgbA1c decreased from baseline in the overall group (-0.12% per month, p=0.003), which was similar within AAs (-0.11% per month, p=0.004) and non-AAs (-0.14% per month, p=0.029). There were no changes in low-density lipoproteins, triglycerides, or high-density lipoproteins over the course of the study. Medication errors were significantly reduced and self-reported medication adherence significantly improved over the course of the study. These results demonstrate the potential efficacy of a pharmacist-led, technology-aided, educational intervention in improving medication safety, diabetes, and hypertension and reducing racial disparities in AA kidney transplant recipients. (ClinicalTrials.gov NCT02763943).

Awareness of Racial Disparities in Kidney Transplantation among Health Care Providers in Dialysis Facilities.

Despite the important role that health care providers at dialysis facilities have in reducing racial disparities in access to kidney transplantation in the United States, little is known about provider awareness of these disparities. We aimed to evaluate health care providers' awareness of racial disparities in kidney transplant waitlisting and identify factors associated with awareness. We conducted a cross-sectional analysis of a survey of providers from low-waitlisting dialysis facilities (n=655) across all 18 ESRD networks administered in 2016 in the United States merged with 2014 US Renal Data System and 2014 US Census data. Awareness of national racial disparity in waitlisting was defined as responding "yes" to the question: "Nationally, do you think that African Americans currently have lower waitlisting rates than white patients on average?" The secondary outcome was providers' perceptions of racial difference in waitlisting at their own facilities. Among 655 providers surveyed, 19% were aware of the national racial disparity in waitlisting: 50% (57 of 113) of medical directors, 11% (35 of 327) of nurse managers, and 16% (35 of 215) of other providers. In analyses adjusted for provider and facility characteristics, nurse managers (versus medical directors; odds ratio, 7.33; 95% confidence interval, 3.35 to 16.0) and white providers (versus black providers; odds ratio, 2.64; 95% confidence interval, 1.39 to 5.02) were more likely to be unaware of a national racial disparity in waitlisting. Facilities in the South (versus the Northeast; odds ratio, 3.05; 95% confidence interval, 1.04 to 8.94) and facilities with a low percentage of blacks (versus a high percentage of blacks; odds ratio, 1.86; 95% confidence interval, 1.02 to 3.39) were more likely to be unaware. One quarter of facilities had >5% racial difference in waitlisting within their own facilities, but only 5% were aware of the disparity. Among a limited sample of dialysis facilities with low waitlisting, provider awareness of racial disparities in kidney transplant waitlisting was low, particularly among staff who may have more routine contact with patients.

Geographic disparity in kidney transplantation under KAS.

The Kidney Allocation System fundamentally altered kidney allocation, causing a substantial increase in regional and national sharing that we hypothesized might impact geographic disparities. We measured geographic disparity in deceased donor kidney transplant (DDKT) rate under KAS (6/1/2015-12/1/2016), and compared that with pre-KAS (6/1/2013-12/3/2014). We modeled DSA-level DDKT rates with multilevel Poisson regression, adjusting for allocation factors under KAS. Using the model we calculated a novel, improved metric of geographic disparity: the median incidence rate ratio (MIRR) of transplant rate, a measure of DSA-level variation that accounts for patient casemix and is robust to outlier values. Under KAS, MIRR was 1.75 1.811.86 for adults, meaning that similar candidates across different DSAs have a median 1.81-fold difference in DDKT rate. The impact of geography was greater than the impact of factors emphasized by KAS: having an EPTS score ≤20% was associated with a 1.40-fold increase (IRR=1.35 1.401.45 , P<.01) and a three-year dialysis vintage was associated with a 1.57-fold increase (IRR=1.56 1.571.59 , P<.001) in transplant rate. For pediatric candidates, MIRR was even more pronounced, at 1.66 1.922.27 . There was no change in geographic disparities with KAS (P=.3). Despite extensive changes to kidney allocation under KAS, geography remains a primary determinant of access to DDKT.

The ASCENT (Allocation System Changes for Equity in Kidney Transplantation) Study: A Randomized Effectiveness-Implementation Study to Improve Kidney Transplant Waitlisting and Reduce Racial Disparity

IntroductionThe United Network for Organ Sharing (UNOS) implemented a new Kidney Allocation System (KAS) in December 2014 that is expected to substantially reduce racial disparities in kidney transplantation among waitlisted patients. However, not all dialysis facility clinical providers and end-stage renal disease (ESRD) patients are aware of how the policy change could improve access to transplantation.MethodsWe describe the ASCENT (Allocation System Changes for Equity in Kidney Transplantation) study, a randomized, controlled effectiveness-implementation study designed to test the effectiveness of a multicomponent intervention to improve access to the early steps of kidney transplantation among dialysis facilities across the United States. The multicomponent intervention consists of an educational webinar for dialysis medical directors, an educational video for patients and an educational video for dialysis staff, and a dialysis facility−specific transplantation performance feedback report. Materials will be developed by a multidisciplinary dissemination advisory board and will undergo formative testing in dialysis facilities across the United States.ResultsThis study is estimated to enroll ∼600 US dialysis facilities with low waitlisting in all 18 ESRD networks. The co-primary outcomes include change in waitlisting and waitlist disparity at 1 year; secondary outcomes include changes in facility medical director knowledge about KAS, staff training regarding KAS, patient education regarding transplantation, and the intent of the medical director to refer patients for transplantation evaluation.DiscussionThe results from the ASCENT study will demonstrate the feasibility and effectiveness of a multicomponent intervention designed to increase access to the deceased donor kidney waitlist and to reduce racial disparities in waitlisting.

Has the Department of Veterans Affairs Found a Way to Avoid Racial Disparities in the Evaluation Process for Kidney Transplantation?

Minority groups are affected by significant disparities in kidney transplantation (KT) in Veterans Affairs (VA) and non-VA transplant centers. However, prior VA studies have been limited to retrospective, secondary database analyses that focused on multiple stages of the KT process simultaneously. Our goal was to determine whether disparities during the evaluation period for KT exist in the VA as has been found in non-VA settings. We conducted a multicenter longitudinal cohort study of 602 patients undergoing initial evaluation for KT at 4 National VA KT Centers. Participants completed a telephone interview to determine whether, after controlling for medical factors, differences in time to acceptance for transplant were explained by patients' demographic, cultural, psychosocial, or transplant knowledge factors. There were no significant racial disparities in the time to acceptance for KT [Log-Rank χ = 1.04; P = 0.594]. Younger age (hazards ratio [HR], 0.98; 95% confidence interval [CI], 0.97-0.99), fewer comorbidities (HR, 0.89; 95% CI, 0.84-0.95), being married (HR, 0.81; 95% CI, 0.66-0.99), having private and public insurance (HR, 1.29; 95% CI, 1.03-1.51), and moderate or greater levels of depression (HR, 1.87; 95% CI, 1.03-3.29) predicted a shorter time to acceptance. The influence of preference for type of KT (deceased or living donor) and transplant center location on days to acceptance varied over time. Our results indicate that the VA National Transplant System did not exhibit the racial disparities in evaluation for KT as have been found in non-VA transplant centers.

Disparities in kidney transplantation across the United States: Does residential segregation play a role?

BackgroundAlthough residential segregation has been implicated in various negative health outcomes, its association with kidney transplantation has not been examined. MethodsAge- and sex-standardized kidney transplantation rates were calculated from the Scientific Registry of Transplant Recipients, 2000–2013. Population characteristics including segregation indices were derived from the 2010 U.S. Census data and the U.S. Renal Data System. Separate multivariable Poisson regression models were constructed to identify factors independently associated with kidney transplantation among Blacks and Whites. ResultsMedian age- and sex-standardized kidney transplantation rates were 114 per 100,000 for Blacks and 38 per 100,000 for Whites. 16.1% of the U.S. population lived in counties with high segregation. There was no difference in the kidney transplantation rates across the levels of segregation among Blacks and Whites. ConclusionFactors other than residential segregation may play roles in kidney transplantation disparities. Continued efforts to identify these factors may be beneficial in reducing transplantation disparities across the U.S. SummaryUsing the Scientific Registry of Transplant Recipients and U.S. census data, we aimed to determine whether residential segregation was associated with kidney transplantation rates. We found that there was no association between residential segregation and kidney transplantation rates.

Racial/Ethnic Differences in the Association Between Hospitalization and Kidney Transplantation Among Waitlisted End-Stage Renal Disease Patients.

Even after placement on the deceased donor waitlist, there are racial disparities in access to kidney transplant. The association between hospitalization, a proxy for health while waitlisted, and disparities in kidney transplant has not been investigated. We used United States Renal Data System Medicare-linked data on waitlisted end-stage renal disease patients between 2005 and 2009 with continuous enrollment in Medicare Parts A & B (n = 24 581) to examine the association between annual hospitalization rate and odds of receiving a deceased donor kidney transplant. We used multilevel mixed effects models to estimate adjusted odds ratios, controlling for individual-, transplant center-, and organ procurement organization-level clustering. Blacks and Hispanics were more likely than whites to be hospitalized for circulatory system or endocrine, nutritional, and metabolic diseases (P < 0.001). After adjustment, compared with individuals not hospitalized, patients who were hospitalized frequently while waitlisted were less likely to be transplanted (>2 vs 0 hospitalizations/year adjusted odds ratios = 0.57; P < 0.001). Though blacks and Hispanics were more likely to be hospitalized than whites (P < 0.001), adjusting for hospitalization did not change estimated racial/ethnic disparities in kidney transplantation. Individuals hospitalized while waitlisted were less likely to receive a transplant. However, hospitalization does not account for the racial disparity in kidney transplantation after waitlisting.

Quantifying the Race Stratified Impact of Socioeconomics on Graft Outcomes in Kidney Transplant Recipients.

Socioeconomic status (SES) is a significant determinant of health outcomes and may be an important component of the causal chain surrounding racial disparities in kidney transplantation. The social adaptability index (SAI) is a validated and quantifiable measure of SES, with a lack of studies analyzing this measure longitudinally or between races. Longitudinal cohort study in adult kidney transplantation transplanted at a single-center between 2005 and 2012. The SAI score includes 5 domains (employment, education, marital status, substance abuse and income), each with a minimum of 0 and maximum of 3 for an aggregate of 0 to 15 (higher score → better SES). One thousand one hundred seventy-one patients were included; 624 (53%) were African American (AA) and 547 were non-AA. African Americans had significantly lower mean baseline SAI scores (AAs 6.5 vs non-AAs 7.8; P < 0.001). Cox regression analysis demonstrated that there was no association between baseline SAI and acute rejection in non-AAs (hazard ratio [HR], 0.92; 95% confidence interval [95% CI], 0.81-1.05), whereas it was a significant predictor of acute rejection in AAs (HR, 0.89; 95% CI, 0.80-0.99). Similarly, a 2-stage approach to joint modelling of time to graft loss and longitudinal SAI did not predict graft loss in non-AAs (HR, 1.01; 95% CI, 0.28-3.62), whereas it was a significant predictor of graft loss in AAs (HR, 0.23; 95% CI, 0.06-0.93). After controlling for confounders, SAI scores were associated with a lower risk of acute rejection and graft loss in AA kidney transplant recipients, whereas neither baseline nor follow-up SAI predicted outcomes in non-AA kidney transplant recipients.

Racial Disparities in Access to and Outcomes of Kidney Transplantation in Children, Adolescents, and Young Adults: Results From the ESPN/ERA-EDTA (European Society of Pediatric Nephrology/European Renal Association−European Dialysis and Transplant Association) Registry

Racial disparities in kidney transplantation in children have been found in the United States, but have not been studied before in Europe. Cohort study. Data were derived from the ESPN/ERA-EDTA Registry, an international pediatric renal registry collecting data from 36 European countries. This analysis included 1,134 young patients (aged≤19 years) from 8 medium- to high-income countries who initiated renal replacement therapy (RRT) in 2006 to2012. Racial background. Differences between racial groups in access to kidney transplantation, transplant survival, and overall survival on RRT were examined using Cox regression analysis while adjusting for age at RRT initiation, sex, and country of residence. 868 (76.5%) patients were white; 59 (5.2%), black; 116 (10.2%), Asian; and 91 (8.0%), from other racial groups. After a median follow-up of 2.8 (range, 0.1-3.0) years, we found that black (HR, 0.49; 95% CI, 0.34-0.72) and Asian (HR, 0.54; 95% CI, 0.41-0.71) patients were less likely to receive a kidney transplant than white patients. These disparities persisted after adjustment for primary renal disease. Transplant survival rates were similar across racial groups. Asian patients had higher overall mortality risk on RRT compared with white patients (HR, 2.50; 95% CI, 1.14-5.49). Adjustment for primary kidney disease reduced the effect of Asian background, suggesting that part of the association may be explained by differences in the underlying kidney disease between racial groups. No data for socioeconomic status, blood group, and HLA profile. We believe this is the first study examining racial differences in access to and outcomes of kidney transplantation in a large European population. We found important differences with less favorable outcomes for black and Asian patients. Further research is required to address the barriers to optimal treatment among racial minority groups.

Racial disparities in kidney transplantation in the USA

Racial disparities in kidney transplantation in the USA

MP79-04 NATIONAL TRENDS AND RACIAL DISPARITIES IN LIVING KIDNEY DONATION: ANALYSIS OF THE UNITED NETWORK OF ORGAN SHARING 1998-2011

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery I1 Apr 2015MP79-04 NATIONAL TRENDS AND RACIAL DISPARITIES IN LIVING KIDNEY DONATION: ANALYSIS OF THE UNITED NETWORK OF ORGAN SHARING 1998-2011 Akshay Sood, Firas Abdollah, Dane Klett, Wooju Jeong, James Peabody, Quoc-Dien Trinh, Mani Menon, and Jesse Sammon Akshay SoodAkshay Sood More articles by this author , Firas AbdollahFiras Abdollah More articles by this author , Dane KlettDane Klett More articles by this author , Wooju JeongWooju Jeong More articles by this author , James PeabodyJames Peabody More articles by this author , Quoc-Dien TrinhQuoc-Dien Trinh More articles by this author , Mani MenonMani Menon More articles by this author , and Jesse SammonJesse Sammon More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2861AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Kidney transplantation (KT) is the treatment of choice for patients with end stage renal disease (ESRD). Racial disparities exist regarding KT, living-donor KT and living kidney donation. Utilizing a nationwide organ sharing registry, we sought to evaluate whether there has been attenuation in disparities over time. METHODS The United Network of Organ Sharing (UNOS; 1998-2011) database was queried to extract patients undergoing KT, living-donor KT and living kidney donation. The incidences were normalized to ESRD incidence (obtained from freely available United States Renal Data System [USRDS] data) to derive the incidence of KT, living-donor KT and living kidney donation per 1000 ESRD patients. The trends were evaluated using the estimated annual change percent methodology (EAPC). RESULTS A total of 184,303 (living-donor=68,381) patients underwent KT over the study years. The overall rate of KT remained low with only 13.5% of the ESRD patients receiving a kidney; however, an encouraging reduction in racial disparity was noted over the study period (Fig. 1a). The rate of KT in Blacks increased over the study at an annual rate of 2.05% from 111 KT per 1000 ESRD in 1998 cases to 141 KT per 1000 ESRD cases in 2011 (p<0.001). The rate of living-donor KT in Blacks however did not change over the study period (EAPC -0.63%; p=0.519) and this was probably driven by poor living kidney donation rate in Blacks (EAPC -0.59%; p=0.578; Fig. 1a and b). CONCLUSIONS Blacks have 3-fold higher incidence of ESRD when compared to Whites. Our study for the first time shows that there is an encouraging attenuation in racial disparities in KT; nonetheless, the rates of live donation and living-donor KT remain low in Blacks and disparities persist. These findings call for initiation of more aggressive outreach programs and improvement in education, patient-physician communication and counseling of Black patients with ESRD. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1011-e1012 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Akshay Sood More articles by this author Firas Abdollah More articles by this author Dane Klett More articles by this author Wooju Jeong More articles by this author James Peabody More articles by this author Quoc-Dien Trinh More articles by this author Mani Menon More articles by this author Jesse Sammon More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Changes in geographic disparity in kidney transplantation since the final rule.

The national organ allocation system for deceased-donor kidney transplant will endure increased burden as the waitlist expands and organ shortage persists. The Department of Health and Human Services issued the "Final Rule" in 1998 that states "Organs and tissues ought to be distributed on the basis of objective priority criteria and not on the basis of accidents of geography." However, it has not been addressed whether the rule was effective in encouraging regions to share the additional burden equitably. To assess the significance of changes of geographic disparities for four metrics since the rule's adoption: waiting times, transplant rates, pretransplant mortality, and organ quality. Using Organ Procurement and Transplant Network data from 1988 through 2009, annual ranges of the metrics were calculated for all donor service areas and United Network for Organ Sharing regions. Time series analyses were used to compare the metrics before and after the enactment of the Final Rule. A total of 412,127 kidney transplant candidates and 178,163 deceased-donor recipients were analyzed. Demographics varied significantly by region. The ranges of the four metrics have worsened by approximately 30% or more after the Final Rule at both the regional and donor service area levels. Increasing geographic disparity in allocation procedures may yield diverging outcomes and experiences in different locations for otherwise similar candidates. Consensus for measuring allocation discrepancies and policy interventions are required to mitigate the inequities.

Health-related and psychosocial concerns about transplantation among patients initiating dialysis.

Disparities in kidney transplantation remain; one mechanism for disparities in access to transplantation (ATT) may be patient-perceived concerns about pursuing transplantation. This study sought to characterize prevalence of patient-perceived concerns, explore interrelationships between concerns, determine patient characteristics associated with concerns, and assess the effect of concerns on ATT. Prevalences of 12 patient-perceived concerns about pursuing transplantation were determined among 348 adults who recently initiated dialysis, recruited from 26 free-standing dialysis centers around Baltimore, Maryland (January 2009-March 2012). Using variable reduction techniques, concerns were clustered into two categories (health-related and psychosocial) and quantified with scale scores. Associations between patient characteristics and concerns were estimated using modified Poisson regression. Associations between concerns and ATT were estimated using Cox models. The most frequently cited patient-perceived concerns were that participants felt they were doing fine on dialysis (68.4%) and felt uncomfortable asking someone to donate a kidney (29.9%). Older age was independently associated with having high health-related (adjusted relative risk, 1.35 [95% confidence interval, 1.20 to 1.51], for every 5 years older for those ≥ 60 years) or psychosocial (1.15 [1.00 to 1.31], for every 5 years older for those aged ≥ 60 years) concerns, as was being a woman (1.72 [1.21 to 2.43] and 1.55 [1.09 to 2.20]), having less education (1.59 [1.08 to 2.35] and 1.77 [1.17 to 2.68], comparing postsecondary education to grade school or less), and having more comorbidities (1.18 [1.08 to 1.30] and 1.18 [1.07 to 1.29], per one comorbidity increase). Having never seen a nephrologist before dialysis initiation was associated with high psychosocial concerns (1.48 [1.01 to 2.18]). Those with high health-related (0.37 [0.16 to 0.87]) or psychosocial (0.47 [0.23 to 0.95]) concerns were less likely to achieve ATT (median follow-up time 2.2 years; interquartile range, 1.6-3.2). Patient-perceived concerns about pursuing kidney transplantation are highly prevalent, particularly among older adults and women. Reducing these concerns may help decrease disparities in ATT.

Early Graft Loss, Cardiovascular Risk Factor Control and African-American Disparities in Kidney Transplantation.

There is continued and significant debate regarding the salient etiologies associated with racial disparities in kidney transplant (KTX) recipients. Methods: This was a longitudinal cohort study of all adult KTX recipients, comparing African-American (AA) and non-AA recipients that had early graft loss (<5 yrs) to those with graft longevity (surviving graft with at least 5 yrs of follow-up). Results: 524 patients were included, 55% AA, 151 with early graft loss (29%) and 373 with graft longevity (71%). In the entire cohort, early graft loss was significantly associated with disability income (adjusted odds-ratio [AOR] 2.2, 95% CI: 1.1-4.5), kidney donor risk index (AOR 3.2, 1.4-7.5), rehospitalization (AOR 2.1, 1.0-4.4) and acute rejection (AOR 4.4, 1.7-11.6). Unique risk factors in AAs included Medicare only insurance (AOR 8.0, 2.3-28) and BK infection (AOR 5.6, 1.3-25). Unique protective factors in AAs included cardiovascular risk factor control; AAs with a mean systolic BP <150 mmHg had 80% lower risk of early graft loss (AOR 0.2, 0.1-0.7), while LDL <100 mg/dL (AOR 0.4, 0.2-0.8), triglycerides <150 mg/dL (AOR 0.4, 0.2-1.0) and HgbA1C <7% (AOR 0.2, 0.1-0.6) were also protective against early graft loss in AA, but not in non-AA recipients. The figure below demonstrates through ROC curve analysis that CV risk factors and control are predictive for graft loss in AA recipients (C-statistic 0.69, p<0.001), but not in non-AA patients (C-statistic 0.57, p=0.211).Figure: No Caption available.Conclusions: These results demonstrate that AA recipients have unique risk factors for early graft loss, suggesting that controlling CV comorbidities may be an important mechanism to reduce racial disparities in kidney transplantation.

Use of Propensity Scoring to Discern the Predominant Etiologies Surrounding Racial Disparities in Kidney Transplant.

Use of Propensity Scoring to Discern the Predominant Etiologies Surrounding Racial Disparities in Kidney Transplant.

Race, Experience of Discrimination, and Other Non-Medical Factors Predict Differences in Acceptance for Kidney Transplantation.

African Americans (AA) take significantly longer to complete evaluation and be accepted for kidney transplant (KT) than Whites (WH). Race disparities persist even when medical factors are controlled, and non-medical reasons for race disparities are poorly understood. We collected primary data from patients in a large KT center to: (a) compare rates of KT acceptance and time to KT acceptance; and (b) assess if demographics, cultural factors (e.g., perceived discrimination, medical mistrust), psychosocial characteristics (e.g., anxiety, depression), and transplant knowledge (TK) predict time to acceptance. Prospective study, in which patients completed telephone interviews after their first clinic appointment, and again after they were accepted or found ineligible for KT. AA (n=259) were younger, had lower incomes, were more likely to be on public insurance, and less likely to be married than WH (n=773). AA experienced significantly more healthcare discrimination, perceived more overall healthcare racism, had higher levels of medical mistrust, greater family loyalty, and more religious objections to KT than WH (ps<.01). WH had higher KT knowledge (p<.001). Although WH were more likely to accept a living donor volunteer (p<.01), AA were more willing to ask someone for a live kidney donation (p<.001). AA were less likely to be accepted for KT (34 vs 57%) and took significantly longer to be accepted for transplant (median=400 vs 295 days) than WH (ps<.001). AA race, older age, lower education, lower income, being on hemodialysis, and experiencing discrimination in healthcare predicted a lower KT acceptance rate. But, private insurance, having a living donor at the start of evaluation, greater social support, and more KT knowledge predicted a higher acceptance rate. Although data collection is ongoing, and results are preliminary, we suggest that interventions to address racial disparities in KT should incorporate non-medical risk factors in patients. Suggestions for interventions include: fast-track evaluation for at-risk patients, increase contact with patients to ensure follow-through with necessary testing, facilitate scheduling of appointments, recruit former recipients as peer mentors, encourage early evaluation of living donors, and enhance the cultural competency of transplant teams to learn about the reasons that patients may take longer to complete evaluation.

Significant Racial Differences in the Key Factors Associated with Early Graft Loss in Kidney Transplant Recipients

Background: There is continued and significant debate regarding the salient etiologies associated with graft loss and racial disparities in kidney transplant recipients. Methods: This was a longitudinal cohort study of all adult kidney transplant recipients, comparing patients with early graft loss (<5 years) to those with graft longevity (surviving graft with at least 5 years of follow-up) across racial cohorts [African-American (AA) and non-AA] to discern risk factors. Results: 524 patients were included, 55% AA, 151 with early graft loss (29%) and 373 with graft longevity (71%). Consistent within both races, early graft loss was significantly associated with disability income [adjusted odds ratio (AOR) 2.2, 95% CI 1.1-4.5], Kidney Donor Risk Index (AOR 3.2, 1.4-7.5), rehospitalization (AOR 2.1, 1.0-4.4) and acute rejection (AOR 4.4, 1.7-11.6). Unique risk factors in AAs included Medicare-only insurance (AOR 8.0, 2.3-28) and BK infection (AOR 5.6, 1.3-25). Unique protective factors in AAs included cardiovascular risk factor control: AAs with a mean systolic blood pressure <150 mm Hg had 80% lower risk of early graft loss (AOR 0.2, 0.1-0.7), while low-density lipoprotein <100 mg/dl (AOR 0.4, 0.2-0.8), triglycerides <150 mg/dl (AOR 0.4, 0.2-1.0) and hemoglobin A_1C <7% (AOR 0.2, 0.1-0.6) were also protective against early graft loss in AA, but not in non-AA recipients. Conclusions: AA recipients have a number of unique risk factors for early graft loss, suggesting that controlling cardiovascular comorbidities may be an important mechanism to reduce racial disparities in kidney transplantation.

The Extent and Predictors of Waiting Time Geographic Disparity in Kidney Transplantation in the United States

Waiting time to deceased donor kidney transplant varies greatly across the United States. This variation violates the final rule, a federal mandate, which demands geographic equity in organ allocation for transplantation. Retrospective analysis of the United States Renal Data System and United Network for Organ Sharing database from 2000 to 2009. Median waiting time was calculated for each of the 58 donor service areas (DSA) in the United States. Multivariate regression was performed to identify DSA predictors for long waiting times to kidney transplantation. The median waiting time varied between the 58 DSAs from 0.61 to 4.57 years, ranging from 0.59 to 5.17 years for standard criteria donor kidneys and 0.41 to 4.69 years for expanded criteria donor kidneys. The disparity in waiting time between the DSAs grew from 3.26 years (range, 0.41-3.67) in 2000 to 4.72 years (range, 0.50-5.22) in 2009. In DSAs with longer waiting times, there were significantly more patients suffering from end-stage renal disease and more patients listed for kidney transplant, lower kidney procurement rates, and higher transplant center competition. Patients were more likely black, sensitized, with lower educational attainment and less likely to waitlist outside of their DSA of residence. Donor organs used in DSAs with long waiting times were more likely hepatitis C positive and had a higher kidney donor profile index. Graft and patient survival at 5 years was worse for deceased donor kidney transplant, but rates for living donor kidney transplant were higher. Our analysis demonstrates significant and worsening geographic disparity in waiting time for kidney transplant across the DSAs. Increase in living donor kidney transplant and use of marginal organs has not mitigated the disparity. Changes to the kidney allocation system might be required to resolve this extensive geographic disparity in kidney allocation.

Of kin and kidneys: Do kinship networks contribute to racial disparities in living donor kidney transplantation?

In the United States, racial disparities in kidney transplantation are large and especially stark for living donor transplants. Medical researchers frequently attribute this to the availability of medically compatible living kidney donors, who are usually kin. This paper evaluates this hypothesis by testing whether African American transplant candidates likely have lesser access to suitable living donors in their kinship networks than white candidates. This paper evaluates this hypothesis using a simulation design. Contrary to prior research on this topic, this simulation analysis concludes that black-white disparities in living donor kidney transplantation are unlikely to be the result of group differences in the availability of suitable donors. Although individual white kin are individually more likely to be suitable donors, African Americans' larger average kinship networks compensate for this difference.

African-American Attitudes Toward Kidney Transplant: A Comparative Analysis

Racial disparities in kidney transplantation continue to persist despite voluminous studies attempting to address this problem. We conducted 26 semi-structured, one-on-one interviews with African-American and Caucasian dialysis patients to analyze whether or not there is a difference in attitudes toward kidney transplantation and whether or not this contributes to these disparities. Pre-dialysis education strongly correlates with a person’s willingness to get listed, while fear of surgery and care of the transplanted kidney, and interaction with peers who have gone through a failed kidney transplant, decrease the chances of getting listed. Subjects did not report racial bias in being referred or worked up for transplant. African Americans were more likely to weigh the pros and cons of transplants while Caucasians were more likely to see dialysis as temporary and viewed transplant as the default treatment for their kidney failure. All dialysis patients, but especially African Americans, may benefit from transplant education tailored to address specific patient concerns.