White Recipients Research Articles

Interaction between socioeconomic deprivation and ethnicity for likelihood of receiving living-donor kidney transplantation

BackgroundThe interplay between ethnicity and socioeconomic deprivation for living-donor kidney transplantation (LDKT) opportunities is unclear.MethodsData for 2040 consecutive kidney-alone transplant recipients receiving an allograft between 1st January 2007 and 30th June 2020 at a single center were retrospectively analyzed. The associations between the proportions of transplants that were LDKT (versus deceased donation) and both ethnicity and socioeconomic deprivation were assessed, with the latter quantified by the Index of Multiple Deprivation (IMD) quintile.ResultsThe cohort comprised recipients of White (64.7%), South Asian (21.7%), Black (7.0%) and other (6.6%) ethnic groups. Recipients tended to be from socioeconomically deprived areas, with the most deprived quintile being the most frequently observed (quintile 1: 38.6% of patients); non-White recipients were significantly more likely to live in socioeconomically deprived areas (p < 0.001). Overall, 36.5% of transplants were LDKT, with this proportion declining progressively with socioeconomic deprivation, from 50.4 to 27.6% in the least versus most deprived IMD quintile (p < 0.001). A significant difference across recipient ethnicities was also observed, with the proportion of LDKTs ranging from 43.2% in White recipients to 17.8% in Black recipients (p < 0.001). Both socioeconomic deprivation (p < 0.001) and ethnicity (p = 0.005) remained significant predictors of LDKT on multivariable analysis, with a significant interaction between these factors also being observed (p < 0.001). Further assessment of this interaction effect found that, whilst there was a marked difference in the proportions of transplants that were LDKT between White versus non-White recipients in the most socioeconomically deprived groups (39.5% versus 19.3%), no such difference was seen in the least deprived recipients (48.5% versus 51.9%).ConclusionsWhilst both socioeconomic deprivation and non-White ethnicity are independent predictors for lower proportions of LDKTs, the significant interaction between the two factors should be appreciated.

Focal Segmental Glomerulosclerosis (FSGS) Progressing to Collapsing Glomerulopathy in Renal Transplant Recipients With and Without COVID-19 Infection.

Collapsing glomerulopathy (CGN) secondary to HIV or COVID-19 infection mainly occurs in patients of African American descent due to APOL-1 gene mutations, but CGN is occasionally reported in white patients. CGNs are rarely reported in renal transplant biopsies and their association with idiopathic focal segmental glomerulosclerosis (FSGS) is unclear. Patient #1 was a 48-year-old Caucasian white man who had a renal transplant 8 years ago and was recently diagnosed with COVID-19 infection. Two weeks post infection, his serum creatinine (SCr) increased to 2.01 mg/dL from a baseline of 1.40 mg/dL, and he developed concomitant nephrotic range proteinuria. The first renal transplant biopsy showed FSGS. Four weeks later, his sCr level increased to 2.65 mg/dL with worsening proteinuria, and a second renal transplant biopsy revealed CGN. Patient #2 was a 32-year-old African American man whose native renal biopsy revealed primary FSGS. He received a renal transplant with initial post-transplant sCr level at 1.17 mg/dL. Four months later, his sCr and protein-to-creatinine ratio began to rise. Sequential biopsies revealed that the patient had developed recurrent FSGS, which progressed to show features of CGN. The CGN was further confirmed in his transplant kidney graft at autopsy later. This is the first case report of CGN in a white renal recipient with COVID-19 infection. The pathologic presentations of FSGS progressing to collapsing FSGS in our 2 renal transplant recipients suggest that FSGS and GGN may share a common pathophysiologic mechanism of podocytopathy.

Racial disparities and trends in kidney transplant outcomes in patients with Alportsyndrome.

Registry data from Europe has shown an increase in age at end-stage kidney disease for patients with Alport syndrome in recent years. Whether a similar delay in transplant age has occurred in the United States for Alport patients across all racial/ethnic groups is unknown. We used data from the Scientific Registry of Transplant Recipients (SRTR) to identify 3,794 Alport patients transplanted between 12/1987 and 12/2017. We divided the study period into five equal eras to assess temporal trends in age at transplant, graft survival, and patient survival across racial groups using linear regression and Cox regression models. The mean age at transplant for Blacks (28.3 years; difference (Black vs. White): 8.9 years; p < 0.0001) and Hispanics (28.7 years; difference (Hispanics vs. White): 8.7 years; p <0.0001) was significantly younger compared with that of Whites. We observed a temporal increase in age at transplant for Whites but not for Blacks and Hispanics (p-value for interaction: 0.001). Black recipients were at a higher risk of graft loss (aHR: 1.78; 95% CI: 1.47, 2.15; p<0.0001) and death (aHR: 1.73; 95% CI: 1.11, 2.69; p=0.02) compared with White recipients. We observed significant improvements in graft survival with each successive era (p<0.01). Temporal trends in graft survival (interaction p=0.46) were not modified by race. We found racial disparities in age at transplant and long-term graft survival for patients with Alport syndrome in the United States. The age at transplant increased over time for Whites but not Black and Hispanic patients.

Racial Differences in Medication Utilization for Secondary Prevention of Cardiovascular Disease in Kidney Transplant Recipients: A Post Hoc Analysis of the FAVORIT Trial Cohort

Rationale & ObjectiveBlack kidney transplant recipients have higher prevalences of cardiovascular disease (CVD) risk factors and less intensive risk factor control than White kidney transplant recipients. Our objective was to evaluate racial disparities in receipt of statins and aspirin for secondary CVD prevention among kidney transplant recipients in the Folic Acid for Vascular Outcome Reduction in Transplantation (FAVORIT) trial.Study DesignCohort study.Setting & ParticipantsFAVORIT participants of White, Black, and Other races from the United States and Canada with a history of CVD at study entry or who experienced a nonfatal CVD event during follow-up.PredictorRace.OutcomeReceipt of statins and aspirin for secondary CVD prevention.Analytical ApproachWe used parametric (Weibull), proportional-hazards, interval-censored survival models to evaluate the independent association of race with receipt of statins and aspirin for secondary CVD prevention.ResultsOf the 4,110 kidney transplant recipients enrolled in FAVORIT trial, 978 met the inclusion criteria (78% White, 17% Black, and 6% Other race). Compared with the White race, Black and Other races were associated with lower hazards of receiving statins (Black race: adjusted HR, 0.76 [95% CI, 0.60-0.97]; Other race: adjusted HR, 0.87 [95% CI, 0.60-1.27]) and aspirin (Black race: adjusted HR, 0.85 [95% CI, 0.67-1.08]; Other race: adjusted HR, 0.63 [95% CI, 0.43-0.94]).LimitationsLack of granular information on potential indications or contraindications for aspirin or statin use for secondary CVD prevention.ConclusionsPost hoc findings from the FAVORIT trial demonstrated that Black race was associated with a lower likelihood of receiving statins and Other race was associated with a lower likelihood of receiving aspirin for secondary CVD prevention. This represents a potential target to improve CVD care in non-White kidney transplant recipients.

Not a New Story: Place- and Race-Based Disparities in COVID-19 and Influenza Hospitalizations among Medicaid-Insured Adults in New York City.

While SARS-CoV-2 is a novel virus, contagious respiratory illnesses are not a new problem. Limited research has examined the extent to which place- and race-based disparities in severe illness are similar across waves of the COVID-19 pandemic and historic influenza seasons. In this study, we focused on these disparities within a low-income population, those enrolled in Medicaid in New York City. We used 2015–2020 New York State Medicaid claims to compare the characteristics of patients hospitalized with COVID-19 during three separate waves of 2020 (first wave: January 1–April 30, 2020; second wave: May 1–August 31, 2020; third wave: September 1–December 31, 2020) and with influenza during the 2016 (July 1, 2016–June 30, 2017) and 2017 influenza seasons (July 1, 2017–June 30, 2018). We found that patterns of hospitalization by race/ethnicity and ZIP code across the two influenza seasons and the first wave of COVID-19 were similar (increased risk among non-Hispanic Black (aOR = 1.17, 95% CI: 1.10–1.25) compared with non-Hispanic white Medicaid recipients). Black/white disparities in hospitalization dissipated in the second COVID wave and reversed in the third wave. The commonality of disparities across influenza seasons and the first wave of COVID-19 suggests there are community factors that increase hospitalization risk across novel respiratory illness incidents that emerge in the period before aggressive public health intervention. By contrast, convergence in hospitalization patterns in later pandemic waves may reflect, in part, the distinctive public health response to COVID-19.

Abstract WP212: Racial Disparities In Perioperative Stroke And Mortality Following Stroke In Adult Cardiac Transplant Recipients

Introduction: In the general US population, Black adults have a higher stroke incidence and mortality rate after stroke compared to white adults. Among heart transplant recipients, Black adults also have a higher mortality rate beginning 6-12 months post-transplant. Whether there are racial disparities in perioperative stroke incidence and all-cause mortality following perioperative stroke among cardiac transplant recipients is unknown. Methods: Using the Scientific Registry of Transplant Recipients, we examined all adults in the United States who received their first heart transplant between January 2008 - December 2018. We used multivariable conditional logistic regression to assess the association between race and perioperative stroke. We used multivariable Cox proportional hazard regression to examine the association between race and mortality among adults who survived a perioperative stroke. In both models, we included age, sex, hospitalization status, prior ventricular assist device (VAD) implantation, extracorporeal membrane oxygenation (ECMO), calendar year, etiology of heart disease, bilirubin, and functional status as covariates. Results: Among 20,912 adults, 428 (2.7%) white recipients and 126 (2.4%) Black recipients had a perioperative stroke. In a multivariable model, there was 11% lower odds of perioperative stroke in Black recipients compared to white recipients (OR = 0.89, 95% CI: 0.71, 1.12). Among perioperative stroke survivors, mortality rates were similar between Black and white recipients within 6 months (HR = 1.02, 95% CI: 0.70, 1.49) and in long-term follow up (HR = 0.95, 95% CI: 0.52, 1.73). However, our regression results were imprecise. Further adjustment for health behaviors and socioeconomic position did not alter the results. Conclusion: Black recipients experienced a lower incidence of perioperative stroke; however, mortality rates were similar between Black and white recipients following perioperative stroke. These unexpected findings warrant further research.

Race and sex associations with tacrolimus pharmacokinetics in stable kidney transplant recipients.

Study ObjectiveThis study investigated race and sex differences in tacrolimus pharmacokinetics and pharmacodynamics in stable kidney transplant recipients.Design and SettingA cross‐sectional, open‐label, single center, 12‐h pharmacokinetic‐pharmacodynamic study was conducted. Tacrolimus pharmacokinetic parameters included area under the concentration‐time curve (AUC0–12), AUC0–4, 12‐h troughs (C 12 h), maximum concentrations (C max), oral clearance (Cl), with dose‐normalized AUC0–12, troughs, and C max with standardized adverse effect scores. Statistical models were used to analyze end points with individual covariate‐adjustment including clinical factors, genotypic variants CYP3A5*3, CYP3A5*6, CYP3A5*7(CYP3A5*3*6*7) metabolic composite, and ATP binding cassette gene subfamily B member 1 (ABCB1) polymorphisms.Patients65 stable, female and male, Black and White kidney transplant recipients receiving tacrolimus and mycophenolic acid ≥6 months post‐transplant were evaluated.Measurements and Main ResultsBlack recipients exhibited higher tacrolimus AUC0–12 (Race: p = 0.005), lower AUC* (Race: p < 0.001; Race × Sex: p = 0.068), and higher Cl (Race: p < 0.001; Sex: p = 0.066). Greater cumulative (Sex: p < 0.001; Race × Sex: p = 0.014), neurologic (Sex: p = 0.021; Race × Sex: p = 0.005), and aesthetic (Sex: p = 0.002) adverse effects were found in females, with highest scores in Black women. In 84.8% of Black and 68.8% of White patients, the target AUC0–12 was achieved (p = 0.027). In 31.3% of White and 9.1% of Black recipients, AUC0–12 was <100 ng‧h/ml despite tacrolimus troughs in the target range (p = 0.027). The novel CYP3A5*3*6*7 metabolic composite was the significant covariate accounting for 15%–19% of tacrolimus variability in dose (p = 0.002); AUC0–12 h* (p < 0.001), and Cl (p < 0.001).ConclusionsTacrolimus pharmacokinetics and adverse effects were different among stable kidney transplant recipient groups based upon race and sex with interpatient variability associated with the CYP3A5*3*6*7 metabolic composite. More cumulative, neurologic, and aesthetic adverse effects were noted among females. Tacrolimus regimens that consider race and sex may reduce adverse effects and enhance allograft outcomes by facilitating more patients to achieve the targeted AUC0–12 h.

Heart Transplantation for Peripartum Cardiomyopathy: Outcomes Over 3 Decades

BackgroundThis study evaluated trends and outcomes of patients undergoing heart transplantation for peripartum cardiomyopathy (PPCM) over the past 3 decades. MethodsThe United Network for Organ Sharing registry was used to identify patients undergoing isolated heart transplantation between 1987 and 2020. Patients were stratified by the decade of transplantation. Overall survival was compared using Kaplan-Meier analysis, and risk-adjustment was performed using Cox proportional hazards modeling. ResultsA total of 76 009 heart transplantations occurred in the study period, including 20 352 female patients and 809 female patients with PPCM. The frequency of transplantation for PPCM increased over the study period (P = .015). Among female patients, PPCM was significantly associated with 1-year mortality compared with nonischemic cardiomyopathy (hazard ratio, 1.38; 95% CI, 1.11-1.69; P = .004). Among patients with PPCM, Black and Hispanic heart transplant recipients had increased 1-year posttransplant mortality risk compared with White recipients. On Kaplan-Meier survival analysis, early and midterm survival was significantly worse in patients with PPCM compared with other female patients. The 5-, 10-, and 15-year survivals in patients with PPCM were 66.5%, 49.0%, and 40.2% compared with 74.3%, 56.0%, and 37.5% in female heart transplant recipients with other heart failure diagnoses, respectively (P < .001). Survival improved significantly in patients who underwent heart transplantation for PPCM in the latest decade from 2010 to 2020 compared with earlier decades (P < .001), and this improvement was most marked for Black recipients. ConclusionsPatients who underwent heart transplantation for PPCM have a significantly elevated risk for 1-year mortality compared with other female transplant recipients. However, survival among these patients has improved in the last decade, particularly for Black transplant recipients.

Assessing the Causal Link between the COVID-19 Pandemic and Racial Discrimination

In this article, we report the results of a randomized controlled experiment that examines how exposure to information about a global pandemic from Asia affects white Americans’ prosocial behavior towards white, black, and Asian Americans. We find that when exposed to a new disease threat from Asia, (1) white Americans donate significantly less money to Asian American recipients than to white or black American recipients, (2) liberals and conservatives are equally likely to discriminate, and (3) a significant spike in media attention about violence against Asians inhibited this discriminatory behavior—at least temporarily. Our experiment allows us to rule out alternative explanations for the unequal treatment of Asian Americans, providing evidence of a causal link between the COVID-19 pandemic and racial discrimination. The study contributes to knowledge about the spillover effects of external threats on race relations and has implications for public health and science communication.

The Effect of Donor-Recipient Race and Ethnicity Match on Liver Transplantation Outcome in The United States

Introduction: Recipient race/ethnicity (R/E) affect liver transplantation (LT) outcomes. However, the effect of donor R/E or donor-recipient R/E match is not well studied. We aimed to describe the impact of different donor and recipient R/E match on post-LT survival in the United States. Methods: We performed a retrospective study using the Scientific Registry of Transplant Recipient (SRTR) database. Donors and recipients are categorized into five R/E groups: Asian, Black, Latino, non-Latino White, and Others. We used Kaplan-Meier and Cox Proportional Hazards models for statistical analyses, adjusted for donor and recipient covariates. Results: 85,427 LT recipients between 2002 and 2019 were included in this study. Compared to non-Latino white donors or recipients, Asian and Black recipients had the lowest and highest risk of post LT mortality, respectively. Additionally, multivariate-adjusted models demonstrated that receiving Asian donor liver is associated with worse survival in all recipients besides Asians. Furthermore, the mortality risk for Black recipients normalized only when receiving livers from Black donors. However, this advantage of exact R/E matching is not distinctly evident in other R/E groups. Lastly, the effect size of donor and recipient R/E on post-LT survival is comparable to, if not higher than, many other known risk factors such as BMI, receiving cardiac death donor grafts, etc., suggesting unknown sources of variance. Conclusion: Donor and recipient R/E has significant associations with post-LT overall survival. Further studies must identify the uncharacterized social determinants of health and biologic factors with particular attention to addressing systemic racism within practice of LT.

Race and retention in permanent supportive housing: a secondary analysis of housing outcomes

ABSTRACT Despite the overrepresentation of People of Color among people experiencing homelessness and ongoing housing discrimination against racial and ethnic minorities, research has paid scant attention to the intersections of race and homelessness, including assessments of race-related outcomes of permanent supportive housing (PSH), a mainstay homeless assistance program in the U.S. The purpose of this study, therefore, framed by the Public Health Critical Race praxis, was to use secondary Homeless Management Information System (HMIS) data obtained from a Continuum of Care in North Texas to explore the intersections of race and PSH outcomes. Given the high representation of veterans of military service among the sample, and the parallel VA service system generally accessible to veterans, separate analyses examined housing loss among veterans and non-veterans. Findings show that, while race does predict housing loss for all participants or any race or veteran-based subgroup, race was associated with demographic identifiers, such as gender, disabling condition, domestic violence victimization, income, and access to benefits, but these factors were also largely insignificant predictors in regression models. The only demographic identifier predicting housing loss was the number of times an individual was homeless in the last three years, predicting housing loss for all service recipients, White service recipients, and non-veteran service recipients. The results of the study are discussed, including important between-group variations that inform recommendations for administrative policy and practice.

Abstract 9759: Race Moderates the Relationship Between Anxiety and Quality of Life in Implantable Cardioverter Defibrillator Recipients

Introduction: The implantable cardioverter defibrillator (ICD) has significantly decreased mortality for populations at high risk for sudden cardiac arrest. Despite its effectiveness, this treatment modality comes with a high potential for psychological distress. The prevalence rate of anxiety in ICD recipients is 50%, with the highest levels reported in Black ICD recipients, yet little is known about the role of race in the relationship between anxiety and quality of life (QOL). Understanding racial disparities in the experience of ICD recipients has been limited due to low numbers of Black participants in research studies. This is reflective of the clinical reality that fewer Black patients for whom an ICD is appropriate are offered or accept the treatment. Methods: In this cross-sectional study we used the Hayes SPSS Process macro for moderation analysis (model 1) with 5000 bootstrap samples to determine whether race moderated the relationship between anxiety (Brief Symptom Inventory) and QOL (EURO-QOL-5D3L). Results: Using data from 136 participants (18% Black, 27% women with mean age 63 + 12 and education 14 + 3), we entered anxiety, race, and the interaction term into a simultaneous regression model while controlling for gender, age, education, depression, history of shock, and ICD knowledge. The interaction between anxiety and race was significant (B = -.1330, SE = .1339, p &lt; .015), suggesting that the effect of anxiety on QOL differed between Black and White ICD recipients. Together, the variables accounted for approximately 33% of the variance in QOL (R 2 = .33, F (1,126) = 6.08, p &lt; .001). Simple slope tests revealed a significant negative association between anxiety and QOL for Black ICD recipients (B = -.3712, SE = .05, p = .005) but not for White ICD recipients (B = -.0412, SE = .0478, p = .390). Conclusion: Assessment, recognition, and referral for treatment of anxiety in ICD recipients, particularly Black ICD recipients, may improve QOL for this population.

Abstract 12875: The Impact of Social Determinants of Health and Race Disparities in Heart Transplant Long-Term Survival

Introduction: : Patients of color have a higher early mortality risk after heart transplantation than White recipients, even after taking differences in comorbidities into account. We aimed to assess long-term heart transplantation success based on patient's social determinants of health. Hypothesis: Socio-demographic indices that identify patients of socioeconomic (SES) disadvantage can predict poorer heart graft survival. Methods: We studied 34,584 adult heart transplant recipients from 2004 to 2020 using OPTN database. Established and modern SES indices—including the Agency for Healthcare Research and Quality index (AHRQ), the Area Deprivation Index (ADI), Social Vulnerability Index (SVI), Social Deprivation Index (SDI), and Crime Risk index—were evaluated. We performed survival analysis using Kaplan-Meier, univariable and multivariable Cox regression. Penalized LASSO algorithm was used during model development for variable selection among large number of patient characteristics (e.g., recipient and donor biological factors and comorbidities) related to heart transplantation. Results: On average, the worst level of disadvantage across different SES indices resulted in a 20% increased risk of graft failure (Table 1A). After accounting for the recipient and donor biological factors and comorbidities, the recipients' indices remained statistically significant. Non-white patients (HR:1.10, p&lt;0.001), no private insurance (HR:1.19,p&lt;0.001), and education less than college (HR:1.09,p=0.006) were also statistically significant . Donor SES indices had numerically higher hazard ratios, without statistical significance (Table 1B). Conclusions: Recipients access to health care and nonadherence may stem from low health literacy, limited social support, and financial burden. Further efforts should be taken to counsel patients with socioeconomic disadvantages to improve heart transplant outcomes.

Feature Importance of Acute Rejection among Black Kidney Transplant Recipients by Utilizing Random Forest Analysis: An Analysis of the UNOS Database.

Background: Black kidney transplant recipients have worse allograft outcomes compared to White recipients. The feature importance and feature interaction network analysis framework of machine learning random forest (RF) analysis may provide an understanding of RF structures to design strategies to prevent acute rejection among Black recipients. Methods: We conducted tree-based RF feature importance of Black kidney transplant recipients in United States from 2015 to 2019 in the UNOS database using the number of nodes, accuracy decrease, gini decrease, times_a_root, p value, and mean minimal depth. Feature interaction analysis was also performed to evaluate the most frequent occurrences in the RF classification run between correlated and uncorrelated pairs. Results: A total of 22,687 Black kidney transplant recipients were eligible for analysis. Of these, 1330 (6%) had acute rejection within 1 year after kidney transplant. Important variables in the RF models for acute rejection among Black kidney transplant recipients included recipient age, ESKD etiology, PRA, cold ischemia time, donor age, HLA DR mismatch, BMI, serum albumin, degree of HLA mismatch, education level, and dialysis duration. The three most frequent interactions consisted of two numerical variables, including recipient age:donor age, recipient age:serum albumin, and recipient age:BMI, respectively. Conclusions: The application of tree-based RF feature importance and feature interaction network analysis framework identified recipient age, ESKD etiology, PRA, cold ischemia time, donor age, HLA DR mismatch, BMI, serum albumin, degree of HLA mismatch, education level, and dialysis duration as important variables in the RF models for acute rejection among Black kidney transplant recipients in the United States.

Exploring Persistent Racial and Ethnic Representation Disparity in U.S. Geography Doctoral Programs: The Disciplinary Underrepresentation Gap

Underrepresentation among U.S. citizen racial and ethnic minorities in geography has a long history, one perpetuated through—and readily measurable by—its doctoral degree–granting record. This article examines the history of efforts to redress underrepresentation since the 1960s, explores modern underrepresentation, measures the degree of its persistence in the discipline and within individual departments, and identifies drivers that exacerbate the racial and ethnic representation disparity among U.S. citizens in geography doctoral programs. To quantify the degree to which the discipline is underperforming demographically, we contrasted the rate of domestic underrepresented minority doctoral degree conferrals with those of White doctoral recipients in geography, the social sciences, and the entire academy over a twenty-three-year period from 1997 through 2019. During that span, geography consistently trailed the social sciences and the academy: This underrepresentation gap has widened in the past decade. Four drivers were identified: (1) lack of dedicated funding for underrepresented minority doctoral students, (2) minimal prior exposure to academic and professional geography, (3) passive recruitment strategies, and (4) pervasive Whiteness of departments. We conclude with a call to action for geographers to meet the moral imperative of racial and ethnic representational equity by becoming agents of measurable change.

Evaluation of Community-Level Vulnerability and Racial Disparities in Living Donor Kidney Transplant

Living donor kidney transplant (LDKT) is the ideal treatment for end-stage kidney disease, but racial disparities in LDKT have increased over the last 2 decades. Recipient clinical and social factors do not account for LDKT racial inequities, although comprehensive measures of community-level vulnerability have not been assessed. To determine if racial disparities persist in LDKT independent of community-level vulnerability. This retrospective, multicenter, cross-sectional study included data from 19 287 adult kidney-only transplant recipients in the Scientific Registry of Transplant Recipients. The study included individuals who underwent transplant between January 1 and December 31, 2018. Recipient race and the 2018 US Centers for Disease Control and Prevention Social Vulnerability Index (SVI). Census tract-level SVI data were linked to census tracts within each recipient zip code. The median SVI measure among the census tracts within a zip code was used to describe community-level vulnerability. Kidney transplant donor type (deceased vs living). Modified Poisson regression was used to evaluate the association between SVI and LDKT, and to estimate LDKT likelihood among races, independent of community-level vulnerability and recipient-level characteristics. Among 19 287 kidney transplant recipients, 6080 (32%) received LDKT. A total of 11 582 (60%) were male, and the median (interquartile range) age was 54 (43-63) years. There were 760 Black LDKT recipients (13%), 4865 White LDKT recipients (80%), and 455 LDKT recipients of other races (7%; American Indian, Asian, multiracial, and Pacific Islander). Recipients who lived in communities with higher SVI (ie, more vulnerable) had lower likelihood of LDKT compared with recipients who lived in communities with lower SVI (ie, less vulnerable) (adjusted relative risk [aRR], 0.97; 95% CI, 0.96-0.98; P < .001). Independent of community-level vulnerability, compared with White recipients, Black recipients had 37% lower likelihood (aRR, 0.63; 95% CI, 0.59-0.67; P < .001) and recipients of other races had 24% lower likelihood (aRR, 0.76; 95% CI, 0.70-0.82; P < .001) of LDKT. The interaction between SVI and race was significant among Black recipients, such that the disparity in LDKT between Black and White recipients increased with greater community-level vulnerability (ratio of aRRs, 0.67; 95% CI, 0.51-0.87; P = .003). Community-level vulnerability is associated with access to LDKT but only partially explains LDKT racial disparities. The adverse effects of living in more vulnerable communities were worse for Black recipients. The interaction of these constructs is worrisome and suggests evaluation of other health system factors that may contribute to LDKT racial disparities is needed.

Recurrent Focal Segmental Glomerulosclerosis After Kidney Transplantation in African Americans: Review of the Current Evidence.

In many countries of sub-Saharan Africa, the most common causes of end-stage kidney disease are hypertension, chronic glomerulonephritis, and diabetes mellitus. So far, literature on recurrent focal segmental glomerulosclerosis in sub-Saharan African populations is limited. With the intention of providing guidance for best practices in sub-Saharan Africa, we reviewed available evidence for African Americans, a population with a similar genetic background. We chose this population as a pseudo-population to show how similar genetic backgrounds can predict disease occurrence in similar populations residing in different continents. Our extended PubMed and Scopus literature search used these key words: "focal segmental glomerulosclerosis in African Americans" (search 1), "recurrent focal segmental glomerulosclerosis after kidney transplantation" (search 2), "risk factors for recurrent focal segmental glomerulosclerosis" (search 3); and "APOL1 gene and kidney transplantation" (search 4). Search 1 yielded 4 articles, search 2 yielded 44 articles, search 3 yielded 6 articles, and search 4 yielded 8 articles. African Americans were shown to be disproportionately predisposed to endstage kidney disease, traceable to focal segmental glomerulosclerosis (the most common cause of glomerulonephritis leading to end-stage kidney disease). Apolipoprotein L1 presence in 22% of African Americans explained the odds ratio of 17 in developing focal segmental glomerulosclerosis and 8 times lifetime risk of end-stage kidney disease. Focal segmental glomerulosclerosis recurred in 30% of kidney transplant recipients; risk factors included young age, rapid progression to end-stage kidney disease, and White race recipient. Circulating permeability factors played a central role in primary and recurrent focal segmental glomerulosclerosis. For recurrent cases, transplant biopsy has remained the gold standard for diagnosis, with treatment involving a multi-modal approach, often resulting in partial or complete remission of proteinuria; allograft loss can occur if treatment is not successful. More randomized clinical trials are needed to chart the way forward for prolonged allograft function.

Racial, Gender, and Socioeconomic Disparities in Liver Transplantation.

Liver transplantation (LT) is a life-saving therapy; therefore, equitable distribution of this scarce resource is of paramount importance. We searched contemporary literature on racial, gender, and socioeconomic disparities across the LT care cascade in referral, waitlist practices, allocation, and post-LT care. We subsequently identified gaps in the literature and future research priorities. Studies found that racial and ethnic minorities (Black and Hispanic patients) have lower rates of LT referral, more advanced liver disease and hepatocellular carcinoma at diagnosis, and are less likely to undergo living donor LT (LDLT). Gender-based disparities were observed in waitlist mortality and LT allocation. Women have lower LT rates after waitlisting, with size mismatch accounting for much of the disparity. Medicaid insurance has been associated with higher rates of chronic liver disease and poor waitlist outcomes. After LT, some studies found lower overall survival among Black compared with White recipients. Studies have also shown lower literacy and limited educational attainment were associated with increased posttransplant complications and lower use of digital technology. However, there are notable gaps in the literature on disparities in LT. Detailed population-based estimates of the advanced liver disease burden and LT referral and evaluation practices, including for LDLT, are lacking. Similarly, little is known about LT disparities worldwide. Evidence-based strategies to improve access to care and reduce disparities have not been comprehensively identified. Prospective registries and alternative "real-world" databases can provide more detailed information on disease burden and clinical practices. Modeling and simulation studies can identify ways to reduce gender disparities attributed to size or inaccurate estimation of renal function. Mixed-methods studies and clinical trials should be conducted to reduce care disparities across the transplant continuum.

Black Race Is Associated With Higher Rates of Early-Onset End-Stage Renal Disease and Increased Mortality Following Liver Transplantation.

Black race is a risk factor for end-stage renal disease (ESRD). Racial disparities in the risks of early and long-term renal complications after liver transplantation (LT) have not been systematically studied. This study evaluated racial differences in the natural history of acute and chronic renal insufficiency after LT. This was a retrospective single-center cohort study of 763 non-Hispanic White and 181 Black LT recipients between 2008 and 2017. Black race was investigated as an independent predictor of the following outcomes: (1) receipt and duration of early post-LT hemodialysis and (2) time to post-LT ESRD. The interaction of race and post-LT ESRD on survival was also studied. Black recipients had higher rates of pre-LT hypertension (P<0.001), but diabetes mellitus and renal function before LT were not different by race (all P>0.05). Overall, 15.2% of patients required early hemodialysis immediately after LT with no difference by race (covariate-adjusted odds ratio, 0.89; P=0.71). Early dialysis discontinuation was lower among Black recipients (covariate-adjusted hazard ratio [aHR], 0.47; P=0.02), whereas their rate of post-LT ESRD was higher (aHR, 1.91; P=0.005). Post-LT survival after ESRD was markedly worse for Black (aHR, 11.18; P<0.001) versus White recipients (aHR, 5.83; P<0.001; interaction P=0.08). Although Black and White LT recipients had comparable pretransplant renal function, post-LT renal outcomes differed considerably, and the impact of ESRD on post-LT survival was greater for Black recipients. This study highlights the need for an individualized approach to post-LT management to improve outcomes for all patients.

Improving Trends in 6-month Mortality after Heart Transplant in White vs. Black Recipients

<h3>Purpose</h3> We previously reported improving 30-year trends in short-term heart transplant outcomes using Scientific Registry of Transplant Recipients (SRTR). While racial disparities in transplant outcomes are well-documented, how these improving trends differ by racial subgroups has not been studied. <h3>Methods</h3> Using SRTR, we identified all adult heart recipients with racial subgroups white or black. Temporal changes in recipients, donors, and providers were described. Outcome of all-cause death 6 months post-transplant was analyzed by race. Multivariable modified Poisson regression estimated yearly risk of mortality compared to 1989 adjusted for population characteristics and tested for race-year interaction. <h3>Results</h3> Among 58,204 heart recipients, frequency of black recipients increased 8.6%-23.9% from 1989-2017. Known risk factors (<i>e.g.</i> age ≥ 55, IABP) were more frequent in white and increased over 30 years in both groups. More black recipients had initial urgency of Status 1a/b. In black recipients, 9.5% experienced all-cause death within 6 months of transplant compared to 10.2% of white. Adjusting for population characteristics, mortality risk in black recipients was 13% higher relative to white recipients (p<0.05); yet we observed similar improving trends in 6-month mortality over time in black and white recipients (p=0.98). <h3>Conclusion</h3> From 1989 to 2017, an increasing proportion of heart recipients are black, a racial subgroup that continues to be associated with heightened mortality risk within 6 months post-transplant. Nevertheless, 30-year trends in short-term outcomes have been improving irrespective of recipient race.