End Stage Kidney Disease in Non-citizen Patients: Epidemiology, Treatment, and an Update to Policy in Illinois

Illinois Transplant Fund Experience: Is It a Pathway to Increased Transplant Access for Hispanic Patients With Kidney Failure?

Rationale & Objective

The Illinois Transplant Fund, established in 2015, provides private health insurance premium support for noncitizen patients with kidney failure in Illinois and thus allows them to qualify for kidney transplants. Our objective was to describe trends in kidney transplant volumes over time to inform the development of a hypothesis regarding the impact of the Illinois Transplant Fund on kidney transplant volumes for adult Hispanic patients with kidney failure in Illinois, especially noncitizen patients.

Study Design

Retrospective study.

Setting & Population

We used data on the annual number of kidney transplants and kidney failure prevalence aggregated to the national and state levels from the Organ Procurement and Transplantation Network and United States Renal Data System, respectively.

Outcomes

The annual number of transplants as a percentage of prevalent kidney failure cases among adults over time from 2010 to 2020 by race/ethnicity for all payer and private insurance-paid transplants and the annual number of transplants by citizenship status (for Hispanic patients only) were examined for the United States (US), Illinois, and 6 selected US states.

Analytical Approach

Descriptive study.

Results

From pre- to post-Illinois Transplant Fund, the average annual number of transplants as a percentage of the average annual prevalent kidney failure cases for Hispanic adults increased by 4% in Illinois while the same figure increased by 33% for privately insured transplants.

Limitations

The observations reported in this paper cannot be interpreted as evidence for the program's impact.

Conclusions

Observed trends suggest plausibility of developing a hypothesis that Illinois Transplant Fund's introduction may have contributed to improvement in kidney transplantation access for Hispanic patients in Illinois, especially noncitizens, but cannot constitute evidence in support of or against this hypothesis. Future research should test whether the Illinois Transplant Fund improved access to kidney transplants for noncitizens with kidney failure.

Plain-Language Summary

Health policies regarding kidney transplant access for undocumented residents vary widely by state. The Illinois Transplant Fund (ITF) provides financial support for health insurance premiums, so undocumented patients with kidney failure in Illinois can qualify for a kidney transplant. In this study, we reported kidney transplant trends in Illinois before and after the creation of the ITF along with kidney transplant trends in the US overall and selected states that share similarities to Illinois.

Experiences With Kidney Transplant Among Undocumented Immigrants in Illinois: A Qualitative Study

Rationale & Objective

Noncitizen, undocumented patients with kidney failure have few treatment options in many states, although Illinois allows for patients to receive a transplant regardless of citizenship status. Little information exists about the experiences of noncitizen patients pursuing kidney transplantation. We sought to understand how access to kidney transplantation affects patients, their family, health care providers, and the health care system.

Study Design

A qualitative study with virtually conducted semistructured interviews.

Setting & Participants

Participants were transplant and immigration stakeholders (physicians, transplant center and community outreach professionals), and patients who have received assistance through the Illinois Transplant Fund (listed for or received transplant; patients could complete the interview with a family member).

Analytical Approach

Interview transcripts were coded using open coding and were analyzed using thematic analysis methods with an inductive approach.

Results

We interviewed 36 participants: 13 stakeholders (5 physicians, 4 community outreach stakeholders, and 4 transplant center professionals), 16 patients, and 7 partners. The following seven themes were identified: (1) devastation from kidney failure diagnosis, (2) resource needs for care, (3) communication barriers to care, (4) importance of culturally competent health care providers, (5) negative impacts of policy gaps, (6) new chance at life after transplant, and (7) recommendations for improving care.

Limitations

The patients we interviewed were not representative of noncitizen patients with kidney failure overall or in other states. The stakeholders were also not representative of health care providers because they were generally well informed on kidney failure and immigration issues.

Conclusions

Although patients in Illinois can access kidney transplants regardless of citizenship status, access barriers, and health care policy gaps continue to negatively affect patients, families, health care professionals, and the health care system. Necessary changes for promoting equitable care include comprehensive policies to increase access, diversifying the health care workforce, and improving communication with patients. These solutions would benefit patients with kidney failure regardless of citizenship.

Successful pathways to liver transplant for undocumented immigrants

Liver transplant (LT) for undocumented immigrants presents numerous challenges. Although the United Network for Organ Sharing has implemented multiple policy changes to lessen the disparities in LT throughout the years, undocumented immigrants remain especially marginalized and disadvantaged when compared with other populations. Since 2013, the Mount Sinai Hospital's Recanati Miller Transplant Institute has transplanted 16 undocumented immigrants with successful outcomes. Here, we will share our experience of evaluating, caring for, and transplanting these patients and also highlight our team's mission to ensure that this population has equitable access to lifesaving medical treatment.

Metrics of sexual behavior stigma among cisgender men who have sex with men in Mexico: exploratory and confirmatory factor analyses

Cisgender gay, bisexual, and other men who have sex with men (MSM) in Mexico experience disparities in sexual health outcomes, perhaps most notably in HIV prevalence, HIV testing and status awareness, and condom use. Sexual behavior stigma, underpinned by socio-structural factors specific to Mexico (e.g., machismo), uniquely shapes these sexual health disparities. However, few reliable, valid measures are available to document, track, and ultimately mitigate sexual behavior stigma in this context. Exploratory and confirmatory factor analyses were performed on responses to a 13-item sexual behavior stigma scale from 15,681 MSM recruited online across Mexico. Associations with extracted factors were tested to assess construct validity. Three subscales were identified in exploratory factor analysis and validated in confirmatory factor analysis: "stigma from family and friends" (α = 0.65), "anticipated healthcare stigma" (α = 0.84), and "general social stigma" (α = 0.70). External construct validity was indicated through each subscale's strong association (all p < 0.001) with perceived community intolerance of MSM and perceived community discrimination toward people living with HIV. These subscales show promise as reliable, valid measures for assessing sexual behavior stigma among MSM in Mexico, and as tools for documenting and tracking sexual behavior stigma trends, comparing regional burdens of sexual behavior stigma, and tracking the progress of stigma-mitigation interventions among MSM in Mexico. Future research is needed to understand the extent to which each subscale is differentially associated with sexual (and other) health outcomes, which can inform the development and implementation of uniquely tailored stigma-mitigation, HIV-prevention, HIV-care, and other needed interventions for MSM in Mexico.