Center-level factors and racial disparities in living donor kidney transplantation

Use of Federal Reimbursement for Living Donor Costs by Racial and Ethnic Minorities: Implications for Disparities in Access to Living Donor Transplantation

BACKGROUND

Minority race, ethnicity, and financial barriers are associated with lower rates of living donor (LD) kidney transplantation (LDKT). Financial reimbursement for LD costs may impact social determinants of health and, therefore, impact disparities in access to LDKT.

METHODS

Among US LDKTs, we studied associations between racial and ethnic minority status and utilization of the National Living Donor Assistance Center (NLDAC), a means-tested reimbursement program for nonmedical LD costs. We analyzed demographic, clinical, income, and survey data from NLDAC and the Scientific Registry of Transplant Recipients (January 1, 2011, to December 31, 2022) to identify predictors of NLDAC utilization.

RESULTS

Among 70 069 US LDKTs, 6093 NLDAC applicants were identified (9% of US LDKTs). Racial and ethnic minorities were over-represented in NLDAC-supported LDKTs compared with non-NLDAC US LDKTs (Black donors 12% versus 9%; Black recipients 15% versus 12%; Hispanic donors 21% versus 14%; Hispanic recipients 23% versus 15%; all P < 0.001). Among preemptive transplants, use of NLDAC by donors to Hispanic recipients (11%) was nearly twice as high as that of non-Hispanic recipients (6%) (P < 0.001). At time of NLDAC application, 72% stated NLDAC "will make it possible" to donate; higher proportions of minority applicants agreed (Black 80%, White 70%, P < 0.001; Hispanic 79%, non-Hispanic 70%, P < 0.001). Racial and ethnic minority-concordant transplants were significantly more likely to use NLDAC (donor/recipient: Black/Black risk-adjusted odds ratio [OR], 1.85, other/other OR 2.59, Hispanic/Hispanic OR 1.53; all P < 0.05).

CONCLUSIONS

Reduction of LD financial barriers may increase access to LDKT, particularly in racial and ethnic minority communities.

Neighborhood Segregation and Access to Live Donor Kidney Transplantation

Importance

Identifying the mechanisms of structural racism, such as racial and ethnic segregation, is a crucial first step in addressing the persistent disparities in access to live donor kidney transplantation (LDKT).

Objective

To assess whether segregation at the candidate's residential neighborhood and transplant center neighborhood is associated with access to LDKT.

Design, Setting, and Participants

In this cohort study spanning January 1995 to December 2021, participants included non-Hispanic Black or White adult candidates for first-time LDKT reported in the US national transplant registry. The median (IQR) follow-up time for each participant was 1.9 (0.6-3.0) years.

Main Outcome and Measures

Segregation, measured using the Theil H method to calculate segregation tertiles in zip code tabulation areas based on the American Community Survey 5-year estimates, reflects the heterogeneity in neighborhood racial and ethnic composition. To quantify the likelihood of LDKT by neighborhood segregation, cause-specific hazard models were adjusted for individual-level and neighborhood-level factors and included an interaction between segregation tertiles and race.

Results

Among 162 587 candidates for kidney transplant, the mean (SD) age was 51.6 (13.2) years, 65 141 (40.1%) were female, 80 023 (49.2%) were Black, and 82 564 (50.8%) were White. Among Black candidates, living in a high-segregation neighborhood was associated with 10% (adjusted hazard ratio [AHR], 0.90 [95% CI, 0.84-0.97]) lower access to LDKT relative to residence in low-segregation neighborhoods; no such association was observed among White candidates (P for interaction = .01). Both Black candidates (AHR, 0.94 [95% CI, 0.89-1.00]) and White candidates (AHR, 0.92 [95% CI, 0.88-0.97]) listed at transplant centers in high-segregation neighborhoods had lower access to LDKT relative to their counterparts listed at centers in low-segregation neighborhoods (P for interaction = .64). Within high-segregation transplant center neighborhoods, candidates listed at predominantly minority neighborhoods had 17% lower access to LDKT relative to candidates listed at predominantly White neighborhoods (AHR, 0.83 [95% CI, 0.75-0.92]). Black candidates residing in or listed at transplant centers in predominantly minority neighborhoods had significantly lower likelihood of LDKT relative to White candidates residing in or listed at transplant centers located in predominantly White neighborhoods (65% and 64%, respectively).

Conclusions

Segregated residential and transplant center neighborhoods likely serve as a mechanism of structural racism, contributing to persistent racial disparities in access to LDKT. To promote equitable access, studies should assess targeted interventions (eg, community outreach clinics) to improve support for potential candidates and donors and ultimately mitigate the effects of segregation.

Racialized and Immigrant Status and the Pursuit of Living Donor Kidney Transplant - a Canadian Cohort Study

Introduction

Both immigrant and racialized status may be associated with the pursuit of living donor kidney transplant (LDKT).

Methods

This study was a secondary analysis of a convenience cross-sectional sample of patients with kidney failure in Toronto, obtained from our "Comprehensive Psychosocial Research Data System" research database. The exposures included racialized, immigrant, and combined immigrant and racialized status (White nonimmigrant, racialized nonimmigrant, White immigrant and racialized immigrant). Outcomes include the following: (i) having spoken about LDKT with others, (ii) having a potential living donor (LD) identified, (iii) having allowed others to share the need for LDKT, (iv) having directly asked a potential donor to be tested, and (v) accept a hypothetical LDKT offer. We assessed the association between exposure and outcomes using univariable, and multivariable binary or multinominal logistic regression (reference: White or White nonimmigrant participants).

Results

Of the 498 participants, 281 (56%) were immigrants; 142 (28%) were African, Caribbean, and Black (ACB); 123 (25%) were Asian; and 233 (47%) were White. Compared to White nonimmigrants, racialized immigrants (relative risk ratio [RRR]: 2.98; 95% confidence interval [CI]: 1.76-5.03) and racialized nonimmigrants (RRR: 2.84; 95% CI: 1.22-6.65) were more likely not to have spoken about LDKT with others (vs. having spoken or planning to do so). Both racialized immigrant (odds ratio [OR]: 4.07; 95% CI: 2.50-6.34), racialized nonimmigrants (OR: 2.68; 95% CI: 1.31-5.51) and White immigrants (OR: 2.68; 95% CI: 1.43-5.05) were more likely not to have a potential LD identified.

Conclusion

Both racialized and immigrant status are associated with less readiness to pursue LDKT. Supporting patients to communicate their need for LDKT may improve equitable access to LDKT.

Improving Health Equity in Living Donor Kidney Transplant: Application of an Implementation Science Framework

BACKGROUND

Interventions to improve racial equity in access to living donor kidney transplants (LDKT) have focused primarily on patients, ignoring the contributions of clinicians, transplant centers, and health system factors. Obtaining access to LDKT is a complex, multi-step process involving patients, their families, clinicians, and health system functions. An implementation science framework can help elucidate multi-level barriers to achieving racial equity in LDKT and guide the implementation of interventions targeted at all levels.

METHODS

We adopted the Pragmatic Robust Implementation and Sustainability Model (PRISM), an implementation science framework for racial equity in LDKT. The purpose was to provide a guide for assessment, inform intervention design, and support planning for the implementation of interventions.

RESULTS

We applied 4 main PRISM domains to racial equity in LDKT: Organizational Characteristics, Program Components, External Environment, and Patient Characteristics. We specified elements within each domain that consider perspectives of the health system, transplant center, clinical staff, and patients.

CONCLUSION

The applied PRISM framework provides a foundation for the examination of multi-level influences across the entirety of LDKT care. Researchers, quality improvement staff, and clinicians can use the applied PRISM framework to guide the assessment of inequities, support collaborative intervention development, monitor intervention implementation, and inform resource allocation to improve equity in access to LDKT.

Distinct clinical profiles and post-transplant outcomes among kidney transplant recipients with lower education levels: uncovering patterns through machine learning clustering

BACKGROUND

Educational attainment significantly influences post-transplant outcomes in kidney transplant patients. However, research on specific attributes of lower-educated subgroups remains underexplored. This study utilized unsupervised machine learning to segment kidney transplant recipients based on education, further analyzing the relationship between these segments and post-transplant results.

METHODS

Using the OPTN/UNOS 2017-2019 data, consensus clustering was applied to 20,474 kidney transplant recipients, all below a college/university educational threshold. The analysis concentrated on recipient, donor, and transplant features, aiming to discern pivotal attributes for each cluster and compare post-transplant results.

RESULTS

Four distinct clusters emerged. Cluster 1 comprised younger, non-diabetic, first-time recipients from non-hypertensive younger donors. Cluster 2 predominantly included white patients receiving their first-time kidney transplant either preemptively or within three years, mainly from living donors. Cluster 3 included younger re-transplant recipients, marked by elevated PRA, fewer HLA mismatches. In contrast, Cluster 4 captured older, diabetic patients transplanted after prolonged dialysis duration, primarily from lower-grade donors. Interestingly, Cluster 2 showcased the most favorable post-transplant outcomes. Conversely, Clusters 1, 3, and 4 revealed heightened risks for graft failure and mortality in comparison.

CONCLUSIONS

Through unsupervised machine learning, this study proficiently categorized kidney recipients with lesser education into four distinct clusters. Notably, the standout performance of Cluster 2 provides invaluable insights, underscoring the necessity for adept risk assessment and tailored transplant strategies, potentially elevating care standards for this patient cohort.

Racial Equity in Living Donor Kidney Transplant Centers, 2008-2018

Importance

It is unclear whether center-level factors are associated with racial equity in living donor kidney transplant (LDKT).

Objective

To evaluate center-level factors and racial equity in LDKT during an 11-year time period.

Design, Setting, and Participants

A retrospective cohort longitudinal study was completed in February 2023, of US transplant centers with at least 12 annual LDKTs from January 1, 2008, to December 31, 2018, identified in the Health Resources Services Administration database and linked to the US Renal Data System and the Scientific Registry of Transplant Recipients.

Main Outcomes and Measures

Observed and model-based estimated Black-White mean LDKT rate ratios (RRs), where an RR of 1 indicates racial equity and values less than 1 indicate a lower rate of LDKT of Black patients compared with White patients. Estimated yearly best-case center-specific LDKT RRs between Black and White individuals, where modifiable center characteristics were set to values that would facilitate access to LDKT.

Results

The final cohorts of patients included 394 625 waitlisted adults, of whom 33.1% were Black and 66.9% were White, and 57 222 adult LDKT recipients, of whom 14.1% were Black and 85.9% were White. Among 89 transplant centers, estimated yearly center-level RRs between Black and White individuals accounting for center and population characteristics ranged from 0.0557 in 2008 to 0.771 in 2018. The yearly median RRs ranged from 0.216 in 2016 to 0.285 in 2010. Model-based estimations for the hypothetical best-case scenario resulted in little change in the minimum RR (from 0.0557 to 0.0549), but a greater positive shift in the maximum RR from 0.771 to 0.895. Relative to the observed 582 LDKT in Black patients and 3837 in White patients, the 2018 hypothetical model estimated an increase of 423 (a 72.7% increase) LDKTs for Black patients and of 1838 (a 47.9% increase) LDKTs for White patients.

Conclusions and Relevance

In this cohort study of patients with kidney failure, no substantial improvement occurred over time either in the observed or the covariate-adjusted estimated RRs. Under the best-case hypothetical estimations, modifying centers' participation in the paired exchange and voucher programs and increased access to public insurance may contribute to improved racial equity in LDKT. Additional work is needed to identify center-level and program-specific strategies to improve racial equity in access to LDKT.

Disparities in Kidney Transplant Waitlisting Among Young Patients Without Medical Comorbidities

Importance

Disparities in kidney transplant referral and waitlisting contribute to disparities in kidney disease outcomes. Whether these differences are rooted in population differences in comorbidity burden is unclear.

Objective

To examine whether disparities in kidney transplant waitlisting were present among a young, relatively healthy cohort of patients unlikely to have medical contraindications to kidney transplant.

Design, Setting, and Participants

This retrospective cohort study used the US Renal Data System Registry to identify patients with end-stage kidney disease who initiated dialysis between January 1, 2005, and December 31, 2019. Patients who were older than 40 years, received a preemptive transplant, were preemptively waitlisted, or had documented medical comorbidities other than hypertension or smoking were excluded, yielding an analytic cohort of 52 902 patients. Data were analyzed between March 1, 2022, and February 1, 2023.

Main Outcome(s) and Measure(s)

Kidney transplant waitlisting after dialysis initiation.

Results

Of 52 902 patients (mean [SD] age, 31 [5] years; 31 132 [59%] male; 3547 [7%] Asian/Pacific Islander, 20 782 [39%] Black/African American, and 28 006 [53%] White) included in the analysis, 15 840 (30%) were waitlisted for a kidney transplant within 1 year of dialysis initiation, 11 122 (21%) were waitlisted between 1 and 5 years after dialysis initiation, and 25 940 (49%) were not waitlisted by 5 years. Patients waitlisted within 1 year of dialysis initiation were more likely to be male, to be White, to be employed full time, and to have had predialysis nephrology care. There were large state-level differences in the proportion of patients waitlisted within 1 year (median, 33%; range, 15%-58%). In competing risk regression, female sex (adjusted subhazard ratio [SHR], 0.92; 95% CI, 0.90-0.94), Hispanic ethnicity (SHR, 0.77; 95% CI, 0.75-0.80), and Black race (SHR, 0.66; 95% CI, 0.64-0.68) were all associated with lower waitlisting after dialysis initiation. Unemployment (SHR, 0.47; 95% CI, 0.45-0.48) and part-time employment (SHR, 0.74; 95% CI, 0.70-0.77) were associated with lower waitlisting compared with full-time employment, and more than 1 year of predialysis nephrology care, compared with none, was associated with greater waitlisting (SHR, 1.51; 95% CI, 1.46-1.56).

Conclusions and Relevance

This retrospective cohort study found that fewer than one-third of patients without major medical comorbidities were waitlisted for a kidney transplant within 1 year of dialysis initiation, with sociodemographic disparities in waitlisting even in this cohort of young, relatively healthy patients unlikely to have a medical contraindication to transplantation. Transplant policy changes are needed to increase transparency and address structural barriers to waitlist access.

United Network for Organ Sharing (UNOS) Database Analysis of Factors Associated With Kidney Transplant Time on Waiting List

INTRODUCTION

 In the United States (U.S.), African Americans and other minority groups have longer wait times for kidney transplantation than Caucasians. To date, many studies analyzing time spent on the waitlist for each race/ethnicity have been done. However, there are few to no studies examining waitlist time after the 2019 policy changes to the geographic distribution of donated kidneys.

METHODS

Data collected from the National Organ Procurement and Transplantation Network database were used to analyze associations between race and time spent on the waitlist for a kidney transplant in the U.S. Additional sub-categorical data were analyzed to determine further associations and potential covariates, such as gender, age, citizenship, primary source of payment, region of transplant center, BMI, Kidney Donor Profile Index (KDPI), renal diagnosis, and presence/type of diabetes. Data were analyzed using odds ratios and validated by Bonferroni-Holm's corrected chi-square tests at confidence intervals of 95% to determine if there are statistically significant differences between transplant time spent on the waitlist and ethnicity, as well as age, diagnosis category, region of transplant center, and KDPI.

RESULTS

Statistically significant increased odds of remaining on the transplant list at two years existed for all non-white races/ethnicities, except those identifying as multiracial. Asian American candidates had the greatest odds of remaining on the waitlist greater than two years in comparison to white candidates: 1.51 times that of a patient categorized as white (odds ratio [OR] 1.51, confidence interval [CI] 1.44-1.57). African American/Black, (OR 1.38, CI 1.34-1.43) Pacific Islander (OR 1.38, CI 1.17-1.63), Hispanic candidates (OR 1.37, CI 1.32-1.41), and American Indian or Native Alaskan candidates (OR 1.23, CI 1.12-1.46) also had increased odds of remaining on the transplant waitlist greater than two years compared to white candidates.

DISCUSSION

In this study, ethnic disparities persisted as a barrier for non-white individuals receiving treatment for end-stage kidney disease, specifically in the context of time spent on the waitlist for a kidney transplant. Further research is needed regarding the causes of these disparities in time spent on the waitlist, such as cultural restrictions in organ donation, racial differences in parameters for organ match, and institutionalized racism in health care practitioners.

Impact of having potential living donors on ethnic/racial disparities in access to kidney transplantation

Racial/ethnic disparities persist in patients' access to living donor kidney transplantation (LDKT). This study assessed the impact of having available potential living donors (PLDs) on candidates' receipt of a kidney transplant (KT) and LDKT at two KT programs. Using data from our clinical trial of waitlisted candidates (January 1, 2014-December 31, 2019), we evaluated Hispanic and Non-Hispanic White (NHW) KT candidates' number of PLDs. Multivariable logistic regression assessed the impact of PLDs on transplantation (KT vs. no KT; for KT recipients, LDKT vs. deceased donor KT). A total of 847 candidates were included, identifying as Hispanic (45.8%) or NHW (54.2%). For Site A, both Hispanic (adjusted OR = 2.26 [95% CI 1.13-4.53]) and NHW (OR = 2.42 [1.10-5.33]) candidates with PLDs completing the questionnaire were more likely to receive a KT. For Site B, candidates with PLDs were not significantly more likely to receive KT. Among KT recipients at both sites, Hispanic (Site A: OR = 21.22 [2.44-184.88]; Site B: OR = 25.54 [7.52-101.54]), and NHW (Site A: OR = 37.70 [6.59-215.67]; Site B: OR = 15.18 [5.64-40.85]) recipients with PLD(s) were significantly more likely to receive a LDKT. Our findings suggest that PLDs increased candidates' likelihood of KT receipt, particularly LDKT. Transplant programs should help candidates identify PLDs early in transplant evaluation.

Disparities in Social Determinants of Health Among Patients Receiving Liver Transplant: Analysis of the National Inpatient Sample From 2016 to 2019

Background

Liver transplantation is the life-saving standard of care for those with end-stage liver disease. Unfortunately, many patients on the liver transplant list die waiting. Several studies have demonstrated significant differences based on disparities in race, gender, and multiple socioeconomic factors. We sought to evaluate recent disparities among patients receiving liver transplants using the latest available data from the National Inpatient Sample (NIS), the largest publicly available inpatient care database in the United States.

Methods

We performed an analysis of discharge data from the NIS between 2016 and 2019. We identified adult patients with chronic liver disease who underwent a liver transplant using the International Classification of Diseases, 10th revision (ICD-10) codes. Multivariate logistic regression was used to adjust for differences in race, gender, socioeconomic status, and comorbidities among those who received a liver transplant.

Results

A total of 24,595 liver transplants were performed over the study period. Female gender was independently associated with decreased transplant rates (adjusted odds ratio (AOR) 0.83, 95% confidence interval (CI), 0.78-0.89, P < 0.001). Compared to White patients, Black patients had decreased transplant rates (AOR 0.86, 95% CI, 0.75-0.99, P = 0.034), as did Native Americans (AOR 0.64; 95% CI, 0.42-0.97, P = 0.035). Hispanics and Asian Americans had increased rates of liver transplantation (AOR 1.16, 95% CI 1.02-1.32, P = 0.022, and 1.36, 95% CI 1.11-1.67, P = 0.003; respectively). The increase in income quartile was associated with an incremental increase in transplant rates. Additionally, patients with private insurance had much higher transplant rates compared to those with Medicare (AOR 2.50, 95% CI 2.31-2.70, P < 0.001) while patients without insurance had the lowest rates of transplantation (AOR 0.18, 95% CI 0.12-0.28, P < 0.001).

Conclusions

Our analysis demonstrates that race, gender, and other social determinants of health have significant impacts on the likelihood of receiving a liver transplant. Our study, on a national level, confirms previously described disparities in receiving liver transplantation. Patient-level studies are needed to better understand how these variables translate into differing liver transplantation rates.

Sociodemographic characteristics of living liver donors: Few changes over 20 years

INTRODUCTION

Although there are well-documented challenges in access to living donor liver transplant (LDLT) among recipients, it is unclear whether living liver donors (LLDs) face similar challenges.

METHODS

We analyzed the UNOS Standard Transplant Analysis and Research database, including LLDs ≥ 18 years in the United States from 1/1998-12/2018. We compared sociodemographic characteristics (age, gender, race/ethnicity, education level, employment status, BMI, and relationship to recipient) of LLDs across three eras-pre-MELD (1998-2002), MELD (2003-2013), and post-direct acting antivirals (DAA) (2014-2018). We also described sociodemographic characteristics of living donor recipients and waitlisted patients. Chi-squared and one-way analysis of variance (ANOVA) were used to compare categorical and continuous variables, respectively.

RESULTS

From 1998-2018, 4,756 LDLTs and 99,765 DDLTs were performed. Across the three eras, LLD age did not change significantly (p = 0.3), but donors were generally young (mean age 37+/-11). While men comprised most LLDs in the pre-MELD era (55.2%), women surpassed them in the post-DAA era (52.9%), p<0.001. In total, White donors comprised 81.5% of total LLDs, while Black and Asian donors were a small minority of total donors (3.7% and 2.5%, respectively). Most donors had at least a college education and were employed. Educational attainment and employment did not significantly change over the study period.

CONCLUSIONS

During the last twenty years, LLDs have remained White, employed, highly educated, and young with increasing numbers of women LLDs. The relative lack of change in the characteristics of donors is likely attributable largely to socioeconomic factors, which should be assessed in future investigation. This article is protected by copyright. All rights reserved.

Health system barriers and facilitators to living donor kidney transplantation: a qualitative case study in British Columbia

BACKGROUND

In patients with kidney failure, living donor kidney transplantation (LDKT) is the best treatment option; yet, LDKT rates have stagnated in Canada and vary widely across provinces. We aimed to identify barriers and facilitators to LDKT in a high-performing health system.

METHODS

This study was conducted using a qualitative exploratory case study of British Columbia. Data collection, conducted between October 2020 and January 2021, entailed document review and semistructured interviews with key stakeholders, including provincial leadership, care teams and patients. We recruited participants via purposive sampling and snowballing technique. We generated themes using thematic analysis.

RESULTS

After analysis of interviews conducted with 22 participants (5 representatives from provincial organizations, 7 health care providers at transplant centres, 8 health care providers from regional units and 2 patients) and document review, we identified the following 5 themes as facilitators to LDKT: a centralized infrastructure, a mandate for timely intervention, an equitable funding model, a commitment to collaboration and cultivating distributed expertise. The relationship between 2 provincial organizations (BC Transplant and BC Renal Agency) was identified as key to enabling the mandate and processes for LDKT. Five barriers were identified that arose from silos between provincial organizations and manifested as inconsistencies in coordinating LDKT along the spectrum of care. These were divided accountability structures, disconnected care processes, missed training opportunities, inequitable access by region and financial burden for donors and recipients.

INTERPRETATION

We found strong links between provincial infrastructure and the processes that facilitate or impede timely intervention and referral of patients for LDKT. Our findings have implications for policy-makers and provide opportunities for cross-jurisdictional comparative analyses.

A scoping review of inequities in access to organ transplant in the United States

Background

Organ transplant is the preferred treatment for end-stage organ disease, yet the majority of patients with end-stage organ disease are never placed on the transplant waiting list. Limited access to the transplant waiting list combined with the scarcity of the organ pool result in over 100,000 deaths annually in the United States. Patients face unique barriers to referral and acceptance for organ transplant based on social determinants of health, and patients from disenfranchised groups suffer from disproportionately lower rates of transplantation. Our objective was to review the literature describing disparities in access to organ transplantation based on social determinants of health to integrate the existing knowledge and guide future research.

Methods

We conducted a scoping review of the literature reporting disparities in access to heart, lung, liver, pancreas and kidney transplantation based on social determinants of health (race, income, education, geography, insurance status, health literacy and engagement). Included studies were categorized based on steps along the transplant care continuum: referral for transplant, transplant evaluation and selection, living donor identification/evaluation, and waitlist outcomes.

Results

Our search generated 16,643 studies, of which 227 were included in our final review. Of these, 34 focused on disparities in referral for transplantation among patients with chronic organ disease, 82 on transplant selection processes, 50 on living donors, and 61 on waitlist management. In total, 15 studies involved the thoracic organs (heart, lung), 209 involved the abdominal organs (kidney, liver, pancreas), and three involved multiple organs. Racial and ethnic minorities, women, and patients in lower socioeconomic status groups were less likely to be referred, evaluated, and added to the waiting list for organ transplant. The quality of the data describing these disparities across the transplant literature was variable and overwhelmingly focused on kidney transplant.

Conclusions

This review contextualizes the quality of the data, identifies seminal work by organ, and reports gaps in the literature where future research on disparities in organ transplantation should focus. Future work should investigate the association of social determinants of health with access to the organ transplant waiting list, with a focus on prospective analyses that assess interventions to improve health equity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01616-x.

Racial disparities in living donor kidney transplantation in the United States

Living donor kidney transplant (LDKT) is the best treatment for end-stage kidney disease, but there are racial disparities in LDKT rates. To study putative mechanisms of these disparities, we identified 58 752 adult kidney transplant candidates first activated on the United States kidney transplant waitlist 2015-2016 and defined four exposure groups by race/primary payer: African American/Medicaid, African American/NonMedicaid, Non-African American/Medicaid, Non-African American/NonMedicaid. We performed competing risk regression to compare risk of LDKT between groups. Among included candidates, 30% had African American race and 9% had Medicaid primary payer. By the end of follow up, 16% underwent LDKT. The cumulative incidence of LDKT was lowest for African American candidates regardless of payer. Compared to African American/Non-Medicaid candidates, the adjusted likelihood of LDKT was higher for both Non-African American/Medicaid (HR 1.60, 95%CI 1.43-1.78) and Non-African American/Non-Medicaid candidates (HR 2.66, 95%CI 2.50-2.83). Results were similar when analyzing only candidates still waitlisted > 2 years after initial activation or candidates with type O blood. Among 9639 candidates who received LDKT, only 13% were African American. Donor-recipient relationships were similar for African American and Non-African American recipients. These findings indicate African American candidates have a lower incidence of LDKT than candidates of other races, regardless of primary payer.

Kidney transplant surgical director training: Urologists represent a functional alternative to general surgeons

INTRODUCTION

Kidney transplant (KT) directors are general surgeons or urologists. All KT centers must meet established performance standards. However, it has not been established if general surgery and urology led programs have disparate outcomes.

METHODS

Transplant outcomes and donor-recipient characteristics by director training were investigated. Organ Procurement and Transplantation Network (OPTN) directory, program websites were analyzed for surgical director demographics. Scientific Registry of Transplant Recipients (SRTR) 1-year kidney survival and deceased donor (DD) wait-time rankings were evaluated. A retrospective analysis of 142 157 KT recipients from 2010 to 2019 was performed using the United Network for Organ Sharing (UNOS) database.

RESULTS

One hunderd and seventy three (90.6%) KT programs were led by general surgeons. There were no significant differences in gender, ethnicity, region, credentials, or fellowship completion. Recipients undergoing KT with urology led programs were older (P = .002) and had longer wait-times (P < .001). These centers used higher KDPI (.47 vs. .45, P < .001) and higher HLA mismatch (3.92 vs. 3.89, P = .02) kidneys. Urology led centers utilized living donors less frequently (32.1% vs. 35.8%, P < .001) and had longer CIT (15.44 vs. 12.21, P < .001). Both had similar SRTR ranking of 1-year survival and DD wait-time.

CONCLUSION

Most directors were general surgeon. Patient outcomes did not differ by transplant director training. Urologists represent a viable option for KT leadership and recruitment should be encouraged.

Destination Transplant: Protocol for a Parallel-group Randomized Trial of an Educational Intervention to Increase Kidney Transplant Among Black People on the Transplant Waiting List

For most patients with kidney failure, living donor kidney transplant (LDKT) is their best treatment option. Compared with White people, Black people are more likely to have kidney failure but less likely to receive LDKTs. In this study, the investigators will test an educational intervention, Destination Transplant, designed to reduce this disparity, among Black people already listed for kidney transplant.

Weighing the waitlist: Weight changes and access to kidney transplantation among obese candidates

High body mass index is a known barrier to access to kidney transplantation in patients with end-stage kidney disease. The extent to which weight and weight changes affect access to transplantation among obese candidates differentially by race/ethnicity has received little attention. We included 10 221 obese patients waitlisted for kidney transplantation prior to end-stage kidney disease onset between 1995–2015. We used multinomial logistic regression models to examine the association between race/ethnicity and annualized change in body mass index (defined as stable [-2 to 2 kg/m²/year], loss [>2 kg/m²/year] or gain [>2 kg/m²/year]). We then used Fine-Gray models to examine the association between weight changes and access to living or deceased donor transplantation by race/ethnicity, accounting for the competing risk of death. Overall, 29% of the cohort lost weight and 7% gained weight; 46% received a transplant. Non-Hispanic blacks had a 24% (95% CI 1.12–1.38) higher odds of weight loss and 22% lower odds of weight gain (95% CI 0.64–0.95) compared with non-Hispanic whites. Hispanics did not differ from whites in their odds of weight loss or weight gain. Overall, weight gain was associated with lower access to transplantation (HR 0.88 [95% CI 0.79–0.99]) compared with maintenance of stable weight, but weight loss was not associated with better access to transplantation (HR 0.96 [95% CI 0.90–1.02]), although this relation differed by baseline body mass index and for recipients of living versus deceased donor organs. For example, weight loss was associated with improved access to living donor transplantation (HR 1.24 [95% CI 1.07–1.44]) in whites but not in blacks or Hispanics. In a cohort of obese patients waitlisted before dialysis, blacks were more likely to lose weight and less likely to gain weight compared with whites. Weight loss was only associated with improved access to living donor transplantation among whites. Further studies are needed to understand the reasons for the observed associations.

Addressing Racial Disparities in Live Donor Kidney Transplantation Through Education and Advocacy Training

Background.

The Live Donor Champion (LDC) program trains kidney transplant (KT) candidates and their family/friends (“champions”) as educator-advocates for live donor KT (LDKT). This program was created to empower patients and champions, particularly African American (AA) waitlist candidates that historically had lower access to LDKT. We assessed changes in knowledge about and comfort discussing live donation and donor referral associated with LDC participation, both overall and by participant race.

Methods.

We compared 163 adult KT candidates who were LDC participants from October 2013 to May 2016 with 489 matched controls, both overall and by race. We compared changes in comfort and knowledge post-LDC using rank-sum tests among participants by race. We compared time to first live donor referral for participants versus controls, by race, using Cox regression.

Results.

Post-LDC versus pre-LDC, participants had higher median knowledge (83% versus 63% on 12-question quiz; P < 0.001) and comfort (1.8 versus 1 on 4-point Likert scale; P < 0.001). Among participants, AAs had similar baseline and final knowledge (P = 0.9 and P = 0.1, respectively) and baseline comfort (P > 0.9) as non-AAs but higher final comfort (2 versus 1.4; P = 0.005) than non-AAs. LDC participants were 5.8 times as likely as controls to have a live donor referral (aHR _3.765.78_8.89; P < 0.001); the impact of LDC participation was similar among non-AAs and AAs (p-interaction = 0.6).

Conclusions.

The LDC program increased knowledge, comfort, and live donor referral for non-AA and AA participants, underscoring the effectiveness in the program in promoting LDKT in a population with historically lower access to LDKT.

Canadian Senior Renal Leaders Community of Practice: Vulnerable Populations With Chronic Kidney Disease-Evidence to Inform Policy

Purpose:

Low socioeconomic status, race, ethnicity, and rural/remote populations are all associated with disparities in access, care, and outcomes for chronic kidney disease (CKD). There have been different interventions supported by Canadian renal programs to address these disparities. This article reviews the evidence for impact of strategies to reduce inequities experienced by vulnerable populations living with or at risk of CKD and to collate and share interprovincial targeted interventions through the newly formed “Canadian Senior Renal Leaders Community of Practice” focused on translating evidence into clinical practice and policy.

Source of Information:

A literature search of Medline, CINAHL, PubMed, and Google Scholar from 2008 to 2018 identified 13 reports of processes and interventions that have been implemented in Australia, Canada, and the United States to reduce inequities in CKD care and can be categorized into 3 broad areas: (1) early screening and prevention, (2) disease management and dialysis, and (3) pretransplant. Web sites from each Canadian jurisdiction and from Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD) Network were used to assess the current state of Canadian initiatives.

Methods:

Reviews were completed to gather information on renal initiatives for vulnerable populations, including (1) identification of populations that experience disparities in access to care or in outcomes in the context of CKD prevention and treatment and (2) interventions that have been implemented to reduce disparities in access, care, and outcomes for vulnerable populations with CKD. A current state summary of Canadian initiatives related to vulnerable populations was conducted through a review of publicly available information, including a review of renal program Web sites and a review of current projects related to vulnerable populations that are part of Can-SOLVE CKD. Can-SOLVE CKD is a Canadian Institutes of Health Research Strategy for Patient-Oriented Research (CIHR-SPOR) funded research network to transform the care of people affected by kidney disease.

Key Findings:

Interventions to improve inequities in access to CKD screening, disease management, and care are successful when developed with community engagement, provided to the patient in their own environment, and tailored to specific populations. Many provincial renal programs have implemented initiatives to support vulnerable populations with or at risk of CKD. Current projects funded through CIHR SPOR focus on underserved populations and involve partnerships with Indigenous populations. Many renal programs in Canada had or were in the process of implementing interventions to support vulnerable populations with CKD; however, information about the initiatives were not readily available online despite a strong interest and opportunity to support interprovincial knowledge sharing. Despite this common interest, little information is systematically shared between Canadian jurisdictions to support interprovincial sharing to promote evidence-informed policy and program development. Efforts will be made through the newly formed Canadian Senior Renal Leaders Community of Practice to collaborate and share learnings to inform future program and policy development, implementation, and evaluation.

Limitations:

As this was not a systematic review, literature search only encompassed studies published in English between 2008 and 2018. It is possible that populations and interventions were overlooked during the search and through the screening process. Furthermore, the controversial definition of “vulnerable” and literature that only came from Canada, the United States, and Australia limits the generalizability of this review.

Inequalities and outcomes: end stage kidney disease in ethnic minorities

Background

The international evidence about outcomes of End Stage Kidney Disease (ESKD) for ethnic minorities was reviewed to identify gaps and make recommendations for researchers and policy makers.

Methods

Nine databases were searched systematically with 112 studies from 14 different countries included and analysed to produce a thematic map of the literature.

Results

Reviews (n = 26) highlighted different mortality rates and specific causes between ethnic groups and by stage of kidney disease associated with individual, genetic, social and environmental factors. Primary studies focussing on uptake of treatment modalities (n = 19) found ethnic differences in access. Research evaluating intermediate outcomes and quality of care in different treatment phases (n = 35) e.g. dialysis adequacy, transplant evaluation and immunosuppression showed ethnic minorities were disadvantaged. This is despite a survival paradox for some ethnic minorities on dialysis seen in studies of longer term outcomes (n = 29) e.g. in survival time post-transplant and mortality. There were few studies which focussed on end of life care (n = 3) and ethnicity.

Gaps identified were: limited evidence from all stages of the ESKD pathway, particularly end of life care; a lack of system oriented studies with a reliance on national routine datasets which are limited in scope; a dearth of qualitative studies; and a lack studies from many countries with limited cross country comparison and learning.

Conclusions

Differences between ethnic groups occur at various points and in a variety of outcomes throughout the kidney care system. The combination of individual factors and system related variables affect ethnic groups differently indicating a need for culturally intelligent policy informed by research to prevent disadvantage.

Direct Delivery of Kidney Transplant Education to Black and Low-Income Patients Receiving Dialysis: A Randomized Controlled Trial

RATIONALE & OBJECTIVE

Compared with others, black and low-income patients receiving dialysis are less likely to receive kidney transplantation (KT) education within dialysis centers. We examined the efficacy of 2 supplementary KT education approaches delivered directly to patients.

STUDY DESIGN

Prospective, 3-arm parallel-group, randomized, controlled trial.

SETTINGS & PARTICIPANTS

Adult, black, and white low-income patients receiving dialysis in Missouri.

INTERVENTION

Patients were randomly assigned to 1 of 3 educational conditions: (1) standard of care, usual KT education provided in dialysis centers (control); (2) Explore Transplant @ Home patient-guided, 4 modules of KT education sent directly to patients using print, video, and text messages; and (3) Explore Transplant @ Home educator-guided, the patient-guided intervention plus 4 telephonic discussions with an educator.

OUTCOMES

Primary: patient knowledge of living (LDKT) and deceased donor KT (DDKT). Secondary: informed decision making, change in attitudes in favor of LDKT and DDKT, and change in the number of new steps taken toward KT.

RESULTS

In intent-to-treat analyses, patients randomly assigned to educator- and patient-guided interventions had greater knowledge gains (1.4 point increase) than control patients (0.8 point increase; P=0.02 and P=0.01, respectively). Compared with control patients, more patients randomly assigned to educator- and patient-guided interventions were able to make informed decisions about starting KT evaluation (82% vs 91% and 95%; P=0.003), pursuing DDKT (70% vs 84% and 84%; P=0.003), and pursuing LDKT (73% vs 91% and 92%; P<0.001).

LIMITATIONS

Potential contamination because of patient-level randomization; no assessment of clinical end points.

CONCLUSIONS

Education presented directly to dialysis patients, with or without coaching by telephone, increased dialysis patients' KT knowledge and informed decision making without increasing educational burden on providers.

FUNDING SOURCE

This project was funded by the National Institutes of Health and Health Resources and Services Administration.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov with study number NCT02268682.

Transplant center characteristics associated with living-donor kidney transplantation: a cohort study with a hierarchical modeling approach

Transplant center organization, that is a modifiable factor, may affect the access to living-donor kidney transplantation (LDKT). The objective of this study was to identify the center characteristics associated with LDKT using a hierarchical analysis. This was a retrospective multicenter observational study of 8701 patients who received a first renal graft between 2010 and 2014 in 32 transplantation centers of France. Hierarchical modeling was used to estimate the center effect and organization associated with LDKT. Among 8507 patients, 1225 (12%) were transplanted with a LD kidney. There was a transplant center effect on the proportion of LDKT. After adjustment for patient and center characteristics, the random effect variance decreased by 47%. Patients transplanted at a center with more than four nephrologists [1.81 (95% CI: 1.10-2.95)] and more than 1.5 nurse transplant coordinators [1.98 (95% CI: 1.26-3.13)] were more likely to be transplanted with a LD kidney. ABO-incompatible program was associated with LDKT [2.23 (95% CI: 1.22-4.06)]. There was a transplant center effect on the proportion of LDKT that could be decreased by modifiable center characteristics. Our study suggests the importance of the transplant team organization on the LDKT utilization.

Health Professional-Identified Barriers to Living Donor Kidney Transplantation: A Qualitative Study

BACKGROUND

Living donor kidney transplantation (LDKT) has several advantages over deceased donor kidney transplantation. Yet rates of living donation are declining in Canada and there exists significant interprovincial variability. Efforts to improve living donation tend to focus on the patient and barriers identified at their level, such as not knowing how to ask for a kidney or lack of education. These efforts favor those who have the means and the support to find living donors. Thus, a Canadian Institutes of Health Research (CIHR)-organized workshop recommended that education efforts to understand and remove barriers should focus on health professionals (HPs). Despite this, little attention has been paid to what they identify as barriers to discussing LDKT with their patients.

OBJECTIVE

Our aim was to explore HP-identified barriers to discuss living donation with patients in 3 provinces of Canada with low (Quebec), moderate (Ontario), and high (British Columbia) rates of LDKT.

DESIGN

This study consists of an interpretive descriptive approach as it enables to move beyond description and inform clinical practice.

SETTING

Purposive criterion and quota sampling were used to recruit HPs from Quebec, Ontario, and British Columbia who are involved in the care of patients with kidney disease and/or with transplant coordination.

PATIENTS

Not applicable.

MEASUREMENTS

Semistructured interviews were conducted. The interview guide was developed based on a preliminary analytical framework and a review of the literature.

METHODS

Thematic analysis was used to analyze the data stemming from the interviews. The coding process comprised of a deductive and inductive approach, and the use of a qualitative analysis software (NVivo 11). Following this, themes were identified and developed. Interviews were conducted until thematic saturation was obtained. In total, we conducted 16 telephone interviews as thematic saturation was attained.

RESULTS

Six predominant themes emerged: (1) lack of communication between transplant and dialysis teams, (2) absence of referral guidelines, (3) role perception and lack of multidisciplinary involvement, (4) HP's lack of information and training, (5) negative attitudes of some HP toward LDKT, (6) patient-level barriers as defined by the HP. HPs did mention patients' attitudes and some characteristics as the main barriers to discussions about living donation; this was noted in all provinces. HPs from Ontario and British Columbia indicated multiple strategies being implemented to address some of these barriers. Those from Ontario mentioned strategies that center on the core principles of provincial-level standardization, while those from British Columbia center on engaging the entire multidisciplinary team and improved role perception. We noted a dearth of such efforts in Quebec; however, efforts around education and promotion, while tentative, have emerged.

LIMITATIONS

Social desirability and selection bias. Our analysis might not be applicable to other provinces.

CONCLUSIONS

HPs involved with the referral and coordination of transplantation play a major role in access to LDKT. We have identified challenges they face when discussing living donation with their patients that warrant further assessment and research to inform policy change.

Imminent Death Donation: Ethical and Practical Policy Considerations

While the practice of organ donation after cardiac death has long been trending upwards in acceptance and use, it is still a highly controversial and practically inefficient method of organ procurement. One policy that has recently been proposed to try and alleviate some of the ethical and practical concerns with organ donation after cardiac death is the practice of imminent death organ donation. This type of live organ donation comes in patients at the end of their life who have decided to withdraw life-sustaining treatment, but still want to ensure that their organs are donated and not wasted, which isn't always the case with organ donation after cardiac death. This paper then gives some ethical and practical reflections and recommendations regarding the potential implementation of this controversial practice into regular transplant practice and policy.

An Explore Transplant Group Randomized Controlled Education Trial to Increase Dialysis Patients' Decision-Making and Pursuit of Transplantation

INTRODUCTION

Dialysis centers must provide transplant education to patients but often do not address the risks and benefits of living and deceased donor transplant.

RESEARCH QUESTIONS

In a group randomized controlled trial of 20 dialysis centers and 253 patients, we assessed whether the Explore Transplant education program increased patients' readiness to pursue transplant, transplant knowledge, informed transplant decision-making, discussions about transplant with potential living donors, pursuit and receipt of living or deceased donor transplant, and whether these effects varied by race.

METHODS

Patients at participating dialysis centers were randomized to receive either (1) a 4-module Explore Transplant education program, including videos, printed materials, and transplant educator discussions or (2) standard-of-care transplant education provided by dialysis centers. The trial had 3 phases: (1) pre- and postsurveying and dialysis center education (2007-2008), (2) follow-up to determine whether patients restarted or began transplant evaluation (2008-2010), and (3) assessment of participants' receipt of a renal transplant (2012-2015).

RESULTS

Compared to patients in standard-of-care dialysis centers, patients who received the intervention were more likely to increase in their stage of readiness for living donor transplantation (odds ratio: 2.50; 95% confidence interval: 1.10-5.66), had greater increases in their transplant knowledge ( P < .001), and were more likely to call to restart/begin transplant evaluation (38% vs 24%, P = .006). When analyses were stratified by race, black patients were more likely to take several steps toward transplant in comparison to whites.

DISCUSSION

The Explore Transplant helps dialysis patients make informed decisions and increases their pursuit of transplant, particularly among black patients.

The Change in Living Kidney Donation in Women and Men in the United States (2005-2015): A Population-Based Analysis

The factors underlying the decline in living kidney donation in the United States since 2005 must be understood to inform strategies to ensure access to this option for future patients. Population-based estimates provide a better assessment of donation activity than do trends in the number of living donor transplants. Using data from the Scientific Registry of Transplant Recipients and the United States Census, we determined longitudinal changes in living kidney donation between 2005 and 2015, focusing on the effect of sex and income. We used multilevel Poisson models to adjust for differences in age, race, the incidence of ESRD, and geographic factors (including population density, urbanization, and daily commuting). During the study period, the unadjusted rate of donation was 30.1 and 19.3 per million population in women and men, respectively, and the adjusted incidence of donation was 44% higher in women (incidence rate ratio [IRR], 1.44; 95% confidence interval [95% CI], 1.39 to 1.49). The incidence of donation was stable in women (IRR, 0.95; 95% CI, 0.84 to 1.07) but declined in men (IRR, 0.75; 95% CI, 0.68 to 0.83). Income was associated with longitudinal changes in donation in both sexes, yet donation was stable in the highest two population income quartiles in women but only in the highest income quartile in men. In both sexes, living related donations declined, irrespective of income. In conclusion, living donation declined in men but remained stable in women between 2005 and 2015, and income appeared to have a greater effect on living donation in men.

The association of discharge decisions after deceased donor kidney transplantation with the risk of early readmission: Results from the deceased donor study

BACKGROUND

Kidney transplant (KT) recipients experience high rates of early (≤30 days) hospital readmission (EHR) after KT, and existing studies provide limited data on modifiable discharge factors that may mitigate EHR risk.

METHODS

We performed a retrospective cohort study of 468 adult deceased donor KT recipients transplanted between 4/2010 and 11/2013 at 5 United States transplant centers. We fit multivariable mixed effects models to assess the association of two potentially modifiable discharge factors with the probability of EHR after KT: (i) weekend discharge and (ii) days to first scheduled follow-up.

RESULTS

Among 468 KT recipients, 38% (n = 178) experienced EHR after KT. In fully adjusted analyses, compared to weekday discharges, KT recipients discharged on the weekend had a 29% lower risk of EHR (adjusted odds ratio [aOR] 0.71, 95% confidence interval [CI] 0.41-0.94). Compared to follow-up within 2 days of discharge, KT recipients with follow-up within 3 to 6 days had a 28% higher probability of EHR (aOR 1.28, 95% CI 1.13-1.45).

CONCLUSIONS

These findings suggest that clinical decisions related to the timing of discharge and follow-up modify EHR risk after KT, independent of traditional risk factors.

Strategies for Increasing Knowledge, Communication, and Access to Living Donor Transplantation: an Evidence Review to Inform Patient Education

Purpose of review

Inadequate knowledge of the benefits, risks and opportunities for living donation is an important, potentially modifiable barrier to living donor transplantation. We assessed the current state of the evidence regarding strategies to increase knowledge, communication and access to living donor transplantation, as reported in peer-reviewed medical literature.

Recent Findings

Nineteen studies were reviewed, categorized as programs evaluated in randomized controlled trials (8 studies) and programs supported by observational (non-randomized) studies (11 studies). Content extraction demonstrated that comprehensive education about living donation and living donor transplantation involves multiple learners - the transplant candidate, potential living donors, and social support networks - and requires communicating complex information about the risks and benefits of donation, transplantation and alternative therapies to these different audiences. Transplant centers can help transplant patients learn about living donor transplantation through a variety of formats and modalities, including center-based, home-based and remote technology-based education, outreach to dialysis centers, and social media. Evaluation of these strategies and program themes informed a new Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) public education brochure.

Summary

Increasing transplant candidate knowledge and comfort in talking about living donation and transplantation can reduce educational barriers to pursuit of living donor transplants. Ongoing efforts are needed to develop, refine and disseminate educational programs to help improve transplant access for more patients in need of organ donors.

Barriers to living donor kidney transplantation in the United Kingdom: a national observational study

Background. Living donor kidney transplantation (LDKT) provides more timely access to transplantation and better clinical outcomes than deceased donor kidney transplantation (DDKT). This study investigated disparities in the utilization of LDKT in the UK.

Methods. A total of 2055 adults undergoing kidney transplantation between November 2011 and March 2013 were prospectively recruited from all 23 UK transplant centres as part of the Access to Transplantation and Transplant Outcome Measures (ATTOM) study. Recipient variables independently associated with receipt of LDKT versus DDKT were identified.

Results. Of the 2055 patients, 807 (39.3%) received LDKT and 1248 (60.7%) received DDKT. Multivariable modelling demonstrated a significant reduction in the likelihood of LDKT for older age {odds ratio [OR] 0.11 [95% confidence interval (CI) 0.08–0.17], P < 0.0001 for 65–75 years versus 18–34 years}; Asian ethnicity [OR 0.55 (95% CI 0.39–0.77), P = 0.0006 versus White]; Black ethnicity [OR 0.64 (95% CI 0.42–0.99), P = 0.047 versus White]; divorced, separated or widowed [OR 0.63 (95% CI 0.46–0.88), P = 0.030 versus married]; no qualifications [OR 0.55 (95% CI 0.42–0.74), P < 0.0001 versus higher education qualifications]; no car ownership [OR 0.51 (95% CI 0.37–0.72), P = 0.0001] and no home ownership [OR 0.65 (95% CI 0.85–0.79), P = 0.002]. The odds of LDKT varied significantly between countries in the UK.

Conclusions. Among patients undergoing kidney transplantation in the UK, there are significant age, ethnic, socio-economic and geographic disparities in the utilization of LDKT. Further work is needed to explore the potential for targeted interventions to improve equity in living donor transplantation.

Association of Race and Ethnicity With Live Donor Kidney Transplantation in the United States From 1995 to 2014

IMPORTANCE

Over the past 2 decades, there has been increased attention and effort to reduce disparities in live donor kidney transplantation (LDKT) for black, Hispanic, and Asian patients with end-stage kidney disease. The goal of this study was to investigate whether these efforts have been successful.

OBJECTIVE

To estimate changes over time in racial/ethnic disparities in LDKT in the United States, accounting for differences in death and deceased donor kidney transplantation.

DESIGN, SETTING, AND PARTICIPANTS

A secondary analysis of a prospectively maintained cohort study conducted in the United States of 453 162 adult first-time kidney transplantation candidates included in the Scientific Registry of Transplant Recipients between January 1, 1995, and December 31, 2014, with follow-up through December 31, 2016.

EXPOSURES

Race/ethnicity.

MAIN OUTCOMES AND MEASURES

The primary study outcome was time to LDKT. Multivariable Cox proportional hazards and competing risk models were constructed to assess changes in racial/ethnic disparities in LDKT among adults on the deceased donor kidney transplantation waiting list and interaction terms were used to test the statistical significance of temporal changes in racial/ethnic differences in receipt of LDKT. The adjusted subhazard ratios are estimates derived from the multivariable competing risk models. Data were categorized into 5-year increments (1995-1999, 2000-2004, 2005-2009, 2010-2014) to allow for an adequate sample size in each analytical cell.

RESULTS

Among 453 162 adult kidney transplantation candidates (mean [SD] age, 50.9 [13.1] years; 39% were women; 48% were white; 30%, black; 16%, Hispanic; and 6%, Asian), 59 516 (13.1%) received LDKT. Overall, there were 39 509 LDKTs among white patients, 8926 among black patients, 8357 among Hispanic patients, and 2724 among Asian patients. In 1995, the cumulative incidence of LDKT at 2 years after appearing on the waiting list was 7.0% among white patients, 3.4% among black patients, 6.8% among Hispanic patients, and 5.1% among Asian patients. In 2014, the cumulative incidence of LDKT was 11.4% among white patients, 2.9% among black patients, 5.9% among Hispanic patients, and 5.6% among Asian patients. From 1995-1999 to 2010-2014, racial/ethnic disparities in the receipt of LDKT increased (P < .001 for all statistical interaction terms in adjusted models comparing white patients vs black, Hispanic, and Asian patients). In 1995-1999, compared with receipt of LDKT among white patients, the adjusted subhazard ratio was 0.45 (95% CI, 0.42-0.48) among black patients, 0.83 (95% CI, 0.77-0.88) among Hispanic patients, and 0.56 (95% CI, 0.50-0.63) among Asian patients. In 2010-2014, compared with receipt of LDKT among white patients, the adjusted subhazard ratio was 0.27 (95% CI, 0.26-0.28) among black patients, 0.52 (95% CI, 0.50-0.54) among Hispanic patients, and 0.42 (95% CI, 0.39-0.45) among Asian patients.

CONCLUSIONS AND RELEVANCE

Among adult first-time kidney transplantation candidates in the United States who were added to the deceased donor kidney transplantation waiting list between 1995 and 2014, disparities in the receipt of live donor kidney transplantation increased from 1995-1999 to 2010-2014. These findings suggest that national strategies for addressing disparities in receipt of live donor kidney transplantation should be revisited.

Pregnancy-Induced Sensitization Promotes Sex Disparity in Living Donor Kidney Transplantation

The presence of sex disparity in living donor kidney transplantation (LDKT) remains controversial. To determine if women fall behind men in LDKT evaluation, we performed an intention to treat study of 2587 candidates listed for kidney transplant at a single transplant center over 7 years. We found that women and men kidney transplant candidates engaged an equivalent type and number of prospective living donors. However, sex-specific differences in sensitization history and histocompatibility reduced the rate of LDKT for women by 30%. Pregnancy-induced incompatibility with spouse donors was limiting given that spouses were among the individuals most likely to complete donation. Notably, participation in a kidney paired exchange program eliminated sex-based differences in LDKT. Collectively, these data suggest that pregnancy is a formidable biologic barrier for women and contributes uniquely to sex disparity in LDKT. Targeted efforts to improve transplant center participation in paired kidney exchanges may increase sex equity in LDKT.

Evaluating living donor kidney transplant rates: Are you reaching your potential?

BACKGROUND

Traditionally, living donor kidney transplant (LDKT) rate has been calculated as a percentage of total kidney transplant volume. We believe this calculation to be inherently flawed because the number of deceased donor kidney transplants has no bearing on the number of LDKT performed. We propose an alternative calculation of LDKT rate as a percentage of the number of new waitlist registrants.

METHODS

We evaluated 192 adult transplant centers in the United States with respect to their LDKT rate according to both the traditional and proposed calculations, using data from the scientific registry of transplant recipients between July 2014 and June 2015.

RESULTS

The median LDKT rate for every 100 new waitlist registrants was 12.3, compared to 27.9 for every 100 total kidney transplants. Based on our proposed calculation of LDKT rate, 16.7% of transplant centers were misevaluated when compared to the national mean using the traditional method.

CONCLUSIONS

A new calculation of LDKT rate based on new waitlist registrants, and not total kidney transplants, is necessary to eliminate the bias associated with the traditional method, allowing for the identification of centers for improvement as well as each individual center's true potential based on their patient demographics.

Systems Biology in Kidney Transplantation: The Application of Multi-Omics to a Complex Model

In spite of reduction of rejection rates and improvement in short-term survival post-kidney transplantation, modest progress has occurred in long-term graft attrition over the years. Timely identification of molecular events that precede clinical and histopathological changes might help in early intervention and thereby increase the graft half-life. Evolution of "omics" tools has enabled systemic investigation of the influence of the whole genome, epigenome, transcriptome, proteome and microbiome on transplant function and survival. In this omics era, systemic approaches, in-depth clinical phenotyping and use of strict validation methods are the key for further understanding the complex mechanisms associated with graft function. Systems biology is an interdisciplinary holistic approach that focuses on complex and dynamic interactions within biological systems. The complexity of the human kidney transplant is unlikely to be captured by a reductionist approach. It appears essential to integrate multi-omics data that can elucidate the multidimensional and multilayered regulation of the underlying heterogeneous and complex kidney transplant model. Herein, we discuss studies that focus on genetic biomarkers, emerging technologies and systems biology approaches, which should increase the ability to discover biomarkers, understand mechanisms and stratify patients and responses post-kidney transplantation.

Social Determinants of Racial Disparities in CKD

Significant disparities in CKD rates and outcomes exist between black and white Americans. Health disparities are defined as health differences that adversely affect disadvantaged populations, on the basis of one or more health outcomes. CKD is the complex result of genetic and environmental factors, reflecting the balance of nature and nurture. Social determinants of health have an important role as environmental components, especially for black populations, who are disproportionately disadvantaged. Understanding the social determinants of health and appreciating the underlying differences associated with meaningful clinical outcomes may help nephrologists treat all their patients with CKD in an optimal manner. Altering the social determinants of health, although difficult, may embody important policy and research efforts, with the ultimate goal of improving outcomes for patients with kidney diseases, and minimizing the disparities between groups.

Inter- and Intrapersonal Barriers to Living Donor Kidney Transplant among Black Recipients and Donors

CONTEXT

End-stage renal disease (ESRD) is more common among Blacks, but Blacks are less likely to receive a live donor kidney transplant (LDKT).

OBJECTIVE

The objective of this study is to identify barriers and coping mechanisms that Black LDKT recipients and donors experienced while receiving or donating a kidney.

DESIGN

A qualitative study was conducted using structured interviews. Thematic analysis was used for data interpretation.

PARTICIPANTS

All 20 participants identified as Black, with two participants identifying themselves as multiracial. The mean age for the 14 recipients was 60, and the average age for the 6 living donors was 47.

RESULTS

Themes emerging from the data suggest both recipients and donors faced barriers in the LDKT experience. Recipients faced barriers associated with their denial and avoidance of the severity of their ESRD, their desire to maintain the privacy of their health status, and their refusal to approach potential donors. Donors encountered negative responses from others about the donors' desire to donate and the initial refusal of recipients to accept a LDKT offer. Recipients identified faith as a coping mechanism, while donors identified normalization of donation as their method of coping. Various types of social support helped donors and recipients navigate the transplant process.

CONCLUSION

Black LDKT recipients and donors must overcome barriers prior to receiving or donating a kidney. Most of these barriers arise from communication and interactions with others that are either lacking or undesirable. Future interventions to promote LDKT among Blacks may benefit by specifically targeting these barriers.

Nephrologists' Perspectives on Recipient Eligibility and Access to Living Kidney Donor Transplantation

BACKGROUND

Wide variations in access to living kidney donation are apparent across transplant centers. Such disparities may be in part explained by nephrologists' beliefs and decisions about recipient eligibility. This study aims to describe nephrologists' attitudes towards recipient eligibility and access to living kidney donor transplantation.

METHODS

Face-to-face semistructured interviews were conducted from June to October 2013 with 41 nephrologists from Australia and New Zealand. Transcripts were analyzed thematically.

RESULTS

We identified five major themes: championing optimal recipient outcomes (maximizing recipient survival, increasing opportunity, accepting justified risks, needing control and certainty of outcomes, safeguarding psychological wellbeing), justifying donor sacrifice (confidence in reasonable utility, sparing the donor, ensuring reciprocal donor benefit), advocating for patients (being proactive and encouraging, addressing ambivalence, depending on supportive infrastructure, avoiding selective recommendations), maintaining professional boundaries (minimizing conflict of interest, respecting shared decision-making, emphasizing patient accountability, restricted decisional power, protecting unit interests), and entrenched inequities (exclusivity of living donors, inherently advantaging self-advocates, navigating language barriers, increasing center transparency, inevitable geographical disadvantage, understanding cultural barriers).

CONCLUSIONS

Nephrologists' decisions about recipient suitability for living donor transplantation aimed to achieve optimal recipient outcomes, but were constrained by competing priorities to ensure reasonable utility derived from the donor kidney and protect the integrity of the transplant program. Comprehensive guidelines that provide explicit recommendations for complex medical and psychosocial risk factors might promote more equitable and transparent decision-making. Psychosocial support and culturally sensitive educational resources are needed to help nephrologists advocate for disadvantaged patients and address disparities in access to living kidney donor transplantation.

Educating Prospective Kidney Transplant Recipients and Living Donors about Living Donation: Practical and Theoretical Recommendations for Increasing Living Donation Rates

A promising strategy for increasing living donor kidney transplant (LDKT) rates is improving education about living donation for both prospective kidney transplant recipients and living donors to help overcome the proven knowledge, psychological, and socioeconomic barriers to LDKT. A recent Consensus Conference on Best Practices in Live Kidney Donation recommended that comprehensive LDKT education be made available to patients at all stages of chronic kidney disease (CKD). However, in considering how to implement this recommendation across different healthcare learning environments, the current lack of available guidance regarding how to design, deliver, and measure the efficacy of LDKT education programs is notable. In the current article, we provide an overview of how one behavior change theory, the Transtheoretical Model of Behavior Change, can guide the delivery of LDKT education for patients at various stages of CKD and readiness for LDKT. We also discuss the importance of creating educational programs for both potential kidney transplant recipients and living donors, and identify key priorities for educational research to reduce racial disparities in LDKT and increase LDKT rates.

Racial and ethnic disparities in access to and utilization of living donor liver transplants

Living donor liver transplantation (LDLT) is a comparable alternative to deceased donor liver transplantation and can mitigate the risk of dying while waiting for transplant. Although evidence exists of decreased utilization of living donor kidney transplants among racial minorities, little is known about access to LDLT among racial/ethnic minorities. We used Organ Procurement and Transplantation Network/United Network for Organ Sharing data from February 27, 2002 to June 4, 2014 from all adult liver transplant recipients at LDLT-capable transplant centers to evaluate differential utilization of LDLTs based on race/ethnicity. We then used data from 2 major urban transplant centers to analyze donor inquiries and donor rule-outs based on racial/ethnic determination. Nationally, of 35,401 total liver transplant recipients performed at a LDLT-performing transplant center, 2171 (6.1%) received a LDLT. In multivariate generalized estimating equation models, racial/ethnic minorities were significantly less likely to receive LDLTs when compared to white patients. For cholestatic liver disease, the odds ratios of receiving LDLT based on racial/ethnic group for African American, Hispanic, and Asian patients compared to white patients were 0.35 (95% CI, 0.20-0.60), 0.58 (95% CI, 0.34-0.99), and 0.11 (95% CI, 0.02-0.55), respectively. For noncholestatic liver disease, the odds ratios by racial/ethnic group were 0.53 (95% CI, 0.40-0.71), 0.78 (95% CI, 0.64-0.94), and 0.45 (95% CI, 0.33-0.60) respectively. Transplant center-specific data demonstrated that African American patients received fewer per-patient donation inquiries than white patients, whereas fewer African American potential donors were ruled out for obesity. In conclusion, racial/ethnic minorities receive a disproportionately low percentage of LDLTs, due in part to fewer initial inquiries by potential donors. This represents a major inequality in access to a vital health care resource and demands outreach to both patients and potential donors.

An overview of disparities and interventions in pediatric kidney transplantation worldwide

Despite the stated goals of the transplant community and the majority of organ allocation systems, persistent racial disparities in pediatric kidney transplantation exist throughout the world. These disparities are evident in both living and deceased donor kidney transplantation and are independent of any clinical differences between racial groups. The reasons for these persistent disparities are multifactorial, reflecting both patient and provider barriers to care. In this review, we examine the most current findings regarding disparities in pediatric kidney transplantation and consider interventions which may help reduce those disparities.

Living Donor Kidney Transplantation: Improving Education Outside of Transplant Centers about Live Donor Transplantation--Recommendations from a Consensus Conference

Living donor kidney transplantation (LDKT) offers better quality of life and clinical outcomes, including patient survival, compared with remaining on dialysis or receiving a deceased donor kidney transplant. Although LDKT education within transplant centers for both potential recipients and living donors is very important, outreach and education to kidney patients in settings other than transplant centers and to the general public is also critical to increase access to this highly beneficial treatment. In June 2014, the American Society of Transplantation's Live Donor Community of Practice, with the support of 10 additional sponsors, convened a consensus conference to determine best practices in LDKT, including a workgroup focused on developing a set of recommendations for optimizing outreach and LDKT education outside of transplant centers. Members of this workgroup performed a structured literature review, conducted teleconference meetings, and met in person at the 2-day conference. Their efforts resulted in consensus around the following recommendations. First, preemptive transplantation should be promoted through increased LDKT education by primary care physicians and community nephrologists. Second, dialysis providers should be trained to educate their own patients about LDKT and deceased donor kidney transplantation. Third, partnerships between community organizations, organ procurement organizations, religious organizations, and transplant centers should be fostered to support transplantation. Fourth, use of technology should be improved or expanded to better educate kidney patients and their support networks. Fifth, LDKT education and outreach should be improved for kidney patients in rural areas. Finally, a consensus-driven, evidence-based public message about LDKT should be developed. Discussion of the effect and potential for implementation around each recommendation is featured, particularly regarding reducing racial and socioeconomic disparities in access to LDKT. To accomplish these recommendations, the entire community of professionals and organizations serving kidney patients must work collaboratively toward ensuring accurate, comprehensive, and up-to-date LDKT education for all patients, thereby reducing barriers to LDKT access and increasing LDKT rates.

Racial disparities in reaching the renal transplant waitlist: is geography as important as race?

BACKGROUND

In the United States, African Americans and whites differ in access to the deceased donor renal transplant waitlist. The extent to which racial disparities in waitlisting differ between United Network for Organ Sharing (UNOS) regions is understudied.

METHODS

The US Renal Data System (USRDS) was linked with US census data to examine time from dialysis initiation to waitlisting for whites (n = 188,410) and African Americans (n = 144,335) using Cox proportional hazards across 11 UNOS regions, adjusting for potentially confounding individual, neighborhood, and state characteristics.

RESULTS

Likelihood of waitlisting varies significantly by UNOS region, overall and by race. Additionally, African Americans face significantly lower likelihood of waitlisting compared to whites in all but two regions (1 and 6). Overall, 39% of African Americans with ESRD reside in Regions 3 and 4--regions with a large racial disparity and where African Americans comprise a large proportion of the ESRD population. In these regions, the African American-white disparity is an important contributor to their overall regional disparity.

CONCLUSIONS

Race remains an important factor in time to transplant waitlist in the United States. Race contributes to overall regional disparities; however, the importance of race varies by UNOS region.

Making house calls increases living donor inquiries and evaluations for blacks on the kidney transplant waiting list

BACKGROUND

Blacks receive live donor kidney transplant (LDKT) less often than patients of all other races. We evaluated the effectiveness of educational interventions in removing barriers to LDKT for blacks.

METHODS

Patients were randomized to three interventions in which health educator(s) delivered an intervention to (a) the patient and his/her guests in the patient's home (house calls [HC], n=54), (b) clusters of patients and their guests in the transplant center (group based [GB], n=49), and (c) the individual patient alone in the transplant center (individual counseling [IC], n=49).

RESULTS

At the 2-year endpoint, 15% (n=8), 8% (n=4), and 6% (n=3) of HC, GB, and IC patients, respectively, received LDKT (P=0.30). Patients in the HC group were more likely than patients in the GB and IC groups to have at least one donor inquiry (82% vs. 61% vs. 47%, P=0.001) and evaluation (65% vs. 39% vs. 27%, P<0.001). Patients in the HC group also were more likely to have higher knowledge, fewer concerns, and higher willingness to talk to others about donation 6 weeks after intervention.

CONCLUSIONS

These findings underscore the importance of including the patient's social network in LDKT education and the potential of the HC intervention to reduce racial disparity in LDKT rates.

Applying best practices to designing patient education for patients with end-stage renal disease pursuing kidney transplant

Despite the known benefits of kidney transplant, less than 30% of the 615 000 patients living with end-stage renal disease (ESRD) in the United States have received a transplant. More than 100 000 people are presently on the transplant waiting list. Although the shortage of kidneys for transplant remains a critical factor in explaining lower transplant rates, another important and modifiable factor is patients' lack of comprehensive education about transplant. The purpose of this article is to provide an overview of known best practices from the broader literature that can be used as an evidence base to design improved education for ESRD patients pursuing a kidney transplant. Best practices in chronic disease education generally reveal that education that is individually tailored, understandable for patients with low health literacy, and culturally competent is most beneficial. Effective education helps patients navigate the complex health care process successfully. Recommendations for how to incorporate these best practices into transplant education design are described. Providing more ESRD patients with transplant education that encompasses these best practices may improve their ability to make informed health care decisions and increase the numbers of patients interested in pursuing transplant.

Identification of strategies to facilitate organ donation among African Americans using the nominal group technique

BACKGROUND AND OBJECTIVES

African Americans are disproportionately affected by ESRD, but few receive a living donor kidney transplant. Surveys assessing attitudes toward donation have shown that African Americans are less likely to express a willingness to donate their own organs. Studies aimed at understanding factors that may facilitate the willingness of African Americans to become organ donors are needed.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A novel formative research method was used (the nominal group technique) to identify and prioritize strategies for facilitating increases in organ donation among church-attending African Americans. Four nominal group technique panel interviews were convened (three community and one clergy). Each community panel represented a distinct local church; the clergy panel represented five distinct faith-based denominations. Before nominal group technique interviews, participants completed a questionnaire that assessed willingness to become a donor; 28 African-American adults (≥19 years old) participated in the study.

RESULTS

In total, 66.7% of participants identified knowledge- or education-related strategies as most important strategies in facilitating willingness to become an organ donor, a view that was even more pronounced among clergy. Three of four nominal group technique panels rated a knowledge-based strategy as the most important and included strategies, such as information on donor involvement and donation-related risks; 29.6% of participants indicated that they disagreed with deceased donation, and 37% of participants disagreed with living donation. Community participants' reservations about becoming an organ donor were similar for living (38.1%) and deceased (33.4%) donation; in contrast, clergy participants were more likely to express reservations about living donation (33.3% versus 16.7%).

CONCLUSIONS

These data indicate a greater opposition to living donation compared with donation after one's death among African Americans and suggest that improving knowledge about organ donation, particularly with regard to donor involvement and donation-related risks, may facilitate increases in organ donation. Existing educational campaigns may fall short of meeting information needs of African Americans.

Your Path to Transplant: a randomized controlled trial of a tailored computer education intervention to increase living donor kidney transplant

BACKGROUND

Because of the deceased donor organ shortage, more kidney patients are considering whether to receive kidneys from family and friends, a process called living donor kidney transplantation (LDKT). Although Blacks and Hispanics are 3.4 and 1.5 times more likely, respectively, to develop end stage renal disease (ESRD) than Whites, they are less likely to receive LDKTs. To address this disparity, a new randomized controlled trial (RCT) will assess whether Black, Hispanic, and White transplant patients' knowledge, readiness to pursue LDKT, and receipt of LDKTs can be increased when they participate in the Your Path to Transplant (YPT) computer-tailored intervention.

METHODS/DESIGN

Nine hundred Black, Hispanic, and White ESRD patients presenting for transplant evaluation at University of California, Los Angeles Kidney and Pancreas Transplant Program (UCLA-KPTP) will be randomly assigned to one of two education conditions, YPT or Usual Care Control Education (UC). As they undergo transplant evaluation, patients in the YPT condition will receive individually-tailored telephonic coaching sessions, feedback reports, video and print transplant education resources, and assistance with reducing any known socioeconomic barriers to LDKT. Patients receiving UC will only receive transplant education provided by UCLA-KPTP. Changes in transplant knowledge, readiness, pros and cons, and self-efficacy to pursue LDKT will be assessed prior to presenting at the transplant center (baseline), during transplant evaluation, and 4- and 8-months post-baseline, while completion of transplant evaluation and receipt of LDKTs will be assessed at 18-months post-baseline. The RCT will determine, compared to UC, whether Black, Hispanic, and White patients receiving YPT increase in their readiness to pursue LDKT and transplant knowledge, and become more likely to complete transplant medical evaluation and pursue LDKT. It will also examine how known patient, family, and healthcare system barriers to LDKT act alone and in combination with YPT to affect patients' transplant decision-making and behavior. Statistical analyses will be performed under an intent-to-treat approach.

DISCUSSION

At the conclusion of the study, we will have assessed the effectiveness of an innovative and cost-effective YPT intervention that could be utilized to tailor LDKT discussion and education based on the needs of individual patients of different races in many healthcare settings.

TRIAL REGISTRATION

ClinicalTrials.gov, number NCT02181114.

Sex differences and attitudes toward living donor kidney transplantation among urban black patients on hemodialysis

BACKGROUND AND OBJECTIVES

Living donor kidney transplantation, the treatment of choice for ESRD, is underused by women and blacks. To better understand sex differences in the context of potential barriers to living donor kidney transplantation, the Dialysis Patient Transplant Questionnaire was administered in two urban, predominantly black hemodialysis units.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The Dialysis Patient Transplant Questionnaire was designed to study barriers to kidney transplantation from previously validated questions. Between July of 2008 and January of 2009, the Dialysis Patient Transplant Questionnaire was administered to 116 patients on hemodialysis, including potentially eligible and ineligible living donor kidney transplantation candidates. Of 101 patients who self-identified as black or African American, 50 (49.5%) patients had the questionnaire entirely administered by the researcher or assistant, 25 (24.8%) patients required some assistance, and 26 (25.7%) patients completed the Dialysis Patient Transplant Questionnaire entirely by themselves. Multiple logistic regression methods were used to determine if the observed bivariate associations and differences persisted when controlled for potential confounders.

RESULTS

Women were less likely to want living donor kidney transplantation compared with men (58.5% versus 87.5%, P=0.003), despite being nearly two times as likely as men to receive unsolicited offers for kidney transplant (73.2% versus 43.2%, P=0.02). They were also less likely to have been evaluated for a kidney transplant (28.3% versus 52.2%, P=0.01). The multiple logistic regression analysis showed that sex was a statistically significant predictor of wanting living donor kidney transplantation (women versus men odds ratio, 0.13; 95% confidence interval, 0.04 to 0.46), controlling for various factors known to influence transplant decisions. A sensitivity analysis indicated that mode of administration did not bias these results.

CONCLUSIONS

In contrast to previous studies, the study found that black women were less likely to want living donor kidney transplantation compared with black men. Black women were also less likely to be evaluated for a kidney transplant, although they were more likely to receive an unsolicited living donor kidney transplantation offer.