Racial/ethnic disparities in waitlisting for deceased donor kidney transplantation 1 year after implementation of the new national kidney allocation system

Kidney Transplant Fast Track and Likelihood of Waitlisting and Transplant: A Nonrandomized Clinical Trial

Importance

Kidney transplant (KT) is the optimal treatment for end-stage kidney disease (ESKD). The evaluation process for KT is lengthy, time-consuming, and burdensome, and racial and ethnic disparities persist.

Objective

To investigate the potential association of the Kidney Transplant Fast Track (KTFT) evaluation approach with the likelihood of waitlisting, KT, and associated disparities compared with standard care.

Design, Setting, and Participants

This nonrandomized clinical trial was a prospective comparative cohort trial with a historical control (HC) comparison and equal follow-up duration at a single urban transplant center. Study duration was 2015 to 2018 for KTFT, with follow-up through 2022, and 2010 to 2014 for HC, with follow-up through 2018. Adult, English-speaking patients with ESKD, no history of KT, and a scheduled KT evaluation appointment were included. Among 1472 eligible patients for the KTFT group, 1288 consented and completed the baseline interview and 170 were excluded for not attending an evaluation appointment; among 1337 patients eligible for the HC group, 1152 consented and completed the baseline interview and none were excluded. Data were analyzed from August 2023 through December 2024.

Exposure

Streamlined, patient-centered, coordinated-care KT evaluation process.

Main Outcomes and Measures

Time to waitlisting for KT and receipt of KT.

Results

The study included 1118 participants receiving KTFT (416 female [37.2%]; mean [SD] age, 57.2 [13.2] years; 245 non-Hispanic Black [21.9%], 790 non-Hispanic White [70.7%], and 83 other race or ethnicity [7.4%]) and 1152 participants in the HC group (447 female [38.8%]; mean [SD] age, 55.5 [13.2] years; 267 non-Hispanic Black [23.2%], 789 non-Hispanic White [68.5%], and 96 other race or ethnicity [8.3%]). After adjusting for demographic and clinical factors, the KTFT compared with the HC group had a higher likelihood of being placed on the active waitlist for KT (subdistribution hazard ratio [SHR], 1.40; 95% CI, 1.24-1.59). Among individuals who were waitlisted, patients in the KTFT vs HC group had a higher likelihood of receiving a KT (SHR, 1.21; 95% CI, 1.04-1.41). Black patients (SHR, 1.54; 95% CI, 1.11-2.14) and White patients (SHR, 1.38; 95% CI, 1.16-1.65) receiving KTFT were more likely to be waitlisted for KT than those in the HC group, but no such difference was found for patients with other race or ethnicity. Among Black patients, those with KTFT were more likely than those in the HC group to undergo KT (SHR, 1.52; 95% CI, 1.06-2.16), but no significant differences were found for White patients or those with other race or ethnicity.

Conclusions and Relevance

This study found that KTFT was associated with a higher likelihood of waitlisting and KT than standard care. Findings suggest that KTFT may be associated with reduced disparities in KT by race and ethnicity.

Trial Registration

ClinicalTrials.gov Identifier: NCT02342119.

Equity and the operational considerations of the kidney transplant allocation system

PURPOSE OF REVIEW

Demonstrate the impact of allocation system design on access to the waitlist and transplantation for patients with end-stage kidney disease (ESKD).

RECENT FINDINGS

Minoritized groups are more likely to be declined from transplant listing owing to psychosocial criteria. Lack of consistent definitions, screening tools with differential subgroup validity, and insufficient evidence-base contribute to concerns about reliance on psychosocial factors in transplant listing decisions.

SUMMARY

Although kidney transplantation is the preferred treatment choice, a shrinking proportion of prevalent patients are waitlisted for this option in the United States, even among our youngest ESKD patients. Recent HRSA proposals to expand data collection to encompass the prewaitlisting process suggest a timely need to capture additional data on transplant referrals to improve access to transplantation. In 2021, KAS250 was implemented in response to concerns of geographic inequities in transplant rates. However, updates to this system have also resulted in a dramatic rise in organ offers, the number of offers needed to successfully place an organ and lowered utilization rates. Since KAS250, the use of alternative pathways to improve organ utilization rates, such as out-of-sequence placements has increased dramatically across the organ quality spectrum and risk exacerbating disparities in access to transplant. Additionally, the current absence of meaningful oversight risks undermining the perception of the transplant system as an objective process.

SUMMARY

There is a need for a more robust evaluation of recent iterative changes in waitlist and organ allocation practices to ensure equity in access for our most vulnerable patients.

Access to Transplant for African American and Latino Patients Under the 2014 US Kidney Allocation System

BACKGROUND

Kidney transplant offers better outcomes and reduced costs compared with chronic dialysis. However, racial and ethnic disparities in access to kidney transplant persist despite efforts to expand access to transplant and improve the equity of deceased donor allocation. Our objective was to evaluate after listing the association of race and ethnicity with access to deceased donor kidney transplant (DDKT) after changes to the allocation system in 2014.

METHODS

This retrospective study evaluated access to DDKT after listing since the implementation of the 2014 kidney allocation system. Waitlist status and transplant outcomes were ascertained from data from the Scientific Registry of Transplant Recipients. Our analysis included every adult kidney transplant candidate on the waiting list in the US from January 1, 2015, through June 30, 2023.

RESULTS

A total of 290 763 candidates were on the waiting list for DDKT during the study period. Of these, 36.4% of candidates were African American and 22.2% were Latino. Compared with White non-Latino patients, access to DDKT after listing was reduced for African American (unadjusted hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.92-0.94) and Latino individuals (unadjusted HR, 0.88; 95% CI, 0.87-0.90). After controlling for demographic and clinical factors, these differences in access to transplant widened substantially for African American (HR, 0.78; 95% CI, 0.77-0.80) and Latino patients (HR, 0.73; 95% CI, 0.72-0.74).

CONCLUSIONS

African American and Latino patients had reduced access to DDKT after listing. More effective approaches to improving access for African American and Latino individuals after listing are needed.

Early Effects of the ESRD Treatment Choices Model on Kidney Transplant Waitlist Additions

Key Points

The ESRD Treatment Choices model did not lead to an increase in kidney transplant waitlisting. The COVID-19 pandemic had a substantial impact on kidney transplant waitlist additions. Financial incentives alone, in the short term, did not lead to a substantial effect on kidney transplant waitlisting practices.

Background

Despite the mortality benefit of kidney transplantation over dialysis, only 13% of patients with ESKD are on the transplant waitlist. Given the low rates of transplant waitlisting in the United States, Medicare launched the ESRD Treatment Choices (ETC) model in 2021, the largest mandatory trial of payment incentives in kidney disease, which randomized 30% of health care markets to financial bonuses/penalties to improve kidney transplantation and home dialysis use. This study examines the effect of ETC payment adjustments on US kidney transplant waitlist additions.

Methods

Using data from the Organ Procurement and Transplantation Network registry, we examined kidney transplant waitlisting trends between January 1, 2017, and June 30, 2022. Participants were divided into intervention and control arms of the ETC model. Using an interrupted time series design, we compared slope changes in waitlist additions after ETC model implementation (implementation date: January 01, 2021) between the two arms, while accounting for differential changes during the coronavirus disease 2019 pandemic. Results were stratified by race and ethnicity (White, Black, Hispanic, and other). To examine balance between the two ETC arms, we conducted supplementary analyses using United States Renal Data System and Medicare data.

Results

After implementation of the ETC model, there were 5550 waitlist additions in the intervention arm and 11,332 additions in the control arm (versus 14,023 and 30,610 additions before the ETC model). After ETC model implementation, there were no significant differences in kidney transplant waitlist additions between the two arms for the overall cohort (slope difference 6.9 new listings/mo; 95% confidence interval [CI], −7.4 to 21.1) or among White (slope difference 2.6/mo; 95% CI, −3.0 to 8.1), Black (slope difference 2.2/mo; 95% CI, −4.3 to 8.7), or Hispanic (slope difference 0.2/mo; 95% CI, −4.5 to 4.9) patients.

Conclusions

In the 18 months after implementation, the ETC model was not associated with significant changes in new kidney transplant waitlist additions.

Reducing Disparities in Access to Kidney Transplantation Regional Study: A Randomized Trial in the Southeastern United States

Key Points

Declines in referral mirror national trends; however, declines were less for some groups receiving the intervention, warranting long-term follow-up. The findings provide important context for future modification and scale-up of multilevel, multicomponent interventions in dialysis settings.

Background

The Southeastern United States has among the lowest rates of kidney transplantation nationally and has documented racial and socioeconomic disparities in transplant access. We assessed the effectiveness and implementation of a multicomponent intervention aimed at increasing access and reducing disparities in access to early transplant steps in Georgia, North Carolina, and South Carolina.

Methods

The Reducing Disparities in Access to Kidney Transplantation Regional Study randomized 440 dialysis facilities in Georgia, North Carolina, and South Carolina to receive the Reducing Disparities in Access to Kidney Transplantation Regional educational and quality intervention or standard of care in 2018. The primary outcome was a change in dialysis facility–level transplant referral within 1 year of dialysis start after intervention, with secondary outcomes examining changes in evaluation start within 6 months of referral and waitlisting within 1 year of evaluation start. A process evaluation included a postimplementation survey (N =220) and semistructured interviews of staff (N =4). Generalized linear mixed-effects models assessed intervention effectiveness overall and in race subgroups.

Results

Among the 25,586 patients with ESKD treated in 440 dialysis facilities, referral rates decreased across both intervention arms 1 year after intervention; however, a greater decrease in referrals was observed among control (11.2% to 9.2%) versus intervention (11.2% to 10.5%) facilities. We observed no significant difference in the likelihood of referral among Black patients in intervention versus control facilities after intervention (adjusted odds ratio, 1.12; 95% confidence interval, 0.94 to 1.33); however, a significant increase in referral was observed among White patients in intervention facilities after intervention (odds ratio, 1.24; 95% confidence interval, 1.02 to 1.51). Interviews highlighted the importance of tailored interventions, federal mandates, and implementation challenges for large pragmatic trials.

Conclusions

Postintervention declines in referral mirror national trends; however, these declines were less for some groups receiving the intervention, warranting long-term follow-up. These findings provide important context for future modification and scale-up of multilevel, multicomponent interventions in dialysis settings.

Clinical Trial registry name and registration number:

The study protocol is available on ClinicalTrials.gov (identifier: NCT02389387 ).

Trends in racial and ethnic disparities in pediatric lung transplantation in the United States

BACKGROUND

Racial and ethnic disparities in pediatric lung transplantation (LTx) related to the shifting cystic fibrosis (CF) population receiving highly effective modulator therapy (HEMT) has not been well investigated.

METHODS

The UNOS Registry was queried for patients age 1-25 years undergoing bilateral LTx between 1 January 2012 and 31 December 2021. Race and ethnicity were classified as non-Hispanic White, non-Hispanic Black, Hispanic, or none of the above. The primary outcome was posttransplant mortality. Trends in the association between race/ethnicity and mortality were examined using transplant year as a continuous variable and stratifying year based on introduction of HEMT (triple combination therapy) in November 2019.

RESULTS

In the study sample (N = 941), 7% of patients were non-Hispanic Black, 15% were Hispanic, and 2% were some other racial or ethnic group. One hundred (11%) received LTx after approval of triple combination therapy, and 407 (43%) died during follow-up. We identified a statistically significant disparity in mortality hazard (hazard ratio: 1.91; 95% confidence interval: 1.31, 2.80) in non-Hispanic Black compared to non-Hispanic White patients in the pre-triple combination therapy era.

CONCLUSIONS

We found higher mortality hazard among non-Hispanic Black compared to non-Hispanic White children undergoing LTx in the United States. Further monitoring of LTx outcomes to identify and address disparities is needed in the current era of triple combination therapy for CF.

Effects of the March 2021 Allocation Policy Change on Key Deceased-donor Kidney Transplant Metrics

BACKGROUND

A major change to deceased-donor kidney allocation in the United States, Kidney Allocation System 250 (KAS250), was implemented on March 15, 2021. Evaluating the consequences of this policy on critical system performance metrics is critical to determining its success.

METHODS

We performed a retrospective analysis of critical performance measures of the kidney transplant system by reviewing all organs procured during a 4-y period in the United States. To mitigate against possible effects of the COVID-19 pandemic, Scientific Registry of Transplant Recipients records were stratified into 2 pre- and 2 post-KAS250 eras: (1) 2019; (2) January 1, 2020-March14, 2021; (3) March 15, 2021-December 31, 2021; and (4) 2022. Between-era differences in rates of key metrics were analyzed using chi-square tests with pairwise z -tests. Multivariable logistic regression and analysis of variations methods were used to evaluate the effects of the policy on rural and urban centers.

RESULTS

Over the period examined, among kidneys recovered for transplant, nonuse increased from 19.7% to 26.4% (all between-era P < 0.05) and among all Kidney Donor Profile Index strata. Cold ischemia times increased ( P < 0.001); however, the distance between donor and recipient hospitals decreased ( P < 0.05). Kidneys from small-metropolitan or nonmetropolitan hospitals were more likely to not be used over all times ( P < 0.05).

CONCLUSIONS

Implementation of KAS250 was associated with increased nonuse rates across all Kidney Donor Profile Index strata, increased cold ischemic times, and shorter distance traveled.

Multifaceted Intervention to Improve Graft Outcome Disparities in African American Kidney Transplants (MITIGAAT Study): Protocol for a Randomized Controlled Trial

BACKGROUND

The outcome disparities for African American recipients of kidney transplant is a public health issue that has plagued the field of transplant since its inception. Based on national data, African American recipients have nearly twice the risk of graft loss at 5 years after transplant, when compared with White recipients. Evidence demonstrates that medication nonadherence and high tacrolimus variability substantially impact graft outcomes and racial disparities, most notably late (>2 years) after the transplant. Nonadherence is a leading cause of graft loss. Prospective multicenter data demonstrate that one-third of all graft loss are directly attributed to nonadherence. We have spent 10 years of focused research to develop a comprehensive model explaining the predominant risk factors leading to disparities in African American kidney recipients. However, there are still gaps in patient-level data that hinder the deeper understanding of the disparities. Lack of data from the patient often lead to provider biases, which will be addressed with this intervention. Culturally competent, pharmacist-led interventions in medication therapy management will also address therapeutic inertia. Pharmacist interventions will mitigate medication access barriers as well (cost and insurance denials). Thus, this multidimensional intervention addresses patient, provider, and structural factors that drive racial disparities in African American kidney recipients.

OBJECTIVE

This prospective, randomized controlled trial aimed to determine the impact of multimodal health services intervention on health outcomes disparities in African American recipients of kidney transplant. The aims of this study are to improve adherence and control of late clinical issues, which are predominant factors for racial disparities in kidney recipients, through a technology-enabled, telehealth-delivered, 4-level intervention.

METHODS

The Multifaceted Intervention to Improve Graft Outcome Disparities in African American Kidney Transplants (MITIGAAT) study is a 24-month, 2-arm, single-center (Medical University of South Carolina), 1:1 randomized controlled trial involving 190 participants (95 in each arm), measuring the impact on adherence and control of late clinical issues for racial disparities in kidney recipients, through a technology-enabled, telehealth-delivered, 4-level intervention. The key clinical issues for this study include tacrolimus variability, blood pressure, and glucose control (in those with diabetes mellitus). We will also assess the impact of the intervention on health care use (hospitalizations and emergency department visits) and conduct a cost-benefit analysis. Finally, we will assess the impact of the intervention on acute rejection and graft survival rates as compared with a large contemporary national cohort.

RESULTS

This study was funded in July 2023. Enrolled began in April 2024 and is expected to be complete in 2026. All patients will complete the study by the end of 2028.

CONCLUSIONS

In this protocol, we describe the study design, methods, aims, and outcome measures that will be used in the ongoing MITIGAAT clinical trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06023615; https://www.clinicaltrials.gov/study/NCT06023615.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/57784.

Identifying when racial and ethnic disparities arise along the continuum of transplant care: a national registry study

Background

Fewer minoritized patients with end-stage kidney disease (ESKD) receive kidney transplantation (KT); efforts to mitigate disparities have thus far failed. Pinpointing the specific stage(s) within the transplant care continuum (being informed of KT options, joining the waiting list, to receiving KT) where disparities emerge among each minoritized population is pivotal for achieving equity. We therefore quantified racial and ethnic disparities across the KT care continuum.

Methods

We conducted a retrospective cohort study (2015-2020), with follow-up through 12/10/2021. Patients with incident dialysis were identified using the US national registry data. The exposure was race and ethnicity (Asian, Black, Hispanic, and White). We used adjusted modified Poisson regression to quantify the adjusted prevalence ratio (aPR) of being informed of KT, and cause-specific hazards models to calculate adjusted hazard ratios (aHR) of listing, and transplantation after listing.

Findings

Among 637,951 adults initiating dialysis, the mean age (SD) was 63.8 (14.6), 41.8% were female, 5.4% were Asian, 26.3% were Black, 16.6% were Hispanic, and 51.7% were White (median follow-up in years [IQR]:1.92 [0.97-3.39]). Black and Hispanic patients were modestly more likely to be informed of KT (Black: aPR = 1.02, 95% confidence interval [CI]:1.01-1.02; Hispanic: aPR = 1.03, 95% CI: 1.02-1.03) relative to White patients. Asian patients were more likely to be listed (aHR = 1.18, 95% CI: 1.15-1.21) but less likely to receive KT (aHR = 0.56, 95% CI: 0.54-0.58). Both Black and Hispanic patients were less likely to be listed (Black: aHR = 0.87, 95% CI: 0.85-0.88; Hispanic: aHR = 0.85, 95% CI: 0.85-0.88) and receive KT (Black: aHR = 0.61, 95% CI: 0.60-0.63; Hispanic: aHR = 0.64, 95% CI: 0.63-0.66).

Interpretation

Improved characterization of the barriers in KT access specific to each racial and ethnic group, and the interventions to address these distinct challenges throughout the KT care continuum are needed; our findings identify specific stages most in need of mitigation.

Funding

National Institutes of Health.

Association of Race and Ethnicity With High Longevity Deceased Donor Kidney Transplantation Under the US Kidney Allocation System

RATIONALE & OBJECTIVE

The US Kidney Allocation System (KAS) prioritizes candidates with a≤20% estimated posttransplant survival (EPTS) to receive high-longevity kidneys defined by a≤20% Kidney Donor Profile Index (KDPI). Use of EPTS in the KAS deprioritizes candidates with older age, diabetes, and longer dialysis durations. We assessed whether this use also disadvantages race and ethnicity minority candidates, who are younger but more likely to have diabetes and longer durations of kidney failure requiring dialysis.

STUDY DESIGN

Observational cohort study.

SETTING & PARTICIPANTS

Adult candidates for and recipients of kidney transplantation represented in the Scientific Registry of Transplant Recipients from January 2015 through December 2020.

EXPOSURE

Race and ethnicity.

OUTCOME

Age-adjusted assignment to≤20% EPTS, transplantation of a≤20% KDPI kidney, and posttransplant survival in longevity-matched recipients by race and ethnicity.

ANALYTIC APPROACH

Multivariable logistic regression, Fine-Gray competing risks survival analysis, and Kaplan-Meier and Cox proportional hazards methods.

RESULTS

The cohort included 199,444 candidates (7% Asian, 29% Black, 19% Hispanic or Latino, and 43% White) listed for deceased donor kidney transplantation. Non-White candidates had significantly higher rates of diabetes, longer dialysis duration, and were younger than White candidates. Adjusted for age, Asian, Black, and Hispanic or Latino candidates had significantly lower odds of having a ETPS score of≤20% (odds ratio, 0.86 [95% CI, 0.81-0.91], 0.52 [95% CI, 0.50-0.54], and 0.49 [95% CI, 0.47-0.51]), and were less likely to receive a≤20% KDPI kidney (sub-hazard ratio, 0.70 [0.66-0.75], 0.89 [0.87-0.92], and 0.73 [0.71-0.76]) compared with White candidates. Among recipients with≤20% EPTS scores transplanted with a≤20% KDPI deceased donor kidney, Asian and Hispanic recipients had lower posttransplant mortality (HR, 0.45 [0.27-0.77] and 0.63 [0.47-0.86], respectively) and Black recipients had higher but not statistically significant posttransplant mortality (HR, 1.22 [0.99-1.52]) compared with White recipients.

LIMITATIONS

Provider reported race and ethnicity data and 5-year post transplant follow-up period.

CONCLUSIONS

The US kidney allocation system is less likely to identify race and ethnicity minority candidates as having a≤20% EPTS score, which triggers allocation of high-longevity deceased donor kidneys. These findings should inform the Organ Procurement and Transplant Network about how to remedy the race and ethnicity disparities introduced through KAS's current approach of allocating allografts with longer predicted longevity to recipients with longer estimated posttransplant survival.

PLAIN-LANGUAGE SUMMARY

The US Kidney Allocation System prioritizes giving high-longevity, high-quality kidneys to patients on the waiting list who have a high estimated posttransplant survival (EPTS) score. EPTS is calculated based on the patient's age, whether the patient has diabetes, whether the patient has a history of organ transplantation, and the number of years spent on dialysis. Our analyses show that Asian, Black or African American, and Hispanic or Latino patients were less likely to receive high-longevity kidneys compared with White patients, despite having similar or better posttransplant survival outcomes.

Care of Adults with Advanced Chronic Kidney Disease

Chronic kidney disease (CKD) impacts over 10% of the global population. Adults with CKD face significant morbidity and mortality. As kidney disease progresses, the risk of adverse outcomes increases. Here, we present an overview of strategies to care for adults with advanced CKD (stage 4-5 CKD, not receiving kidney replacement therapy). We aim to guide clinicians through several aspects of CKD care, ranging from recommended laboratory assessments to interdisciplinary support for patients as they plan for kidney replacement therapy (dialysis, transplantation, or conservative management). We incorporate considerations of health equity and person-centered care, empowering clinicians to deliver high-quality care to people with CKD.

Lost in Transplantation: Characterizing Racial Gaps in Physician Organ Offer Acceptance

Background

There are known racial disparities in the organ transplant allocation system in the United States. However, prior work has yet to establish if transplant center decisions on offer acceptance-the final step in the allocation process-contribute to these disparities.

Objective

To estimate racial differences in the acceptance of organ offers by transplant center physicians on behalf of their patients.

Design

Retrospective cohort analysis using data from the Scientific Registry of Transplant Recipients (SRTR) on patients who received an offer for a heart, liver, or lung transplant between January 1, 2010 and December 31, 2020.

Setting

Nationwide, waitlist-based.

Patients

32,268 heart transplant candidates, 102,823 liver candidates, and 25,780 lung candidates, all aged 18 or older.

Measurements

1) Association between offer acceptance and two race-based variables: candidate race and donor-candidate race match; 2) association between offer rejection and time to patient mortality.

Results

Black race was associated with significantly lower odds of offer acceptance for livers (OR=0.93, CI: 0.88-0.98) and lungs (OR=0.80, CI: 0.73-0.87). Donor-candidate race match was associated with significantly higher odds of offer acceptance for hearts (OR=1.11, CI: 1.06-1.16), livers (OR=1.10, CI: 1.06-1.13), and lungs (OR=1.13, CI: 1.07-1.19). Rejecting an offer was associated with lower survival times for all three organs (heart hazard ratio=1.16, CI: 1.09-1.23; liver HR=1.74, CI: 1.66-1.82; lung HR=1.21, CI: 1.15-1.28).

Limitations

Our study analyzed the observational SRTR dataset, which has known limitations.

Conclusion

Offer acceptance decisions are associated with inequity in the organ allocation system. Our findings demonstrate the additional barriers that Black patients face in accessing organ transplants and demonstrate the need for standardized practice, continuous distribution policies, and better organ procurement.

The Impact of Health Care Algorithms on Racial and Ethnic Disparities : A Systematic Review

BACKGROUND

There is increasing concern for the potential impact of health care algorithms on racial and ethnic disparities.

PURPOSE

To examine the evidence on how health care algorithms and associated mitigation strategies affect racial and ethnic disparities.

DATA SOURCES

Several databases were searched for relevant studies published from 1 January 2011 to 30 September 2023.

STUDY SELECTION

Using predefined criteria and dual review, studies were screened and selected to determine: 1) the effect of algorithms on racial and ethnic disparities in health and health care outcomes and 2) the effect of strategies or approaches to mitigate racial and ethnic bias in the development, validation, dissemination, and implementation of algorithms.

DATA EXTRACTION

Outcomes of interest (that is, access to health care, quality of care, and health outcomes) were extracted with risk-of-bias assessment using the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool and adapted CARE-CPM (Critical Appraisal for Racial and Ethnic Equity in Clinical Prediction Models) equity extension.

DATA SYNTHESIS

Sixty-three studies (51 modeling, 4 retrospective, 2 prospective, 5 prepost studies, and 1 randomized controlled trial) were included. Heterogenous evidence on algorithms was found to: a) reduce disparities (for example, the revised kidney allocation system), b) perpetuate or exacerbate disparities (for example, severity-of-illness scores applied to critical care resource allocation), and/or c) have no statistically significant effect on select outcomes (for example, the HEART Pathway [history, electrocardiogram, age, risk factors, and troponin]). To mitigate disparities, 7 strategies were identified: removing an input variable, replacing a variable, adding race, adding a non-race-based variable, changing the racial and ethnic composition of the population used in model development, creating separate thresholds for subpopulations, and modifying algorithmic analytic techniques.

LIMITATION

Results are mostly based on modeling studies and may be highly context-specific.

CONCLUSION

Algorithms can mitigate, perpetuate, and exacerbate racial and ethnic disparities, regardless of the explicit use of race and ethnicity, but evidence is heterogeneous. Intentionality and implementation of the algorithm can impact the effect on disparities, and there may be tradeoffs in outcomes.

PRIMARY FUNDING SOURCE

Agency for Healthcare Quality and Research.

Impact of OPTN policy 3.7D providing waiting time modification for candidates affected by race-inclusive eGFR calculations: Early results from a single center

INTRODUCTION

OPTN Policy 3.7D, implemented January 5, 2023, mandates that all kidney transplant programs modify waiting time for candidates affected by race-inclusive eGFR calculations. We report the early impact of this policy change.

METHODS

Our transplant program reviewed all listed transplant candidates and identified patients potentially eligible for waiting time modification. Eligible candidates received waiting time modification after submission of supporting evidence to the OPTN. We reviewed the impact on waiting time and transplant activity through October 1, 2023.

RESULTS

Forty-six adult patients on our center's active waiting list self-identified as Black/African American. 25 (54.3%) candidates qualified for waiting time modification. A median 451 (321, 1543.5) additional days of waiting time was added for qualifying patients. Of the 25 patients who qualified for waiting time modification, 11 patients received a deceased donor kidney in the early period following waiting time modification, including 5 patients transplanted within 1 month after modification.

CONCLUSIONS

Policy 3.7D is one of few national mandates to address specifically structural racism within transplantation. Implementation has yielded near immediate effects with greater than 40% of time-adjusted patients at our center receiving a deceased donor kidney transplant in the initial months after policy enactment. Early assessment demonstrates great potential impact for this policy.

Implementation of the ASCENT Trial to Improve Transplant Waitlisting Access

Introduction

The Allocation System for changes in Equity in Kidney Transplantation (ASCENT) study was a hybrid type 1 trial of a multicomponent intervention among 655 US dialysis facilities with low kidney transplant waitlisting to educate staff and patients about kidney allocation system (KAS) changes and increase access to and reduce racial disparities in waitlisting. Intervention components included a staff webinar, patient and staff educational videos, and facility-specific feedback reports.

Methods

Implementation outcomes were assessed using the Reach, Effectiveness, Adoption, Implementation, and Maintenance Framework. Postimplementation surveys were administered among intervention group facilities (n = 334); interviews were conducted with facility staff (n = 6). High implementation was defined as using 3 to 4 intervention components, low implementation as using 1 to 2 components, and nonimplementation as using no components.

Results

A total of 331 (99%) facilities completed the survey; 57% were high implementers, 31% were low implementers, and 12% were nonimplementers. Waitlisting events were higher or similar among high versus low implementer facilities for incident and prevalent populations; for Black incident patients, the mean proportion waitlisted in low implementer facilities was 0.80% (95% confidence interval [CI]: 0.73-0.87) at baseline and 0.55% at 1-year (95% CI: 0.48-0.62) versus 0.83% (95% CI: 0.78-0.88) at baseline and 1.40% at 1-year (95% CI: 1.35-1.45) in high implementer facilities. Interviews revealed that the intervention helped facilities prioritize transplant education, but that intervention components were not uniformly shared.

Conclusion

The findings provide important context to interpret ASCENT effectiveness results and identified key barriers and facilitators to consider for future modification and scale-up of multilevel, multicomponent interventions in dialysis settings.

Unrecognized opportunities: The landscape of pediatric kidney-paired donation in the United States

BACKGROUND

Pediatric (age < 18 years) kidney transplant (KT) candidates face increasingly complex choices. The 2014 kidney allocation system nearly doubled wait times for pediatric recipients. Given longer wait times and new ways to optimize compatibility, more pediatric candidates may consider kidney-paired donation (KPD). Motivated by this shift and the potential impact of innovations in KPD practice, we studied pediatric KPD procedures in the US from 2008 to 2021.

METHODS

We describe the characteristics and outcomes of pediatric KPD recipients with comparison to pediatric non-KPD living donor kidney transplants (LDKT), pediatric LDKT recipients, and pediatric deceased donor (DDKT) recipients.

RESULTS

Our study cohort includes 4987 pediatric DDKTs, 3447 pediatric non-KPD LDKTs, and 258 pediatric KPD transplants. Fewer centers conducted at least one pediatric KPD procedure compared to those that conducted at least one pediatric LDKT or DDKT procedure (67, 136, and 155 centers, respectively). Five centers performed 31% of the pediatric KPD transplants. After adjustment, there were no differences in graft failure or mortality comparing KPD recipients to non-KPD LDKT, LDKT, or DDKT recipients.

DISCUSSION

We did not observe differences in transplant outcomes comparing pediatric KPD recipients to controls. Considering these results, KPD may be underutilized for pediatric recipients. Pediatric KT centers should consider including KPD in KT candidate education. Further research will be necessary to develop tools that could aid clinicians and families considering the time horizon for future KT procedures, candidate disease and histocompatibility characteristics, and other factors including logistics and donor protections.

Mitigating Health Disparities in Transplantation Requires Equity, Not Equality

Despite decades of research and evidence-based mitigation strategies, disparities in access to transplantation persist for all organ types and in all stages of the transplant process. Although some strategies have shown promise for alleviating disparities, others have fallen short of the equity goal by providing the same tools and resources to all rather than tailoring the tools and resources to one's circumstances. Innovative solutions that engage all stakeholders are needed to achieve equity regardless of race, sex, age, socioeconomic status, or geography. Mitigation of disparities is paramount to ensure fair and equitable access for those with end-stage disease and to preserve the trust of the public, upon whom we rely for their willingness to donate organs. In this overview, we present a summary of recent literature demonstrating persistent disparities by stage in the transplant process, along with policies and interventions that have been implemented to combat these disparities and hypotheses for why some strategies have been more effective than others. We conclude with future directions that have been proposed by experts in the field and how these suggested strategies may help us finally arrive at equity in transplantation.

Promoting Equity In Clinical Decision Making: Dismantling Race-Based Medicine

As the use of artificial intelligence has spread rapidly throughout the US health care system, concerns have been raised about racial and ethnic biases built into the algorithms that often guide clinical decision making. Race-based medicine, which relies on algorithms that use race as a proxy for biological differences, has led to treatment patterns that are inappropriate, unjust, and harmful to minoritized racial and ethnic groups. These patterns have contributed to persistent disparities in health and health care. To reduce these disparities, we recommend a race-aware approach to clinical decision support that considers social and environmental factors such as structural racism and social determinants of health. Recent policy changes in medical specialty societies and innovations in algorithm development represent progress on the path to dismantling race-based medicine. Success will require continued commitment and sustained efforts among stakeholders in the health care, research, and technology sectors. Increasing the diversity of clinical trial populations, broadening the focus of precision medicine, improving education about the complex factors shaping health outcomes, and developing new guidelines and policies to enable culturally responsive care are important next steps.

Race, Age, and Kidney Transplant Waitlisting Among Patients Receiving Incident Dialysis in the United States

Rationale & Objective

Patients with kidney failure from racial and ethnic minority groups and older patients have reduced access to the transplant waitlist relative to White and younger patients. Although racial disparities in the waitlisting group have declined after the 2014 kidney allocation system change, whether there is intersectionality of race and age in waitlisting access is unknown.

Study Design

Retrospective cohort study.

Setting & Participants

439,455 non-Hispanic White and non-Hispanic Black US adults initiating dialysis between 2015 and 2019 were identified from the United States Renal Data System, and followed through 2020.

Exposures

Patient race and ethnicity (non-Hispanic White and non-Hispanic Black) and age group (18-29, 30-49, 50-64, and 65-80 years).

Outcomes

Placement on the United Network for Organ Sharing deceased donor waitlist.

Analytical Approach

Age- and race-stratified waitlisting rates were compared. Multivariable Cox proportional hazards models, censored for death, examined the association between race and waitlisting, and included interaction term for race and age.

Results

Over a median follow-up period of 1 year, the proportion of non-Hispanic White and non-Hispanic Black patients waitlisted was 20.7% and 20.5%, respectively. In multivariable models, non-Hispanic Black patients were 14% less likely to be waitlisted (aHR, 0.86, 95% CI, 0.77-0.95). Relative differences between non-Hispanic Black and non-Hispanic White patients were different by age group. Non-Hispanic Black patients were 27%, 12%, and 20% less likely to be waitlisted than non-Hispanic White patients for ages 18-29 years (aHR, 0.73; 95% CI, 0.61-0.86), 50-64 (aHR, 0.88; 95% CI, 0.80-0.98), and 65-80 years (aHR, 0.80; 95% CI, 0.71-0.90), respectively, but differences were attenuated among patients aged 30-49 years (aHR, 0.89; 95% CI, 0.77-1.02).

Limitations

Race and ethnicity data is physician reported, residual confounding, and analysis is limited to non-Hispanic White and non-Hispanic Black patients.

Conclusions

Racial disparities in waitlisting exist between non-Hispanic Black and non-Hispanic White individuals and are most pronounced among younger patients with kidney failure. Results suggest that interventions to address inequalities in waitlisting may need to be targeted to younger patients with kidney failure.

Plain-Language Summary

Research has shown that patients from racial and ethnic minority groups and older patients have reduced access to transplant waitlisting relative to White and younger patients; nevertheless, how age impacts racial disparities in waitlisting is unknown. We compared waitlisting between non-Hispanic Black and non-Hispanic White patients with incident kidney failure, within age strata, using registry data for 439,455 US adults starting dialysis (18-80 years) during 2015-2019. Overall, non-Hispanic Black patients were less likely to be waitlisted and relative differences between the two racial groups differed by age. After adjusting for patient-level factors, the largest disparity in waitlisting was observed among adults aged 18-29 years. These results suggest that interventions should target younger adults to reduce disparities in access to kidney transplant waitlisting.

Inequities in Organ Donation and Transplantation Among Immigrant Populations in Italy: A Narrative Review of Evidence, Gaps in Research and Potential Areas for Intervention

Immigrants from outside Europe have increased over the past two decades, especially in Southern European countries including Italy. This influx coincided with an increased number of immigrants with end-stage organ diseases. In this narrative review, we reviewed evidence of the gaps between native-born and immigrant populations in the Organ Donation and Transplantation (ODT) process in Italy. Consistent with prior studies, despite the availability of a publicly funded health system with universal healthcare coverage, non-European-born individuals living in Italy are less likely to receive living donor kidney transplantation and more likely to have inferior long-term kidney graft function compared with EU-born and Eastern European-born individuals. While these patients are increasingly represented among transplant recipients (especially kidney and liver transplants), refusal rates for organ donation are higher in some ethnic groups compared with native-born and other foreign-born referents, with the potential downstream effects of prolonged waiting times and inferior transplant outcomes. In the process, we identified gaps in relevant research and biases in existing studies. Given the Italian National Transplant Center's (CNT) commitment to fighting inequities in ODT, we illustrated actions taken by CNT to tackle inequities in ODT among immigrant communities in Italy.

Increased volume of organ offers and decreased efficiency of kidney placement under circle-based kidney allocation

The newest kidney allocation policy kidney allocation system 250 (KAS250) broadened geographic distribution while increasing allocation system complexity. We studied the volume of kidney offers received by transplant centers and the efficiency of kidney placement since KAS250. We identified deceased-donor kidney offers (N = 907,848; N = 36,226 donors) to 185 US transplant centers from January 1, 2019, to December 31, 2021 (policy implemented March 15, 2021). Each unique donor offered to a center was considered a single offer. We compared the monthly volume of offers received by centers and the number of centers offered before the first acceptance using an interrupted time series approach (pre-/post-KAS250). Post-KAS250, transplant centers received more kidney offers (level change: 32.5 offers/center/mo, P < .001; slope change: 3.9 offers/center/mo, P = .003). The median monthly offer volume post-/pre-KAS250 was 195 (interquartile range 137-253) vs. 115 (76-151). There was no significant increase in deceased-donor transplant volume at the center level after KAS250, and center-specific changes in offer volume did not correlate with changes in transplant volume (r = -0.001). Post-KAS250, the number of centers to whom a kidney was offered before acceptance increased significantly (level change: 1.7 centers/donor, P < .001; slope change: 0.1 centers/donor/mo, P = .014). These findings demonstrate the logistical burden of broader organ sharing, and future allocation policy changes will need to balance equity in transplant access with the operational efficiency of the allocation system.

Sociodemographic Variables in Canadian Organ Donation Organizations: A Health Information Survey

Health systems must collect equity-relevant sociodemographic variables to measure and mitigate health inequities. The specific variables collected by organ donation organizations (ODOs) across Canada, variable definitions, and processes of the collection are not defined. We undertook a national health information survey of all ODOs in Canada. These results will inform the development of a standard national dataset of equity-relevant sociodemographic variables.

Methods

We conducted an electronic, self-administered cross-sectional survey of all ODOs in Canada from November 2021 to January 2022. We targeted key knowledge holders familiar with the data collection processes within each Canadian ODO known to Canadian Blood Services. Categorical item responses are presented as numbers and proportions.

Results

We achieved a 100% response rate from 10 Canadian ODOs. Most data were collected by organ donation coordinators. Only 2 of 10 ODOs reported using scripts explaining why sociodemographic data are being collected or incorporated training in cultural sensitivity for any given variable. A lack of cultural sensitivity training was endorsed by 50% of respondents as a barrier to the collection of sociodemographic variables by ODOs, whereas 40% of respondents identified a lack of training in sociodemographic variable collection as a significant barrier.

Conclusions

Few programs routinely collect sufficient data to examine health inequities with an intersectional lens. Most data collection occurs midway through the ODO interaction, creating a missed opportunity to better understand differences in social identities of patients who register their intention to donate in advance or who decline the donation. National standardization of equity-relevant data collection definitions and processes of the collection is needed.

Ethics of allocation of donor organs

PURPOSE OF REVIEW

There is no widely accepted single ethical principle for the fair allocation of scarce donor organs for transplantation. Although most allocation systems use combinations of allocation principles, there is a particular tension between 'prioritizing the worst-off' and 'maximizing total benefits'. It is often suggested that empirical research on public preferences should help solve the dilemma between equity and efficiency in allocation policy-making.

RECENT FINDINGS

This review shows that the evidence on public preferences for allocation principles is limited, and that the normative role of public preferences in donor organ allocation policy making is unclear. The review seeks to clarify the ethical dilemma to the transplant community, and draws attention to recent attempts at balancing and rank-ordering of allocation principles.

SUMMARY

This review suggests that policy makers should make explicit the relative weights attributed to equity and efficiency considerations in allocation policies, and monitor the effects of policy changes on important ethics outcomes, including equitable access among patient groups. Also, it draws attention to wider justice issues associated not with the distribution of donor organs among patients on waiting lists, but with barriers in referral for transplant evaluation and disparities among patient groups in access to waiting lists.

Factors associated with health inequities in access to kidney transplantation in the USA: A scoping review

BACKGROUND

The kidney is the most needed organ for transplantation in the United States. However, demand and scarcity of this organ has caused significant inequities for historically marginalized groups. In this review, we report on the frequency of inequities in all steps of kidney transplantation from 2016 to 2022. Search criteria was based on the National Institute of Health's (NIH) 2022 list of populations who experience health inequities, which includes: race and ethnicity; sex or gender; Lesbian, Gay, Bisexual, Transgender, Queer + (LGBTQ+); underserved rural communities; education level; income; and occupation status. We outline steps for future research aimed at assessing interventions and programs to improve health outcomes.

METHODS

This scoping review was developed following guidelines from the Joanna Briggs Institute and PRISMA extension for scoping reviews. In July 2022, we searched Medline (via PubMed) and Ovid Embase databases to identify articles addressing inequities in access to kidney transplantation in the United States. Articles had to address at least one of the NIH's 2022 health inequity groups.

RESULTS

Our sample of 44 studies indicate that Black race, female sex or gender, and low socioeconomic status are negatively associated with referral, evaluation, and waitlisting for kidney transplantation. Furthermore, only two studies from our sample investigated LGBTQ+ identity since the NIH's addition of SGM in 2016 regarding access to transplantation. Lastly, we found no detectable trend in studies for the four most investigated inequity groups between 2016 and 2022.

CONCLUSION

Investigations in inequities for access to kidney transplantation for the two most studied groups, race/ethnicity and sex or gender, have shown no change in frequencies. Regarding race and ethnicity, continued interventions focused on educating Black patients and staff of dialysis facilities may increase transplant rates. Studies aimed at assessing effectiveness of the Kidney Paired Donation program are highly warranted due to incompatibility problems in female patients. The sparse representation for the LGBTQ+ population may be due to a lack of standardized data collection for sexual orientation. We recommend this community be engaged via surveys and further investigations.

The unfinished journey toward transplant equity: an analysis of racial/ethnic disparities for children after the implementation of the Kidney Allocation System in 2014

BACKGROUND

Disparities in pediatric kidney transplantation (KT) result in reduced access and worse outcomes for minority children. We assessed the impact of recent systems changes on these disparities.

METHODS

This is a retrospective cohort study of pediatric patients utilizing data from the US Renal Data System (n = 7547) and Scientific Registry of Transplant Recipients (n = 6567 waitlisted and n = 6848 transplanted patients). We compared access to transplantation, time to deceased donor kidney transplant (DDKT), and allograft failure (ACGF) in the 5 years preceding implementation of the Kidney Allocation System (KAS) to the 5 years post-KAS implementation 2010-2014 vs. 2015-2019, respectively.

RESULTS

Compared to the pre-KAS era, post-KAS candidates were more likely to be pre-emptively listed (26.8% vs. 38.1%, p < 0.001), pre-emptively transplanted (23.8% vs. 28.0%, p < 0.001), and less likely to have private insurance (35.6% vs. 32.3%, p = 0.01), but these were not uniform across racial groups. Compared to white children, Black and Hispanic children had a lower likelihood of transplant listing within 2 years of first dialysis service (aHR 0.590.670.76 and 0.730.820.92, respectively) in the post-KAS era. Time to DDKT was comparable across all racial groups in the post-KAS era. Compared to white children, Black DDKT recipients have more 5-year ACGF (aHR 1.001.432.06 p = 0.05) while there was no difference in 3- or 5-year ACGF among LDKT recipients.

CONCLUSIONS

After KAS implementation, there is equity in time to DDKT. Pre-KAS increased hazard of ACGF among Black children has decreased in the post-KAS era; however, persistent disparities exist in time to transplant listing among Black and Hispanic children when compared to white children. A higher resolution version of the Graphical abstract is available as Supplementary information.

The ASCENT Intervention to Improve Access and Reduce Racial Inequalities in Kidney Waitlisting: A Randomized, Effectiveness-Implementation Trial

BACKGROUND

The US kidney allocation system (KAS) changed in 2014, but dialysis facility staff (including nephrologists, social workers, nurse managers, and facility administrators) had low awareness of how this policy change could affect their patients' access to transplant. We assessed the effectiveness of a multicomponent and multilevel educational and outreach intervention targeting US dialysis facilities with low waitlisting, with a goal of increasing waitlisting and reducing Black versus White racial disparities in waitlisting.

METHODS

The Allocation System Changes for Equity in Kidney Transplantation (ASCENT) study was a cluster-randomized, pragmatic, multilevel, effectiveness-implementation trial including 655 US dialysis facilities with low waitlisting, randomized to receive either the ASCENT intervention (a performance feedback report, a webinar, and staff and patient educational videos) or an educational brochure. Absolute and relative differences in coprimary outcomes (1-year waitlisting and racial differences in waitlisting) were reported among incident and prevalent patients.

RESULTS

Among 56,332 prevalent patients, 1-year waitlisting decreased for patients in control facilities (2.72%-2.56%) and remained the same for patients in intervention facilities (2.68%-2.75%). However, the proportion of prevalent Black patients waitlisted in the ASCENT interventions increased from baseline to 1 year (2.52%-2.78%), whereas it remained the same for White patients in the ASCENT intervention facilities (2.66%-2.69%). Among incident patients in ASCENT facilities, 1-year waitlisting increased among Black patients (from 0.87% to 1.07%) but declined among White patients (from 1.54% to 1.27%). Significant racial disparities in waitlisting were observed at baseline, with incident Black patients in ASCENT facilities less likely to waitlist compared with White patients (adjusted odds ratio [aOR], 0.56; 95% confidence interval [CI], 0.35 to 0.92), but 1 year after the intervention, this racial disparity was attenuated (aOR, 0.84; 95% CI, 0.49 to 1.42).

CONCLUSIONS

The ASCENT intervention may have a small effect on extending the reach of the new KAS policy by attenuating racial disparities in waitlisting among a population of US dialysis facilities with low waitlisting.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

National Institutes of Health ( NCT02879812 ).

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_03_08_CJN09760822.mp3.

The Impact of the COVID-19 Pandemic on Kidney Transplant Candidate Waitlist Status across Demographic and Geographic Groups: A National Analysis of UNOS STAR Data

The primary goal of this retrospective study is to understand how the COVID-19 pandemic differentially impacted transplant status across race, sex, age, primary insurance, and geographic regions by examining which candidates: (i) remained on the waitlist, (ii) received transplants, or (iii) were removed from the waitlist due to severe sickness or death on a national level. Methods: The trend analysis aggregated by monthly transplant data from 1 December 2019 to 31 May 2021 (18 months) at the transplant center level. Ten variables about every transplant candidate were extracted from UNOS standard transplant analysis and research (STAR) data and analyzed. Characteristics of demographical groups were analyzed bivariately using t-test or Mann-Whitney U test for continuous variables and using Chi-sq/Fishers exact tests for categorical variables. Results: The trend analysis with the study period of 18 months included 31,336 transplants across 327 transplant centers. Patients experienced a longer waiting time when their registration centers in a county where high numbers of COVID-19 deaths were observed (SHR < 0.9999, p < 0.01). White candidates had a more significant transplant rate reduction than minority candidates (-32.19% vs. -20.15%) while minority candidates were found to have a higher waitlist removal rate than White candidates (9.23% vs. 9.45%). Compared to minority patients, White candidates' sub-distribution hazard ratio of the transplant waiting time was reduced by 55% during the pandemic period. Candidates in the Northwest United States had a more significant reduction in the transplant rate and a greater increase in the removal rate during the pandemic period. Conclusions: Based on this study, waitlist status and disposition varied significantly based on patient sociodemographic factors. During the pandemic period, minority patients, those with public insurance, older patients, and those in counties with high numbers of COVID-19 deaths experienced longer wait times. In contrast, older, White, male, Medicare, and high CPRA patients had a statistically significant higher risk of waitlist removal due to severe sickness or death. The results of this study should be considered carefully as we approach a reopening world post-COVID-19, and further studies should be conducted to elucidate the relationship between transplant candidate sociodemographic status and medical outcomes during this era.

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.

Black patients are more likely to undergo parathyroidectomy for secondary hyperparathyroidism

BACKGROUND

Prior studies have demonstrated racial disparities in the severity of secondary hyperparathyroidism among dialysis patients. Our primary objective was to study the racial and socioeconomic differences in the timing and likelihood of parathyroidectomy in patients with secondary hyperparathyroidism.

METHODS

We used the United States Renal Data System to identify 634,428 adult (age ≥18) patients who were on maintenance dialysis between 2006 and 2016 with Medicare as their primary payor. Adjusted multivariable Cox regression was performed to quantify the differences in parathyroidectomy by race.

RESULTS

Of this cohort, 27.3% (173,267) were of Black race. Compared to 15.4% of White patients, 23.1% of Black patients lived in a neighborhood that was below a predefined poverty level (P < .001). The cumulative incidence of parathyroidectomy at 10 years after dialysis initiation was 8.8% among Black patients compared to 4.3% among White patients (P < .001). On univariable analysis, Black patients were more likely to undergo parathyroidectomy (adjusted hazard ratio = 1.83; 95% confidence interval, 1.74-1.93). This association persisted after adjusting for age, sex, cause of end-stage renal disease, body mass index, comorbidities, dialysis modality, and poverty level (adjusted hazard ratio = 1.35; 95% confidence interval, 1.27-1.43). Therefore, patient characteristics and socioeconomic status explained 26% of the association between race and likelihood of parathyroidectomy.

CONCLUSION

Black patients with secondary hyperparathyroidism due to end-stage renal disease are more likely to undergo parathyroidectomy with shorter intervals between dialysis initiation and parathyroidectomy. This association is only partially explained by patient characteristics and socioeconomic factors.

Improving equity in kidney transplant allocation policies through a novel genetic metric: The Matched Donor Potential

The demand for donors' kidneys continues to increase amid a shortage of available donors. Managing policies to thoughtfully allocate this scarce resource is a complex process. Although human leukocyte antigen (HLA) matching has been shown to prolong graft survival, its relative contribution to allocation schemes is empirically compromised owing to competing priorities. We explored using a new metric, Matched Donor Potential (MDP), to facilitate improved HLA matching while promoting equity. We interrogated all active kidney waitlist patients (N = 164 427), their corresponding unacceptable antigen files, and all effective donors in the Scientific Registry of Transplant Recipients (January 1, 2016-December 31, 2017). Cause-specific hazard functions were evaluated to assess the potential impact of the MDP metric on deceased donor transplant access rates for all candidates. Access was affected by ethnicity, blood group type, and calculated Panel Reactive Antibody (cPRA). Importantly, we show that access to transplantation is influenced by the patient's own HLA makeup regardless of their ethnicity and by the HLA makeup of effective donors. The MDP metric demonstrates a high association with access to transplantation. Adjusting Cox models to include this new metric resulted in improved access to kidney transplantation for waitlist candidates of minority heritage while significantly promoting HLA matching. Thus, the MDP metric accounts for balanced, equitable organ allocation algorithms.

Referral and Evaluation for Kidney Transplantation Following Implementation of the 2014 National Kidney Allocation System

RATIONALE & OBJECTIVE

The national kidney allocation system (KAS) implemented in December 2014 in the United States redefined the start of waiting time from the time of waitlisting to the time of kidney failure. Waitlisting has declined post-KAS, but it is unknown if this is due to transplant center practices or changes in dialysis facility referral and evaluation. The purpose of this study was to assess the impact of the 2014 KAS policy change on referral and evaluation for transplantation among a population of incident and prevalent patients with kidney failure.

STUDY DESIGN

Cohort study.

SETTING & PARTICIPANTS

37,676 incident (2012-2016) patients in Georgia, North Carolina, and South Carolina identified within the US Renal Data System at 9 transplant centers and followed through December 2017. A prevalent population of 6,079 patients from the same centers receiving maintenance dialysis in 2012 but not referred for transplantation in 2012.

EXPOSURE

KAS era (pre-KAS vs post-KAS).

OUTCOME

Referral for transplantation, start of transplant evaluation, and waitlisting.

ANALYTICAL APPROACH

Multivariable time-dependent Cox models for the incident and prevalent population.

RESULTS

Among incident patients, KAS was associated with increased referrals (adjusted HR, 1.16 [95% CI, 1.12-1.20]) and evaluation starts among those referred (adjusted HR, 1.16 [95% CI, 1.10-1.21]), decreased overall waitlisting (adjusted HR, 0.70 [95% CI, 0.65-0.76]), and lower rates of active waitlisting among those evaluated compared to the pre-KAS era (adjusted HR, 0.81 [95% CI, 0.74-0.90]). Among the prevalent population, KAS was associated with increases in overall waitlisting (adjusted HR, 1.74 [95% CI, 1.15-2.63]) and active waitlisting among those evaluated (adjusted HR, 2.01 [95% CI, 1.16-3.49]), but had no significant impact on referral or evaluation starts among those referred.

LIMITATIONS

Limited to 3 states, residual confounding.

CONCLUSIONS

In the southeastern United States, the impact of KAS on steps to transplantation was different among incident and prevalent patients with kidney failure. Dialysis facilities referred more incident patients and transplant centers evaluated more incident patients after implementation of KAS, but fewer evaluated patients were placed onto the waitlist. Changes in dialysis facility and transplant center behaviors after KAS implementation may have influenced the observed changes in access to transplantation.

Protocol for the AKT-MP trial: Access to Kidney Transplantation in Minority Populations

Background

Kidney transplant (KT) is the optimal treatment for kidney failure (KF), and although completion of KT evaluation is an essential step in gaining access to transplantation, the process is lengthy, time consuming, and burdensome. Furthermore, despite similar referral rates to non-Hispanic Whites, both Hispanic/Latinos and American Indians are less likely to be wait-listed or to undergo KT.

Methods

The Access to Kidney Transplantation in Minority Populations (AKT-MP) Trial compares two patient-centered methods to facilitate KT evaluation: kidney transplant fast track (KTFT), a streamlined KT evaluation process; and peer navigators (PN), a peer-assisted evaluation program that incorporates motivational interviewing. This pragmatic randomized trial will use a comparative effectiveness approach to assess whether KTFT or PN can help patients overcome barriers to transplant listing. We will randomly assign patients to the two conditions. We will track participants' medical records and conduct surveys prior to their initial evaluation clinic visit and again after they complete or discontinue evaluation.

Conclusion

Our aims are to (1) compare KTFT and PN to assess improvements in kidney transplant (KT) related outcomes and cost effectiveness; (2) examine how each approach effects changes in cultural/contextual factors, KT concerns, KT knowledge, and KT ambivalence; and (3) develop a framework for widespread implementation of either approach. The results of this trial will provide key information for facilitating the evaluation process, improving patient care, and decreasing disparities in KT.

The New Distance-Based Kidney Allocation System: Implications for Patients, Transplant Centers, and Organ Procurement Organizations

Purpose of Review

The goal of deceased donor kidney allocation policy is to provide objective prioritization for donated kidneys, and policy has undergone a series of revisions in the past decade in attempt to achieve equity and utility in access to kidney transplantation. Most recently, to address geographic disparities in access to kidney transplantation, the Kidney Allocation System changed to a distance-based allocation system—colloquially termed “KAS 250”—moving away from donor service areas as the geographic basis of allocation. We review the early impact of this policy change on access to transplant for patients, and on complexity of organ allocation and transplantation for transplant centers and organ procurement organizations.

Recent Findings

Broader sharing of kidneys has increased complexity of the allocation system, as transplant centers and OPOs now interact in larger networks. The increased competition resulting from this system, and the increased operational burden on centers and OPOs resulting from greater numbers of organ offers, may adversely affect organ utilization. Preliminary results suggest an increase in transplant rate overall but a trend toward higher kidney discard and increased cold ischemia time.

Summary

The KAS 250 allocation policy changed the geographic basis of deceased donor kidney distribution in a manner that is intended to reduce geographic disparities in access to kidney transplantation. Close monitoring of this policy’s impact on patients, transplant center behavior, and process measures is critical to the aim of maximizing access to transplant while achieving transplant equity.

Defining the ethical considerations surrounding kidney transplantation for frail and cognitively impaired patients: a Delphi study of geriatric transplant experts

BACKGROUND

Among adult kidney transplant (KT) candidates, 21% are frail and 55% have cognitive impairment, increasing the risk of pre- and post-KT mortality. Centers often assess frailty status and cognitive function during transplant evaluation to help identify appropriate candidate. Yet, there are no ethical guidelines regarding the use of frailty and cognitive function during this evaluation. We seek to develop a clinical consensus on balancing utility and justice in access to KT for frail and cognitively impaired patients.

METHODS

Twenty-seven experts caring for ESRD patients completed a two-round Delphi panel designed to facilitate consensus (> 80% agreement).

RESULTS

Experts believed that denying patients transplantation based solely on expected patient survival was inequitable to frail or cognitively impaired candidates; 100% agreed that frailty and cognitive impairment are important factors to consider during KT evaluation. There was consensus that health related quality of life and social support are important to consider before waitlisting frail or cognitively impaired patients. Experts identified important factors to consider before waitlisting frail (likely to benefit from KT, frailty reversibility, age, and medical contraindications) and cognitively impaired (degree of impairment and medication adherence) patients.

CONCLUSIONS

Clinical experts believed it was ethically unacceptable to allocate organs solely based on patients' expected survival; frailty and cognitive impairment should be measured at evaluation when weighed against other clinical factors. Ethical guidelines regarding the use of frailty and cognitive function during KT evaluation ought to be developed.

Case Vignettes in Transplant Psychiatry Ethics

The demand for liver transplants continues to far exceed the number of available viable donor organs; hence, it is of utmost importance to determine those individuals who are best able to care for these valuable, limited resources as potential recipients. At the same time, psychiatric comorbidity is common in the course of end-stage liver disease and can be mutually complicating. This article focuses on liver transplant candidacy from a psychiatric perspective, using illustrative cases to underscore the foundational facets of medical ethics that serve as the guide to these complex medical and ethical decisions.

Kidney Organ Allocation System: How to Be Fair

Transplantation is a life-saving medical intervention that unfortunately is constrained by scarcity of available organs. An ideal system for allocating organs should seek to achieve the greatest good for the greatest number of people. It also must be fair and not disadvantage certain populations. However, policies aimed at reducing disparities also must be balanced with considerations of utility (graft outcomes), cost, efficiency, and any adverse effects on organ utilization. Here, we discuss the ethical challenges of creating a fair and equitable organ allocation system, focusing on the principles governing deceased donor kidney transplant waitlists around the world. The kidney organ allocation systems in the United States, Australia, and Hong Kong are used as illustrations.

A tool for decision-making in kidney transplant candidates with poor prognosis to receive deceased donor transplantation in the United States

The primary outcomes for kidney transplant candidates are receipt of deceased or living donor transplant, death or removal from the waiting list. Here, we conducted a retrospective analysis of national Scientific Registry of Transplant Recipients data to evaluate outcomes for 208,717 adult kidney transplant candidates following the 2014 Kidney Allocation System in the United States. Competing risks models were utilized to evaluate Time to Equivalent Risk (TiTER) of deceased donor transplantation (DDTX) and death versus waitlist removal. We also evaluated TiTER based on kidney donor profile index (KDPI) and donor age. For all groups, the cumulative incidence of DDTX was initially higher from time of listing than death or waitlist removal. However, following accrued time on the waiting list, the cumulative incidence of death or waitlist removal exceeded DDTX for certain patient groups, particularly older, diabetic, blood type B and O and shorter pre-listing dialysis time. TiTER for all candidates aged 65-69 averaged 41 months and for 70 and older patients 28 months. Overall, 39.6% of candidates were in risk groups with TiTER under 72 months and 18.5% in groups with TiTER under 24 months. Particularly for older candidates, TiTER for kidneys was substantially shorter for younger donors or lower KDPI. Thus, our findings reveal that a large proportion of waitlisted patients in the United States have poor prognoses to ever undergo DDTX and our data may improve shared decision-making for candidates at time of waitlist placement. Hence, for specific patient groups, TiTER may be a useful tool to disseminate and quantify benefits of accepting relatively high risk donor organs.

Pediatric Kidney Transplantation-Can We Do Better? The Promise and Limitations of Epitope/Eplet Matching

Kidney transplant is the optimal treatment for end-stage kidney disease as it offers significant survival and quality of life advantages over dialysis. While recent advances have significantly improved early graft outcomes, long-term overall graft survival has remained largely unchanged for the last 20 years. Due to the young age at which children receive their first transplant, most children will require multiple transplants during their lifetime. Each subsequent transplant becomes more difficult because of the development of de novo donor specific HLA antibodies (dnDSA), thereby limiting the donor pool and increasing mortality and morbidity due to longer time on dialysis awaiting re-transplantation. Secondary prevention of dnDSA through increased post-transplant immunosuppression in children is constrained by a significant risk for viral and oncologic complications. There are currently no FDA-approved therapies that can meaningfully reduce dnDSA burden or improve long-term allograft outcomes. Therefore, primary prevention strategies aimed at reducing the risk of dnDSA formation would allow for the best possible long-term allograft outcomes without the adverse complications associated with over-immunosuppression. Epitope matching, which provides a more nuanced assessment of immunological compatibility between donor and recipient, offers the potential for improved donor selection. Although epitope matching is promising, it has not yet been readily applied in the clinical setting. Our review will describe current strengths and limitations of epitope matching software, the evidence for and against improved outcomes with epitope matching, discussion of eplet load vs. variable immunogenicity, and conclude with a discussion of the delicate balance of improving matching without disadvantaging certain populations.

Survey of current transplant center practices regarding COVID-19 vaccine mandates in the United States

An electronic survey canvassing current policies of transplant centers regarding a COVID-19 vaccine mandate for transplant candidates and living donors was distributed to clinicians at US solid organ transplant centers performing transplants from October 14, 2021-November 15, 2021. Responses were received from staff at 141 unique transplant centers. These respondents represented 56.4% of US transplant centers, and responding centers performed 78.5% of kidney transplants and 82.4% of liver transplants in the year prior to survey administration. Only 35.7% of centers reported implementing a vaccine mandate, while 60.7% reported that vaccination was not required. A minority (42%) of responding centers with a vaccine mandate for transplant candidates also mandated vaccination for living organ donors. Centers with a vaccine mandate most frequently cited clinical evidence supporting the efficacy of pre-transplant vaccination (82%) and stewardship obligations to ensure organs were transplanted into the lowest risk patients (64%). Centers without a vaccine mandate cited a variety of reasons including administrative, equity, and legal considerations for their decision. Transplant centers in the United States exhibit significant heterogeneity in COVID-19 vaccination mandate policies for transplant candidates. While all centers encourage vaccination, most centers have not mandated COVID-19 vaccination for candidates and living donors, citing administrative opposition, legal prohibitions, and concern about equity in access to transplants.

Past and Present Policy Efforts in Achieving Racial Equity in Kidney Transplantation

Purpose of Review

Recent Findings

Summary

Exacerbation of Racial Disparities in Living Donor Kidney Transplantation During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic profoundly impacted transplant services, with a particularly strong impact on living donor kidney transplantation.The COVID-19 pandemic appears to have disproportionately impacted Black patients' access to living donor kidney transplantation.As the pandemic evolves through surges and vaccine acceptance disparities persist, ongoing attention to transplant disparities is needed.

Use of Machine Learning Consensus Clustering to Identify Distinct Subtypes of Black Kidney Transplant Recipients and Associated Outcomes

Importance

Among kidney transplant recipients, Black patients continue to have worse graft function and reduced patient and graft survival. Better understanding of different phenotypes and subgroups of Black kidney transplant recipients may help the transplant community to identify individualized strategies to improve outcomes among these vulnerable groups.

Objective

To cluster Black kidney transplant recipients in the US using an unsupervised machine learning approach.

Design, Setting, and Participants

This cohort study performed consensus cluster analysis based on recipient-, donor-, and transplant-related characteristics in Black kidney transplant recipients in the US from January 1, 2015, to December 31, 2019, in the Organ Procurement and Transplantation Network/United Network for Organ Sharing database. Each cluster's key characteristics were identified using the standardized mean difference, and subsequently the posttransplant outcomes were compared among the clusters. Data were analyzed from June 9 to July 17, 2021.

Exposure

Machine learning consensus clustering approach.

Main Outcomes and Measures

Death-censored graft failure, patient death within 3 years after kidney transplant, and allograft rejection within 1 year after kidney transplant.

Results

Consensus cluster analysis was performed for 22 687 Black kidney transplant recipients (mean [SD] age, 51.4 [12.6] years; 13 635 men [60%]), and 4 distinct clusters that best represented their clinical characteristics were identified. Cluster 1 was characterized by highly sensitized recipients of deceased donor kidney retransplants; cluster 2, by recipients of living donor kidney transplants with no or short prior dialysis; cluster 3, by young recipients with hypertension and without diabetes who received young deceased donor transplants with low kidney donor profile index scores; and cluster 4, by older recipients with diabetes who received kidneys from older donors with high kidney donor profile index scores and extended criteria donors. Cluster 2 had the most favorable outcomes in terms of death-censored graft failure, patient death, and allograft rejection. Compared with cluster 2, all other clusters had a higher risk of death-censored graft failure and death. Higher risk for rejection was found in clusters 1 and 3, but not cluster 4.

Conclusions and Relevance

In this cohort study using an unsupervised machine learning approach, the identification of clinically distinct clusters among Black kidney transplant recipients underscores the need for individualized care strategies to improve outcomes among vulnerable patient groups.

Early Referral, Living Donation, and Preemptive Kidney Transplant

BACKGROUND

Preemptive kidney transplant (PKT) is recognized as the most beneficial and cost-effective form of renal replacement therapy among patients with end-stage renal disease. Despite optimal outcomes and improved quality of life associated with PKT, its use as a first renal replacement therapy remains low among patients with end-stage renal disease. The goal of this retrospective cohort study was to compare, among adult kidney transplant recipients, characteristics across PKT status.

METHODS

We compared the characteristics of patients who did and did not have a PKT over 5 years, from 2010 to 2014, using the electronic health records of Kaiser Permanente Mid-Atlantic States.

RESULTS

A total of 233 patients received a kidney-alone transplant, and, of these, 44 patients (19%) were PKT and 189 patients (81%) were non-PKT. Of the patients in the PKT group, 43% received a kidney from a deceased donor. PKT recipients were more often White, had polycystic kidney disease or glomerulonephritis, received a living donor organ, and were transplanted at certain transplant centers. Estimated glomerular filtration rate on listing for those who received a deceased donor transplant was higher in PKT than non-PKT patients listed pre-dialysis.

CONCLUSIONS

PKT was associated with having a living kidney donor and with having a higher estimated glomerular filtration rate at listing for deceased donor recipients.

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.

Racial disparities in cardiac transplantation: Chronological perspective and outcomes

BACKGROUND

The objective of this study was to evaluate annual heart transplant volumes and 3-year post-transplant outcomes since establishment of United Network for Organ Sharing (UNOS) database stratified by race.

METHODS

The UNOS thoracic transplant database was evaluated for adult patients since 1987. The available database was then stratified by Race: Black, White and Other and era of transplant: group 1(1987-1991), group 2(1992-1996), group 3(1997-2001), group 4(2002-2006), group 5(2007-2011), group 6(2012-2016) and group 7(2017 and later). Demographic and clinical factors were evaluated.

RESULTS

A total of 105,266 adults have been listed since 1987 and 67,824 have been transplanted. Of the transplanted patients 11,235 were Black, 48,786 White and 6803 were of Other race. The proportion of Black patients listed increased from 7% in 1987 to 13.4% in 1999 and 25% in 2019 and those transplanted increased from 5% in 1987 to 13.4% in 2001 and 26% in 2019. The survival of Black patients gradually improved.

CONCLUSION

Historically, fewer Black patients received cardiac transplantation however, their access gradually improved over the years and account for over 25% of cardiac transplantations performed in recent years. The historically poor survival of Black patients has recently improved and became comparable to the rest.