Racial differences in completion of the living kidney donor evaluation process

Living Donor Candidates' Self-reported Health and Health Perceptions and Completion of Donor Evaluation: A Cohort Study

Rationale & Objective

Given the organ shortage in the United States, increasing living donation is vital to improving access to kidney transplantation, but many donor candidates do not complete the donor evaluation. Our objective was to understand potential living donors' perceived health and its association with the likelihood of completing the donor evaluation process.

Study Design

Potential donors' self-reported health was ascertained using the Patient Reported Outcomes Measurement Information System (PROMIS) global physical and mental health and the Davies and Ware Health Perceptions surveys.

Setting & Participants

Potential living donors who expressed interest in donation at a single medical center were recruited prospectively between 2017 and 2022.

Exposure

Donors' self-reported health and health perceptions.

Outcomes

Completion of the donor evaluation.

Analytical Approach

Adjusted linear and logistic regression models were used to examine the association between self-reported health and health perceptions with outcomes.

Results

A total of 1,347 individuals were included for study; 46% (N = 613) were < 40 years of age, 71% (n = 951) were female, 22% (n = 294) were of Hispanic ethnicity, and 16% (n = 215) completed the donor evaluation. The mean PROMIS global physical health (17.0 ± 1.9) and mental health (15.5 ± 2.7) raw scores were higher among donor candidates proceeding to completion of the donor evaluation when compared with those who withdrew early in the process (16.3 ± 2.2 for physical health and 14.9 ± 3.1 for mental health). Every z-score change in the PROMIS physical health score was associated with 1.48-fold higher odds of completing the donor evaluation (95% CI, 1.19-1.85). Fully adjusted models incorporating the PROMIS scores for predicting the completion of donor evaluations had a c-statistic of 0.70. Potential donors' Davies and Wares health perceptions did not predict the likelihood of completing the donor evaluation in fully adjusted models.

Limitations

Data are derived from a single center and may not generalize to the donor evaluation process at other transplant centers.

Conclusions

Donor candidates' self-reported physical health may serve as a predictor of the likelihood of completing the donor evaluation process and a potential avenue for future interventions.

Evaluation and Long-Term Follow-Up of Living Kidney Donors

The evaluation of living kidney donor candidates is a complex and lengthy process. Donor candidates face geographic and socioeconomic barriers to completing donor evaluation. Inequities in access to living donations persist. With a growing demand for kidney transplants and a shortage of living donors, transplant centers are more permissive of accepting less-than-ideal donor candidates. Donors have an increased lifetime risk of kidney failure, but the absolute risk increase is small. Efforts are needed to support donor candidates to complete donor nephrectomy safely and efficiently and receive optimal follow-up care to prevent risk factors for kidney disease and detect complications early. In this article, the authors address key elements of donor kidney evaluation, including current living donation policy requirements and transplant center practices. The authors present a simplified comprehensive practical approach to help guide providers in completing donor evaluation and follow-up care with best outcomes possible.

Progress made toward equitable transplantation in children and young adults with kidney disease

Racial disparities in pediatric kidney transplantation have been well described over the last two decades and include disparities in preemptive transplantation, waitlisting, time from activation to transplantation, living donation, and graft outcomes. Changes to the organ allocation system including the institution of Share 35 in 2005 and the Kidney Allocation System (KAS) of 2014 have resulted in resolution of some, but not all racial-ethnic disparities. Despite overall improvements in time from waitlist activation to transplant, disparities remain in preemptive transplantation, time to waitlisting, and living donor transplantation. Although improving under the KAS, racial disparities remain in graft survival as well. Racial disparity in kidney transplant access and graft survival is an international problem within pediatric nephrology. Although the racial group affected may differ, various minoritized pediatric groups across the world are affected by transplant disparities. Social determinants of health including financial access, language barriers, and the presence of a healthy living donor play a role in mediating these disparities. Further investigation is needed to better understand and intervene upon modifiable social, biological, and cultural factors driving the remaining disparity in transplant outcomes.

Seasonal Patterns of Living Kidney Donation in the United States From 1995 to 2019

BACKGROUND

The number of living kidney donors in the United States has declined since 2005, with variations based on the donor-recipient relationship. The reasons for this decline are unclear, and strategies to mitigate declined donations remain elusive. We examined the change in donor number monthly (within-year) versus annually (between-years) to inform potentially modifiable factors for future interventions.

METHODS

In this registry-based cohort analysis of 141 759 living kidney donors between 1995 and 2019, we used linear mixed-effects models for donor number per month and year to analyze between-year and within-year variation in donation. We used Poisson regression to quantify the change in the number of donors per season before and after 2005, stratified by donor-recipient relationship and zip-code household income tertile.

RESULTS

We observed a consistent summer surge in donations during June, July, and August. This surge was statistically significant for related donors (incidence rate ratio [IRR] range: 1.12-1.33) and unrelated donors (IRR range: 1.06-1.16) across donor income tertiles.

CONCLUSION

Our findings indicate lower rates of living kidney donation in non-summer months across income tertiles. Interventions are needed to address barriers to donation in non-summer seasons and facilitate donations throughout the year. Since the Organ Donor Leave Law provides a solid foundation for supporting year-round donation, extending the law's provisions beyond federal employees may mitigate identified seasonal barriers.

Donor Perceptions and Preferences of Telemedicine and In-Person Visits for Living Kidney Donor Evaluation

Introduction

Living kidney donor evaluation is a lengthy and complex process requiring in-person visits. Access to transplant centers, travel costs, lost wages, and dependent care arrangements are barriers to willing donors initiating evaluation. Telemedicine can help streamline and epedite the evaluation process. We aimed to deeply understand donor experiences and preferences using hybrid telemedicine video/in-person visits to ease access to donor evaluation or counseling.

Methods

We conducted in-depth, semistructured interviews with donors or donor candidates who completed their evaluation through telemedicine/in-person, or in-person only visits at a tertiary transplant center between November 27, 2019 and March 1, 2021. Enrollment continued until data saturation was reached (interviews with 20 participants) when no new information emerged from additional interviews. Transcripts were analyzed using inductive thematic analysis.

Results

Eight themes were identified as follows: (i) reducing financial and logistical burdens (minimizing travel time and travel-related expenses), (ii) enhancing flexibility with scheduling (less time off work and child or family caregiver arrangements), (iii) importance of a walkthrough and establishing shared understanding, (iv) supporting information with technology and visual aids, (v) key role of the coordinator, (vi) preferred visit by provider role (meeting donor surgeon in-person to create rapport and engaging primary care provider in donor evaluation/follow-up), (vii) comparing modality differences in human connection, and (viii) opportunity for family and support network engagement (allowing loved ones to be involved in telemedicine visits irrespective of geographic locations and pandemic restrictions).

Conclusion

Telemedicine/in-person hybrid model can make donor evaluation more accessible and convenient. Our findings help inform about determinants that influence the adoption of telemedicine to initiate donor evaluation to motivate willing donors. In addition, our results call for policy and legislation that support telemedicine services for living donor kidney transplantation across states.

Relationships, race/ethnicity, gender, age, and living kidney donation evaluation willingness

Racial/ethnic and gender disparities in living donor kidney transplantation are large and persistent but incompletely explained. One previously unexplored potential contributor to these disparities is differential willingness to donate to recipients in specific relationships such as children, parents, and friends. We collected and analyzed data from an online sample featuring an experimental vignette in which respondents were asked to rate their willingness to donate to a randomly chosen member of their family or social network. Results show very large differences in respondents' willingness to donate to recipients with different relationships to them, favoring children, spouses/partners, siblings, and parents, and disfavoring friends, aunts/uncles, and coworkers. Evidence suggesting an interactive effect between relationship, respondent race/ethnicity, respondent or recipient gender, was limited to a few cases. At the p < 0.05 level, the parent-recipient gender interaction was statistically significant, favoring mothers over fathers, as was other/multiracial respondents' greater willingness to donate to friends compared to Whites. Additionally, other interactions were significant at the p < 0.10 level, such as Hispanics' and women's higher willingness to donate to parents compared to Whites and men respectively, women's lower willingness to donate to friends compared to men, and Blacks' greater willingness to donate to coworkers than Whites. We also examined differences by age and found that older respondents were less willing to donate to recipients other than their parents. Together these results suggest that differential willingness to donate by relationship group may be a moderately important factor in understanding racial/ethnic and gender disparities in living donor kidney transplantation.

The Determinants and Consequences of Living Donor Discussion Direction

Introduction: Living donor discussions in which kidney transplant candidates discuss living kidney donation with their social network are an important step in the living donor kidney transplant process. No prior research has investigated whether who initiates discussion or influences evaluation agreement rates or how these processes may contribute to disparities. Research Questions: This study aimed to determine how common candidate- and potential-donor-initiated discussions were, at what rate each discussion type resulted in agreement to be evaluated for living donation, and what sociodemographic characteristics predicted living donor discussion and agreements. Design: A 2015 cross-sectional survey at a single, large Southeastern US transplant center measured kidney transplant candidates' social networks, including whether they had a donor discussion, who initiated it, and whether the discussion resulted in the donor evaluation agreement. Candidate-network member pairs' probability of having a candidate-initiated discussion, potential-living donor-initiated discussion, or no discussions were compared in multinomial logistic regression, and the probability of the discussion resulted in evaluation agreement was evaluated in multinomial logistic regression. Results: Sixty-six kidney transplant candidates reported on 1421 social network members. Most (80%) candidate/network-member pairs did not have a living donor discussion, with candidate-initiated discussions (11%) slightly more common than potential-donor-initiated discussions (10%). Evaluation agreement was much more common for potential-donor-initiated (72%) than for candidate-initiated discussions (39%). Potential-donor-initiated discussions were more common for White candidates (16%) than for Black candidates (7%). Conclusion: Potential-donor-initiated discussions resulted in evaluation agreement much more frequently than candidate-initiated discussions. This dynamic may contribute to racial living donation disparities.

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.

African American/Black race, apolipoprotein L1 , and serum creatinine among persons with HIV

OBJECTIVE

Accurate estimation of kidney function is critical among persons with HIV (PWH) to avoid under-dosing of antiretroviral therapies and ensure timely referral for kidney transplantation. Existing estimation equations for kidney function include race, the appropriateness of which has been debated. Given advancements in understanding of race and the necessity of accuracy in kidney function estimation, this study aimed to examine whether race, or genetic factors, improved prediction of serum creatinine among PWH.

DESIGN

This cross-sectional study utilized data from the Center for AIDS Research Network of Integrated Clinical Systems cohort (2008-2018). The outcome was baseline serum creatinine.

METHODS

Ordinary least squares regression was used to examine whether inclusion of race or genetic factors [ apolipoprotein-L1 ( APOL1 ) variants and genetic African ancestry] improved serum creatinine prediction. A reduction in root mean squared error (RMSE) greater than 2% was a clinically relevant improvement in predictive ability.

RESULTS

There were 4183 PWH included. Among PWH whose serum creatinine was less than 1.7 mg/dl, race was significantly associated with serum creatinine ( β  = 0.06, SE = 0.01, P  < 0.001) but did not improve predictive ability. African ancestry and APOL1 variants similarly failed to improve predictive ability. Whereas, when serum creatinine was at least 1.7 mg/dl, inclusion of race reduced the RMSE by 2.1%, indicating improvement in predictive ability. APOL1 variants further improved predictive ability by reducing the RMSE by 2.9%.

CONCLUSION

These data suggest that, among PWH, inclusion of race or genetic factors may only be warranted at higher serum creatinine levels. Work eliminating existing healthcare disparities while preserving the utility of estimating equations is needed.

Change in Body Mass Index and Attributable Risk of New-Onset Hypertension Among Obese Living Kidney Donors

OBJECTIVE

To examine whether body mass index (BMI) changes modify the association between kidney donation and incident hypertension.

BACKGROUND

Obesity increases hypertension risk in both general and living kidney donor (LKD) populations. Donation-attributable risk in the context of obesity, and whether weight change modifies that risk, is unknown.

METHODS

Nested case-control study among 1558 adult LKDs (1976-2020) with obesity (median follow-up: 3.6 years; interquartile range: 2.0-9.4) and 3783 adults with obesity in the Coronary Artery Risk Development in Young Adults (CARDIA) and Atherosclerosis Risk in Communities (ARIC) studies (9.2 y; interquartile range: 5.3-15.8). Hypertension incidence was compared by donor status using conditional logistic regression, with BMI change investigated for effect modification.

RESULTS

Overall, LKDs and nondonors had similar hypertension incidence [incidence rate ratio (IRR): 1.16, 95% confidence interval (95% CI): 0.94-1.43, P =0.16], even after adjusting for BMI change (IRR: 1.25, 95% CI: 0.99-1.58, P =0.05). Although LKDs and nondonors who lost >5% BMI had comparable hypertension incidence (IRR: 0.78, 95% CI: 0.46-1.34, P =0.36), there was a significant interaction between donor and >5% BMI gain (multiplicative interaction IRR: 1.62, 95% CI: 1.15-2.29, P =0.006; relative excess risk due to interaction: 0.90, 95% CI: 0.24-1.56, P =0.007), such that LKDs who gained weight had higher hypertension incidence than similar nondonors (IRR: 1.83, 95% CI: 1.32-2.53, P <0.001).

CONCLUSIONS

Overall, LKDs and nondonors with obesity had similar hypertension incidence. Weight stability and loss were associated with similar hypertension incidence by donor status. However, LKDs who gained >5% saw increased hypertension incidence versus similar nondonors, providing support for counseling potential LKDs with obesity on weight management postdonation.

Dialysis Patients' Social Networks and Living Donation Offers

Rationale & Objective

Most living kidney donors are members of a hemodialysis patient's social network. Network members are divided into core members, those strongly connected to the patient and other members; and peripheral members, those weakly connected to the patient and other members. We identify how many hemodialysis patients' network members offered to become kidney donors, whether these offers were from core or peripheral network members, and whose offers the patients accepted.

Study Design

A cross-sectional interviewer-administered hemodialysis patient social network survey.

Setting & Participants

Prevalent hemodialysis patients in 2 facilities.

Predictors

Network size and constraint, a donation from a peripheral network member.

Outcomes

Number of living donor offers, accepting an offer.

Analytical Approach

We performed egocentric network analyses for all participants. Poisson regression models evaluated associations between network measures and number of offers. Logistic regression models determined the associations between network factors and accepting a donation offer.

Results

The mean age of the 106 participants was 60 years. Forty-five percent were female, and 75% self-identified as Black. Fifty-two percent of participants received at least one living donor offer (range 1-6); 42% of the offers were from peripheral members. Participants with larger networks received more offers (incident rate ratio [IRR], 1.26; 95% CI, 1.12-1.42; P = 0.001), including networks with more peripheral members (constraint, IRR, 0.97; 95% CI, 0.96-0.98; P < 0.001). Participants who received a peripheral member offer had 3.6 times greater odds of accepting an offer (OR, 3.56; 95% CI, 1.15-10.8; P = 0.02) than those who did not receive a peripheral member offer.

Limitations

A small sample of only hemodialysis patients.

Conclusions

Most participants received at least one living donor offer, often from peripheral network members. Future living donor interventions should focus on both core and peripheral network members.

Testing the Differential Access Hypothesis That Black Kidney Transplant Candidates Perceive Social Network Access to Fewer Potential Living Donors Than White Candidates

INTRODUCTION

Many studies of Black-White disparities in living donor kidney transplantation hypothesize that they were partially due to Black-White differences in candidate social network access to healthy, willing donors. This differential access hypothesis has not been tested using directly measured social network data.

RESEARCH QUESTIONS

Do black kidney transplant candidates have perceived lower social network access to health and/or willing living donors than white candidates?

DESIGN

A cross-sectional survey that measured the social network members was collected in 2015. Black-White differences in patient counts of perceived healthy and/or willing potential donors in social networks, and individual network members' probability of being perceived healthy and/or willing, were compared using logistic and negative binomial regression models.

RESULTS

The survey included 66 kidney transplant candidates reporting on 1474 social network members at a large Southeastern US transplant center in 2015. Black and White patients had similar access to perceived healthy, likely potential donors (86% vs 87% had 1 or more, P = .92; 5.91 vs 4.13 mean counts, P = .20) and perceived healthy, agreed potential donors (56% vs 48%, P = .54; 1.77 vs 1.74, P = .97). Black patients' network members were individually more likely to be perceived healthy and likely potential donors (26% vs 21%, P = .04), and White patients' network members were more likely to have agreed (13% vs 9%, P = .03), but these differences were statistically insignificant in demographically adjusted models.

CONCLUSION

Black and White transplant candidates perceived access to similar numbers of potential donors in their social networks. This result does not support the differential access hypothesis.

The impact of COVID-19 on kidney transplant care

The SARS-CoV-2 virus precipitated the coronavirus 2019 (COVID-19) pandemic, which placed considerable strain on healthcare systems and necessitated immediate and rapid alterations in the delivery of healthcare. In the transplant population, COVID-19 directly impacts an inherently vulnerable population in the setting of immunosuppression and co-morbidities, but also further complicates the clinical evaluation and management of kidney transplant candidates and recipients in a strained healthcare environment being challenged by the pandemic. Many transplant centers around the world saw mortality rate spikes in organ recipients related to COVID-19, and changes in care delivery abound. This review evaluates the care of the kidney transplant patient through all phases of the process including pre-operative evaluations, perioperative care, post-transplantation considerations, and how the global pandemic has changed the way we care for our patients.

Changing landscape of living kidney donation and the role of telemedicine

PURPOSE OF REVIEW

There has been a decline in living kidney donation over the last two decades. Donors from low-income families or racial/ethnic minorities face greater disproportionate geographic, financial, and logistical barriers to completing lengthy and complex evaluations. This has contributed to the decreased proportion of these subgroups. The authors view telemedicine as a potential solution to this problem.

RECENT FINDINGS

Since the initial decline of donors in 2005, biologically related donors have experienced a lack of growth across race/ethnicity. Conversely, unrelated donors have emerged as the majority of donors in recent years across race/ethnicity, except for unrelated black donors. Disparities in access to living kidney donation persist. Telemedicine using live-video visits can overcome barriers to access transplant centers and facilitate care coordination. In a U.S. survey, nephrologists, surgeons, coordinators, social workers, and psychologists/psychologists across transplant centers are favorably disposed to use telemedicine for donor evaluation/follow-up beyond the coronavirus disease 2019 pandemic. However, with the waning of relaxed telemedicine regulations under the Public Health Emergency, providers perceive payor policy and out-of-state licensing as major factors hindering telemedicine growth prospects.

SUMMARY

Permanent federal and state policies that support telemedicine services for living kidney donation can enhance access to transplant centers and help overcome barriers to donor evaluation.

Telemedicine services for living kidney donation: A US survey of multidisciplinary providers

Individuals considering living kidney donation face geographic, financial, and logistical challenges. Telemedicine can facilitate healthcare access/care coordination. Yet difficulties exist in telemedicine implementation and sustainability. We sought to examine centers' practices and providers' attitudes toward telemedicine to improve services for donors. We surveyed multidisciplinary providers from 194 active adult US living donor kidney transplant centers; 293 providers from 128 unique centers responded to the survey (center representation rate = 66.0%), reflecting 83.9% of practice by donor volume and 91.5% of US states/territories. Most centers (70.3%) plan to continue using telemedicine beyond the pandemic for donor evaluation/follow-up. Video was mostly used by nephrologists, surgeons, and psychiatrists/psychologists. Telephone and video were mostly used by social workers, while video or telephone was equally used by coordinators. Half of respondent nephrologists and surgeons were willing to accept a remote completion of physical exam; 68.3% of respondent psychiatrists/psychologists and social workers were willing to accept a remote completion of mental status exam. Providers strongly agreed that telemedicine was convenient for donors and would improve the likelihood of completing donor evaluation. However, providers (65.5%) perceived out-of-state licensing as a key policy/regulatory barrier. These findings help inform practice and underscore the instigation of policies to remove barriers using telemedicine to increase living kidney donation.

Health Disparities in Autosomal Dominant Polycystic Kidney Disease (ADPKD) in the United States

BACKGROUND AND OBJECTIVES

Autosomal dominant polycystic kidney disease (ADPKD) occurs at conception and is often diagnosed decades prior to kidney failure. Nephrology care and transplantation access should be independent of race and ethnicity. However, institutional racism and barriers to health care may affect patient outcomes in ADPKD. We sought to ascertain the effect of health disparities on outcomes in ADPKD by examining age at onset of kidney failure and access to preemptive transplantation and transplantation after dialysis initiation.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Retrospective cohort analyses of adults with ADPKD in the United States Renal Data System from January 2000 to June 2018 were merged to US Census income data and evaluated by self-reported race and ethnicity. Age at kidney failure was analyzed in a linear model, and transplant rates before and after dialysis initiation were analyzed in logistic and proportional hazards models in Black and Hispanic patients with ADPKD compared with White patients with ADPKD.

RESULTS

A total of 41,485 patients with ADPKD were followed for a median of 25 (interquartile range, 5-54) months. Mean age was 56±12 years; 46% were women, 13% were Black, and 10% were Hispanic. Mean ages at kidney failure were 55±13, 53±12, and 57±12 years for Black patients, Hispanic patients, and White patients, respectively. Odds ratios for preemptive transplant were 0.33 (95% confidence interval, 0.29 to 0.38) for Black patients and 0.50 (95% confidence interval, 0.44 to 0.56) for Hispanic patients compared with White patients. Transplant after dialysis initiation was 0.61 (95% confidence interval, 0.58 to 0.64) for Black patients and 0.78 (95% confidence interval, 0.74 to 0.83) for Hispanic patients.

CONCLUSIONS

Black and Hispanic patients with ADPKD reach kidney failure earlier and are less likely to receive a kidney transplant preemptively and after initiating dialysis compared with White patients with ADPKD.

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.

Impact of education on APOL1 testing attitudes among prospective living kidney donors

It is unknown how providing prospective living donors with information about APOL1, including the benefits and drawbacks of testing, influences their desire for testing. In this study, we surveyed 102 participants with self-reported African ancestry and positive family history of kidney disease, recruited from our nephrology waiting room. We assessed views on APOL1 testing before and after presentation of a set of potential benefits and drawbacks of testing and quantified the self-reported level of influence individual benefits and drawbacks had on participants' desire for testing in the proposed context of living donation. The majority of participants (92%) were aware of organ donation and more than half (56%) had considered living donation. And though we found no significant change in response following presentation of the potential benefits and the drawbacks of APOL1 testing by study end significance, across all participants, "becoming aware of the potential risk of kidney disease among your immediate family" was the benefit with the highest mean influence (3.3±1.4), while the drawback with the highest mean influence (2.9±1.5) was "some transplant centers may not allow you to donate to a loved one". This study provides insights into the priorities of prospective living donors and suggests concern for how the information affects family members may strongly influence desires for testing. It also highlights the need for greater community engagement to gain a deeper understanding of the priorities that influence decision making on APOL1 testing.

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.

The Scope of Telemedicine in Kidney Transplantation: Access and Outreach Services

Access to transplant centers is a key barrier for kidney transplant evaluation and follow-up care for both the recipient and donor. Potential kidney transplant recipients and living kidney donors may face geographic, financial, and logistical challenges in engaging with a transplant center and maintaining post-transplant continuity of care. Telemedicine via synchronous video visits has the potential to overcome the access barrier to transplant centers. Transplant centers can start the evaluation process for potential recipients and donors via telemedicine, especially for those who have challenges to come for an in-person visit or when there are restrictions on clinic capacities, such as during a pandemic. Similarly, transplant centers can use telemedicine to sustain post-transplant follow-up care while avoiding the burden of travel and its associated costs. However, expansion to telemedicine-based kidney transplant services is substantially dependent on telemedicine infrastructure, insurer policy, and state regulations. In this review, we discuss the practice of telemedicine in kidney transplantation and its implications for expanding access to kidney transplant services and outreach from pretransplant evaluation to post-transplant follow-up care for the recipient and donor.

Disparities in living donation

PURPOSE OF REVIEW

Living organ donation provides improved access to transplantation, thereby shortening transplant wait times and allowing for more deceased organ transplants. However, disparity in access to living donation has resulted in decreased rates of living donor transplants for some populations of patients.

RECENT FINDINGS

Though there have been marked improvements in deceased donor equity, there are still challenges as it relates to gender, racial/ethnic, and socio-economic disparity. Improvements in living donation rates in Hispanic and Asian populations are tempered by challenges in African American rates of organ donation. Socio-economic disparity may drive gender disparities in organ donation resulting in disproportionate female living donors. Tailored approaches relating to language-specific interventions as well as directed educational efforts have helped mitigate disparity. Additionally, the use of apolipoprotein1 testing and modifications of glomerular filtration rate calculators may improve rates of African American donation. This review will evaluate recent data in living donor disparity as well as highlight successes in mitigating disparity.

SUMMARY

Though there are still challenges in living donor disparity, many efforts at tailoring education and access as well as modifying living donor evaluation and identifying systemic policy changes may result in improvements in living donation rates.

The Impact of Race, Ethnicity and Insurance Status on Surgery Rates for Benign Prostatic Hyperplasia

OBJECTIVE

To determine whether patient race/ethnicity are associated with differences in likelihood of undergoing surgical treatment for LUTS/BPH.

METHODS

Queried hospital network database between 1/2011 and 10/2018. Men over age 40 on medical therapy for LUTS (selective alpha blockade and/or 5-alpha-reductase inhibitor), with 2+ provider visits, and without bladder/prostate malignancy were included. Ethnicity/race determined by self-identification. Insurance status classified as public (Medicare/Medicaid/Tricare), private, self-pay, or other. Multivariable backwards step-wise logistic regression was performed to compare odds of undergoing a surgical procedure by race/ethnicity, controlling for patient age, insurance status, comorbidities, and type of medical therapy.

RESULTS

30,466 patients included, with White (n=24,443, 80.2%), Hispanic (n=2,715, 8.9%), Black (n=1,245, 4.1%), and other race/ethnicity (2,073, 6.8%) identified within the study population. After adjusting for age, insurance status, major comorbidities, and type of medical therapy, Black patients were less likely to undergo surgery than White patients (OR 0.57, 95% CI 0.37 - 0.88, P = .011), as were patients of other race/ethnicity (OR 0.67, 95% CI 0.49 - 0.92, P = .013).

CONCLUSIONS

Adjusting for age, insurance status, major comorbidities and type of LUTS medication, men categorized as Black were significantly less likely to undergo surgical treatment for LUTS/BPH than White patients. It is unknown whether this difference results from differences in counseling, access, or other bias in therapy. Efforts to understand and respond to this disparity are necessary. Limitations include lack of IPSS data, additional comorbidity data, limited geographic area, and retrospective nature.

How Can We Help Alleviate the Financial Concerns of Non-Directed (Altruistic) Living Kidney Donors?

INTRODUCTION

The recent increase in non-directed donors (NDDs) in the United States (U.S.) may help reduce the overwhelming number of patients on the waitlist. However, non-directed donation may be limiting its full potential. Out-of-pocket donation costs upward of $8,000 may be a barrier to potential donors with altruistic tendencies, but inadequate financial support. This study aimed to describe the financial concerns of 31 U.S. NDDs.

METHODS

We conducted qualitative interviews and administered quantitative demographic surveys between April 2013 and April 2015. Interview transcripts were analyzed using grounded theory techniques to describe and expand on themes relevant to the NDD experience.

FINDINGS

We identified 4 sub-themes related to the theme of financial concerns: (1) direct costs related to transportation, lodging, and parking, (2) indirect costs of lost wages encountered from taking time off work to recover from surgery, (3) sources of financial support, and (4) suggestions for alleviating donor financial burden. Two thirds of participants (20) expressed concerns about direct and indirect donation costs. 11 NDDs reported the negative impact of direct costs,15 NDDs had concerns about indirect costs; only 7 donors received supplemental financial support from state mandates and transplant programs.

DISCUSSION

Understanding the financial concerns of NDDs may guide improvements in the NDD donation experience that could support individuals who are interested in donating but lack the financial stability to donate. Removing financial disincentives may help increase nondirected donation rates, increase the living donor pool, and the number of kidneys available for transplantation.

The first increase in live kidney donation in the United States in 15 years

The first sustained increase in live kidney donation in the United States in 15 years was observed from 2017 to 2019. To help sustain this surge, we studied 35 900 donors (70.3% white, 14.5% Hispanic, 9.3% black, 4.4% Asian) to understand the increase in 2017-2019 vs 2014-2016 using Poisson regression. Among biologically related donors aged <35, 35-49, and ≥50 years, the number of donors did not change across race/ethnicity but increased by 38% and 29% for Hispanic and black ≥50. Among unrelated donors <35, 35-49, and ≥50, white donors increased by 18%, 14%, and 27%; Hispanic donors <35 did not change but increased by 22% and 35% for 35-49 and ≥50; black donors <35 declined by 23% and did not change for 35-49 and ≥50; Asian donors did not change. Among kidney paired donors <35, 35-49, and ≥50, white donors increased by 42%, 50%, and 68%; Hispanic donors <35 and 35-49 increased by 36% and 55% and did not change for ≥50; black donors did not change; Asian donors <35 did not change but increased by 107% and 82% for 35-49 and ≥50. The increase in donation was driven predominantly by unrelated and paired white donors. Donation among unrelated black individuals should be promoted.

Using race to estimate glomerular filtration and its impact in kidney transplantation

Since direct measurement of glomerular filtration rate (GFR) is time-consuming and more expensive, estimated GFR (eGFR) based on measured laboratory values is widely used to determine kidney function. Commonly used formulae to calculate eGFR are dependent on variables, which include filtration markers like serum creatinine and patient characteristics including race. Medical algorithms which utilize race are increasingly being scrutinized, as race is recognized to be a social construct rather than a biologic one. eGFR calculations have important implications for kidney transplantation, both in the listing of candidates as well as in the evaluation of potential kidney donors. This review considers the specific implications of race-based eGFR calculations on recipient evaluation and on decisions related to living kidney donation. We suggest a potential policy solution to ensure that racial and ethnic minority patients are not disadvantaged by eGFR as a result of current calculation methods.

Care of international living kidney donor candidates in the United States: A survey of contemporary experience, practice, and challenges

The evaluation and care of non-US citizen, non-US residents who wish to come to the United States to serve as international living kidney donors (ILKDs) can pose unique challenges. We surveyed US transplant programs to better understand practices related to ILKD care. We distributed the survey by email and professional society list-servs (Fall 2018, assessing 2017 experience). Eighty-five programs responded (36.8% program response rate), of which 80 considered ILKD candidates. Only 18 programs had written protocols for ILKD evaluation. Programs had a median of 3 (range: 0,75) ILKD candidates who initiated contact during the year, from origin countries spanning 6 continents. Fewer (median: 1, range: 0,25) were approved for donation. Program-reported reasons for not completing ILKD evaluations included visa barriers (58.6%), inability to complete evaluation (34.3%), concerns regarding follow-up (31.4%) or other healthcare access (28.6%), and financial impacts (21.4%). Programs that did not evaluate ILKDs reported similar concerns. Staff time required to evaluate ILKDs was estimated as 1.5-to-3-times (47.9%) or >3-times (32.9%) that needed for domestic candidates. Among programs accepting ILKDs, on average 55% reported successful completion of 1-year follow-up. ILKD evaluation is a resource-intensive process with variable outcomes. Planning and commitment are necessary to care for this unique candidate group.

Association of Socioeconomic Status and Comorbidities with Racial Disparities during Kidney Transplant Evaluation

BACKGROUND AND OBJECTIVES

Black patients referred for kidney transplantation have surpassed many obstacles but likely face continued racial disparities before transplant. The mechanisms that underlie these disparities are unclear. We determined the contributions of socioeconomic status (SES) and comorbidities as mediators to disparities in listing and transplant.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We studied a cohort (n=1452 black; n=1561 white) of patients with kidney failure who were referred for and started the transplant process (2009-2018). We estimated the direct and indirect effects of SES (self-reported income, education, and employment) and medical comorbidities (self-reported and chart-abstracted) as mediators of racial disparities in listing using Cox proportional hazards analysis with inverse odds ratio weighting. Among the 983 black and 1085 white candidates actively listed, we estimated the direct and indirect effects of SES and comorbidities as mediators of racial disparities on receipt of transplant using Poisson regression with inverse odds ratio weighting.

RESULTS

Within the first year, 876 (60%) black and 1028 (66%) white patients were waitlisted. The relative risk of listing for black compared with white patients was 0.76 (95% confidence interval [95% CI], 0.69 to 0.83); after adjustment for SES and comorbidity, the relative risk was 0.90 (95% CI, 0.83 to 0.97). The proportion of the racial disparity in listing was explained by SES by 36% (95% CI, 26% to 57%), comorbidity by 44% (95% CI, 35% to 61%), and SES with comorbidity by 58% (95% CI, 44% to 85%). There were 409 (42%) black and 496 (45%) white listed candidates transplanted, with a median duration of follow-up of 3.9 (interquartile range, 1.2-7.1) and 2.8 (interquartile range, 0.8-6.3) years, respectively. The incidence rate ratio for black versus white candidates was 0.87 (95% CI, 0.79 to 0.96); SES and comorbidity did not explain the racial disparity.

CONCLUSIONS

SES and comorbidity partially mediated racial disparities in listing but not for transplant.

The "oldest and coldest" shipped living donor kidneys transplanted through kidney paired donation

To date, thousands of living donor kidneys have been shipped through kidney paired donation (KPD). To expand on this growing segment of living donor transplantation, we evaluated the effect of advanced age donation ("oldest kidneys") and prolonged cold ischemia time ("coldest kidneys") on graft function and survival using the National Kidney Registry database from February 2008 to May 2018. Donors were stratified by age at time of donation (<65 or ≥65 years) and kidneys were stratified by cold ischemia time (<16 or ≥16 hours). We evaluated delayed graft function and death-censored graft failure (DCGF) for up to seven posttransplant years. Of the 2363 shipped living donor kidney transplants, 4.1% of donors were ≥65 years and 6.0% of transplanted kidneys had cold ischemia times ≥16 hours. Delayed graft function and DCGF occurred in 5.2% and 4.7% of cases. There were no significant associations between delayed graft function and donor age (P = .947) or cold ischemia (P = .532). Donor age and cold ischemia time were not predictive of delayed graft function (OR = 0.86,1.20; P = .8, .6) or DCGF (HR = 1.38,0.35, P = .5, .1). These findings may alleviate concerns surrounding the utilization of kidneys from older donors or those originating from distant transplant centers.

The changing landscape of live kidney donation in the United States from 2005 to 2017

The number of live kidney donors has declined since 2005. This decline parallels the evolving knowledge of risk for biologically related, black, and younger donors. To responsibly promote donation, we sought to identify declining low-risk donor subgroups that might serve as targets for future interventions. We analyzed a national registry of 77 427 donors and quantified the change in number of donors per 5-year increment from 2005 to 2017 using Poisson regression stratified by donor-recipient relationship and race/ethnicity. Among related donors aged <35, 35 to 49, and ≥50 years, white donors declined by 21%, 29%, and 3%; black donors declined by 30%, 31%, and 12%; Hispanic donors aged <35 and 35 to 49 years declined by 18% and 15%, and those aged ≥50 increased by 10%. Conversely, among unrelated donors aged <35, 35 to 49, and ≥50 years, white donors increased by 12%, 4%, and 24%; black donors aged <35 and 35 to 49 years did not change but those aged ≥50 years increased by 34%; Hispanic donors increased by 16%, 21%, and 46%. Unlike unrelated donors, related donors were less likely to donate in recent years across race/ethnicity. Although this decline might be understandable for related younger donors, it is less understandable for lower-risk related older donors (≥50 years). Biologically related older individuals are potential targets for interventions to promote donation.

Bariatric surgery for prospective living kidney donors with obesity?

The obesity epidemic has gripped the transplant community. With nearly 40% of adults in the United States being obese (BMI ≥30 kg/m² ) and 20% being morbidly obese (BMI ≥35 kg/m² ), the implications for both donors and recipients of solid organs continue to grow.¹ Nowhere is this more impactful than the candidacy of living kidney donors (LKDs). As increasing numbers of obese adults present for LKD consideration and evidence of inferior outcomes among obese LKDs grows, transplant surgeons will become progressively challenged by how to manage these patients in the clinic. Therefore, we offer this Personal Viewpoint to the transplant surgery community in order to review the current impact of obesity on living kidney donation, highlight what weight-loss interventions have already been attempted, and discuss the role that referral for weight-loss interventions including bariatric surgery might have going forward.

Ethnic background is associated with no live kidney donor identified at the time of first transplant assessment-an opportunity missed? A single-center retrospective cohort study

Patients from ethnocultural minorities have reduced access to live donor kidney transplant (LDKT). To explore early pretransplant ethnocultural disparities in LDKT readiness, and the impact of the interactions with the transplant program, we assessed if patients had a potential live donor (LD) identified at first pretransplant assessment, and if patients with no LD initially received LDKT subsequently. Single-center, retrospective cohort of adults referred for kidney transplant (KT) assessment. Multivariable logistic regression assessed the association between ethnicity and having a potential LD. Cox proportional hazard analysis assessed the association between no potential LD initially and subsequent LDKT. Of 1617 participants, 66% of Caucasians indicated having a potential LD, compared with 55% of South Asians, 44% of African Canadians, and 41% of East Asians (P < 0.001). In multivariable logistic regression analysis, the odds of having a potential LD identified was significantly lower for African, East and South Asian Canadians. No potential LD at initial KT assessment was associated with lower likelihood of LDKT subsequently (hazard ratio [HR], 0.14; [0.10-0.19]). Compared to Caucasians, African, East and South Asian and African Canadians are less likely to have a potential LD identified at first KT assessment, which predicts a lower likelihood of subsequent LDKT.

African-Americans with End Stage Renal Disease in the Early Years of Kidney Transplantation

INTRODUCTION

The first successful kidney transplant in humans was performed in 1954. In the following 25 years, the biomedical, ethical, and social implications of kidney transplantation were widely discussed by both healthcare professionals and the public. Issues relating to race, however, were not commonly addressed, representing a "blind spot" regarding racial disparities in access and health outcomes.

METHODS

Through primary sources in the medical literature and lay press, this paper explores the racial dynamics of kidney transplantation in the 1950-1970s in the United States as the procedure grew from an experimental procedure to the standard of care for patients in end-stage renal disease (ESRD).

RESULTS & DISCUSSION

An extensive search of the medical literature found very few papers about ESRD, dialysis, or renal transplant that mentioned the race of the patients before 1975. While the search did not reveal whether race was explicitly used in determining patient access to dialysis or transplant, the scant data that exist show that African-Americans disproportionately developed ESRD and were underrepresented in these early treatment populations. Transplant outcome data in the United States failed to include race demographics until the late 1970s. The Social Security Act of 1972 (PL 92-603) extended Medicare coverage to almost all Americans with ESRD and led to a rapid increase in both dialysis and kidney transplantation for African-Americans in ESRD, but disparities persist today.

Black Ethnicity is Not a Risk Factor for Mortality or Graft Loss After Kidney Transplant in the United Kingdom

OBJECTIVES

There are conflicting reports in the literature regarding outcomes after kidney transplant for patients of black ethnicity. To investigate further, we compared outcomes for black versus white kidney transplant recipients in a single UK transplant center.

MATERIALS AND METHODS

We analyzed 1066 kidney transplant recipients (80 black patients, 986 white patients) within a single-center cohort (2007-2017) in the United Kingdom, with cumulative 4446 patient-year follow-up. Data were electronically extracted from the Department of Health Informatics database for every study recruit, with manual data linkage to the UK Transplant Registry (for graft survival, delayed graft function, and rejection data) and Office for National Statistics (for mortality data). Primary outcomes of interest were graft/patient survival.

RESULTS

Black recipients have increased baseline risk profiles with longer wait times, difficulty in matching, worse HLA matching, more socioeconomic deprivation, and lower rates of living kidney donors. Postoperatively, black versus white recipients had increased risk for delayed graft function (34.3% vs 10.2%; P < .001), increased 1-year rejection (16.7% vs 7.3%; P = .012), higher 1-year creatinine levels (166 vs 138 mmol/L; P = .003), and longer posttransplant length of stay (14.5 vs 9.5 days; P = .020). Although black recipients did not have increased risk of death versus white recipients (10.0% vs 11.0%, respectively; P = .486), they did have increased risk for death-censored graft loss (23.8% vs 11.1%; P = .002). However, in an adjusted Cox regression model, black ethnicity was not associated with increased risk for death-censored graft loss (hazard ratio of 1.209, 95% confidence interval, 0.660-2.216; P = .539).

CONCLUSIONS

Black kidney transplant recipients in the United Kingdom have increased risk of adverse graft-related outcomes due to high-risk baseline variables rather than their black ethnicity per se.