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Kim S, van Zwieten A, Wyld M, Ladhani M, Guha C, Dominello A, Mallitt KA, Francis A, Mannon RB, Wong G. Sociodemographic Drivers of Donor and Recipient Gender Disparities in Living Kidney Donation in Australia. Kidney Int Rep 2023; 8:1553-1561. [PMID: 37547516 PMCID: PMC10403665 DOI: 10.1016/j.ekir.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 05/02/2023] [Accepted: 05/15/2023] [Indexed: 08/08/2023] Open
Abstract
Background Females account for 60% of all living kidney donors worldwide. We defined the proportion of female to male donors for living donor kidney transplantation stratified by recipient gender, and explored the factors associated with female kidney donation. Methods Data from the ANZDATA (Australian and New Zealand Dialysis and Transplantation) and ANZOD (Australian and New Zealand Organ Donor) registries (2002-2019) were used to identify the sociodemographic characteristics and their interactions associated with living donation from female donors. We derived the predicted probabilities from adjusted logistic models using marginal means. Results Of 3523 living donor pairs, 2203 (63%) recipients were male, and 2012 (57%) donors were female. Male recipients were more likely to receive kidneys from female donors than male donors. Donor and recipient sex association was modified by donor-recipient relationship (P < 0.01), with sensitivity analysis suggesting that spousal donor-recipient pairs drive this interaction. Older recipients residing in regional or remote areas were more likely to receive kidneys from female donors compared with those from major cities (aged ≥60 years: 0.67 [0.63-0.71] vs. aged <60 years: 0.57 [0.53-0.60]). Conclusions Factors associated with female donation include recipient sex, with spousal donors contributing to the interaction between recipient gender and donor-recipient relationship. Recipient age and location of residence have interactive effects on the likelihood of living donor transplantation from female donors.
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Affiliation(s)
- Siah Kim
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Anita van Zwieten
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Melanie Wyld
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
- Department of Renal and Transplantation Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Maleeka Ladhani
- Department of Renal Medicine, Lyell McEwin Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Science, Adelaide University Medical School, Adelaide, South Australia, Australia
| | - Chandana Guha
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Amanda Dominello
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Kylie-Ann Mallitt
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Anna Francis
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Child and Adolescent Renal Service, Queensland Children’s Hospital, South Brisbane, Queensland, Australia
| | - Roslyn B. Mannon
- Division of Nephrology, University of Nebraska Medical Centre, Omaha Nebraska, USA
| | - Germaine Wong
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
- Department of Renal and Transplantation Medicine, Westmead Hospital, Sydney, New South Wales, Australia
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Salas MAP, Chua E, Rossi A, Shah S, Katz-Greenberg G, Coscia L, Sawinski D, Adey D. Sex and gender disparity in kidney transplantation: Historical and future perspectives. Clin Transplant 2022; 36:e14814. [PMID: 36097741 PMCID: PMC10069947 DOI: 10.1111/ctr.14814] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/22/2022] [Accepted: 08/29/2022] [Indexed: 12/27/2022]
Abstract
Sex and gender disparity exist in various stages of kidney transplantation. Females were found to be less likely to be referred for kidney transplant, complete pre-transplant evaluation, be placed on the waitlist, and receive a kidney transplant compared to their male counterparts. Interestingly, females comprise the majority of living kidney donors. This review explores the biological and psychosocial factors that contribute to sex and gender disparity in kidney transplantation and proposes ways to address the disparity.
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Affiliation(s)
- Maria Aurora Posadas Salas
- Department of Medicine, Division of Nephrology and Hypertension, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Elizabeth Chua
- Renal Associates of Montgomery, Montgomery, Alabama, USA
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia, USA
| | - Silvi Shah
- Division of Nephrology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Goni Katz-Greenberg
- Department of Medicine, Division of Nephrology, Duke University, Durham, North Carolina, USA
| | - Lisa Coscia
- Transplant Pregnancy Registry International, Philadelphia, Pennsylvania, USA
| | - Deirdre Sawinski
- Department of Medicine, Division of Nephrology, Weill Cornell Medicine, New York, New York, USA
| | - Deborah Adey
- Department of Medicine, Division of Nephrology, University of California San Francisco, San Francisco, California, USA
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Adoli L, Raffray M, Châtelet V, Vigneau C, Lobbedez T, Gao F, Bayer F, Campéon A, Vabret E, Laude L, Jais JP, Daugas E, Couchoud C, Bayat S. Women's Access to Kidney Transplantation in France: A Mixed Methods Research Protocol. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13524. [PMID: 36294104 PMCID: PMC9603645 DOI: 10.3390/ijerph192013524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/15/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
Kidney transplantation is the best renal replacement therapy (medically and economically) for eligible patients with end-stage kidney disease. Studies in some French regions and in other countries suggest a lower access to the kidney transplant waiting listing and also to kidney transplantation, once waitlisted, for women. Using a mixed methods approach, this study aims to precisely understand these potential sex disparities and their causes. The quantitative study will explore the geographic disparities, compare the determinants of access to the waiting list and to kidney transplantation, and compare the reasons and duration of inactive status on the waiting list in women and men at different scales (national, regional, departmental, and census-block). The qualitative study will allow describing and comparing women's and men's views about their disease and transplantation, as well as nephrologists' practices relative to the French national guidelines on waiting list registration. This type of study is important in the current societal context in which the reduction of sex/gender-based inequalities is a major social expectation.
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Affiliation(s)
- Latame Adoli
- Université de Rennes, EHESP, CNRS, INSERM, Arènes–UMR 6051, RSMS–U1309, 35000 Rennes, France
| | - Maxime Raffray
- Université de Rennes, EHESP, CNRS, INSERM, Arènes–UMR 6051, RSMS–U1309, 35000 Rennes, France
| | - Valérie Châtelet
- U1086 INSERM, Anticipe, Centre de Lutte Contre le Cancer François Baclesse, Centre Universitaire des Maladies Rénales, 14000 Caen, France
| | - Cécile Vigneau
- IRSET (Institut de Recherche en Santé, Environnement et Travail), Université de Rennes, Chu Rennes, INSERM, EHESP, UMR_s 1085, 35000 Rennes, France
| | - Thierry Lobbedez
- U1086 INSERM, Anticipe, Centre de Lutte Contre le Cancer François Baclesse, Centre Universitaire des Maladies Rénales, 14000 Caen, France
| | - Fei Gao
- Université de Rennes, EHESP, CNRS, INSERM, Arènes–UMR 6051, RSMS–U1309, 35000 Rennes, France
| | - Florian Bayer
- Renal Epidemiology and Information Network (Rein) Registry, Biomedecine Agency, Saint-Denis-la-Plaine, 93212 Paris, France
| | - Arnaud Campéon
- Arènes–UMR 6051, ISSAV, EHESP, CNRS, 35000 Rennes, France
| | - Elsa Vabret
- Service de Néphrologie, Chu Rennes, 35000 Rennes, France
| | - Laëtitia Laude
- Université de Rennes, EHESP, CNRS, INSERM, Arènes–UMR 6051, RSMS–U1309, 35000 Rennes, France
| | - Jean-Philippe Jais
- Unité de Biostatistique, Hôpital Necker-Enfants Malades, AP-HP, Institut Imagine, Université Paris-Cité, 75015 Paris, France
| | - Eric Daugas
- INSERM U1149, Université Paris Cité, Assistance Publique-Hôpitaux de Paris, Service de Néphrologie, Hôpital Bichat, 75018 Paris, France
| | - Cécile Couchoud
- Renal Epidemiology and Information Network (Rein) Registry, Biomedecine Agency, Saint-Denis-la-Plaine, 93212 Paris, France
| | - Sahar Bayat
- Université de Rennes, EHESP, CNRS, INSERM, Arènes–UMR 6051, RSMS–U1309, 35000 Rennes, France
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4
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Wong ZY, Low ZR, Chen Y, Danaee M, Nah SA. Meta-analysis of donor-recipient gender profile in paediatric living donor liver transplantation. Arch Dis Child 2022; 107:878-883. [PMID: 35676083 DOI: 10.1136/archdischild-2022-323892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 04/21/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Paediatric living donor liver transplantation (LDLT) has gained popularity due to limited deceased donor organ supply. Some studies report inequalities in donor and recipient gender profiles, but data are sparse. We evaluated LDLT donor-recipient gender profiles, comparing country income categories and gender disparity level. DESIGN We performed a systematic review, searching PubMed, Embase and Cochrane databases for publications dated January 2006-September 2021. We included full-text English articles reporting gender in ≥40 universally sampled donor-recipient pairs. Search terms were permutations of 'liver transplant', 'living donor' and 'paediatric'. Countries were grouped as high/middle/low-income economies based on World Bank criteria and into groups based on deviation from gender parity in Gender Development Index (GDI) values (group 1 indicating closest to gender parity, group 5 indicating furthest). Proportions analysis with corresponding 95% CI were used for analysis of dichotomous variables, with significance when 95% CI did not cross 0.5. Data are reported as female proportion (%) and 95% CI. RESULTS Of 12 525 studies identified, 14 retrospective studies (12 countries; 6152 recipients and 6138 donors) fulfilled study inclusion criteria. Male recipient preponderance was seen in lower middle-income countries (all were also GDI group 5) (39.3 (95% CI 34.7 to 44.0)) and female recipient preponderance in GDI groups 1 and 3. Female donor preponderance was seen overall (57.4% (95% CI 55.1 to 59.6)), in middle income countries and in three of four GDI groups represented. CONCLUSION There are significant imbalances in recipient-donor gender profiles in paediatric LDLT that are not well explained. The reasons for overall female donor preponderance across income tiers must be scrutinised.
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Affiliation(s)
- Zhen Yu Wong
- Division of Paediatric & Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Zhi Rong Low
- Division of Paediatric & Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Yong Chen
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Mahmoud Danaee
- Department of Social & Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Shireen Anne Nah
- Division of Paediatric & Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Gender Disparities in Kidney Transplantation Referral Vary by Age and Race – A Multi-Regional Cohort Study in the Southeast US. Kidney Int Rep 2022; 7:1248-1257. [PMID: 35694555 PMCID: PMC9174037 DOI: 10.1016/j.ekir.2022.03.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/23/2022] [Accepted: 03/28/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Methods Results Conclusion
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6
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A scoping review of inequities in access to organ transplant in the United States. Int J Equity Health 2022; 21:22. [PMID: 35151327 PMCID: PMC8841123 DOI: 10.1186/s12939-021-01616-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 12/24/2021] [Indexed: 02/06/2023] Open
Abstract
Background Organ transplant is the preferred treatment for end-stage organ disease, yet the majority of patients with end-stage organ disease are never placed on the transplant waiting list. Limited access to the transplant waiting list combined with the scarcity of the organ pool result in over 100,000 deaths annually in the United States. Patients face unique barriers to referral and acceptance for organ transplant based on social determinants of health, and patients from disenfranchised groups suffer from disproportionately lower rates of transplantation. Our objective was to review the literature describing disparities in access to organ transplantation based on social determinants of health to integrate the existing knowledge and guide future research. Methods We conducted a scoping review of the literature reporting disparities in access to heart, lung, liver, pancreas and kidney transplantation based on social determinants of health (race, income, education, geography, insurance status, health literacy and engagement). Included studies were categorized based on steps along the transplant care continuum: referral for transplant, transplant evaluation and selection, living donor identification/evaluation, and waitlist outcomes. Results Our search generated 16,643 studies, of which 227 were included in our final review. Of these, 34 focused on disparities in referral for transplantation among patients with chronic organ disease, 82 on transplant selection processes, 50 on living donors, and 61 on waitlist management. In total, 15 studies involved the thoracic organs (heart, lung), 209 involved the abdominal organs (kidney, liver, pancreas), and three involved multiple organs. Racial and ethnic minorities, women, and patients in lower socioeconomic status groups were less likely to be referred, evaluated, and added to the waiting list for organ transplant. The quality of the data describing these disparities across the transplant literature was variable and overwhelmingly focused on kidney transplant. Conclusions This review contextualizes the quality of the data, identifies seminal work by organ, and reports gaps in the literature where future research on disparities in organ transplantation should focus. Future work should investigate the association of social determinants of health with access to the organ transplant waiting list, with a focus on prospective analyses that assess interventions to improve health equity. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01616-x.
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7
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Hödlmoser S, Gehrig T, Antlanger M, Kurnikowski A, Lewandowski M, Krenn S, Zee J, Pecoits-Filho R, Kramar R, Carrero JJ, Jager KJ, Tong A, Port FK, Posch M, Winkelmayer WC, Schernhammer E, Hecking M, Ristl R. Sex Differences in Kidney Transplantation: Austria and the United States, 1978–2018. Front Med (Lausanne) 2022; 8:800933. [PMID: 35141249 PMCID: PMC8819173 DOI: 10.3389/fmed.2021.800933] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 12/21/2021] [Indexed: 11/23/2022] Open
Abstract
Background Systematic analyses about sex differences in wait-listing and kidney transplantation after dialysis initiation are scarce. We aimed at identifying sex-specific disparities along the path of kidney disease treatment, comparing two countries with distinctive health care systems, the US and Austria, over time. Methods We analyzed subjects who initiated dialysis from 1979–2018, in observational cohort studies from the US and Austria. We used Cox regression to model male-to-female cause-specific hazard ratios (csHRs, 95% confidence intervals) for transitions along the consecutive states dialysis initiation, wait-listing, kidney transplantation and death, adjusted for age and stratified by country and decade of dialysis initiation. Results Among 3,053,206 US and 36,608 Austrian patients starting dialysis, men had higher chances to enter the wait-list, which however decreased over time [male-to-female csHRs for wait-listing, 1978–1987: US 1.94 (1.71, 2.20), AUT 1.61 (1.20, 2.17); 2008–2018: US 1.35 (1.32, 1.38), AUT 1.11 (0.94, 1.32)]. Once wait-listed, the advantage of the men became smaller, but persisted in the US [male-to-female csHR for transplantation after wait-listing, 2008–2018: 1.08 (1.05, 1.11)]. The greatest disparity between men and women occurred in older age groups in both countries [male-to-female csHR for wait-listing after dialysis, adjusted to 75% age quantile, 2008–2018: US 1.83 (1.74, 1.92), AUT 1.48 (1.02, 2.13)]. Male-to-female csHRs for death were close to one, but higher after transplantation than after dialysis. Conclusions We found evidence for sex disparities in both countries. Historically, men in the US and Austria had 90%, respectively, 60% higher chances of being wait-listed for kidney transplantation, although these gaps decreased over time. Efforts should be continued to render kidney transplantation equally accessible for both sexes, especially for older women.
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Affiliation(s)
- Sebastian Hödlmoser
- Clinical Division of Nephrology & Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Teresa Gehrig
- Clinical Division of Nephrology & Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Marlies Antlanger
- Department of Internal Medicine 2, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
| | - Amelie Kurnikowski
- Clinical Division of Nephrology & Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michał Lewandowski
- Clinical Division of Nephrology & Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Simon Krenn
- Clinical Division of Nephrology & Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI, United States
| | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, MI, United States
- School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil
| | | | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Kitty J. Jager
- European Renal Association - European Dialysis and Transplant Association Registry, Department of Medical Informatics, Academic University Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Allison Tong
- Clinical Division of Nephrology & Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Friedrich K. Port
- Arbor Research Collaborative for Health, Ann Arbor, MI, United States
| | - Martin Posch
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Wolfgang C. Winkelmayer
- Section of Nephrology, Baylor College of Medicine, Selzman Institute for Kidney Health, Houston, TX, United States
| | - Eva Schernhammer
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Manfred Hecking
- Clinical Division of Nephrology & Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- *Correspondence: Manfred Hecking
| | - Robin Ristl
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
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Pérez-Sáez MJ, Arias-Cabrales CE, Dávalos-Yerovi V, Redondo D, Faura A, Vera M, Bach A, Pedreira G, Junyent E, Crespo M, Marco E, Rodríguez-Mañas L, Pascual J. Frailty among chronic kidney disease patients on the kidney transplant waiting list: the sex–frailty paradox. Clin Kidney J 2022; 15:109-118. [PMID: 35035941 PMCID: PMC8757431 DOI: 10.1093/ckj/sfab133] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Indexed: 01/04/2023] Open
Abstract
Background Frailty is defined as decreased physiologic reserve and resistance to stressors that predisposes patients towards poor health results. Its prevalence in chronic kidney disease (CKD) patients who are kidney transplant (KT) candidates is high. Frailty is associated with a higher rate of complications and mortality after transplant. It is unknown whether frailty phenotype differs depending on sex in this population. Methods This was a prospective longitudinal study of 455 KT candidates evaluated for frailty by physical frailty phenotype at the time of inclusion on the KT waiting list. Pre-frailty was defined as the presence of two criteria and frailty as three or more criteria. Univariate and multivariate analyses searched for associations of frailty status, frailty components and gender differences. Results Thirty percent of the total cohort resulted to be pre-frail (20%) or frail (10.3%), but disparities were observed between sexes, with 22.5% of men and 47.2% of women falling into one of these categories. Among frailty criteria, women presented with a higher percentage of exhaustion (39.6% versus 17%) and slowness (22.2% versus 9.6%) compared with men. Comorbidity burden was higher among frail men, whereas social factors were poorer between frail women. Disability was common among those patients who were frail, both men and women. Conclusions Frailty is twice as frequent in advanced CKD women as men. Frailty criteria distribution and phenotype seem to differ among sexes, which might have implications in terms of specific and individualized interventions to improve their status before transplantation.
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Affiliation(s)
| | | | - Vanesa Dávalos-Yerovi
- Physical Medicine and Rehabilitation Department, Parc de Salut Mar (Hospital del Mar-Hospital de l’Esperança), Rehabilitation Research Group, Hospital del Mar Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Anna Faura
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - María Vera
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Anna Bach
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | | | | | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Ester Marco
- Physical Medicine and Rehabilitation Department, Parc de Salut Mar (Hospital del Mar-Hospital de l’Esperança), Rehabilitation Research Group, Hospital del Mar Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
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9
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Vinson AJ, Kiberd BA, West K, Mannon RB, Foster BJ, Tennankore KK. Disparities in Access to Preemptive Repeat Kidney Transplant: Still Missing the Mark? KIDNEY360 2021; 3:144-152. [PMID: 35368561 PMCID: PMC8967618 DOI: 10.34067/kid.0003162021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 10/18/2021] [Indexed: 01/10/2023]
Abstract
Background The need for repeat transplant due to failing kidney allografts is increasing over time. The benefit of preemptive kidney retransplant (PKre-T) is controversial. Marginalized populations are less likely to undergo their first transplant preemptively; however, whether inequities exist for those undergoing PKre-T is unknown. Methods We performed a cohort study of adult patients undergoing live and deceased kidney transplant in the United States from 2000 to 2018 identified using the Scientific Registry of Transplant Recipients, and we identified patients with first preemptive kidney transplant (PKT) and PKre-T. In the primary analysis, a multivariable logistic regression was used to identify independent predictors of PKre-T. In secondary analyses, multivariable Cox models were used to determine the association of PKre-T with death-censored and all-cause graft loss. Results In total, 4910 (15.5%) patients underwent PKre-T, and 43,293 (19.1%) underwent first PKT. Inequities in access to PKre-T persisted (OR, 0.49; 95% CI, 0.44 to 0.55 for unemployed versus full time; OR, 1.61; 95% CI, 1.14 to 2.25 for graduate school versus not completing high school; OR, 0.61; 95% CI, 0.52 to 0.70 for Black versus White race); 7.1% of all transplanted Black patients received PKre-T versus 17.4% of White patients. Women were more likely to undergo PKre-T than men (OR, 1.42; 95% CI, 1.29 to 1.57). PKre-T was associated with superior graft survival relative to retransplant after a period of dialysis (HR, 0.73; 95% CI, 0.67 to 0.80 for all-cause graft failure; HR, 0.72; 95% CI, 0.65 to 0.81 for death-censored graft loss). Conclusions Despite improved patient and graft survival, inequities in access to PKre-T persist. Patients with lower education, patients with reduced employment status, patients of Black race, and men are less likely to receive PKre-T.
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Affiliation(s)
- Amanda J. Vinson
- Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada,Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bryce A. Kiberd
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kenneth West
- Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada,Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Roslyn B. Mannon
- Division of Nephrology, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Bethany J. Foster
- Division of Nephrology, Montreal Children’s Hospital of the McGill University Health Centre, Montreal, Quebec, Canada,Department of Pediatrics, McGill University, Montreal, Quebec, Canada,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Karthik K. Tennankore
- Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada,Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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10
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Meeting Report: First State of the Art Meeting on Gender Disparity in Kidney Transplantation in the Asia-Pacific. Transplantation 2021; 105:1888-1891. [PMID: 34416749 DOI: 10.1097/tp.0000000000003841] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Ahearn P, Johansen KL, Tan JC, McCulloch CE, Grimes BA, Ku E. Sex Disparity in Deceased-Donor Kidney Transplant Access by Cause of Kidney Disease. Clin J Am Soc Nephrol 2021; 16:241-250. [PMID: 33500250 PMCID: PMC7863650 DOI: 10.2215/cjn.09140620] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 12/14/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Women with kidney failure have lower access to kidney transplantation compared with men, but the magnitude of this disparity may not be uniform across all kidney diseases. We hypothesized that the attributed cause of kidney failure may modify the magnitude of the disparities in transplant access by sex. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a retrospective cohort study of adults who developed kidney failure between 2005 and 2017 according to the United States Renal Data System. We used adjusted Cox models to examine the association between sex and either access to waitlist registration or deceased-donor kidney transplantation, and tested for interaction between sex and the attributed cause of kidney failure using adjusted models. RESULTS Among a total of 1,478,037 patients, 271,111 were registered on the waitlist and 89,574 underwent deceased-donor transplantation. The rate of waitlisting was 6.5 per 100 person-years in women and 8.3 per 100 person-years for men. In adjusted analysis, women had lower access to the waitlist (hazard ratio, 0.89; 95% confidence interval, 0.89 to 0.90) and to deceased-donor transplantation after waitlisting (hazard ratio, 0.96; 95% confidence interval, 0.94 to 0.98). However, there was an interaction between sex and attributed cause of kidney disease in adjusted models (P<0.001). Women with kidney failure due to type 2 diabetes had 27% lower access to the kidney transplant waitlist (hazard ratio, 0.73; 95% confidence interval, 0.72 to 0.74) and 11% lower access to deceased-donor transplantation after waitlisting compared with men (hazard ratio, 0.89; 95% confidence interval, 0.86 to 0.92). In contrast, sex disparities in access to either the waitlist or transplantation were not observed in kidney failure secondary to cystic disease. CONCLUSIONS The disparity in transplant access by sex is not consistent across all causes of kidney failure. Lower deceased-donor transplantation rates in women compared with men are especially notable among patients with kidney failure attributed to diabetes.
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Affiliation(s)
- Patrick Ahearn
- Division of Nephrology, Stanford University, Palo Alto, California
| | - Kirsten L. Johansen
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, Minnesota,Division of Nephrology, University of Minnesota, Minneapolis, Minnesota
| | - Jane C. Tan
- Division of Nephrology, Stanford University, Palo Alto, California
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Barbara A. Grimes
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Elaine Ku
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California,Division of Nephrology, University of California, San Francisco, California,Division of Pediatric Nephrology, University of California, San Francisco, California
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12
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Melk A, Schmidt BMW, Geyer S, Epping J. Sex disparities in dialysis initiation, access to waitlist, transplantation and transplant outcome in German patients with renal disease-A population based analysis. PLoS One 2020; 15:e0241556. [PMID: 33180815 PMCID: PMC7660568 DOI: 10.1371/journal.pone.0241556] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 10/18/2020] [Indexed: 12/31/2022] Open
Abstract
Background Renal transplantation access and outcome differ between men and women, but no analysis has considered all transition phases and transplant outcome using the same data set. We analyzed sex disparities in all phases of patients’ clinical path (progression to dialysis, waitlisting, transplantation, graft failure/death). Methods In a population based approach using health insurance data (2005–2013) we examined patients’ risk of changing from one phase to another applying Cox Proportional Hazards model. Results After adjusting for age and comorbidities, women had a 16% lower risk of progression to ESRD (HR/95%-CI: 0.84/0.79–0.88). Access to the waitlist was lowered by 18% in women compared to men (HR/95%-CI: 0.82/0.70–0.96). An age stratified analysis did not reveal differences in any age group. Once waitlisted, the chance to receive a transplant was identical (HR/95%-CI: 0.96/0.81–1.15). The risk of transplant failure/death was identical for both sexes (HR/95%-CI: 0.99/0.73–1.35), but the effect was modified by age: in younger women (18–45 years) the risk was twice as high compared to men (HR/95%-CI: 2.08/1.04–4.14), whereas the risk in elderly women (> 65 years) was only half the risk of men (HR/95%-CI: 0.47/0.24–0.93). Conclusion Sex disparities occurred at different steps in the history of patients with renal disease and affected progression to dialysis, waitlisting and transplantation outcome in a population with equal access to medical treatment.
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Affiliation(s)
- Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
- * E-mail:
| | | | - Siegfried Geyer
- Department of Medical Sociology, Hannover Medical School, Hannover, Germany
| | - Jelena Epping
- Department of Medical Sociology, Hannover Medical School, Hannover, Germany
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13
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Ladhani M, Craig JC, Wong G. Obesity and gender-biased access to deceased donor kidney transplantation. Nephrol Dial Transplant 2020; 35:184-189. [PMID: 31203364 DOI: 10.1093/ndt/gfz100] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 04/16/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Despite the survival advantage of transplantation over dialysis, obese patients are less likely to be listed on the deceased donor waiting list and subsequently transplanted. This study aimed to determine the association between obesity and access to deceased donor transplantation and whether any association observed was applicable to men and women equally. METHODS Cox proportional hazards models were conducted to determine the association between obesity and waitlisting for transplantation and then subsequent receipt of a kidney transplant using data from the Australian and New Zealand Dialysis and Transplant Registry (2007-14). RESULTS Of 11633 patients included, 4408 (37.9%) were obese. Over a follow-up period of 26306 patient-years during waitlisting and 5607 patient-years from waitlisting to transplantation, 3515 candidates were listed (28.4% obese) and 1662 were transplanted (29.3% obese). Obesity was associated with a reduced likelihood of waitlisting {adjusted hazard ratio [aHR] 0.66 [95% confidence interval (CI) 0.58-0.76]} but not kidney transplantation once waitlisted [aHR 1.10 (95% CI 0.97-1.24)]. The impact of obesity and waitlisting was modified by gender (P-value for interaction = 0.01). Women who were obese were 34% less likely to be listed than normal-weight women [aHR 0.66 (95% CI 0.58-0.76)], compared with obese men who were 14% less likely [aHR 0.86 (95% CI 0.77-0.97)]. CONCLUSIONS Overall, obesity reduces the likelihood of being listed for deceased donor transplantation, especially among women, but not transplantation once listed. Transplant physicians who regulate access to the deceased donor waiting list should be aware of this apparent inequity and seek to understand and ameliorate contributing factors.
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Affiliation(s)
- Maleeka Ladhani
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia.,Lyell McEwin Hospital, Elizabeth Vale, SA, Australia
| | - Jonathan C Craig
- Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia.,Centre for Renal and Transplant Research, Westmead Institute for Medical Research, Westmead Hospital, Westmead, NSW, Australia
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14
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Direct Health Care Costs, Health Services Utilization, and Outcomes of Biliary Atresia: A Population-based Cohort Study. J Pediatr Gastroenterol Nutr 2020; 70:436-443. [PMID: 31834111 DOI: 10.1097/mpg.0000000000002582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Biliary atresia (BA) is the most common reason for liver transplant in childhood, and outcomes worsen with older age at hepatoportoenterostomy (HPE). We determined direct health care costs in children with BA, compared to controls in a population-based cohort of children in Ontario, Canada. METHODS We used health administrative data to identify all children diagnosed with BA between 2002 and 2016 (n = 121) and matched controls (n = 602). We determined annual direct healthcare costs, and rates of health services utilization, liver transplantation, death, portal hypertension, cirrhosis, esophageal varices, and major upper gastrointestinal bleeding requiring hospitalization. Multivariable regression models determined the association between age at HPE, risk of liver transplant, and direct costs. RESULTS Incidence of BA was 6.07 (4.99-7.15) per 100,000 live births. The annual median (interquartile range) direct health care costs were higher in BA cases ($4210; interquartile range $1091-$16,765) compared to controls ($283; $112-$634). Compared to age at HPE <45 days, there was no significant association between direct costs and HPE ≥90 days (rate ratio 1.24, 95% confidence interval [CI] 0.78-1.97) or 45 to 90 days (rate ratio 1.05, 95% CI 0.73-1.50). Age at HPE ≥90 days was significantly associated with risk of undergoing liver transplant compared to age <45 days (hazard ratio 5.27, 95% CI 2.45-11.34). Direct costs were higher in patients with BA who underwent liver transplantation compared to those who did not ($39,476±$84,367 vs $22,579 ± $67,913). CONCLUSIONS Direct ealth care costs were high in patients with BA, especially in those who underwent liver transplantation. Age at HPE was associated with risk of liver transplantation, but not direct health care costs, utilization, or other risk outcomes.
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15
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Bonnéric S, Karadkhele G, Couchoud C, Patzer RE, Greenbaum LA, Hogan J. Sex and Glomerular Filtration Rate Trajectories in Children. Clin J Am Soc Nephrol 2020; 15:320-329. [PMID: 32111703 PMCID: PMC7057295 DOI: 10.2215/cjn.08420719] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 01/21/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Differences in CKD progression by sex have been hypothesized to explain disparities in access to kidney transplantation in children. This study aims to identify distinct trajectories of eGFR decline and to investigate the association of sex with eGFR decline. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used data from the CKD in Children study. Latent class mixed models were used to identify eGFR trajectories and patient characteristics were compared between trajectories. Progression was studied to two outcomes: ESKD (dialysis or transplantation) and a combined outcome of ESKD or 50% eGFR decline from baseline, using multivariable parametric failure time models. RESULTS Among 888 patients, 613 with nonglomerular and 275 with glomerular diseases, we observed four and two distinct GFR trajectories, respectively. Among patients with nonglomerular diseases, there was a higher proportion of males in the group with a low baseline GFR. This group had an increased risk of ESKD or 50% GFR decline, despite a similar absolute decline in GFR. Eight patients with nonglomerular diseases, mostly males with obstructive uropathies, had a more rapid absolute GFR decline. However, the association between male sex and rapid absolute GFR decline was NS after adjustment for age, baseline GFR, and proteinuria. Among patients with glomerular diseases, a subgroup including mostly females with systemic immunologic diseases or crescentic GN had a rapid absolute GFR decline. CONCLUSIONS This study identifies different trajectories of CKD progression in children and found a faster progression of CKD in females in patients with glomerular diseases, but no significant sex difference in patients with nonglomerular diseases. The differences in progression seem likely explained by sex differences in the underlying primary kidney disease and in baseline GFR rather than by a direct effect of sex on progression.
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Affiliation(s)
- Stéphanie Bonnéric
- Department of Pediatric Nephrology, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Geeta Karadkhele
- Department of Surgery, Emory Transplant Center, Emory School of Medicine, Atlanta, Georgia
| | - Cécile Couchoud
- Renal Epidemiology and Information Network (REIN) Registry, French Biomedicine Agency, La Plaine-Saint Denis, France
| | - Rachel E Patzer
- Department of Surgery, Emory Transplant Center, Emory School of Medicine, Atlanta, Georgia.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; and
| | - Larry A Greenbaum
- Department of Pediatric Nephrology, Children's Healthcare of Atlanta, Emory School of Medicine, Atlanta, Georgia
| | - Julien Hogan
- Department of Pediatric Nephrology, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; .,Department of Surgery, Emory Transplant Center, Emory School of Medicine, Atlanta, Georgia
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16
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Arya S, Melanson TA, George EL, Rothenberg KA, Kurella Tamura M, Patzer RE, Hockenberry JM. Racial and Sex Disparities in Catheter Use and Dialysis Access in the United States Medicare Population. J Am Soc Nephrol 2020; 31:625-636. [PMID: 31941721 DOI: 10.1681/asn.2019030274] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 11/18/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Despite efforts to increase arteriovenous fistula and graft use, 80% of patients in the United States start hemodialysis on a central venous catheter (CVC). METHODS To better understand in incident hemodialysis patients how sex and race/ethnicity are associated with time on a central venous catheter and transition to an arteriovenous fistula and graft, our observational cohort study analyzed US Renal Data System data for patients with incident ESKD aged ≥66 years who started hemodialysis on a CVC in July 2010 through 2013. RESULTS At 1 year, 32.7% of 74,194 patients transitioned to an arteriovenous fistula, 10.8% transitioned to an arteriovenous graft, 32.1% stayed on a CVC, and 24.5% died. Women spent a significantly longer time on a CVC than men. Compared with white patients, patients who were black, Hispanic, or of another racial/ethnicity minority spent significantly more days on a CVC. In competing risk regression, women were significantly less likely than men to transition to a fistula and more likely to transition to a graft. Compared with white patients, blacks were significantly less likely to transition to a fistula but more likely to transition to a graft, Hispanics were significantly more likely to transition to a fistula, and other races/ethnicities were significantly more likely to transition to either a fistula or a graft. CONCLUSIONS Female patients spend a longer time on a CVC and are less likely to transition to permanent access. Compared with white patients, minorities also spend longer time on a CVC, but are more likely to eventually transition to permanent access. Strategies to speed transition to permanent access should target groups that currently lag in this area.
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Affiliation(s)
- Shipra Arya
- Division of Vascular Surgery and .,Division of Vascular Surgery, Surgical Services Line and
| | - Taylor A Melanson
- Division of Transplant, Department of Surgery, Emory School of Medicine
| | | | - Kara A Rothenberg
- Division of Vascular Surgery and.,Department of Surgery, University of California, San Francisco East Bay, Oakland, California
| | - Manjula Kurella Tamura
- Geriatric Research and Education Clinical Center, Palo Alto Veterans Affairs Healthcare System, Palo Alto, California.,Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Rachel E Patzer
- Department of Surgery, Emory School of Medicine.,Department of Epidemiology, Rollins School of Public Health, and
| | - Jason M Hockenberry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia; and
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18
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Huml AM, Albert JM, Thornton JD, Sehgal AR. Outcomes of Deceased Donor Kidney Offers to Patients at the Top of the Waiting List. Clin J Am Soc Nephrol 2017; 12:1311-1320. [PMID: 28751577 PMCID: PMC5544513 DOI: 10.2215/cjn.10130916] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 05/02/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Transplant centers may accept or refuse deceased-donor kidneys that are offered to their patients at the top of the waiting list. We sought to determine the outcomes of deceased-donor kidney offers and their association with characteristics of waitlisted patients and organ donors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We examined all 7 million deceased-donor adult kidney offers in the United States from 2007 to 2012 that led to eventual transplantation. Data were obtained from the national organ allocation system through the United Network of Organ Sharing. The study cohort consisted of 178,625 patients waitlisted for a deceased-donor kidney transplant and 31,230 deceased donors. We evaluated offers made to waitlisted patients and their outcomes (transplantation or specific reason for refusal). RESULTS Deceased-donor kidneys were offered a median of seven times before being accepted for transplantation. The most common reasons for refusal of an offer were donor-related factors, e.g., age or organ quality (3.2 million offers, 45.0%), and transplant center bypass, e.g., minimal acceptance criteria not met (3.2 million offers, 44.0%). After adjustment for characteristics of waitlisted patients, organ donors, and transplant centers, male (odds ratio [OR], 0.93; 95% confidence interval [95% CI], 0.91 to 0.95) and Hispanic (OR, 0.96; 95% CI, 0.93 to 0.99) waitlisted patients were less likely to have an offer accepted than female and white patients, respectively. The likelihood of offer acceptance varied greatly across transplant centers (interquartile ratio, 2.28). CONCLUSIONS Transplant centers frequently refuse deceased-donor kidneys. Such refusals differ by patient and donor characteristics, may contribute to disparities in access to transplantation, and vary greatly across transplant centers. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_07_27_Huml.mp3.
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Affiliation(s)
- Anne M Huml
- Center for Reducing Health Disparities and
- Divisions of Nephrology and
- Division of Nephrology, Department of Medicine, University Hospitals, Cleveland, Ohio
| | - Jeffrey M Albert
- Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio
| | - J Daryl Thornton
- Center for Reducing Health Disparities and
- Pulmonary and Critical Care Medicine, Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio; and
| | - Ashwini R Sehgal
- Center for Reducing Health Disparities and
- Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio
- Divisions of Nephrology and
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Lassalle M, Fezeu LK, Couchoud C, Hannedouche T, Massy ZA, Czernichow S. Obesity and access to kidney transplantation in patients starting dialysis: A prospective cohort study. PLoS One 2017; 12:e0176616. [PMID: 28493926 PMCID: PMC5426620 DOI: 10.1371/journal.pone.0176616] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 04/13/2017] [Indexed: 12/02/2022] Open
Abstract
Background Obesity has been linked to poor access to medical care. Although scientific evidence suggest that kidney transplantation improves survival and quality of life in obese patients with end-stage renal disease (ESRD), few data exist on the impact of obesity on access to kidney transplantation in this population. Objectives We aimed to characterize the relationships between body mass index (BMI) at the start of dialysis, changes in BMI after the start of dialysis, and either access to kidney transplantation or overall mortality in dialysis or transplantation among ESRD patients. Methods Between 2002 and 2011, 19524 dialysis patients with ESRD were included in the study via the French nationwide Renal Epidemiology and Information Network. Data on sociodemographic factors, comorbidities and laboratory test results were recorded upon entry into the registry. BMI were obtained at the start of dialysis and then yearly. Cubic spline regression analyses provided a graphic evaluation of the relationships between BMI at the start of dialysis and outcomes. Joint models were used to evaluate the association between the change over time in BMI and outcomes. Results During a median follow-up of 20.3 months, 6634 patients underwent kidney transplantation. A BMI >31 kg/m2 at the start of the dialysis was associated with a lower likelihood of receiving a kidney transplant, and the likelihood decreased even further with higher BMI values. For patients with BMI ≥30kg/m2 at the start of the dialysis, a 1 kg/m2 decrease in BMI during follow-up was associated with a 9% to 11% increase in the likelihood of receiving a transplant. There was an L-shaped relationship between BMI at the start of dialysis and overall mortality. We showed that obese patients with ESRD face barriers to the receipt of a kidney transplant without valid reasons. Conclusion Greater attention to this issue would improve the fairness of the organ allocation process and might improve outcomes for obese patients with ESRD.
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Affiliation(s)
- Mathilde Lassalle
- REIN registry, Agence de la Biomédecine, F-93212 Saint-Denis-la-Plaine cedex, France
| | - Léopold K. Fezeu
- Université Paris 13, Equipe de Recherche en Epidémiologie Nutritionnelle (EREN), Centre de Recherche en Epidémiologie et Statistiques, INSERM (U1153), INRA (U1125), CNAM, COMUE Sorbonne Paris Cité, F-93017 Bobigny, France
| | - Cécile Couchoud
- REIN registry, Agence de la Biomédecine, F-93212 Saint-Denis-la-Plaine cedex, France
| | - Thierry Hannedouche
- Department of Nephrology, University of Strasbourg & Hôpitaux Universitaires de Strasbourg, F-67000, Strasbourg, France
| | - Ziad A. Massy
- Division of Nephrology, Ambroise Paré University Hospital, Assistance Publique—Hôpitaux de Paris, F-92100, Boulogne-Billancourt, France
- INSERM U1018, Research Centre in Epidemiology and Population Health (CESP) Team 5, F-94807, Villejuif, France
| | - Sébastien Czernichow
- INSERM UMS 011, F-94807, Villejuif, France
- University Paris Descartes, Paris, France
- Department of Nutrition, Assistance Publique—Hôpitaux de Paris, Hôpital Européen Georges-Pompidou, Paris, F-75015 France
- * E-mail:
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20
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McPherson L, Basu M, Gander J, Pastan SO, Mohan S, Wolf MS, Chiles M, Russell A, Lipford K, Patzer RE. Decisional conflict between treatment options among end-stage renal disease patients evaluated for kidney transplantation. Clin Transplant 2017; 31. [PMID: 28457025 PMCID: PMC10067135 DOI: 10.1111/ctr.12991] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2017] [Indexed: 11/26/2022]
Abstract
Although kidney transplantation provides a significant benefit over dialysis, many patients with end-stage renal disease (ESRD) are conflicted about their decision to undergo kidney transplant. We aimed to identify the prevalence and characteristics associated with decisional conflict between treatment options in ESRD patients presenting for transplant evaluation. Among a cross-sectional sample of patients with ESRD (n=464) surveyed in 2014 and 2015, we assessed decisional conflict through a validated 10-item questionnaire. Decisional conflict was dichotomized into no decisional conflict (score=0) and any decisional conflict (score>0). We investigated potential characteristics of patients with decisional conflict using bivariate and multivariable logistic regression. The overall mean age was 50.6 years, with 62% male patients and 48% African American patients. Nearly half (48.5%) of patients had decisional conflict regarding treatment options. Characteristics significantly associated with decisional conflict in multivariable analysis included male sex, lower educational attainment, and less transplant knowledge. Understanding characteristics associated with decisional conflict in patients with ESRD could help identify patients who may benefit from targeted interventions to help patients make informed, value-based, and supported decisions when deciding how to best treat their kidney disease.
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Affiliation(s)
- Laura McPherson
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Mohua Basu
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jennifer Gander
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Stephen O Pastan
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Sumit Mohan
- Renal and Pancreatic Transplant Program, Columbia University Medical Center, New York, NY, USA
| | - Michael S Wolf
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mariana Chiles
- Renal and Pancreatic Transplant Program, Columbia University Medical Center, New York, NY, USA
| | - Allison Russell
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kristie Lipford
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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22
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Gombotz H, Schreier G, Neubauer S, Kastner P, Hofmann A. Gender disparities in red blood cell transfusion in elective surgery: a post hoc multicentre cohort study. BMJ Open 2016; 6:e012210. [PMID: 27965248 PMCID: PMC5168603 DOI: 10.1136/bmjopen-2016-012210] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES A post hoc gender comparison of transfusion-related modifiable risk factors among patients undergoing elective surgery. SETTINGS 23 Austrian centres randomly selected and stratified by region and level of care. PARTICIPANTS We consecutively enrolled in total 6530 patients (3465 women and 3065 men); 1491 underwent coronary artery bypass graft (CABG) surgery, 2570 primary unilateral total hip replacement (THR) and 2469 primary unilateral total knee replacement (TKR). MAIN OUTCOME MEASURES Primary outcome measures were the number of allogeneic and autologous red blood cell (RBC) units transfused (postoperative day 5 included) and differences in intraoperative and postoperative transfusion rate between men and women. Secondary outcomes included perioperative blood loss in transfused and non-transfused patients, volume of RBCs transfused, perioperative haemoglobin values and circulating red blood volume on postoperative day 5. RESULTS In all surgical groups, the transfusion rate was significantly higher in women than in men (CABG 81 vs 49%, THR 46 vs 24% and TKR 37 vs 23%). In transfused patients, the absolute blood loss was higher among men in all surgical categories while the relative blood loss was higher among women in the CABG group (52.8 vs 47.8%) but comparable in orthopaedic surgery. The relative RBC volume transfused was significantly higher among women in all categories (CABG 40.0 vs 22.3; TKR 25.2 vs 20.2; THR 26.4 vs 20.8%). On postoperative day 5, the relative haemoglobin values and the relative circulating RBC volume were higher in women in all surgical categories. CONCLUSIONS The higher transfusion rate and volume in women when compared with men in elective surgery can be explained by clinicians applying the same absolute transfusion thresholds irrespective of a patient's gender. This, together with the common use of a liberal transfusion strategy, leads to further overtransfusion in women.
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Affiliation(s)
- Hans Gombotz
- Department of Anaesthesiology and Intensive Care,General Hospital Linz, Vienna, Austria
- AIT Austrian Institute of Technology GmbH 8020, Graz, Austria
| | - Günter Schreier
- AIT Austrian Institute of Technology GmbH 8020, Graz, Austria
| | - Sandra Neubauer
- AIT Austrian Institute of Technology GmbH 8020, Graz, Austria
| | - Peter Kastner
- AIT Austrian Institute of Technology GmbH 8020, Graz, Austria
| | - Axel Hofmann
- Department of Anaesthesiology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, School of Surgery, Dentistry and Health Sciences, University of Western Australia, Western Australia, Australia
- Faculty of Health Sciences, Curtin University, Western Australia, Australia
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23
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Tafulo S, Malheiro J, Dias L, Mendes C, Osório E, Martins LS, Santos J, Pedroso S, Almeida M, Castro-Henriques A. Low transplantability of 0 blood group and highly sensitized candidates in the Portuguese kidney allocation algorithm: quantifying an old problem in search of new solutions. HLA 2016; 88:232-238. [DOI: 10.1111/tan.12895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 08/16/2016] [Accepted: 08/24/2016] [Indexed: 12/21/2022]
Affiliation(s)
- S. Tafulo
- Oporto Blood and Transplantation Center; Instituto Português do Sangue e da Transplantacão; Porto Portugal
| | - J. Malheiro
- Nephrology and Kidney Transplantation Department; Centro Hospitalar do Porto, Hospital de Santo António; Porto Portugal
| | - L. Dias
- Nephrology and Kidney Transplantation Department; Centro Hospitalar do Porto, Hospital de Santo António; Porto Portugal
| | - C. Mendes
- Oporto Blood and Transplantation Center; Instituto Português do Sangue e da Transplantacão; Porto Portugal
| | - E. Osório
- Oporto Blood and Transplantation Center; Instituto Português do Sangue e da Transplantacão; Porto Portugal
| | - L. S. Martins
- Nephrology and Kidney Transplantation Department; Centro Hospitalar do Porto, Hospital de Santo António; Porto Portugal
| | - J. Santos
- Nephrology and Kidney Transplantation Department; Centro Hospitalar do Porto, Hospital de Santo António; Porto Portugal
| | - S. Pedroso
- Nephrology and Kidney Transplantation Department; Centro Hospitalar do Porto, Hospital de Santo António; Porto Portugal
| | - M. Almeida
- Nephrology and Kidney Transplantation Department; Centro Hospitalar do Porto, Hospital de Santo António; Porto Portugal
| | - A. Castro-Henriques
- Nephrology and Kidney Transplantation Department; Centro Hospitalar do Porto, Hospital de Santo António; Porto Portugal
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Hogan J, Couchoud C, Bonthuis M, Groothoff JW, Jager KJ, Schaefer F, Van Stralen KJ. Gender Disparities in Access to Pediatric Renal Transplantation in Europe: Data From the ESPN/ERA-EDTA Registry. Am J Transplant 2016; 16:2097-105. [PMID: 26783738 DOI: 10.1111/ajt.13723] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 01/08/2016] [Accepted: 01/11/2016] [Indexed: 01/25/2023]
Abstract
Inequalities between genders in access to transplantation have been demonstrated. We aimed to validate this gender inequality in a large pediatric population and to investigate its causes. This cohort study included 6454 patients starting renal replacement therapy before 18 years old, in 35 countries participating in the European Society for Paediatric Nephrology/European Renal Association-European Dialysis and Transplant Association Registry. We used cumulative incidence competing risk and proportional hazards frailty models to study the time to receive a transplant and hierarchical logistic regression to investigate access to preemptive transplantation. Girls had a slower access to renal transplantation because of a 23% lower probability of receiving preemptive transplantation. We found a longer follow-up time before renal replacement therapy in boys compared with girls despite a similar estimated glomerular filtration rate at first appointment. Girls tend to progress faster toward end-stage renal disease than boys, which may contribute to a shorter time available for pretransplantation workup. Overall, medical factors explained only 70% of the gender difference. In Europe, girls have less access to preemptive transplantation for reasons that are only partially related to medical factors. Nonmedical factors such as patient motivation and parent and physician attitudes toward transplantation and organ donation may contribute to this inequality. Our study should raise awareness for the management of girls with renal diseases.
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Affiliation(s)
- J Hogan
- REIN Registry, Agence de la Biomédecine, La Plaine Saint-Denis, France.,Department of Pediatric Nephrology, Robert Debré University Hospital, Paris, France
| | - C Couchoud
- REIN Registry, Agence de la Biomédecine, La Plaine Saint-Denis, France
| | - M Bonthuis
- ESPN/ERA-EDTA Registry and ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Centre, Amsterdam, the Netherlands
| | - J W Groothoff
- Department of Pediatric Nephrology, Emma Children's Hospital AMC, Amsterdam, the Netherlands.,Department of Pediatrics, Emma Children's Hospital AMC, Amsterdam, the Netherlands
| | - K J Jager
- ESPN/ERA-EDTA Registry and ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Centre, Amsterdam, the Netherlands
| | - F Schaefer
- Department of Pediatric Nephrology, University of Heidelberg Centre for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - K J Van Stralen
- ESPN/ERA-EDTA Registry and ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Centre, Amsterdam, the Netherlands
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Kihal-Talantikite W, Vigneau C, Deguen S, Siebert M, Couchoud C, Bayat S. Influence of Socio-Economic Inequalities on Access to Renal Transplantation and Survival of Patients with End-Stage Renal Disease. PLoS One 2016; 11:e0153431. [PMID: 27082113 PMCID: PMC4833352 DOI: 10.1371/journal.pone.0153431] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 03/29/2016] [Indexed: 11/18/2022] Open
Abstract
Background Public and scientific concerns about the social gradient of end-stage renal disease and access to renal replacement therapies are increasing. This study investigated the influence of social inequalities on the (i) access to renal transplant waiting list, (ii) access to renal transplantation and (iii) patients’ survival. Methods All incident adult patients with end-stage renal disease who lived in Bretagne, a French region, and started dialysis during the 2004–2009 period were geocoded in census-blocks. To each census-block was assigned a level of neighborhood deprivation and a degree of urbanization. Cox proportional hazards models were used to identify factors associated with each study outcome. Results Patients living in neighborhoods with low level of deprivation had more chance to be placed on the waiting list and less risk of death (HR = 1.40 95%CI: [1.1–1.7]; HR = 0.82 95%CI: [0.7–0.98]), but this association did not remain after adjustment for the patients’ clinical features. The likelihood of receiving renal transplantation after being waitlisted was not associated with neighborhood deprivation in univariate and multivariate analyses. Conclusions In a mixed rural and urban French region, patients living in deprived or advantaged neighborhoods had the same chance to be placed on the waiting list and to undergo renal transplantation. They also showed the same mortality risk, when their clinical features were taken into account.
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Affiliation(s)
| | - Cécile Vigneau
- CHU Pontchaillou, Service de néphrologie, Rennes, France
- Université de Rennes 1, UMR 6290, équipe Kyca, Rennes, France
| | - Séverine Deguen
- EHESP School of Public Health, Sorbonne Paris Cité, Rennes, France
| | - Muriel Siebert
- CHU Pontchaillou, Service de néphrologie, Rennes, France
| | - Cécile Couchoud
- REIN Registry, Agence de la biomédecine, Saint Denis La Plaine, France
| | - Sahar Bayat
- EHESP School of Public Health, Sorbonne Paris Cité, EA MOS, Rennes, France
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DiNofia AM, Salazar E, Seif AE, Li Y, Huang YSV, Bagatell R, Fisher BT, Aplenc R. Bortezomib Inpatient Prescribing Practices in Free-Standing Children's Hospitals in the United States. PLoS One 2016; 11:e0151362. [PMID: 26978062 PMCID: PMC4792468 DOI: 10.1371/journal.pone.0151362] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 02/27/2016] [Indexed: 01/30/2023] Open
Abstract
This study is a pharmacoepidemiologic description of pediatric bortezomib use. Exposure was identified through billing codes in patients admitted to US children's hospitals that participated with the Pediatric Health Information System between 2004 and 2013. Associated information on underlying diseases, demographics, institutional use, mortality, and physician type was collected. Exposure to bortezomib was identified in 314 patients. Hematologist/Oncologists prescribed half of the bortezomib used. Use increased during the study period. Inpatient volume was positively correlated with bortezomib utilization. Bortezomib use in pediatrics is increasing for a variety of diseases. Variation in use exists across institutions. Further studies are needed to characterize bortezomib's efficacy in pediatric diseases.
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Affiliation(s)
- Amanda M. DiNofia
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- * E-mail:
| | - Elizabeth Salazar
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Alix E. Seif
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Yimei Li
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Yuan-Shung Vera Huang
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Rochelle Bagatell
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Brian T. Fisher
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Richard Aplenc
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
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Patzer RE, Plantinga LC, Paul S, Gander J, Krisher J, Sauls L, Gibney EM, Mulloy L, Pastan SO. Variation in Dialysis Facility Referral for Kidney Transplantation Among Patients With End-Stage Renal Disease in Georgia. JAMA 2015; 314:582-94. [PMID: 26262796 PMCID: PMC4571496 DOI: 10.1001/jama.2015.8897] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Dialysis facilities in the United States are required to educate patients with end-stage renal disease about all treatment options, including kidney transplantation. Patients receiving dialysis typically require a referral for kidney transplant evaluation at a transplant center from a dialysis facility to start the transplantation process, but the proportion of patients referred for transplantation is unknown. OBJECTIVE To describe variation in dialysis facility-level referral for kidney transplant evaluation and factors associated with referral among patients initiating dialysis in Georgia, the US state with the lowest kidney transplantation rates. DESIGN, SETTING, AND PARTICIPANTS Examination of United States Renal Data System data from a cohort of 15,279 incident, adult (18-69 years) patients with end-stage renal disease from 308 Georgia dialysis facilities from January 2005 to September 2011, followed up through September 2012, linked to kidney transplant referral data collected from adult transplant centers in Georgia in the same period. MAIN OUTCOMES AND MEASURES Referral for kidney transplant evaluation within 1 year of starting dialysis at any of the 3 Georgia transplant centers was the primary outcome; placement on the deceased donor waiting list was also examined. RESULTS The median within-facility percentage of patients referred within 1 year of starting dialysis was 24.4% (interquartile range, 16.7%-33.3%) and varied from 0% to 75.0%. Facilities in the lowest tertile of referral (<19.2%) were more likely to treat patients living in high-poverty neighborhoods (absolute difference, 21.8% [95% CI, 14.1%-29.4%]), had a higher patient to social worker ratio (difference, 22.5 [95% CI, 9.7-35.2]), and were more likely nonprofit (difference, 17.6% [95% CI, 7.7%-27.4%]) compared with facilities in the highest tertile of referral (>31.3%). In multivariable, multilevel analyses, factors associated with lower referral for transplantation, such as older age, white race, and nonprofit facility status, were not always consistent with the factors associated with lower waitlisting. CONCLUSIONS AND RELEVANCE In Georgia overall, a limited proportion of patients treated with dialysis were referred for kidney transplant evaluation between 2005 and 2011, but there was substantial variability in referral among facilities. Variables associated with referral were not always associated with waitlisting, suggesting that different factors may account for disparities in referral.
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Affiliation(s)
- Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia2Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia3Emory Transplant Center, Atlanta, Georgia
| | - Laura C Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia4Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Jennifer Gander
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jenna Krisher
- Southeastern Kidney Council Inc of End Stage Renal Disease Network 6, Raleigh, North Carolina
| | - Leighann Sauls
- Southeastern Kidney Council Inc of End Stage Renal Disease Network 6, Raleigh, North Carolina
| | - Eric M Gibney
- Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, Georgia
| | - Laura Mulloy
- Division of Nephrology, Department of Medicine, Georgia Regents University, Augusta
| | - Stephen O Pastan
- Emory Transplant Center, Atlanta, Georgia4Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Vanholder R, Lameire N, Annemans L, Van Biesen W. Cost of renal replacement: how to help as many as possible while keeping expenses reasonable? Nephrol Dial Transplant 2015; 31:1251-61. [PMID: 26109485 DOI: 10.1093/ndt/gfv233] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 05/12/2015] [Indexed: 02/06/2023] Open
Abstract
The treatment of kidney diseases consumes a substantial amount of the health budget for a relatively small fraction of the overall population. If the nephrological community and society do not develop mechanisms to contain those costs, it will become impossible to continue assuring optimal outcomes and quality of life while treating all patients who need it. In this article, we describe several mechanisms to maintain sustainability of renal replacement therapy. These include (i) encouragement of transplantation after both living and deceased donation; (ii) stimulation of alternative dialysis strategies besides classical hospital haemodialysis, such as home haemodialysis, peritoneal dialysis or self-care and necessitating less reimbursement; (iii) promotion of educational activities guiding the patients towards therapies that are most suited for them; (iv) consideration of one or more of cost containment incentives such as bundling of reimbursement (if not affecting quality of the treatment), timely patient referral, green dialysis, start of dialysis based on clinical necessity rather than renal function parameters and/or prevention of CKD or its progression; (v) strategically planned adaptations to the expected growth of the ageing population in need of renal replacement; (vi) the necessity for support of research in the direction of helping as large as possible patient populations for acceptable costs; and (vii) the need for more patient-centred approaches. We also extend the discussion to the specific situation of kidney diseases in low- and middle-income countries. Finally, we point to the dramatic differences in accessibility and reimbursement of different modalities throughout Europe. We hope that this text will offer a framework for the nephrological community, including patients and nurses, and the concerned policy makers and caregivers on how to continue reaching all patients in need of renal replacement for affordable expenses.
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Affiliation(s)
- Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Ghent, Belgium
| | - Norbert Lameire
- Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Ghent, Belgium
| | - Lieven Annemans
- Department of Public Health, University Ghent, Ghent, Belgium
| | - Wim Van Biesen
- Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Ghent, Belgium
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Beuscart JB, Pagniez D, Boulanger E, Duhamel A. Registration on the renal transplantation waiting list and mortality on dialysis: an analysis of the French REIN registry using a multi-state model. J Epidemiol 2014; 25:133-41. [PMID: 25721069 PMCID: PMC4310874 DOI: 10.2188/jea.je20130193] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Access to the renal transplantation (RT) waiting list depends on factors related to lower mortality rates and often occurs after dialysis initiation. The aim of the study was to use a flexible regression model to determine if registration on the RT waiting list is associated with mortality on dialysis, independent of the comorbidities associated with such registration. METHODS Data from the French REIN registry on 7138 incident hemodialysis (HD) patients were analyzed. A multi-state model including four states ('HD, not wait-listed', 'HD, wait-listed', 'death', and 'RT') was used to estimate the effect of being wait-listed on the probability of death. RESULTS During the study, 1392 (19.5%) patients were wait-listed. Of the 2954 deaths observed in the entire cohort during follow-up, 2921 (98.9%) were observed in the not wait-listed group compared with only 33 (1.1%) in the wait-listed group. In the multivariable analysis, the adjusted hazard ratio for death associated with non-registration on the waiting list was 3.52 (95% CI, 1.70-7.30). The risk factors for death identified for not wait-listed patients were not found to be significant risk factors for wait-listed patients, with the exception of age. CONCLUSIONS The use of a multi-state model allowed a flexible analysis of mortality on dialysis. Patients who were not wait-listed had a much higher risk of death, regardless of co-morbidities associated with being wait-listed, and did not share the same risk factors of death as wait-listed patients. Registration on the waiting list should therefore be taken into account in survival analysis of patients on dialysis.
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Sex-specific differences in hemodialysis prevalence and practices and the male-to-female mortality rate: the Dialysis Outcomes and Practice Patterns Study (DOPPS). PLoS Med 2014; 11:e1001750. [PMID: 25350533 PMCID: PMC4211675 DOI: 10.1371/journal.pmed.1001750] [Citation(s) in RCA: 158] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 09/18/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND A comprehensive analysis of sex-specific differences in the characteristics, treatment, and outcomes of individuals with end-stage renal disease undergoing dialysis might reveal treatment inequalities and targets to improve sex-specific patient care. Here we describe hemodialysis prevalence and patient characteristics by sex, compare the adult male-to-female mortality rate with data from the general population, and evaluate sex interactions with mortality. METHODS AND FINDINGS We assessed the Human Mortality Database and 206,374 patients receiving hemodialysis from 12 countries (Australia, Belgium, Canada, France, Germany, Italy, Japan, New Zealand, Spain, Sweden, the UK, and the US) participating in the international, prospective Dialysis Outcomes and Practice Patterns Study (DOPPS) between June 1996 and March 2012. Among 35,964 sampled DOPPS patients with full data collection, we studied patient characteristics (descriptively) and mortality (via Cox regression) by sex. In all age groups, more men than women were on hemodialysis (59% versus 41% overall), with large differences observed between countries. The average estimated glomerular filtration rate at hemodialysis initiation was higher in men than women. The male-to-female mortality rate ratio in the general population varied from 1.5 to 2.6 for age groups <75 y, but in hemodialysis patients was close to one. Compared to women, men were younger (mean = 61.9 ± standard deviation 14.6 versus 63.1 ± 14.5 y), were less frequently obese, were more frequently married and recipients of a kidney transplant, more frequently had coronary artery disease, and were less frequently depressed. Interaction analyses showed that the mortality risk associated with several comorbidities and hemodialysis catheter use was lower for men (hazard ratio [HR] = 1.11) than women (HR = 1.33, interaction p<0.001). This study is limited by its inability to establish causality for the observed sex-specific differences and does not provide information about patients not treated with dialysis or dying prior to a planned start of dialysis. CONCLUSIONS Women's survival advantage was markedly diminished in hemodialysis patients. The finding that fewer women than men were being treated with dialysis for end-stage renal disease merits detailed further study, as the large discrepancies in sex-specific hemodialysis prevalence by country and age group are likely explained by factors beyond biology. Modifiable variables, such as catheter use, showing significant sex interactions suggest interventional targeting. Please see later in the article for the Editors' Summary.
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Salter ML, Gupta N, King E, Bandeen-Roche K, Law AH, McAdams-DeMarco MA, Meoni LA, Jaar BG, Sozio SM, Kao WHL, Parekh RS, Segev DL. Health-related and psychosocial concerns about transplantation among patients initiating dialysis. Clin J Am Soc Nephrol 2014; 9:1940-8. [PMID: 25212908 DOI: 10.2215/cjn.03310414] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND OBJECTIVES Disparities in kidney transplantation remain; one mechanism for disparities in access to transplantation (ATT) may be patient-perceived concerns about pursuing transplantation. This study sought to characterize prevalence of patient-perceived concerns, explore interrelationships between concerns, determine patient characteristics associated with concerns, and assess the effect of concerns on ATT. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Prevalences of 12 patient-perceived concerns about pursuing transplantation were determined among 348 adults who recently initiated dialysis, recruited from 26 free-standing dialysis centers around Baltimore, Maryland (January 2009-March 2012). Using variable reduction techniques, concerns were clustered into two categories (health-related and psychosocial) and quantified with scale scores. Associations between patient characteristics and concerns were estimated using modified Poisson regression. Associations between concerns and ATT were estimated using Cox models. RESULTS The most frequently cited patient-perceived concerns were that participants felt they were doing fine on dialysis (68.4%) and felt uncomfortable asking someone to donate a kidney (29.9%). Older age was independently associated with having high health-related (adjusted relative risk, 1.35 [95% confidence interval, 1.20 to 1.51], for every 5 years older for those ≥ 60 years) or psychosocial (1.15 [1.00 to 1.31], for every 5 years older for those aged ≥ 60 years) concerns, as was being a woman (1.72 [1.21 to 2.43] and 1.55 [1.09 to 2.20]), having less education (1.59 [1.08 to 2.35] and 1.77 [1.17 to 2.68], comparing postsecondary education to grade school or less), and having more comorbidities (1.18 [1.08 to 1.30] and 1.18 [1.07 to 1.29], per one comorbidity increase). Having never seen a nephrologist before dialysis initiation was associated with high psychosocial concerns (1.48 [1.01 to 2.18]). Those with high health-related (0.37 [0.16 to 0.87]) or psychosocial (0.47 [0.23 to 0.95]) concerns were less likely to achieve ATT (median follow-up time 2.2 years; interquartile range, 1.6-3.2). CONCLUSIONS Patient-perceived concerns about pursuing kidney transplantation are highly prevalent, particularly among older adults and women. Reducing these concerns may help decrease disparities in ATT.
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Affiliation(s)
- Megan L Salter
- Departments of Epidemiology and Johns Hopkins Center on Aging and Health, Baltimore, Maryland
| | | | | | - Karen Bandeen-Roche
- Johns Hopkins Center on Aging and Health, Baltimore, Maryland; Biostatistics, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Andrew H Law
- Departments of Epidemiology and Departments of Surgery and
| | | | - Lucy A Meoni
- Biostatistics, Johns Hopkins School of Public Health, Baltimore, Maryland; Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland
| | - Bernard G Jaar
- Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland; Nephrology Center of Maryland, Baltimore, Maryland
| | - Stephen M Sozio
- Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland
| | - Wen Hong Linda Kao
- Departments of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland
| | - Rulan S Parekh
- Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Nephrology, Hospital for Sick Children, University Health Network, Toronto, Ontario, Canada; and Departments of Pediatrics and Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Dorry L Segev
- Departments of Epidemiology and Departments of Surgery and
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Shen C, Shih YCT, Xu Y, Yao JC. Octreotide long-acting repeatable use among elderly patients with carcinoid syndrome and survival outcomes: a population-based analysis. Cancer 2014; 120:2039-49. [PMID: 24676892 DOI: 10.1002/cncr.28653] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 02/05/2014] [Accepted: 02/17/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND Octreotide long-acting repeatable (LAR) is indicated for the treatment of carcinoid syndrome and diarrhea related to VIPoma, and may delay tumor growth in patients with neuroendocrine tumors (NETs). To the authors' knowledge, the pattern of octreotide LAR use in clinical practice and its impact on survival outcomes has not been well documented. METHODS Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, the authors identified patients with NET aged ≥ 65 years who were diagnosed between July 1999 and December 2007. Patients with US Food and Drug Administration-approved indications for octreotide LAR were identified from Medicare claims. Multivariate logistic regression was performed to ascertain factors associated with octreotide LAR use, whereas the Cox proportional hazards model was used to evaluate the impact of octreotide LAR on survival. RESULTS Among those with Food and Drug Administration-approved indications, 245 of 4848 patients with distant-stage disease (51%) and 81 of 807 patients with local/regional disease (10%) initiated treatment with octreotide LAR within 6 months of diagnosis. Multivariate logistic regression indicated that among those with distant-stage disease, older age (≥ 80 years vs 65-69 years) (odds ratio [OR], 0.43; 95% confidence interval [95% CI], 0.23-0.81), female sex (OR, 0.62; 95% CI, 0.40-0.97), and living in the South (vs Northeast) (OR, 0.36; 95% CI, 0.18-0.72) were associated with a lower likelihood of using octreotide LAR. The multivariate proportional hazards model showed that octreotide LAR provided a significant 5-year survival benefit for patients with distant-stage disease (hazards ratio, 0.61; P ≤ .001), whereas this survival benefit was not shown for the patients with local/regional stage (hazards ratio, 0.88; P = .563). CONCLUSIONS The results of this retrospective study suggest a possible survival benefit for the use of octreotide LAR in elderly patients with distant-stage NET with carcinoid syndrome. The results of the current study also suggest that octreotide LAR is underused in this population despite recommended guidelines.
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Affiliation(s)
- Chan Shen
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Hogan J, Savoye E, Macher MA, Bachetta J, Garaix F, Lahoche A, Ulinski T, Harambat J, Couchoud C. Rapid access to renal transplant waiting list in children: impact of patient and centre characteristics in France. Nephrol Dial Transplant 2014; 29:1973-9. [DOI: 10.1093/ndt/gfu220] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Salter ML, McAdams-Demarco MA, Law A, Kamil RJ, Meoni LA, Jaar BG, Sozio SM, Kao WHL, Parekh RS, Segev DL. Age and sex disparities in discussions about kidney transplantation in adults undergoing dialysis. J Am Geriatr Soc 2014; 62:843-9. [PMID: 24801541 PMCID: PMC4024077 DOI: 10.1111/jgs.12801] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To explore whether disparities in age and sex in access to kidney transplantation (KT) originate at the time of prereferral discussions about KT. DESIGN Cross-sectional survey. SETTING Outpatient dialysis centers in Maryland (n = 26). PARTICIPANTS Individuals who had recently initiated hemodialysis treatment (N = 416). MEASUREMENTS Participants reported whether medical professionals (nephrologist, primary medical doctor, dialysis staff) and social group members (significant other, family member, friend) discussed KT with them and, when applicable, rated the tone of discussions. Relative risks were estimated using modified Poisson regression. RESULTS Participants aged 65 and older were much less likely than those who were younger to have had discussions with medical professionals (44.5% vs 74.8%, P < .001) or social group members (47.3% vs 63.1%, P = .005). Irrespective of sex and independent of race, health-related factors, and dialysis-related characteristics, older adults were more likely not to have had discussions with medical professionals (relative risk (RR) = 1.13, 95% confidence interval (CI) = 1.03-1.24, for each 5-year increase in age through 65; RR = 1.28, 95% CI = 1.14-1.42, for each 5-year increase in age beyond 65). Irrespective of age, women were more likely (RR = 1.45, 95% CI = 1.12-1.89) not to have had discussions with medical professionals. For each 5-year increase in age, men (RR = 1.04, 95% CI = 0.99-1.10) and women (RR = 1.17, 95% CI = 1.10-1.24) were more likely not to have discussions with social group members. Of those who had discussions with medical professionals or social group members, older participants described these discussions as less encouraging (all P < .01). CONCLUSION Older adults and women undergoing hemodialysis are less likely than younger adults and men to have discussions about KT as a treatment option, supporting a need for better clinical guidelines and education for these individuals, their social network, and their providers.
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Affiliation(s)
- Megan L Salter
- Department of Epidemiology, School of Public Health, Johns Hopkins University, Baltimore, Maryland; Center on Aging and Health, Johns Hopkins University, Baltimore, Maryland
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Akolekar D, Forsythe JLR, Oniscu GC. Impact of patient characteristics and comorbidity profile on activation of patients on the kidney transplantation waiting list. Transplant Proc 2014; 45:2115-22. [PMID: 23953520 DOI: 10.1016/j.transproceed.2013.03.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 03/06/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of this study was to examine which demographic and comorbidity factors affected the activation of patients with end-stage renal disease on the national kidney transplantation waiting list. METHODS This was a prospective cohort study across 13 transplantation centers in the United Kingdom from October 1, 2006 to September 30, 2007. Data were collected for all new adult patients (n = 1530) referred to the renal transplantation assessment clinic. The proportion of patients who were activated to the waiting list after a minimum one year follow-up was estimated. Factors influencing activation of patients on the waiting list were examined. RESULTS A total of 872 (58.9%) patients were activated to the transplantation waiting list. The likelihood of activation to the transplantation waiting list was lower in patients older than 65 years (P = .021), nonwhite ethnicity (P < .0001), smokers (P < .0001), and those in whom diabetes was the cause of renal failure (P = .004). Multivariate analysis showed that there was an adverse impact of comorbidity such as ischemic heart disease (P = .003), diabetes (P = .006), and peripheral vascular disease (P = .007) on the likelihood of activation to the waiting list. CONCLUSION Patient characteristics and comorbidity are associated with the probability of activation of patients to the waiting list.
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Affiliation(s)
- D Akolekar
- Transplant Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, United Kingdom
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Harambat J, van Stralen KJ, Verrina E, Groothoff JW, Schaefer F, Jager KJ. Likelihood of children with end-stage kidney disease in Europe to live with a functioning kidney transplant is mainly explained by nonmedical factors. Pediatr Nephrol 2014; 29:453-9. [PMID: 24232194 DOI: 10.1007/s00467-013-2665-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 09/30/2013] [Accepted: 10/11/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Registry data can be used to assess associations between medical and health-policy factors and the likelihood of children on renal replacement therapy (RRT) to live with a functioning kidney transplant in Europe. METHODS A survey questionnaire was distributed among renal registry representatives in 38 European countries, and additional data was obtained from the European Society for Pediatric Nephrology/European Renal Association-European Dialysis and Transplant Association (ESPN/ERA-EDTA) registry. RESULTS Thirty-two countries with a pediatric RRT program responded. The median percentage of children by country on RRT with a functioning transplant was 62 % (interquartile range 39-77). One per million population increase in donation rate from deceased donors was associated with a 5 % increase in the percentage of functioning transplants; the existence of an intermediate and high pediatric priority policy doubled and tripled this percentage, respectively, compared with no priority, whereas an increase in living donor pediatric kidney transplant rate of one per million children was associated with a 14 % higher percentage of functioning transplants. The percentage of functioning transplants was also strongly associated with the gross domestic product (GDP). CONCLUSION Considerable variations exist in the percentages of prevalent pediatric RRT populations with functioning renal transplants across Europe. A macroeconomic indicator such as GDP is the most important determinant of these international differences. Efforts should be made for living donation programs and pediatric allocation priority to increase access to kidney transplantation for children.
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Harambat J, van Stralen KJ, Schaefer F, Grenda R, Jankauskiene A, Kostic M, Macher MA, Maxwell H, Puretic Z, Raes A, Rubik J, Sørensen SS, Toots U, Topaloglu R, Tönshoff B, Verrina E, Jager KJ. Disparities in policies, practices and rates of pediatric kidney transplantation in Europe. Am J Transplant 2013; 13:2066-74. [PMID: 23718940 DOI: 10.1111/ajt.12288] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 04/03/2013] [Accepted: 04/04/2013] [Indexed: 01/25/2023]
Abstract
We aimed to provide an overview of kidney allocation policies related to children and pediatric kidney transplantation (KTx) practices and rates in Europe, and to study factors associated with KTx rates. A survey was distributed among renal registry representatives in 38 European countries. Additional data were obtained from the ESPN/ERA-EDTA and ERA-EDTA registries. Thirty-two countries (84%) responded. The median incidence rate of pediatric KTx was 5.7 (range 0-13.5) per million children (pmc). A median proportion of 17% (interquartile range 2-29) of KTx was performed preemptively, while the median proportion of living donor KTx was 43% (interquartile range 10-52). The median percentage of children on renal replacement therapy (RRT) with a functioning graft was 62%. The level of pediatric prioritization was associated with a decreased waiting time for deceased donor KTx, an increased pediatric KTx rate, and a lower proportion of living donor KTx. The rates of pediatric KTx, distribution of donor source and time on waiting list vary considerably between European countries. The lack of harmonization in kidney allocation to children raises medical and ethical issues. Harmonization of pediatric allocation policies should be prioritized.
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Affiliation(s)
- J Harambat
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands.
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Sandhu GS, Khattak M, Pavlakis M, Woodward R, Hanto DW, Wasilewski MA, Dimitri N, Goldfarb-Rumyantzev A. Recipient's unemployment restricts access to renal transplantation. Clin Transplant 2013; 27:598-606. [PMID: 23808849 DOI: 10.1111/ctr.12177] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2013] [Indexed: 01/06/2023]
Abstract
Equitable distribution of a scarce resource such as kidneys for transplantation can be a challenging task for transplant centers. In this study, we evaluated the association between recipient's employment status and access to renal transplantation in patients with end-stage renal disease (ESRD). We used data from the United States Renal Data System (USRDS). The primary variable of interest was employment status at ESRD onset. Two outcomes were analyzed in Cox model: (i) being placed on the waiting list for renal transplantation or being transplanted (whichever occurred first); and (ii) first transplant in patients who were placed on the waiting list. We analyzed 429 409 patients (age of ESRD onset 64.2 ± 15.2 yr, 55.0% males, 65.1% White). Compared with patients who were unemployed, patients working full time were more likely to be placed on the waiting list/transplanted (HR 2.24, p < 0.001) and to receive a transplant once on the waiting list (HR 1.65, p < 0.001). Results indicate that recipient's employment status is strongly associated with access to renal transplantation, with unemployed and partially employed patients at a disadvantage. Adding insurance status to the model reduces the effect size, but the association still remains significant, indicating additional contribution from other factors.
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Affiliation(s)
- Gurprataap S Sandhu
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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A New Approach for Measuring Gender Disparity in Access to Renal Transplantation Waiting Lists. Transplantation 2012; 94:513-9. [DOI: 10.1097/tp.0b013e31825d156a] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Patibandla BK, Narra A, DeSilva R, Chawla V, Goldfarb-Rumyantzev AS. Access to renal transplantation in the diabetic population-effect of comorbidities and body mass index. Clin Transplant 2012; 26:E307-15. [PMID: 22686955 PMCID: PMC3756087 DOI: 10.1111/j.1399-0012.2012.01661.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND In this study, we hypothesized that higher level of comorbidity and greater body mass index (BMI) may mediate the association between diabetes and access to transplantation. METHODS We used data from the United States Renal Data System (01/01/2000-24/09/2007; n = 619,151). We analyzed two outcomes using Cox model: (i) time to being placed on the waiting list or transplantation without being listed and (ii) time to transplantation after being listed. Two primary Cox models were developed based on different levels of adjustment. RESULTS In Cox models adjusted for a priori defined potential confounders, history of diabetes was associated with reduced transplant access (compared with non-diabetic population) - both for wait-listing/transplant without being listed (hazard ratio, HR = 0.80, p < 0.001) and for transplant after being listed (HR = 0.72, p < 0.001). In Cox models adjusted for BMI and comorbidity index along with the potential confounders, history of diabetes was associated with shorter time to wait-listing or transplantation without being listed (HR = 1.07, p < 0.001), and there was no significant difference in time to transplantation after being listed (HR = 1.01, p = 0.42). CONCLUSION We demonstrated that higher level of comorbidity and greater BMI mediate the association between diabetes and reduced access to transplantation.
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Affiliation(s)
- Bhanu K Patibandla
- Division of Nephrology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA.
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Kucirka LM, Grams ME, Balhara KS, Jaar BG, Segev DL. Disparities in provision of transplant information affect access to kidney transplantation. Am J Transplant 2012; 12:351-7. [PMID: 22151011 DOI: 10.1111/j.1600-6143.2011.03865.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Recently Centers for Medicare and Medicaid Services (CMS) began asking providers on Form-2728 whether they informed patients about transplantation, and if not, to select a reason. The goals of this study were to describe national transplant education practices and analyze associations between practices and access to transplantation (ATT), based on United States Renal Data System (USRDS) data from 2005 to 2007. Multinomial logistic regression was used to examine factors associated with not being informed about transplantation, and modified Poisson regression to examine associations between not being informed and ATT (all models adjusted for demographics/comorbidities). Of 236,079 incident end-stage renal disease (ESRD) patients, 30.1% were not informed at time of 2728 filing, for reasons reported by providers as follows: 42.1% unassessed, 30.4% medically unfit, 16.9% unsuitable due to age, 3.1% psychologically unfit and 1.5% declined counsel. Older, obese, uninsured, Medicaid-insured and patients at for-profit centers were more likely to be unassessed. Women were more likely to be reported as unsuitable due to age, medically unfit and declined, and African Americans as psychologically unfit. Uninformed patients had a 53% lower rate of ATT, a disparity persisting in the subgroup of uninformed patients who were unassessed. Disparities in ATT may be partially explained by disparities in provision of transplant information; dialysis centers should ensure this critical intervention is offered equitably.
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Affiliation(s)
- L M Kucirka
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Wong G, Howard K, Chapman JR, Chadban S, Cross N, Tong A, Webster AC, Craig JC. Comparative survival and economic benefits of deceased donor kidney transplantation and dialysis in people with varying ages and co-morbidities. PLoS One 2012; 7:e29591. [PMID: 22279541 PMCID: PMC3261160 DOI: 10.1371/journal.pone.0029591] [Citation(s) in RCA: 136] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Accepted: 11/30/2011] [Indexed: 11/18/2022] Open
Abstract
Background Deceased donor kidneys for transplantation are in most countries allocated preferentially to recipients who have limited co-morbidities. Little is known about the incremental health and economic gain from transplanting those with co-morbidities compared to remaining on dialysis. The aim of our study is to estimate the average and incremental survival benefits and health care costs of listing and transplantation compared to dialysis among individuals with varying co-morbidities. Methods A probabilistic Markov model was constructed, using current outcomes for patients with defined co-morbidities treated with either dialysis or transplantation, to compare the health and economic benefits of listing and transplantation with dialysis. Findings Using the current waiting time for deceased donor transplantation, transplanting a potential recipient, with or without co-morbidities achieves survival gains of between 6 months and more than three life years compared to remaining on dialysis, with an average incremental cost-effectiveness ratio (ICER) of less than $50,000/LYS, even among those with advanced age. Age at listing and the waiting time for transplantation are the most influential variables within the model. If there were an unlimited supply of organs and no waiting time, transplanting the younger and healthier individuals saves the most number of life years and is cost-saving, whereas transplanting the middle-age to older patients still achieves substantial incremental gains in life expectancy compared to being on dialysis. Conclusions Our modelled analyses suggest transplanting the younger and healthier individuals with end-stage kidney disease maximises survival gains and saves money. Listing and transplanting those with considerable co-morbidities is also cost-effective and achieves substantial survival gains compared with the dialysis alternative. Preferentially excluding the older and sicker individuals cannot be justified on utilitarian grounds.
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Affiliation(s)
- Germaine Wong
- Centre for Kidney Research, Children's Hospital at Westmead, Westmead, Australia.
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Mathur AK, Schaubel DE, Gong Q, Guidinger MK, Merion RM. Sex-based disparities in liver transplant rates in the United States. Am J Transplant 2011; 11:1435-43. [PMID: 21718440 PMCID: PMC3132137 DOI: 10.1111/j.1600-6143.2011.03498.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We sought to characterize sex-based differences in access to deceased donor liver transplantation. Scientific Registry of Transplant Recipients data were used to analyze n = 78 998 adult candidates listed before (8/1997-2/2002) or after (2/2002-2/2007) implementation of Model for End-Stage Liver Disease (MELD)-based liver allocation. The primary outcome was deceased donor liver transplantation. Cox regression was used to estimate covariate-adjusted differences in transplant rates by sex. Females represented 38% of listed patients in the pre-MELD era and 35% in the MELD era. Females had significantly lower covariate-adjusted transplant rates in the pre-MELD era (by 9%; p < 0.0001) and in the MELD era (by 14%; p < 0.0001). In the MELD era, the disparity in transplant rate for females increased as waiting list mortality risk increased, particularly for MELD scores ≥15. Substantial geographic variation in sex-based differences in transplant rates was observed. Some areas of the United States had more than a 30% lower covariate-adjusted transplant rate for females compared to males in the MELD era. In conclusion, the disparity in liver transplant rates between females and males has increased in the MELD era. It is especially troubling that the disparity is magnified among patients with high MELD scores and in certain regions of the United States.
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Affiliation(s)
- A K Mathur
- Division of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
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Abstract
Kidney transplantation is the treatment of choice for the majority of pediatric patients with end-stage kidney disease. Previous studies demonstrating racial or gender disparities in access to the deceased donor transplant list could not evaluate the impact of medical concerns or patient preference on waitlist status. We undertook a retrospective cohort study using the NAPRTCS registry to begin to determine barriers to wait list registration for kidney transplantation among pediatric dialysis patients. Clinical and demographic factors were compared in listed vs. non-listed patients. Reasons cited for not listing patients were examined by clinical and demographic factors. At dialysis initiation, 88.7% of pediatric dialysis patients were not on the renal transplant wait list. Twelve months after dialysis initiation, 67.1% of pediatric dialysis patients were not on the wait list. The groups least likely to be on the wait list were infants (adjusted OR 0.23, 95% CI 0.16, 0.32) and girls (adjusted OR 0.78, 95% CI 0.67, 0.90) after adjusting for multiple confounders. The reason most often cited for not listing was medical reason for young infants and that the transplant workup was pending for girls. Further study is needed to identify barriers to wait list registration.
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Machado EL, Caiaffa WT, César CC, Gomes IC, Andrade EIG, Acúrcio FDA, Cherchiglia ML. Iniquities in the access to renal transplant for patients with end-stage chronic renal disease in Brazil. CAD SAUDE PUBLICA 2011; 27 Suppl 2:S284-97. [DOI: 10.1590/s0102-311x2011001400015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2010] [Accepted: 09/10/2010] [Indexed: 11/21/2022] Open
Abstract
The objective of this present study is to analyze individual and contextual factors associated with access to renal transplant in Brazil. An observational, prospective and non-concurrent study was carried out, based on data from the National Database on renal replacement therapies in Brazil. Patients undergoing dialysis between 01/Jan/2000 and 31/Dec/2000 were included and monitored up to the point of transplant, death or until the end of the study period. Variables that were analyzed included: individual variables (age, sex, region of residence, primary renal disease, hospitalizations); and context variables concerning both the dialysis unit (level of complexity, juridical nature, hemodialysis machines and location) and the city (geographic region, location and HDI). Proportional hazard models were adjusted with hierarchical entry to identify factors associated with the risk of transplant. The results point to differentials in access according to socio-demographic, clinical, geographic and social factors, indicating that the organ allocation system has not eliminated avoidable disparities for those who compete for an organ in the nationwide waiting list.
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The Effect of Race, Sex, and Insurance Status on Time-to-Listing Decisions for Liver Transplantation. J Transplant 2010; 2010:467976. [PMID: 21234099 PMCID: PMC3014672 DOI: 10.1155/2010/467976] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Revised: 08/13/2010] [Accepted: 09/23/2010] [Indexed: 12/13/2022] Open
Abstract
Fair allocation of organs to candidates listed for transplantation is fundamental to organ-donation policies. Processes leading to listing decisions are neither regulated nor understood. We explored whether patient characteristics affected timeliness of listing using population-based data on 144,507 adults hospitalized with liver-related disease in Pennsylvania. We linked hospitalizations to other secondary data and found 3,071 listed for transplants, 1,537 received transplants, and 57,020 died. Among candidates, 61% (n = 1,879) and 85.5% (n = 2,626) were listed within 1 and 3 years of diagnosis; 26.7% (n = 1,130) and 95% (n = 1,468) of recipients were transplanted within 1 and 3 years of listing. Using competing-risks models, we found few overall differences by sex, but both black patients and those insured by Medicare and Medicaid (combined) waited longer before being listed. Patients with combined Medicare and Medicaid insurance, as well as those with Medicaid alone, were also more likely to die without ever being listed. Once listed, the time to transplant was slightly longer for women, but it did not differ by race/ethnicity or insurance. The early time period from diagnosis to listing for liver transplantation reveals unwanted variation related to demographics that jeopardizes overall fairness of organ allocation and needs to be further explored.
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Intermediate-Term Outcomes Associated With Kidney Transplantation in Recipients 80 Years and Older: An Analysis of the OPTN/UNOS Database. Transplantation 2010; 90:974-9. [DOI: 10.1097/tp.0b013e3181f5c3bf] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kianda MN, Wissing KM, Broeders NE, Lemy A, Ghisdal L, Hoang AD, Mikhalski D, Donckier V, Vereerstraeten P, Abramowicz D. Ineligibility for renal transplantation: prevalence, causes and survival in a consecutive cohort of 445 patients. Clin Transplant 2010; 25:576-83. [PMID: 20718825 DOI: 10.1111/j.1399-0012.2010.01317.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Little is known about the proportion of renal transplant candidates who are considered ineligible by the transplant center, the reasons of their ineligibility and their survival during dialysis. In this retrospective, single-center study of 445 adult patients referred between 2001 and 2006, 36 (8%) were deemed ineligible for medical contraindications. The leading reason was cardiovascular (CV) (75%), specifically aorto-iliac, and/or limb vessels atheromatosis or calcifications; ischemic heart disease; or a combination thereof. Nine patients had other contraindications that were absolute for three of them; six patients displayed a combination of relative contraindications. When compared to eligible patients (N = 409), those ineligible were significantly older (60 yr vs. 48), more often diabetics (50% vs. 15%), obese (39% vs. 17%) suffering from coronary artery disease (53% vs. 11%) and peripheral arterial disease (86% vs. 11%). Their primary nephropathy was more often diabetic and/or hypertensive/nephroangiosclerosis (61% vs. 23%), and their median dialysis vintage prior to evaluation was longer (29 months vs. 10, p < 0.0001). The actuarial survival of ineligible patients was significantly lower than that of eligible patients (at five yr: 53% vs. 88%). Adequate control of CV risk factors before dialysis and early referral for transplantation might help to improve eligibility of renal transplant candidates.
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Affiliation(s)
- Mireille N Kianda
- Renal Transplantation Clinic, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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Ravanan R, Udayaraj U, Ansell D, Collett D, Johnson R, O'Neill J, Tomson CRV, Dudley CRK. Variation between centres in access to renal transplantation in UK: longitudinal cohort study. BMJ 2010; 341:c3451. [PMID: 20647283 PMCID: PMC2907479 DOI: 10.1136/bmj.c3451] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess whether equity exists in access to renal transplantation in the UK after adjustment for case mix in incident patients with end stage renal disease. DESIGN Longitudinal cohort study. SETTING UK Renal Registry and UK Transplant Registry. PARTICIPANTS All incident renal replacement treatment patients (n=16 202) from 65 renal centres submitting data to the UK Renal Registry between 1 January 2003 and 31 December 2005, followed until 31 December 2008 (or until transplantation or death, whichever was earliest). OUTCOME MEASURES Proportion of incident dialysis patients at each renal centre who were registered on the national transplant list; time taken to achieve registration; and proportion of patients subsequently transplanted. RESULTS We found that recipients' age, ethnicity, and primary renal diagnosis were associated with the likelihood of accessing the waiting list or receiving a transplant. After adjustment for case mix, significant inter-centre variability existed in access to the transplant list (change in -2LogL=89.9, df=1, P<0.001), in the time taken to register patients on the waiting list (change in -2LogL=247.4, df=64, P<0.001), in receipt of a renal transplant from a donor after brain stem death (change in -2LogL=15.1, df=1, P=0.001), and in receipt of a renal transplant from a living donor or a donor after cardiac death (change in -2LogL=46.1, df=1, P<0.001). CONCLUSIONS Significant variation in access to renal transplantation exists between centres within the UK that cannot be explained by differences in case mix.
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Affiliation(s)
- R Ravanan
- Richard Bright Renal Unit, Southmead Hospital, Bristol BS10 5NB.
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