Living Donor Kidney Transplantation: Overcoming Disparities in Live Kidney Donation in the US--Recommendations from a Consensus Conference

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

"Weighing the Pros and Cons of Everything": A Qualitative Descriptive Study Exploring Perspectives About Living Donor Kidney Transplantation From Parents of Chinese Canadian Pediatric Patients With Chronic Kidney Disease

Background

As of 2021, more than 6000 children and youth in Canada were living with end-stage kidney disease (ESKD), for which kidney transplantation is considered the preferred treatment by health professionals. Research shows that living donor kidney transplantation (LDKT) has superior allograft and recipient survival compared to deceased donor kidney transplantation (DDKT). However, in a pediatric setting, the choice of LDKT or DDKT is a summative consideration of factors weighed carefully by the patient's family, health care team, and patient. Decision-making surrounding transplantation may be more complex for racial and ethnic minorities as culturally specific values and beliefs are interwoven within dominant understandings and concepts of health and accepted models of health care. For example, Chinese Canadians have an increased risk of ESKD, yet reduced access to LDKT compared to White patients, despite being the largest visible minority population in Canada.

Objective

The objective of this qualitative study is to deepen our understandings of the decision-making process surrounding DDKT versus LDKT among parents of Chinese Canadian pediatric patients with chronic kidney disease (CKD).

Design

Qualitative descriptive study design.

Setting

The Nephrology Program at The Hospital for Sick Children in Toronto, Canada.

Participants

Caregivers of Chinese Canadian patients with CKD, 18 years of age or older, and who spoke English, Cantonese, or Mandarin.

Methods

One-on-one, semistructured interviews were conducted virtually, by a member of the research team and were audio-recorded and transcribed verbatim. Thematic analysis was used to explore participants' shared experience.

Results

Seven interviews were conducted with 6 mothers and 1 father of 6 Chinese Canadian pediatric patients with CKD: 4 patients had undergone a kidney transplant, and 2 were not yet listed for transplant. Analysis of data highlighted that cultural influences affected whether parents shared with others about their child's illness and experience. The cultural understanding that it is inappropriate to burden others contributed to the creation of an isolating experience for participants. Cultural influences also impacted whether parents asked others to be a living donor as participants articulated this would place a physical burden on the living donor (e.g., potential risk to their health) and an emotional burden on the participant as they would be indebted to a willing donor. Ultimately, parents' decision to choose DDKT or LDKT for their patient-child was a result of evaluating both options carefully and within an understanding that the ideal treatment choice reflected what was best for all family members.

Limitations

Findings reflect experiences of a small sample from a single recruitment site which may limit transferability.

Conclusions

Parents in this study felt that they had access to the necessary evidence-based information to make an informed decision about the choice of DDKT versus LDKT for their child. Participant narratives described feeling isolated within cultural communities of family and friends and participants' suggestion of benefiting from increased support may guide future research directions. Practitioners can offer direct and indirect support to families, with recognition of the importance of cultural values and family-centered care on decision-making within families. Opportunities are needed for accessible, virtual social support platforms to increase parental feelings of culturally mediated peer support from parents who share similar experiences.

Experiences of living kidney donors: A synthesis of unsolicited patient narratives

INTRODUCTION

Despite the lauded benefits of living kidney donation, there is growing evidence of the challenges that living kidney donors (LKD) encounter in their donation trajectory and gaps in healthcare service provision. However, most of the evidence is derived from research conducted by clinicians or academic investigators. Significantly less attention has been devoted to analyzing unsolicited accounts of LKDs' experiences.

METHODS

We conducted a review and synthesis of published unsolicited first-person narratives of LKDs and aimed to synthesize their experiences and identify care needs. Four electronic databases were searched and 27 LKD narratives were included in our final analysis. Thematic synthesis was used to generate themes inductively.

RESULTS

Although the majority of LKDs reported the act of donation to be a fulfilling experience, almost 48% reported encountering challenges in the care that they received. Also, 29% of LKDs reported experiencing an adverse clinical event. Five distinct themes emerged surrounding the donation experience and healthcare needs: 1) Educational needs due to perceived lack of transparency and compensating for knowledge gaps; 2) Respect for donor autonomy due to coercive influences from family or healthcare providers, lack of respect for donor preferences and loopholes in the consent process; 3) Unmet care needs related to poor communication with healthcare providers, coordination issues and inconsistent and inadequate long-term care; 4) Unanticipated outcomes due to economic costs and the emotional burden of donation; and 5) Contributing beyond the donation event by advocating for a balanced view of donation and generating support mechanisms.

CONCLUSION

In this synthesis of LKDs narratives, important care gaps and the need to advocate for a balanced perspective on living kidney donation were highlighted. Our review underscores the value of patients' own stories as critical evidence that can inform improvement in healthcare service delivery.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Temporal trends in kidney paired donation in the United States: 2006-2021 UNOS/OPTN database analysis

Kidney paired donation (KPD) is a major innovation that is changing the landscape of kidney transplantation in the United States. We used the 2006-2021 United Network for Organ Sharing data to examine trends over time. KPD is increasing, with 1 in 5 living donor kidney transplants (LDKTs) in 2021 facilitated by KPD. The proportion of LDKT performed via KPD was comparable for non-Whites and Whites. An increasing proportion of KPD transplants are going to non-Whites. End-chain recipients are not identified in the database. To what extent these trends reflect how end-chain kidneys are allocated, as opposed to increase in living donation among minorities, remains unclear. Half the LDKT in 2021 in sensitized (panel reactive antibody ≥ 80%) and highly sensitized (panel reactive antibody ≥ 98%) groups occurred via KPD. Yet, the proportion of KPD transplants performed in sensitized recipients has declined since 2013, likely due to changes in the deceased donor allocation policies and newer KPD strategies such as compatible KPD. In 2021, 40% of the programs reported not performing any KPD transplants. Our study highlights the need for understanding barriers to pursuing and expanding KPD at the center level and the need for more detailed and accurate data collection at the national level.

Social network interventions to reduce race disparities in living kidney donation: Design and rationale of the friends and family of kidney transplant patients study (FFKTPS)

INTRODUCTION

Racial/ethnic disparities in living donor kidney transplantation (LDKT) are a persistent challenge. Although nearly all directed donations are from members of patients' social networks, little is known about which social network members take steps toward living kidney donation, which do not, and what mechanisms contribute to racial/ethnic LDKT disparities.

METHODS

We describe the design and rationale of the Friends and Family of Kidney Transplant Patients Study, a factorial experimental fielding two interventions designed to promote LKD discussions. Participants are kidney transplant candidates at two centers who are interviewed and delivered an intervention by trained center research coordinators. The search intervention advises patients on which social network members are most likely to be LKD contraindication-free; the script intervention advises patients on how to initiate effective LKD discussions. Participants are randomized into four conditions: no intervention, search only, script only, or both search and script. Patients also complete a survey and optionally provide social network member contact information so they can be surveyed directly. This study will seek to enroll 200 transplant candidates. The primary outcome is LDKT receipt. Secondary outcomes include live donor screening and medical evaluations and outcomes. Tertiary outcomes include LDKT self-efficacy, concerns, knowledge, and willingness, measured before and after the interventions.

CONCLUSION

This study will assess the effectiveness of two interventions to promote LKD and ameliorate Black-White disparities. It will also collect unprecedented information on transplant candidates' social network members, enabling future work to address network member structural barriers to LKD.

Sex and Gender Disparities in Living Kidney Donation: A Scoping Review

Background

Women are more likely than men to be living kidney donors. We summarized the evidence concerning the reasons behind sex and gender disparities in living kidney donation (LKD).

Methods

A scoping review of quantitative and qualitative evidence on reasons for sex and gender disparities in LKD was conducted from inception to March 2023.

Results

Of 1123 studies screened, 45 were eligible for inclusion. Most studies were from North America, Europe, and Central Asia (n = 33, 73%). A predominance of women as living donors (55%-65%) was observed in 15 out of 18 (83%) studies. Reasons for sex and gender disparities in LKD included socioeconomic, biological, and cognitive or emotional factors. A gendered division of roles within the families was observed in most studies, with men being the primary income earner and women being the main caregiver. Fear of loss of income was a barrier to male donation. Human leukocyte antigen sensitization through pregnancy in female recipients precluded male partner donation, whereas female donation was supported by altruism and a positive attitude toward LKD.

Conclusions

Sex imbalance in LKD is prevalent, with a predominance of women as living donors. Such disparities are driven by societal and cultural perceptions of gender roles, pregnancy-induced sensitization, and attitudes toward donation and at least some of these factors are modifiable. Donor compensation to support predonation assessments and income loss, implementation of innovative desensitization treatments, promotion of paired kidney exchange program, and targeted educational initiatives to promote equitable living donation may help to close the gender gap in LKD.

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

INTRODUCTION

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

RESEARCH QUESTIONS

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Health System-Level Barriers to Living Donor Kidney Transplantation: Protocol for a Comparative Case Study Analysis

BACKGROUND

Living donor kidney transplantation (LDKT) is the best treatment option for patients with kidney failure and offers significant medical and economic advantages for both patients and health systems. Despite this, rates of LDKT in Canada have stagnated and vary significantly across Canadian provinces, the reasons for which are not well understood. Our prior work has suggested that system-level factors may be contributing to these differences. Identifying these factors can help inform system-level interventions to increase LDKT.

OBJECTIVE

Our objective is to generate a systemic interpretation of LDKT delivery across provincial health systems with variable performance. We aim to identify the attributes and processes that facilitate the delivery of LDKT to patients, and those that create barriers and compare these across systems with variable performance. These objectives are contextualized within our broader goal of increasing rates of LDKT in Canada, particularly in lower-performing provinces.

METHODS

This research takes the form of a qualitative comparative case study analysis of 3 provincial health systems in Canada that have high, moderate, and low rates of LDKT performance (the percentage of LDKT to all kidney transplantations performed). Our approach is underpinned by an understanding of health systems as complex adaptive systems that are multilevel and interconnected, and involve nonlinear interactions between people and organizations, operating within a loosely bounded network. Data collection will comprise semistructured interviews, document reviews, and focus groups. Individual case studies will be conducted and analyzed using inductive thematic analysis. Following this, our comparative analysis will operationalize resource-based theory to compare case study data and generate explanations for our research question.

RESULTS

This project was funded from 2020 to 2023. Individual case studies were carried out between November 2020 and August 2022. The comparative case analysis will begin in December 2022 and is expected to conclude in April 2023. Submission of the publication is projected for June 2023.

CONCLUSIONS

By investigating health systems as complex adaptive systems and making comparisons across provinces, this study will identify how health systems can improve the delivery of LDKT to patients with kidney failure. Our resource-based theory framework will provide a granular analysis of the attributes and processes that facilitate or create barriers to LDKT delivery across multiple organizations and levels of practice. Our findings will have practice and policy implications and help inform transferrable competencies and system-level interventions conducive to increasing LDKT.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44172.

Living Donor Kidney Transplantation in Quebec: A Qualitative Case Study of Health System Barriers and Facilitators

Background

Patients with kidney failure represent a major public health burden, and living donor kidney transplantation (LDKT) is the best treatment option for these patients. Current work to optimize LDKT delivery to patients has focused on microlevel interventions and has not addressed interdependencies with meso and macro levels of practice.

Objective

We aimed to learn from a health system with historically low LDKT performance to identify facilitators and barriers to LDKT. Our specific aims were to understand how LDKT delivery is organized through interacting macro, meso, and micro levels of practice and identify what attributes and processes of this health system facilitate the delivery of LDKT to patients with kidney failure and what creates barriers.

Design

We conducted a qualitative case study, applying a complex adaptive systems approach to LDKT delivery, that recognizes health systems as being made up of dynamic, nested, and interconnected levels, with the patient at its core.

Setting

The setting for this case study was the province of Quebec, Canada.

Participants

Thirty-two key stakeholders from all levels of the health system. This included health care professionals, leaders in LDKT governance, living kidney donors, and kidney recipients.

Methods

Semi-structured interviews with 32 key stakeholders and a document review were undertaken between February 2021 and December 2021. Inductive thematic analysis was used to generate themes.

Results

Overall, we identified strong links between system attributes and processes and LDKT delivery, and more barriers than facilitators were discerned. Barriers that undermined access to LDKT included fragmented LDKT governance and expertise, disconnected care practices, limited resources, and regional inequities. Some were mitigated to an extent by the intervention of a program launched in 2018 to increase LDKT. Facilitators driven by the program included advocacy for LDKT from individual member(s) of the care team, dedicated resources, increased collaboration, and training opportunities that targeted LDKT delivery at multiple levels of practice.

Limitations

Delineating the borders of a "case" is a challenge in case study research, and it is possible that some perspectives may have been missed. Participants may have produced socially desirable answers.

Conclusions

Our study systematically investigated real-world practices as they operate throughout a health system. This novel approach has cross-disciplinary methodological relevance, and our findings have policy implications that can help inform multilevel interventions to improve LDKT.

Health System–Level Barriers to Living Donor Kidney Transplantation: Protocol for a Comparative Case Study Analysis (Preprint).. [DOI: 10.2196/preprints.44172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

Living donor kidney transplantation (LDKT) is the best treatment option for patients with kidney failure and offers significant medical and economic advantages for both patients and health systems. Despite this, rates of LDKT in Canada have stagnated and vary significantly across Canadian provinces, the reasons for which are not well understood. Our prior work has suggested that system-level factors may be contributing to these differences. Identifying these factors can help inform system-level interventions to increase LDKT.

OBJECTIVE

Our objective is to generate a systemic interpretation of LDKT delivery across provincial health systems with variable performance. We aim to identify the attributes and processes that facilitate the delivery of LDKT to patients, and those that create barriers and compare these across systems with variable performance. These objectives are contextualized within our broader goal of increasing rates of LDKT in Canada, particularly in lower-performing provinces.

METHODS

This research takes the form of a qualitative comparative case study analysis of 3 provincial health systems in Canada that have high, moderate, and low rates of LDKT performance (the percentage of LDKT to all kidney transplantations performed). Our approach is underpinned by an understanding of health systems as complex adaptive systems that are multilevel and interconnected, and involve nonlinear interactions between people and organizations, operating within a loosely bounded network. Data collection will comprise semistructured interviews, document reviews, and focus groups. Individual case studies will be conducted and analyzed using inductive thematic analysis. Following this, our comparative analysis will operationalize resource-based theory to compare case study data and generate explanations for our research question.

RESULTS

This project was funded from 2020 to 2023. Individual case studies were carried out between November 2020 and August 2022. The comparative case analysis will begin in December 2022 and is expected to conclude in April 2023. Submission of the publication is projected for June 2023.

CONCLUSIONS

By investigating health systems as complex adaptive systems and making comparisons across provinces, this study will identify how health systems can improve the delivery of LDKT to patients with kidney failure. Our resource-based theory framework will provide a granular analysis of the attributes and processes that facilitate or create barriers to LDKT delivery across multiple organizations and levels of practice. Our findings will have practice and policy implications and help inform transferrable competencies and system-level interventions conducive to increasing LDKT.

INTERNATIONAL REGISTERED REPORT

DERR1-10.2196/44172

Geospatial Analysis of Organ Transplant Referral Regions

IMPORTANCE

System and center-level interventions to improve health equity in organ transplantation benefit from robust characterization of the referral population served by each transplant center. Transplant referral regions (TRRs) define geographic catchment areas for transplant centers in the US, but accurately characterizing the demographics of populations within TRRs using US Census data poses a challenge.

OBJECTIVE

To compare 2 methods of linking US Census data with TRRs-a geospatial intersection method and a zip code cross-reference method.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study compared spatial congruence of spatial intersection and zip code cross-reference methods of characterizing TRRs at the census block level. Data included adults aged 18 years and older on the waiting list for kidney transplant from 2008 through 2018.

EXPOSURES

End-stage kidney disease.

MAIN OUTCOMES AND MEASURES

Multiple assignments, where a census tract or block group crossed the boundary between 2 hospital referral regions and was assigned to multiple different TRRs; misassigned area, the portion of census tracts or block groups assigned to a TRR using either method but fall outside of the TRR boundary.

RESULTS

In total, 102 TRRs were defined for 238 transplant centers. The zip code cross-reference method resulted in 4627 multiple-assigned census block groups (representing 18% of US land area assigned to TRRs), while the spatial intersection method eliminated this problem. Furthermore, the spatial method resulted in a mean and median reduction in misassigned area of 65% and 83% across all TRRs, respectively, compared with the zip code cross-reference method.

CONCLUSIONS AND RELEVANCE

In this study, characterizing populations within TRRs with census block groups provided high spatial resolution, complete coverage of the country, and balanced population counts. A spatial intersection approach avoided errors due to duplicative and incorrect assignments, and allowed more detailed and accurate characterization of the sociodemographics of populations within TRRs; this approach can enrich transplant center knowledge of local referral populations, assist researchers in understanding how social determinants of health may factor into access to transplant, and inform interventions to improve heath equity.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Apolipoprotein L1 Opinions of African American Living Kidney Donors, Kidney Transplant Patients, and Nonpatients

INTRODUCTION

The discovery of apolipoprotein L1 (ApoL1) has raised important ethical and clinical questions about genetic testing in the context of living and deceased kidney donation. Largely missing from this discussion are the perspectives of those African Americans (AA) most likely to be impacted by ApoL1 testing.

METHODS

We surveyed 331 AA potential and former living kidney donors (LKDs), kidney transplant candidates and recipients, and nonpatients at three United States transplant programs about their ApoL1 testing attitudes.

RESULTS

Overall, 72% felt that transplant programs should offer ApoL1 testing to AA potential LKDs. If a potential LKD has the high-risk genotype, 79% felt that the LKD should be allowed to make their own donation decision or participate in shared decision-making with transplant doctors. More than half of the potential LKDs (58%) would undergo ApoL1 testing and 81% of former LKDs would take the test now if offered. Most transplant candidates expressed a low likelihood of accepting a kidney from a LKD (79%) or a deceased donor (67%) with the high-risk genotype.

CONCLUSIONS

There is strong support among LKDs and transplant patients for ApoL1 testing when evaluating potential kidney donors of African ancestry. Inclusion of AA stakeholders in developing guidelines and educational programs for ApoL1 testing is critical.

Examination of Racial and Socioeconomic Disparity in Use of Nondirected Kidney Donation in the US

BACKGROUND

Nondirected donor (NDD) kidney transplant (NDDKT) continues to improve organ access for waitlisted candidates. Although NDDs are becoming increasingly common, there has been no contemporary evaluation of NDD allograft use, and it is vital to understand sociodemographic, as well as center-level, use across the US.

STUDY DESIGN

Using national data from the Scientific Registry for Transplant Recipients, this study characterized NDDs, NDDKT recipients, and center-level distribution of NDDKT. Directed donor and NDD characteristics were compared using Fisher's exact and Wilcoxon rank-sum tests for categorical and continuous variables, respectively. Multivariable logistic regression was used to identify characteristics associated with receiving NDDKT, and center distribution of NDDKT was assessed using the Gini coefficient.

RESULTS

NDDKT increased from 1.4% (n = 154) of all living donor kidney transplants in 2010 to 6.5% (n = 338) in 2020. Compared with directed living donors, NDDs were older (median [IQR], 44 [33 to 54] vs 43 [33 to 52], p < 0.01), more often male (40.2% vs 36.7%, p < 0.001), and White (91.4% vs 69.5%, p < 0.001). White adult candidates were more likely to receive NDDKT compared with Black (adjusted odds ratio [aOR], 0.300.340.39, p < 0.001), Hispanic/Latino (aOR, 0.360.420.48, p < 0.001), and Other (aOR, 0.410.470.55, p < 0.001) candidates. Black pediatric candidates had lower odds of receiving NDDKT (aOR, 0.090.220.54, p = 0.02). The proportion of centers performing NDDKT has increased from 2010 to 2020 (Gini = 0.77 vs 0.68).

CONCLUSIONS

Although more centers are performing NDDKT, racial disparities persist among NDDs and NDDKT recipients. Continued effort is needed to recruit living kidney donors and improve access to living donation for minority groups in the US. (J Am Coll Surg 2022;234:000-00. © 2022 by the American College of Surgeons).

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

BACKGROUND

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

METHODS

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

RESULTS

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

INTERPRETATION

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

The Landscape of Nondirected Living Liver Donation in the United States

BACKGROUND

Living donor liver transplants (LDLTs) including those from nondirected donors (NDDs) have increased during the past decade, and center-level variations in LDLTs have not yet been described. We sought to quantify changes in the volume of NDD transplants over time and variation in NDD volume between transplant centers. We further examined characteristics of living liver donors and identified factors potentially associated with receiving an NDD liver transplant.

METHODS

Using Scientific Registry of Transplant Recipients data between March 01, 2002, and December 31, 2020, we compared 173 NDDs with 5704 DLDs and 167 NDD recipients with 1153 waitlist candidates.

RESULTS

NDDs increased from 1 (0.4% of LDLTs) in 2002 to 58 (12% of LDLTs) in 2020. Of 150 transplant centers, 35 performed at least 1 NDD transplant. Compared with waitlist candidates, adult NDD recipients were less frequently males (39% versus 62%, P < 0.001), had a lower model for end-stage liver disease (16 versus 18, P = 0.01), and spent fewer days on the waitlist (173 versus 246, P = 0.02). Compared with waitlist candidates, pediatric NDD recipients were younger (50% versus 12% age <2 y, P < 0.001) and more often diagnosed with biliary atresia (66% versus 41%, P < 0.001). Compared with DLDs, NDDs were older (40 versus 35 y, P < 0.001), college educated (83% versus 64%, P < 0.001), White (92% versus 78%, P < 0.001), and more frequently donated left-lateral segment grafts (32.0% versus 14%, P < 0.001).

CONCLUSIONS

Liver NDD transplants continue to expand but remain concentrated at a few centers. Graft distribution favors female adults and pediatric patients with biliary atresia. Racial inequities in adult or pediatric center-level NDD graft distribution were not observed.

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

Factors Associated with the Willingness to Become a Living Kidney Donor: A National Cross-Sectional Study

Introduction: Living donor kidney transplantation is the preferred method of treating kidney failure. The donor agrees to undergo an elective procedure for the benefit of the recipient. Aim: To assess the attitude toward living kidney donation and to investigate the factors that contribute to kidney donation willingness. Methods: A cross-sectional study was carried out between December 2020 and February 2021. The study covered a representative group of 953 Poles aged 18−77, living in all Polish voivodships. The relationship between sociodemographic factors, personal values (Personal Values List), the total score of life satisfaction (Satisfaction with Life Scale) and the willingness to donate a kidney to another human was assessed using a logistic regression model. Results: The most frequently chosen personal values were: good health; physical and mental fitness; love and friendship; knowledge and wisdom. The most frequently chosen symbols of happiness were: good health, successful family life, being needed by others. The median satisfaction with life for the entire group was 20 [16; 24]. Voluntary donation of a kidney to another human being i.e., family, friends, strangers were more often declared by women (OR = 1.21; Cl95%: 1.03−1.42), for whom the most important symbol of happiness was a life full of adventures, travels (OR = 1.39; Cl95%: 1.06−1.82) and the most important personal value was goodness and tenderness (OR = 1.21; Cl95%: 1.05−1.40). Total scores of The Satisfaction with Life Scale correlated positively with the willingness to voluntarily donate a kidney (OR = 1.03; Cl95%: 1.003−1.06), while age correlated negatively (OR = 0.99; Cl95%: 0.98−0.99). Conclusions: Respondents who declare their willingness to be a living kidney donor are mainly female, for which the most important symbol of happiness is a life full of adventures and travel, and the most important values are personal goodness and tenderness. The desire to donate a kidney to another person decreases with age and grows with life satisfaction. Trial registration: ClinicalTrials.gov (ID: NCT04789122).

Employment status at transplant influences ethnic disparities in outcomes after deceased donor kidney transplantation

Background

African American (AA) recipients of deceased-donor (DD) kidney transplants (KT) have shorter allograft survival than recipients of other ethnic groups. Reasons for this disparity encompass complex interactions between donors and recipients characteristics.

Methods

Outcomes from 3872 AA and 19,719 European American (EA) DDs who had one kidney transplanted in an AA recipient and one in an EA recipient were analyzed. Four donor/recipient pair groups (DRP) were studied, AA/AA, AA/EA, EA/AA, and EA/EA. Survival random forests and Cox proportional hazard models were fitted to rank and evaluate modifying effects of DRP on variables associated with allograft survival. These analyses sought to identify factors contributing to the observed disparities in transplant outcomes among AA and EA DDKT recipients.

Results

Transplant era, discharge serum creatinine, delayed graft function, and DRP were among the top predictors of allograft survival and mortality among DDKT recipients. Interaction effects between DRP with the kidney donor risk index and transplant era showed significant improvement in allograft survival over time in EA recipients. However, AA recipients appeared to have similar or poorer outcomes for DDKT performed after 2010 versus before 2001; allograft survival hazard ratios (95% CI) were 1.15 (0.74, 1.76) and 1.07 (0.8, 1.45) for AA/AA and EA/AA, compared to 0.62 (0.54, 0.71) and 0.5 (0.41, 0.62) for EA/EA and AA/EA DRP, respectively. Recipient mortality improved over time among all DRP, except unemployed AA/AAs. Relative to DDKT performed pre-2001, employed AA/AAs had HR = 0.37 (0.2, 0.69) versus 0.59 (0.31, 1.11) for unemployed AA/AA after 2010.

Conclusion

Relative to DDKT performed before 2001, similar or worse overall DCAS was observed among AA/AAs, while EA/EAs experienced considerable improvement regardless of employment status, KDRI, and EPTS. AA recipients of an AA DDKT, especially if unemployed, had worse allograft survival and mortality and did not appear to benefit from advances in care over the past 20 years.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02631-4.

Remnant renal volume can predict prognosis of remnant renal function in kidney transplantation donors: a prospective observational study

Background

Safety and survival during and after donor nephrectomy (DN) are one of the main concerns in living kidney donors (LKDs). Therefore, kidney (left/right) to be procured should be determined after considering the difficulty of DN, as well as the preservation of remnant renal function (RRF). In this prospective study, we investigated the roles of computed tomography volumetry (CTV) in split renal function (SRF) and established a predictive model for RRF in LKDs.

Methods

We assessed 103 LKDs who underwent DN at our institute. The Volume Analyzer SYNAPSE VINCENT image analysis system were used as CTV. RRF was defined as the estimated glomerular filtration rate (eGFR) 12 months after DN. The association between various factors measured by CTV and RRF were investigated, and a role of CTV on prediction for RRF was assessed.

Results

The median age and the preoperative eGFR were 58 years and 80.7 mL/min/1.73m², respectively. Each factor measured by CTV showed an association with RRF. The ratio of remnant renal volume to body surface area (RRV/BSA) could predict RRF. In addition, RRV/BSA could predict RRF more accurately when used together with age and 24-h creatinine clearance (CrCl).

Conclusions

Our findings suggest that RRV/BSA measured by CTV can play an important role in predicting RRF, and a comprehensive assessment including age and CrCl is important to determine the kidney to be procured.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02568-8.

Racial/ethnic and prior willingness disparities in potential living kidney donors' self-assessed responses to advancing American kidney health regulation

Background

Racial/ethnic disparities in living donor kidney transplantation (LDKT) are large, and rates of LDKT may be limited by indirect costs of living donation. A 2019 Executive Order– Advancing American Kidney Health (AAKH)– sought to remove indirect costs through an expanded reimbursement program. We examine how potential living kidney donors in the U.S. believe regulation stemming from the AAKH initiative will impact their living donor evaluation likelihood, how these beliefs vary by minority race/ethnicity and prior willingness to be evaluated, and how differences are explained by ability to benefit or knowledge and attitudes.

Methods

Data from a 2019 online survey (Families of Renal Patients Survey) were used. Respondents are U.S. adult (> 18 years) members of the Qualtrics Survey Panel who reported having relatives with weak or failing kidneys (N = 590). Respondents’ likelihood to be evaluated for living kidney donation are measured by self-report. Prior willingness is measured by past donation-related actions and current attitudes. Ability to benefit is measured by self-reported labor force participation and financial strain. Transplant knowledge is measured by self-report and a knowledge test, and transplant-related attitudes are measured by self-report. Average marginal effects of minority race/ethnicity and prior willingness for response to each provision in fully-adjusted models were estimated. Formal tests of mediation were conducted using the Karlson, Holm, and Breen (KHB) mediation model. Stata/MP 14.2 was used to conduct all analyses.

Results

Majorities of all groups report favorable responses to the provisions stipulated in AAKH regulation. Responses to provisions are significantly associated with race/ethnicity and prior willingness, with racial/ethnic minorities and those not previously willing to be evaluated less likely to report favorable responses to these provisions. Prior willingness differences are partially explained by group differences in ability to benefit and transplant-related knowledge and attitudes, but racial/ethnic differences largely are not.

Conclusions

Regulation stemming from the AAKH initiative is likely to effectively promote LDKT, but may also exacerbate racial/ethnic disparities. Therefore, the regulation may need to be supplemented by efforts to address non-financial obstacles to LDKT in racial/ethnic minority communities in order to ensure equitable increases in LDKT rates and living donor support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12023-w.

Can Living Donor Liver Transplantation in the United States Reach Its Potential?

Living donor liver transplantation (LDLT) is a vital tool to address the growing organ shortage in the United States caused by increasing numbers of patients diagnosed with end-stage liver disease. LDLT still only makes up a very small proportion of all liver transplantations performed each year, but there are many innovations taking place in the field that may increase its acceptance among both transplant programs and patients. These innovations include ways to improve access to LDLT, such as through nondirected donation, paired exchange, transplant chains, transplant of ABO-incompatible donors, and transplants in patients with high Model for End-Stage Liver Disease scores. Surgical innovations, such as laparoscopic donor hepatectomy, robotic hepatectomy, and portal flow modulation, are also increasingly being implemented. Policy changes, including decreasing the financial burden associated with LDLT, may make it a more feasible option for a wider range of patients. Lastly, center-level behavior, such as ensuring surgical expertise and providing culturally competent education, will help toward LDLT expansion. Although it is challenging to know which of these innovations will take hold, we are already seeing LDLT numbers improve within the past 2 years.

A Cascade of Structural Barriers Contributing to Racial Kidney Transplant Inequities

Stark racial disparities in access to and receipt of kidney transplantation, especially living donor and pre-emptive transplantation, have persisted despite decades of investigation and intervention. The causes of these disparities are complex, are inter-related, and result from a cascade of structural barriers to transplantation which disproportionately impact minoritized individuals and communities. Structural barriers contributing to racial transplant inequities have been acknowledged but are often not fully explored with regard to transplant equity. We describe longstanding racial disparities in transplantation, and we discuss contributing structural barriers which occur along the transplant pathway including pretransplant health care, evaluation, referral processes, and the evaluation of transplant candidates. We also consider the role of multilevel socio-contextual influences on these processes. We believe focused efforts which apply an equity lens to key transplant processes and systems are required to achieve greater structural competency and, ultimately, racial transplant equity.

Disparities in living donation

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Using increased trust in medical researchers to increase minority recruitment: The RECRUIT cluster randomized clinical trial

While extensive literature exists on barriers and strategies to increase minority participation in clinical trials, progress is limited. Few strategies were evaluated in randomized trials. We studied the impact of RECRUIT, a trust-based, cluster randomized minority recruitment trial layered on top of four traditional NIH-funded parent trials (BMT CTN, CABANA, PACES, STEADY-PD III; fifty specialty sites). RECRUIT was conducted from July 2013 through April 2017. Intervention sites implemented trust-based approaches customized to individual sites, promoting relationships between physician-investigators and minority-serving physicians and their minority patients. Control sites implemented only parent trials' recruitment procedures. Adjusting for within-site clustering, we detected no overall intervention effect, odds ratio 1.3 (95% confidence limits 0.7,2.4). Heterogeneity among parent trials may have obscured the effect. Of the four parent trials, three enrolled more minorities in intervention versus control sites. CABANA odds ratio = 4.2 (adjusted 95%CL 1.5,11.3). PACES intervention sites enrolled 63% (10/16) minorities; control sites enrolled one participant in total, a minority, yielding an incalculable odds ratio. STEADY-PD III odds ratio = 2.2 (adjusted 95%CL 0.6,8.5). BMT CTN odds ratio < 1, 0.8 (adjusted 95%CL 0.4,1.8). In conclusion, RECRUIT findings suggest the unique trust-based intervention increased minority recruitment to intervention trials in ¾ of studied trials. Physician-investigators' participation was critical to recruitment success. Lack of commitment to minority recruitment remained a barrier for some physician-investigators, especially in control sites. We recommend prospective physician investigators commit to minority recruitment activities prior to selection as site investigators and trial funding include some compensation for minority recruitment efforts. TRIAL REGISTRATION ClinicalTrials.govNCT01911208.

Implementation of the Kidney Team at Home Intervention: Evaluating Generalizability, Implementation Process, and Effects

Research has shown that a home-based educational intervention for patients with chronic kidney disease results in better knowledge and communication, and more living donor kidney transplantations (LDKT). Implementation research in the field of renal care is almost non-existent. The aims of this study were (1) to demonstrate generalizability, (2) evaluate the implementation process, and (3) to assess the relationship of intervention effects on LDKT-activity. Eight hospitals participated in the project. Patients eligible for all kidney replacement therapies (KRT) were invited to participate. Effect outcomes were KRT-knowledge and KRT-communication, and treatment choice. Feasibility, fidelity and intervention costs were assessed as part of the process evaluation. 332 patients completed the intervention. There was a significant increase in KRT-knowledge and KRT-communication among participants. 129 out of 332 patients (39%) had LDKT-activity, which was in line with the results of the clinical trials. Protocol adherence, knowledge and age were correlated with LDKT-activity. This unique implementation study shows that the results in practice are comparable to the previous trials, and show that the intervention can be implemented, while maintaining quality. Results from the project resulted in the uptake of the intervention in standard care. We urge other countries to investigate the uptake of the intervention.

Policy in pediatric nephrology: successes, failures, and the impact on disparities

Pediatric nephrology has a history rooted in pediatric advocacy and has made numerous contributions to child health policy affecting pediatric kidney diseases. Despite this progress, profound social disparities remain for marginalized and socially vulnerable children with kidney disease. Different risk factors, such as genetic predisposition, environmental factors, social risk factors, or health care access influence the emergence and progression of pediatric kidney disease, as well as access to life-saving interventions, leading to disparate outcomes. This review will summarize the breadth of literature on social determinants of health in children with kidney disease worldwide and highlight policy-based initiatives that mitigate the adverse social factors to generate greater equity in pediatric kidney disease.

Social Determinants of Health and Race Disparities in Kidney Transplant

BACKGROUND AND OBJECTIVES

Black patients have a higher incidence of kidney failure but lower rate of deceased- and living-donor kidney transplantation compared with White patients, even after taking differences in comorbidities into account. We assessed whether social determinants of health (e.g., demographics, cultural, psychosocial, knowledge factors) could account for race differences in receiving deceased- and living-donor kidney transplantation.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Via medical record review, we prospectively followed 1056 patients referred for kidney transplant (2010-2012), who completed an interview soon after kidney transplant evaluation, until their kidney transplant. We used multivariable competing risk models to estimate the cumulative incidence of receipt of any kidney transplant, deceased-donor transplant, or living-donor transplant, and the factors associated with each outcome.

RESULTS

Even after accounting for social determinants of health, Black patients had a lower likelihood of kidney transplant (subdistribution hazard ratio, 0.74; 95% confidence interval, 0.55 to 0.99) and living-donor transplant (subdistribution hazard ratio, 0.49; 95% confidence interval, 0.26 to 0.95), but not deceased-donor transplant (subdistribution hazard ratio, 0.92; 95% confidence interval, 0.67 to 1.26). Black race, older age, lower income, public insurance, more comorbidities, being transplanted before changes to the Kidney Allocation System, greater religiosity, less social support, less transplant knowledge, and fewer learning activities were each associated with a lower probability of any kidney transplant. Older age, more comorbidities, being transplanted before changes to the Kidney Allocation System, greater religiosity, less social support, and fewer learning activities were each associated with a lower probability of deceased-donor transplant. Black race, older age, lower income, public insurance, higher body mass index, dialysis before kidney transplant, not presenting with a potential living donor, religious objection to living-donor transplant, and less transplant knowledge were each associated with a lower probability of living-donor transplant.

CONCLUSIONS

Race and social determinants of health are associated with the likelihood of undergoing kidney transplant.

African Americans' discussions about living-donor kidney transplants with family or friends: Who, what, and why not?

BACKGROUND

Although discussions with family or friends can improve access to living-donor kidney transplantation (LDKT), they remain an understudied step in the LDKT process.

METHODS

Among 300 African American transplant candidates, we examined how sociodemographic, clinical, LDKT-related, and psychosocial characteristics related to the occurrence of LDKT discussions with family or friends. We also analyzed the relation between discussion occurrence and donor activation on transplant candidates' behalves (at least one donor inquiry or completed donor evaluation in the medical record). We assessed associations of discussion characteristics (context, content, and perceptions) with donor activation among discussants, and we identified discussion barriers among non-discussants.

RESULTS

Most candidates (90%) had discussed LDKT. Only family functioning was statistically significantly associated with discussion occurrence. Specifically, family dysfunction was associated with 62% lower odds of discussion than family function. Family functioning, discussion occurrence, and different discussion characteristics were statistically significantly related to donor activation. The most prevalent discussion barrier was never having thought about discussing LDKT.

CONCLUSIONS

Family functioning affected the likelihood of discussing LDKT, and family functioning, discussion occurrence, and discussion characteristics were associated with donor activation. Advancing understanding of how family functioning and LDKT discussions affect progression to LDKT may benefit interventions to increase LDKT.

Investigating Ethnic Disparity in Living-Donor Kidney Transplantation in the UK: Patient-Identified Reasons for Non-Donation among Family Members

There is ethnic inequity in access to living-donor kidney transplants in the UK. This study asked kidney patients from Black, Asian and minority ethnic groups why members of their family were not able to be living kidney donors. Responses were compared with responses from White individuals. This questionnaire-based mixed-methods study included adults transplanted between 1/4/13–31/3/17 at 14 UK hospitals. Participants were asked to indicate why relatives could not donate, selecting all options applicable from: Age; Health; Weight; Location; Financial/Cost; Job; Blood group; No-one to care for them after donation. A box entitled ‘Other—please give details’ was provided for free-text entries. Multivariable logistic regression was used to analyse the association between the likelihood of selecting each reason for non-donation and the participant’s self-reported ethnicity. Qualitative responses were analysed using inductive thematic analysis. In total, 1240 questionnaires were returned (40% response). There was strong evidence that Black, Asian and minority ethnic group individuals were more likely than White people to indicate that family members lived too far away to donate (adjusted odds ratio (aOR) = 3.25, 95% Confidence Interval (CI) 2.30–4.58), were prevented from donating by financial concerns (aOR = 2.95, 95% CI 2.02–4.29), were unable to take time off work (aOR = 1.88, 95% CI 1.18–3.02), were “not the right blood group” (aOR = 1.65, 95% CI 1.35–2.01), or had no-one to care for them post-donation (aOR = 3.73, 95% CI 2.60–5.35). Four qualitative themes were identified from responses from Black, Asian and minority ethnic group participants: ‘Burden of disease within the family’; ‘Differing religious interpretations’; ‘Geographical concerns’; and ‘A culture of silence’. Patients perceive barriers to living kidney donation in the UK Black, Asian and minority ethnic population. If confirmed, these could be targeted by interventions to redress the observed ethnic inequity.

The impact of religiously tailored and ethically balanced education on intention for living organ donation among Muslim Americans

We tested the efficacy of religiously tailored and ethically balanced education upon living kidney organ donation intent among Muslim Americans. Pre-post changes in participant stage of change, preparedness, and likelihood judged efficacy. Among 137 participants, mean stage of change toward donation appeared to improve (0.59; SD ± 1.07, P < .0001), as did the group's preparedness to make a donation decision (0.55; SD ± 0.86, P < .0001), and likelihood to donate a kidney (0.39; SD ± 0.85, P < .0001). Mean change in likelihood to encourage a loved one, a co-worker, or a mosque community member with ESRD to seek a living donor also increased (0.22; SD ± 0.84, P = .0035, 0.23; SD ± 0.82, P = .0021, 0.33; SD ± 0.79, P < .0001 respectively). Multivariate ordered logistic regression models revealed that gains in biomedical knowledge regarding organ donation increased odds for positive change in preparedness (OR = 1.20; 95% CI 1.01-1.41, P = .03), while increasing age associated with lower odds of positive change in stage of change (OR = 0.98, 95% CI 0.96-0.998, P = .03), and prior registration as an organ donor lowered odds for an increase in likelihood to donate a kidney (OR = 0.22; 95% CI 0.08-0.60, P = .003). Our intervention appears to enhance living kidney donation-related intent among Muslim Americans [Clinicaltrials.gov number: NCT04443114].

Unexpected Race and Ethnicity Differences in the US National Veterans Affairs Kidney Transplant Program

BACKGROUND

Racial/ethnic minorities have lower rates of deceased kidney transplantation (DDKT) and living donor kidney transplantation (LDKT) in the United States. We examined whether social determinants of health (eg, demographics, cultural, psychosocial, knowledge factors) could account for differences in the Veterans Affairs (VA) Kidney Transplantation (KT) Program.

METHODS

We conducted a multicenter longitudinal cohort study of 611 Veterans undergoing evaluation for KT at all National VA KT Centers (2010-2012) using an interview after KT evaluation and tracking participants via medical records through 2017.

RESULTS

Hispanics were more likely to get any KT (subdistribution hazard ratios [SHR] [95% confidence interval (CI)]: 1.8 [1.2-2.8]) or DDKT (SHR [95% CI]: 2.0 [1.3-3.2]) than non-Hispanic white in univariable analysis. Social determinants of health, including marital status (SHR [95% CI]: 0.6 [0.4-0.9]), religious objection to LDKT (SHR [95% CI]: 0.6 [0.4-1.0]), and donor preference (SHR [95% CI]: 2.5 [1.2-5.1]), accounted for some racial differences, and changes to Kidney Allocation System policy (SHR [95% CI]: 0.3 [0.2-0.5]) mitigated race differences in DDKT in multivariable analysis. For LDKT, non-Hispanic African American Veterans were less likely to receive an LDKT than non-Hispanic white (SHR [95% CI]: 0.2 [0.0-0.7]), but accounting for age (SHR [95% CI]: 1.0 [0.9-1.0]), insurance (SHR [95% CI]: 5.9 [1.1-33.7]), presenting with a living donor (SHR [95% CI]: 4.1 [1.4-12.3]), dialysis duration (SHR [95% CI]: 0.3 [0.2-0.6]), network of potential donors (SHR [95% CI]: 1.0 [1.0-1.1]), self-esteem (SHR [95% CI]: 0.4 [0.2-0.8]), transplant knowledge (SHR [95% CI]: 1.3 [1.0-1.7]), and changes to Kidney Allocation System policy (SHR [95% CI]: 10.3 [2.5-42.1]) in multivariable analysis eliminated those disparities.

CONCLUSIONS

The VA KT Program does not exhibit the same pattern of disparities in KT receipt as non-VA centers. Transplant centers can use identified risk factors to target patients who may need more support to ensure they receive a transplant.

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

BACKGROUND AND OBJECTIVES

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

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

Mediators of Socioeconomic Inequity in Living-donor Kidney Transplantation: Results From a UK Multicenter Case-Control Study

Supplemental Digital Content is available in the text.

There is evidence of socioeconomic inequity in access to living-donor kidney transplantation, but limited evidence as to why. We investigated possible mediators of the inequity.

Best practices to optimize utilization of the National Living Donor Assistance Center for the financial assistance of living organ donors

Living organ donors face direct costs when donating an organ, including transportation, lodging, meals, and lost wages. For those most in need, the National Living Donor Assistance Center (NLDAC) provides reimbursement to defray travel and subsistence costs associated with living donor evaluation, surgery, and follow-up. While this program currently supports 9% of all US living donors, there is tremendous variability in its utilization across US transplant centers, which may limit patient access to living donor transplantation. Based on feedback from the transplant community, NLDAC convened a Best Practices Workshop on August 2, 2018, in Arlington, VA, to identify strategies to optimize transplant program utilization of this valuable resource. Attendees included team members from transplant centers that are high NLDAC users; the NLDAC program team; and Advisory Group members. After a robust review of NLDAC data and engagement in group discussions, the workgroup identified concrete best practices for administrative and transplant center leadership involvement; for individuals filing NLDAC applications at transplant centers; and to improve patient education about potential financial barriers to living organ donation. Multiple opportunities were identified for intervention to increase transplant programs' NLDAC utilization and reduce financial burdens inhibiting expansion of living donor transplantation in the United States.

Beliefs of UK Transplant Recipients about Living Kidney Donation and Transplantation: Findings from a Multicentre Questionnaire-Based Case-Control Study

Differing beliefs about the acceptability of living-donor kidney transplants (LDKTs) have been proposed as explaining age, ethnic and socioeconomic disparities in their uptake. We investigated whether certain patient groups hold beliefs incompatible with LDKTs. This questionnaire-based case–control study was based at 14 hospitals in the United Kingdom. Participants were adults transplanted between 1 April 2013 and 31 March 2017. LDKT recipients were compared to deceased-donor kidney transplant (DDKT) recipients. Beliefs were determined by the direction and strength of agreement with ten statements. Multivariable logistic regression was used to investigate the association between beliefs and LDKT versus DDKT. Sex, age, ethnicity, religion, and education were investigated as predictors of beliefs. A total of 1240 questionnaires were returned (40% response). DDKT and LDKT recipients responded in the same direction for 9/10 statements. A greater strength of agreement with statements concerning the ‘positive psychosocial effects’ of living kidney donation predicted having an LDKT over a DDKT. Older age, Black, Asian and Minority Ethnic (BAME) group ethnicity, and having a religion other than Christianity were associated with greater degree of uncertainty regarding a number of statements, but there was no evidence that individuals in these groups hold strong beliefs against living kidney donation and transplantation. Interventions should address uncertainty, to increase LDKT activity in these groups.

A Qualitative Assessment of the Living Donor Navigator Program to Identify Core Competencies and Promising Practices for Implementation

Introduction:

The best strategy to increase awareness of and access to living kidney donation remains unknown. To build upon the existing strategies, we developed the Living Donor Navigator program, combining advocacy training of patient advocates with enhanced health-care systems training of patient navigators to address potential living donor concerns during the evaluation process. Herein, we describe a systematic assessment of the delivery and content of the program through focus group discussion.

Methods:

We conducted focus groups with 9 advocate participants in the Living Donor Navigator program to identify knowledge, skills, and abilities needed for both advocates and navigators. We focused on 2 organizational levels: (1) the participant level or the advocacy training of the advocates and (2) the programmatic level or the support role provided by the navigators and administration of the program.

Findings:

From 4 common themes (communication, education, support, and commitment), we identified several core competencies and promising practices, at both the participant and programmatic levels. These themes highlighted the potential for several improvements of program content and delivery, the importance of cultural sensitivity among the Living Donor navigators, and the opportunity for informal caregiver support and accountability provided by the program.

Discussion:

These competencies and promising practices represent actionable strategies for content refinement, optimal training of advocates, and engagement of potential living donors through the Living Donor Navigator program. These findings may also assist with program implementation at other transplant centers in the future.

Living Donor Kidney Transplantation Should Be Promoted Among "Elderly" Patients

Age criteria for kidney transplantation have been liberalized over the years resulting in more waitlisted elderly patients. What are the prospects of elderly patients on the waiting list?

Barriers to access in pediatric living-donor liver transplantation

Children receiving a LDLT have superior post-transplant outcomes, but this procedure is only used for 10% of transplant recipients. Better understanding about barriers toward LDLT and the sociodemographic characteristics that influence these underlying mechanisms would help to inform strategies to increase its use. We conducted an online, anonymous survey of parents/caregivers for children awaiting, or have received, a liver transplant regarding their knowledge and attitudes about LDLT. The survey was completed by 217 respondents. While 97% of respondents understood an individual could donate a portion of their liver, only 72% knew the steps in evaluation, and 69% understood the donor surgery was covered by the recipient's insurance. Individuals with public insurance were less likely than those with private insurance to know the steps for LDLT evaluation (44% vs 82%; P < 0.001). Respondents with public insurance were less likely to know someone that had been a living donor (44% vs 56%; P = 0.005) as were individuals without a college degree (64% vs 85%; P = 0.007). Nearly all respondents generally trusted their healthcare team. Among respondents, 82% believed they were well-informed about LDLT but individuals with public insurance were significantly less likely to feel well-informed (67% vs 87%; P = 0.03) and to understand how donor surgery might impact donor work/time off (44% vs 81%; P = 0.001). Substantial gaps exist in parental understanding about LDLT, including its evaluation, potential benefits, and complications. Greater emphasis on addressing these barriers, especially to individuals with fewer resources, will be helpful to expand the use of LDLT.

Evaluation of Preoperative Abdominal Adipose Tissue-, Inflammation-, Muscle Mass-, and Nutritional Status-based Prognostic Markers to Assess Renal Dysfunction in Living Kidney Donors

BACKGROUND

Living kidney donors (LKDs) are at high risk of renal dysfunction after undergoing a donor nephrectomy (DN), resulting in poor prognosis associated with the development of cardiovascular or cerebrovascular disease. Decreasing this risk can improve the survival rate of LKDs. We investigated the effects of preoperative conditions in LKDs on renal dysfunction after DN using abdominal adipose tissue, inflammation, nutritional status, and muscle mass as markers for this assessment.

METHODS

Our retrospective study included 79 LKDs. Body composition markers were assessed using preoperative unenhanced computed tomographic images. Inflammation- and nutritional status-based markers were assessed using preoperative laboratory blood tests. The association between each marker was investigated, and prognostic markers for renal dysfunction after DN were identified.

RESULTS

The LKDs in this cohort comprised 30 men and 49 women. The median age at the time of DN and the preoperative estimated glomerular filtration rate were 58 years and 81.9 mL/min/1.73 m², respectively. Abdominal subcutaneous adipose tissue and muscle mass significantly differed between the sexes. Each adipose tissue-, inflammation-, nutritional status-, and muscle mass-based marker showed an association with each other. Abdominal visceral adipose tissue and nutritional status could be independent prognostic markers for renal dysfunction after DN.

CONCLUSIONS

Our findings suggest that the preoperative condition of LKDs (assessed using specific markers such as abdominal visceral adipose tissue mass per volume and nutritional status) could affect renal dysfunction after DN. Optimal preoperative management can lead to better outcomes in LKDs. Further research is needed to establish appropriate exercise programs and nutritional interventions.

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

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