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Smout SA, Yang EM, Mohottige D, Nonterah CW. A systematic review of psychosocial and sex-based contributors to gender disparities in the United States across the steps towards kidney transplantation. Transplant Rev (Orlando) 2024; 38:100858. [PMID: 38729062 DOI: 10.1016/j.trre.2024.100858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 05/02/2024] [Accepted: 05/02/2024] [Indexed: 05/12/2024]
Abstract
INTRODUCTION Persistent findings suggest women and patients identified as "female" are less likely to receive a kidney transplant. Furthermore, the limited research on transplantation among transgender and gender diverse people suggests this population is susceptible to many of the same psychosocial and systemic barriers. OBJECTIVE This review sought to 1) highlight terminology used to elucidate gender disparities, 2) identify barriers present along the steps to transplantation, and 3) summarize contributors to gender disparities across the steps to transplantation. METHODS A systematic review of gender and sex disparities in the steps towards kidney transplantation was conducted in accordance with PRISMA guidelines across four social science and public health databases from 2005 to 23. RESULTS The search yielded 1696 initial results, 33 of which met inclusion criteria. A majority of studies followed a retrospective cohort design (n = 22, 66.7%), inconsistently used gender and sex related terminology (n = 21, 63.6%), and reported significant findings for gender and sex disparities within the steps towards transplantation (n = 28, 84.8%). Gender disparities among the earlier steps were characterized by patient-provider communication and perception of medical suitability whereas disparities in the later steps were characterized by differential outcomes based on older age, an above average BMI, and Black racial identity. Findings for transgender patients pointed to issues computing eGFR and the need for culturally tailored care. DISCUSSION Providers should be encouraged to critically examine the diagnostic criteria used to determine transplant eligibility and adopt practices that can be culturally tailored to meet the needs of patients.
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Affiliation(s)
- Shelby A Smout
- Department of Psychology, University of Richmond, 114 UR Drive, Richmond Virginia, USA.
| | - Emily M Yang
- Department of Psychology, University of Richmond, 114 UR Drive, Richmond Virginia, USA
| | - Dinushika Mohottige
- Institute of Health Equity Research, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place Box 1077, New York New York, USA
| | - Camilla W Nonterah
- Department of Psychology, University of Richmond, 114 UR Drive, Richmond Virginia, USA; Department of Psychiatry, Virginia Commonwealth University School of Medicine, 501 N. 2nd Street Box 980309, Richmond Virginia, USA
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2
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Shelton BA, Sen B, Becker DJ, MacLennan PA, Budhwani H, Locke JE. Quantifying the association of individual-level characteristics with disparities in kidney transplant waitlist addition among people with HIV. AIDS 2024; 38:731-737. [PMID: 38100633 PMCID: PMC10939916 DOI: 10.1097/qad.0000000000003817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 12/04/2023] [Accepted: 12/07/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Over 45% of people with HIV (PWH) in the United States at least 50 years old and are at heightened risk of aging-related comorbidities including end-stage kidney disease (ESKD), for which kidney transplant is the optimal treatment. Among ESKD patients, PWH have lower likelihood of waitlisting, a requisite step in the transplant process, than individuals without HIV. It is unknown what proportion of the inequity by HIV status can be explained by demographics, medical characteristics, substance use history, and geography. METHODS The United States Renal Data System, a national database of all individuals ESKD, was used to create a cohort of people with and without HIV through Medicare claims linkage (2007-2017). The primary outcome was waitlisting. Inverse odds ratio weighting was conducted to assess what proportion of the disparity by HIV status could be explained by individual characteristics. RESULTS Six thousand two hundred and fifty PWH were significantly younger at ESKD diagnosis and more commonly Black with fewer comorbidities. PWH were more frequently characterized as using tobacco, alcohol and drugs. Positive HIV-status was associated with 57% lower likelihood of waitlisting [adjusted hazard ratio (aHR): 0.43, 95% confidence interval (CI): 0.46-0.48, P < 0.001]. Controlling for demographics, medical characteristics, substance use and geography explained 39.8% of this observed disparity (aHR: 0.69, 95% CI: 0.59-0.79, P < 0.001). CONCLUSION PWH were significantly less likely to be waitlisted, and 60.2% of that disparity remained unexplained. HIV characteristics such as CD4 + counts, viral loads, antiretroviral therapy adherence, as well as patient preferences and provider decision-making warrant further study.
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Affiliation(s)
- Brittany A. Shelton
- Department of Public Health, University of Tennessee, Knoxville, Tennessee
- Heersink School of Medicine
- Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bisakha Sen
- Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - David J. Becker
- Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Henna Budhwani
- College of Nursing, Florida State University, Tallahassee, Florida, USA
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Nonterah CW. Systems Connected to Inequities in Access to Kidney Transplantation and the Value of Intersectionality. Transpl Int 2024; 37:11658. [PMID: 38344260 PMCID: PMC10853452 DOI: 10.3389/ti.2024.11658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 01/10/2024] [Indexed: 02/15/2024]
Abstract
Patients from minoritized backgrounds based on race/ethnicity, gender, sexuality, and other social identities are more likely to experience inequities in access in kidney transplantation. Although these inequities have been reported over the decades, limited research focuses on the experiences of patients with intersecting minoritized social statuses and the mechanisms that contribute to their reduced access to transplantation. Intersectionality, a framework for understanding the ways in which multiple social identities represent interacting systems of oppression and privilege, offers a nuanced approach for understanding the experiences of patients diagnosed with end-stage organ disease with intersecting social identities. This article outlines complex systems that perpetuate inequities by highlighting the value of intersectionality in studying disparate outcomes to transplant and providing recommendations for the transplant community. This article aligns with the ESOT call for action to promote equity in transplantation worldwide.
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Affiliation(s)
- Camilla W. Nonterah
- Department of Psychology, University of Richmond, Richmond, VA, United States
- Department of Psychiatry, Virginia Commonwealth University Health System, Richmond, VA, United States
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Dawson AE, Ray Bignall ON, Spencer JD, McLeod DJ. A Call to Comprehensively Understand Our Patients to Provide Equitable Pediatric Urological Care. Urology 2023; 179:126-135. [PMID: 37393019 DOI: 10.1016/j.urology.2023.05.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/02/2023] [Accepted: 05/16/2023] [Indexed: 07/03/2023]
Affiliation(s)
- Anne E Dawson
- Division of Psychology and Neuropsychology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio; The Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, Ohio
| | - O N Ray Bignall
- The Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, Ohio; Division of Nephrology and Hypertension, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - John David Spencer
- The Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, Ohio; Division of Nephrology and Hypertension, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Daryl J McLeod
- The Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, Ohio; Department of Urology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio.
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Jones EL, Shakespeare K, McLaughlin L, Noyes J. Understanding people's decisions when choosing or declining a kidney transplant: a qualitative evidence synthesis. BMJ Open 2023; 13:e071348. [PMID: 37562929 PMCID: PMC10423837 DOI: 10.1136/bmjopen-2022-071348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 07/26/2023] [Indexed: 08/12/2023] Open
Abstract
OBJECTIVES To synthesise qualitative research exploring patients' perspectives, experiences and factors influencing their decision-making preferences when choosing or declining kidney transplantation. DESIGN A qualitative evidence synthesis. DATA SOURCES Electronic databases were searched from 2000 to June 2021: PubMed, MEDLINE, CINAHL, Embase, PsycINFO, Web of Science, ProQuest Core Databases for Dissertations and Theses, and Google Scholar. ELIGIBILITY CRITERIA Qualitative studies exploring and reporting decision-making preferences of people with kidney disease, which reported influencing factors when choosing or declining kidney transplantation, published in English from high-income and middle-income countries. DATA EXTRACTION AND SYNTHESIS Titles were screened against the inclusion criteria. Thematic synthesis was done with the use of the Critical Appraisal Skills Programme qualitative checklist to assess study quality, and assessment of confidence in the qualitative findings was done using the Grading of Recommendation, Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative Research. FINDINGS 37 studies from 11 countries reported the perspectives of 1366 patients with kidney disease. Six descriptive themes were developed: decisional preferences influenced patients' readiness to pursue kidney transplantation, gathering sufficient information to support decision-making, navigating the kidney transplant assessment pathway, desire for kidney transplantation, opposed to kidney transplantation and uncertainties while waiting for the kidney transplant. A new enhanced theoretical model was developed to aid understanding of the complexities of decision-making in people with kidney disease, by integrating the Theory of Planned Behaviour and the Adaptive Decision Maker Framework to incorporate the novel findings. CONCLUSION The synthesis provides a better understanding of the extremely complex decision-making processes of people with kidney disease, which are aligned to their kidney transplantation preferences. Further research is needed to better understand the reasons for declining kidney transplantation, and to underpin development of personalised information, interventions and support for patients to make informed decisions when presented with kidney replacement options. PROSPERO REGISTRATION NUMBER CRD42021272588.
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Affiliation(s)
- Emma Louise Jones
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Kate Shakespeare
- Betsi Cadwaladr University Health Board, Clinical Psychology Dept, Royal Alexandra Hospital, Rhyl, UK
| | - Leah McLaughlin
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Jane Noyes
- School of Medical and Health Sciences, Bangor University, Bangor, UK
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6
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Strauss AT, Sidoti CN, Purnell TS, Sung HC, Jackson JW, Levin S, Jain VS, Malinsky D, Segev DL, Hamilton JP, Garonzik‐Wang J, Gray SH, Levan ML, Scalea JR, Cameron AM, Gurakar A, Gurses AP. Multicenter study of racial and ethnic inequities in liver transplantation evaluation: Understanding mechanisms and identifying solutions. Liver Transpl 2022; 28:1841-1856. [PMID: 35726679 PMCID: PMC9796377 DOI: 10.1002/lt.26532] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/15/2022] [Accepted: 06/06/2022] [Indexed: 01/02/2023]
Abstract
Racial and ethnic disparities persist in access to the liver transplantation (LT) waiting list; however, there is limited knowledge about underlying system-level factors that may be responsible for these disparities. Given the complex nature of LT candidate evaluation, a human factors and systems engineering approach may provide insights. We recruited participants from the LT teams (coordinators, advanced practice providers, physicians, social workers, dieticians, pharmacists, leadership) at two major LT centers. From December 2020 to July 2021, we performed ethnographic observations (participant-patient appointments, committee meetings) and semistructured interviews (N = 54 interviews, 49 observation hours). Based on findings from this multicenter, multimethod qualitative study combined with the Systems Engineering Initiative for Patient Safety 2.0 (a human factors and systems engineering model for health care), we created a conceptual framework describing how transplant work system characteristics and other external factors may improve equity in the LT evaluation process. Participant perceptions about listing disparities described external factors (e.g., structural racism, ambiguous national guidelines, national quality metrics) that permeate the LT evaluation process. Mechanisms identified included minimal transplant team diversity, implicit bias, and interpersonal racism. A lack of resources was a common theme, such as social workers, transportation assistance, non-English-language materials, and time (e.g., more time for education for patients with health literacy concerns). Because of the minimal data collection or center feedback about disparities, participants felt uncomfortable with and unadaptable to unwanted outcomes, which perpetuate disparities. We proposed transplant center-level solutions (i.e., including but not limited to training of staff on health equity) to modifiable barriers in the clinical work system that could help patient navigation, reduce disparities, and improve access to care. Our findings call for an urgent need for transplant centers, national societies, and policy makers to focus efforts on improving equity (tailored, patient-centered resources) using the science of human factors and systems engineering.
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Affiliation(s)
- Alexandra T. Strauss
- Department of MedicineSchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA,Malone Center for Engineering in HealthcareWhiting School of Engineering, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Carolyn N. Sidoti
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Tanjala S. Purnell
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA,Department of EpidemiologyBloomberg School of Public, Health Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Hannah C. Sung
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - John W. Jackson
- Department of EpidemiologyBloomberg School of Public, Health Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Scott Levin
- Malone Center for Engineering in HealthcareWhiting School of Engineering, Johns Hopkins UniversityBaltimoreMarylandUSA,Department of Emergency MedicineSchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Vedant S. Jain
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Daniel Malinsky
- Department of BiostatisticsColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Dorry L. Segev
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA,Department of EpidemiologyBloomberg School of Public, Health Johns Hopkins UniversityBaltimoreMarylandUSA
| | - James P. Hamilton
- Department of MedicineSchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | | | - Stephen H. Gray
- Department of SurgerySchool of Medicine, University of MarylandBaltimoreMarylandUSA
| | - Macey L. Levan
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Joseph R. Scalea
- Department of SurgerySchool of Medicine, University of MarylandBaltimoreMarylandUSA
| | - Andrew M. Cameron
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Ahmet Gurakar
- Department of MedicineSchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Ayse P. Gurses
- Department of Emergency MedicineSchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA,Center for Health Care Human FactorsArmstrong Institute for Patient Safety and Quality, Johns Hopkins MedicineBaltimoreMarylandUSA,Anesthesiology and Critical Care Medicine, Biomedical Informatics and Data Science (General Internal Medicine)School of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA,Department of Health Policy and ManagementBloomberg School of Public Health, Johns Hopkins UniversityBaltimoreMarylandUSA
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7
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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: 64] [Impact Index Per Article: 32.0] [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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Khalili M, Cardinal H, Ballesteros F, Fortin MC. Kidney transplant candidates' and recipients' perspectives on the decision-making process to accept or refuse a deceased donor kidney offer: Trust and graft survival matter. Clin Transplant 2022; 36:e14604. [PMID: 35099833 DOI: 10.1111/ctr.14604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 01/13/2022] [Accepted: 01/26/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The decision to accept a kidney from a deceased donor can be a difficult one. This study aims to capture the perspectives of transplant candidates (TCs) and kidney transplant recipients (KTRs) on the decision-making process when a deceased kidney is offered. METHODS We conducted six focus groups with KTRs and TCs. The content of the focus groups was analyzed using the qualitative thematic method. RESULTS KTRs reported that the experience of being offered a kidney could be difficult because of the circumstances of the offer and unpreparedness to participate in the discussion. Both KTRs and TCs trusted the medical expertise. Age and having experience with dialysis could influence the decision to accept an offer. In order to engage in the discussion, patients wanted to obtain estimates of expected graft survival. Patients did not express interest for a web-based calculator for patient use, but expected transplant physicians to summarize and explain the information that would impact graft survival time. CONCLUSION TCs and KTRs wanted to be involved in the decision to accept a deceased donor kidney. Tools that can help physicians communicate the risks and benefits of accepting an offer could improve patient participation in the decision-making process.
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Affiliation(s)
- Myriam Khalili
- Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Héloïse Cardinal
- Faculty of Medicine, Université de Montréal, Montreal, Canada.,Department of Medicine, Centre de recherche du CHUM, Montreal, Canada.,Department of Medicine, Canadian Donation and Transplantation Research Program, Edmonton, Canada
| | | | - Marie-Chantal Fortin
- Faculty of Medicine, Université de Montréal, Montreal, Canada.,Department of Medicine, Centre de recherche du CHUM, Montreal, Canada.,Department of Medicine, Canadian Donation and Transplantation Research Program, Edmonton, Canada
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9
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Non-medical barriers in access to early steps of kidney transplantation in the United States - A scoping review. Transplant Rev (Orlando) 2021; 35:100654. [PMID: 34597944 DOI: 10.1016/j.trre.2021.100654] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND In the United States (US), barriers in access to later steps in the kidney transplantation process (i.e. waitlisting) have been well documented. Barriers in access to earlier steps (i.e. referral and evaluation) are less well described due to the lack of national surveillance data. In this review, we summarize the available literature on non-medical barriers in access to kidney transplant referral and evaluation. METHODS Following PRISMA guidelines, we conducted a scoping review of the literature through June 3, 2021. We included all studies (quantitative and qualitative) reporting on barriers to kidney transplant referral and evaluation in the US published from 1990 onwards in English and among adult end-stage kidney disease (ESKD) patients (PROSPERO registration number: CRD42014015027). We narratively synthesized results across studies. RESULTS We retrieved information from 33 studies published from 1990 to 2021 (reporting data between 1990 and 2018). Most studies (n = 28, 85%) described barriers among patient populations, three (9%) among provider populations, and two (6%) included both patients and providers. Key barriers were identified across multiple levels and included patient- (e.g. demographic, socioeconomic, sociocultural, and knowledge), provider- (e.g. miscommunication, staff availability, provider perceptions and attitudes), and system- (e.g. geography, distance to care, healthcare logistics) level factors. CONCLUSIONS A multi-pronged approach (e.g. targeted and systemwide interventions, and policy change) implemented at multiple levels of the healthcare system will be necessary to reduce identified barriers in access to early kidney transplant steps. Collection of national surveillance data on these early kidney transplant steps is also needed to enhance our understanding of barriers to referral and evaluation.
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Harding JL, Perez A, Patzer RE. Nonmedical barriers to early steps in kidney transplantation among underrepresented groups in the United States. Curr Opin Organ Transplant 2021; 26:501-507. [PMID: 34310358 DOI: 10.1097/mot.0000000000000903] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Despite numerous targeted interventions and policy reforms, underrepresented minorities and patients with low socioeconomic status (SES) continue to have unequal access to kidney transplant. In this review, we summarize the most recent evidence on barriers to early kidney transplant steps (i.e. referral and evaluation) among underrepresented racial and ethnic minorities and low SES groups in the United States. RECENT FINDINGS This review highlights the interconnectedness of several patient-level (e.g. medical mistrust, transplant knowledge, access to care), provider-level (e.g. dialysis profit status, patient--provider communication; staff accessibility), and system-level (e.g. center-specific criteria, healthcare logistics, neighborhood poverty, healthcare logistics) factors associated with lower rates of referral and evaluation among underrepresented minorities and low SES groups, and the influence of systemic racism operating at all levels. SUMMARY Collection of national surveillance data on early transplant steps, as well as routinely captured data on upstream social determinants of health, including the measurement of racism rather than race, is necessary to enhance our understanding of barriers to referral and evaluation. A multipronged approach (e.g. targeted and systemwide interventions, and policy change) implemented at multiple levels of the healthcare system will be necessary to reduce disparities in early transplant steps.
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Affiliation(s)
- Jessica L Harding
- Division of Transplantation, Department of Surgery
- Department of Medicine, Emory University School of Medicine
- Department of Epidemiology, Rollins School of Public Health, Emory University
- Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Rachel E Patzer
- Division of Transplantation, Department of Surgery
- Department of Medicine, Emory University School of Medicine
- Department of Epidemiology, Rollins School of Public Health, Emory University
- Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
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Ku E, McCulloch CE, Adey DB, Li L, Johansen KL. Racial Disparities in Eligibility for Preemptive Waitlisting for Kidney Transplantation and Modification of eGFR Thresholds to Equalize Waitlist Time. J Am Soc Nephrol 2021; 32:677-685. [PMID: 33622978 PMCID: PMC7920175 DOI: 10.1681/asn.2020081144] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/07/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Patients may accrue wait time for kidney transplantation when their eGFR is ≤20 ml/min. However, Black patients have faster progression of their kidney disease compared with White patients, which may lead to disparities in accruable time on the kidney transplant waitlist before dialysis initiation. METHODS We compared differences in accruable wait time and transplant preparation by CKD-EPI estimating equations in Chronic Renal Insufficiency Cohort participants, on the basis of estimates of kidney function by creatinine (eGFRcr), cystatin C (eGFRcys), or both (eGFRcr-cys). We used Weibull accelerated failure time models to determine the association between race (non-Hispanic Black or non-Hispanic White) and time to ESKD from an eGFR of ≤20 ml/min per 1.73 m2. We then estimated how much higher the eGFR threshold for waitlisting would be required to achieve equity in accruable preemptive wait time for the two groups. RESULTS By eGFRcr, 444 CRIC participants were eligible for waitlist registration, but the potential time between eGFR ≤20 ml/min per 1.73 m2 and ESKD was 32% shorter for Blacks versus Whites. By eGFRcys, 435 participants were eligible, and Blacks had 35% shorter potential wait time compared with Whites. By the eGFRcr-cys equation, 461 participants were eligible, and Blacks had a 31% shorter potential wait time than Whites. We estimated that registering Blacks on the waitlist as early as an eGFR of 24-25 ml/min per 1.73 m2 might improve racial equity in accruable wait time before ESKD onset. CONCLUSIONS Policies allowing for waitlist registration at higher GFR levels for Black patients compared with White patients could theoretically attenuate disparities in accruable wait time and improve racial equity in transplant access.
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Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Deborah B. Adey
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Libo Li
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Kirsten L. Johansen
- Division of Nephrology, Department of Medicine and University of Minnesota, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
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