Non-medical barriers in access to early steps of kidney transplantation in the United States - A scoping review

Barriers to Kidney Transplantation in Urban Hemodialysis Centers in Pakistan: A Cross-Sectional Study

BACKGROUND AND AIMS

End-stage kidney disease is a global health challenge that has greatly affected low-income and middle-income countries. While a living donor kidney transplant (LDKT) is the most optimal treatment for end-stage kidney disease, many medical and nonmedical barriers persist which hinder transplant rates. This study aims to identify the various medical, psychological, and socioeconomic barriers to LDKT among patients in urban hemodialysis centers in Pakistan.

METHODS

A cross-sectional study of patients undergoing hemodialysis in urban hospitals across three urban cities in Pakistan was conducted. Participants were given a structured questionnaire addressing demographics, medical history, socioeconomic status, and transplantation awareness.

RESULTS

The median age was 54 years (IQR 20), with 56.2% male participants. Barriers were identified as socioeconomic (61.4%), medical (32.6%), and psychological (6%). Significant differences in median age were observed across groups (P < .01), with socioeconomic barriers associated with younger patients (median age 49 years) compared to medical (median 63 years) and psychological (59 years) barriers. Patients with socioeconomic barriers were younger (P ≤ .01), had lower income (P = .02), and had relatively lower rates of marriage (P = .02) compared to those in other categories. Lack of donors and lack of financial resources were the most common barriers, cited by 50.2% and 50% of participants, respectively.

CONCLUSIONS

Socioeconomic barriers are the leading obstacles to LDKT in Pakistan. Efforts must be made to address these barriers, such as a deceased donor program, financial aid, and improving patient knowledge about LDKT. Further studies should explore rural populations and psychological barriers in greater depth.

Utility and bias in psychosocial evaluations for transplant listing

PURPOSE OF REVIEW

Disparities in access to transplantation are persistent and pervasive among minoritized populations, and remain incompletely explained by socioeconomic status, insurance, geography, or medical factors. Although much attention has been paid to factors contributing to disparities in organ allocation, fewer studies have focused on barriers to the transplant waitlist. Given increasing calls for equity in organ transplantation, we examine the role of nonmedical factors used in transplant listing decisions, including psychosocial factors like social support, motivation, and knowledge in improving utility in transplant listing decisions, as well as their potential for reinforcing bias.

RECENT FINDINGS

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

SUMMARY

Improving consistency and evidence-based approaches in patient evaluation and listing decisions will require greater efforts to identify which psychosocial risk factors are predictive of posttransplant outcomes. Social needs screening presents a strengths-based framework for incorporating psychosocial factors in transplant listing decisions.

Immediate Postintervention Outcomes from a Randomized Trial that Sought to Enhance Access to Live Donor Kidney Transplant for Black and African Americans

INTRODUCTION

Eliminating racial inequities in access to kidney transplantation requires multilevel interventions that target both patients and health systems.

RESEARCH QUESTION

The aim of this study was to determine whether adding culturally sensitive, web-based patient education to a transplant center-level intervention was associated with increased knowledge, motivation to pursue living donor kidney transplant, and confidence in the behavioral skills to discuss living donation among Black/African American patients with end-stage kidney disease.

DESIGN

A total of 411 transplant candidates were randomized to intervention (N = 222) or control groups (N = 189) and completed measures at baseline and immediate follow-up during the transplant evaluation visit.

RESULTS

Results indicated no significant change in knowledge across time or study condition. At immediate follow-up, participants of both study conditions exhibited a significantly higher motivation to pursue living donation (t = 3.066, P < .01) versus at baseline. Both study conditions demonstrated increased confidence in the behavioral skills to discuss living donation over time (t = 3.580, P < .001). Process evaluation findings demonstrated limited engagement with the online video content across both conditions.

CONCLUSION

Results suggest that the intervention did not perform better than control but raised important considerations for the delivery of transplant education targeting Black/African American patients in a busy clinical setting.

A national registry study evaluated the landscape of kidney transplantation among presumed unauthorized immigrants in the United States

Unauthorized immigrants and permanent residents may experience challenges in accessing kidney transplantation due to limited healthcare access, socioeconomic and cultural barriers. Understanding the United States (US) national landscape of kidney transplantation for non-citizens may inform policy changes. To evaluate this, we utilized two cohorts from the US national registry (2013-2023): 287,481 adult candidates for first transplant listing and 190,176 adult first transplant recipients. Citizenship was categorized as US citizen (reference), permanent resident, and presumed unauthorized immigrant. Negative binomial regression was used to quantify the incidence rate ratio over time by citizenship status. Cause-specific hazards models, with clustering at the state of listing/transplant, were used to calculate the adjusted hazard ratio of waitlist mortality, kidney transplant, and post-transplant outcomes (mortality/death-censored graft failure) by citizenship category. The crude proportion of presumed unauthorized immigrants listed increased over time (2013: 0.9%, 2023:1.9%). However, after accounting for case mix and waitlist size, there was no change in listing over time. Presumed unauthorized immigrants were less likely to experience waitlist mortality (adjusted Hazard Ratio 0.54, 95% Confidence Interval: 0.46-0.62), were more likely to obtain deceased donor kidney transplant (1.11: 1.05-1.18), but less likely to receive live donor (0.80: 0.71-0.90) or preemptive kidney transplant (0.52: 0.43-0.62). When stratified by insurance status, presumed unauthorized immigrants on Medicaid were less likely to receive deceased donor kidney transplants compared to their citizen counterparts; however, presumed unauthorized immigrants with private insurance or Medicare were more likely to receive deceased donor kidney transplants. Presumed unauthorized immigrants were less likely to experience post-transplant death (0.56: 0.43-0.69) and graft failure (0.69: 0.57-0.84). Residents had similar pre- and post-transplant outcomes. Despite the barriers to kidney transplantation faced by presumed unauthorized immigrants and residents in the US, better post-transplant outcomes for presumed unauthorized immigrants compared to citizens persisted, even after accounting for differences in patient characteristics.

Language and cultural concordance to promote equity in organ transplantation for Hispanics with limited English proficiency

PURPOSE OF REVIEW

Hispanics with limited English proficiency (LEP) face unique challenges in accessing organ transplantation due to limited culturally concordant care and linguistically appropriate resources, leading to disparities in healthcare delivery and transplantation outcomes. This review examines how language barriers affect access to kidney and liver transplant, and highlights the importance of institutional support for quality interpretation services in promoting healthcare equity in transplantation.

RECENT FINDINGS

Hispanics experience greater disease burden, but are less likely to receive a transplant compared to non-Hispanic Whites. LEP is a significant barrier to transplantation. Culturally and linguistically concordant interventions, such as the "Hispanic Kidney Transplant Program," have demonstrated success in improving transplant-related outcomes among Hispanics. However, limited resources affect widespread implementation, and the broad lack of interpretation services in healthcare settings delay timely care in transplantation.

SUMMARY

Despite some progress demonstrated by culturally and linguistically concordant clinical intervention trials, disparities in transplantation for Hispanics with LEP remain. Enhancing the availability of interpretation services, recruiting and hiring bilingual healthcare professionals, and training healthcare staff to effectively engage with language and interpretation resources are critical to improving health equity. Efforts must prioritize language access and cultural concordance to address the unique challenges faced by Hispanics with LEP.

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

Key Points

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

Background

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

Methods

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

Results

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

Conclusions

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

Clinical Trial registry name and registration number:

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

«I can't imagine it without my nurse»: Experiences of people with chronic kidney disease in the evaluation process as kidney transplant candidates

This qualitative study aimed to explore the experiences of 11 adults with chronic kidney disease (CKD) undergoing evaluation for kidney transplant (KT) and examine the role played by the nurse in the process. Employing a descriptive phenomenology approach, semi-structured interviews were conducted between October 2022 and July 2023. Thematic analysis, facilitated by Atlas. ti software, revealed a systemic management diagram with "The candidate for kidney transplant and their reality" at the center, followed by "The process of chronic kidney disease and kidney transplantation," and concluding with the most distal category centered on "The kidney transplant access nurse." This organizational framework provided insights into the layers of relationships between emerging themes. The findings underscored the complexity and multidimensionality of the CKD and KT process, emphasizing the nurse's pivotal role as a guide and protector throughout the evaluation process for accessing kidney transplantation. The convergence of results with existing literature highlighted the need to address challenges such as lack of time, resources, and emotional support to enhance the quality of care. Recognizing the nurse's crucial importance in this process, the study emphasizes the significance of addressing these challenges to improve patient care and calls for attention to the nurse's role in guiding individuals through the intricate journey of CKD and kidney transplantation.

Renal Disease and Kidney Transplantation in Hispanic American Persons

The Hispanic population of the United States is the second largest racial or ethnic group, comprising 18.7% of the population. However, this population is incredibly heterogeneous differing in genetic traits, cultural upbringing, educational backgrounds, and financial status. The impact of this heterogeneity on the prevalence and outcomes of renal disease and kidney transplantation is understudied compared with non-Hispanic White and Black populations. What is known appears to be underrecognized. This review aims to critically assess current medical literature on Hispanic individuals, focusing on etiological factors, disease progression, and outcomes related to CKD and kidney transplantation. By doing so, we aim to underscore key areas for further in-depth investigation.

Lower access to kidney transplantation for women in France is not explained by comorbidities and social deprivation

BACKGROUND

Access to kidney transplantation (KT) remains challenging for patients with end-stage kidney disease. This study assessed women's access to KT in France by considering comorbidities and neighbourhood social deprivation.

METHODS

All incident patients 18-85 years old starting dialysis in France between 1 January 2017 and 31 December 2019 were included. Three outcomes were assessed: access to the KT waiting list after dialysis start, KT access after waitlisting and KT access after dialysis start. Cox and Fine-Gray models were used. Gender-European Deprivation Index and gender-age interactions were tested and analyses were performed among strata if required.

RESULTS

A total of 29 395 patients were included (35% of women). After adjusting for social deprivation and comorbidities, women were less likely to be waitlisted at 1 year {adjusted hazard ratio [adjHR] 0.91 [95% confidence interval (CI) 0.87-0.96]} and 3 years [adjHR 0.87 (95% CI 0.84-0.91)] after dialysis initiation. This disparity concerned mainly women ≥60 years of age [adjHR 0.76 (95% CI 0.71-0.82) at 1 year and 0.75 (0.71-0.81) at 3 years]. Access to KT after 2 years of waitlisting was similar between genders. Access to KT was similar between genders at 3 years after dialysis start but decreased for women after 4 years [adjHR 0.93 (95% CI 0.88-0.99)] and longer [adjHR 0.90 (95% CI 0.85-0.96)] follow-up.

CONCLUSIONS

In France, women are less likely to be waitlisted and undergo KT. This is driven by the ≥60-year-old group and is not explained by comorbidities or social deprivation level.

Quality of life of patients after kidney transplant: ADHERE Brazil multicenter cross-sectional study

BACKGROUND

Quality of life (QoL) is a measure to evaluate kidney transplant (KT) results.

AIM

To describe the QoL profile in a larger sample of Brazilian patients who underwent KT according to age, sex, and access to KT.

METHODS

We conducted a secondary data analysis of the ADHERE BRAZIL multicenter cross-sectional study including 1105 patients from 20 centers, considering KT access region and transplant activity. QoL was assessed by the WHOQOL-BREF. Data was compared using Generalized Estimating Equations.

RESULTS

Overall, 58.5 % of the patients were men, mean age of 47.6 ± 12.6 years. The general QoL score was 81 ± 15.1, 58.6 ± 11.6 for physical, 65.5 ± 11.4 for psychological, 68.3 ± 17.1 for social relationships, and 64.2 ± 13.3 for environmental domain. Higher QoL scores were observed in men compared to women in three WHOQOL-BREF domains: psychological (OR:2.62; CI, 1.29 ̶ 3.95, p < 0.0001), social relationships (OR:3.21; CI, 1.2 ̶ 5.23, p = 0.002) and environmental (OR:3.79; CI:2.23 ̶ 5.35, p < 0.0001). Younger patients (18-44 years) had higher scores in the psychological (OR:-2.69; CI, -4.13 ̶ -1.25; p < 0.001; OR:-3.52; CI, -5.39 ̶ -1.66; p < 0.001) and social (OR:-3.46; CI, -5.64 ̶ -1.27; p = 0.002; OR:-7.17; CI, -10 ̶ -4.35; p < 0.0001) domains than older ones (45-59 and > 60 years, respectively). Patients from higher KT access region had higher scores in environmental domain (OR:3.53; CI, 0.28 ̶ 6.78; p = 0.033).

CONCLUSIONS

Featuring the results of KT under patient view, the physical and social relationships domains were the most and least affected, respectively. Lower QoL subgroups (females and age > 45 years) should be targeted in future multi-professional interventions.

Setting reasonable goals for kidney transplant referral among dialysis facilities

BACKGROUND

Determining whether a patient is eligible for kidney transplantation is complex. In this study, we estimate what proportion of patients with end-stage kidney disease (ESKD) might have been suitable candidates for kidney transplantation but were not referred.

METHODS

We identified 43,952 people initiating dialysis for kidney failure between 2012 and 2017 in the states of Georgia, North Carolina, or South Carolina from the United States Renal Data System and linked to the Early-Steps to Transplant Access Registry to obtain data on referral and waitlisting up until December 2020. We identified 'good transplant candidates' as those who were waitlisted within 2-years of referral, among all patients referred within 1-year of dialysis initiation. Using propensity score cut-offs, logistic regression, and area under the curve (AUC), we then estimated the proportion of individuals who may have been good transplant candidates, but were not referred.

RESULTS

Overall, 42.6% of incident dialysis patients were referred within one year and among them, 32.9% were waitlisted within 2 years of referral. Our model had reasonably good discrimination for identifying good transplant candidates with an AUC of 0.70 (95%CI 0.69-0.71), sensitivity of 0.68 and specificity of 0.61. Overall, 25% of individuals not referred for transplant may have been 'good' transplant candidates. Adding these patients to the existing 18,725 referred patients would increase the proportion of incident ESKD patients being referred within one year from 42.6% to 57.2% (a ~ 14.6% increase).

CONCLUSIONS

In this study, we show that a significant proportion of potentially good transplant candidates are not being referred for transplant. A ~ 14% increase in the proportion of patients being referred from dialysis facilities is both a meaningful and realistic goal and could lead to more qualified patients being referred and subsequently waitlisted for a lifesaving transplant.

A systematic review of psychosocial and sex-based contributors to gender disparities in the United States across the steps towards kidney transplantation

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.

Complex management and descriptive cost analysis of kidney transplant candidates: a descriptive cross-sectional study

BACKGROUND

The organisational care needs involved in accessing kidney transplant have not been described in the literature and therefore a detailed analysis thereof could help to establish a framework (including appropriate timing, investment, and costs) for the management of this population. The main objective of this study is to analyse the profile and care needs of kidney transplant candidates in a tertiary hospital and the direct costs of studying them.

METHODS

A descriptive, cross-sectional study was conducted using data on a range of variables (sociodemographic and clinical characteristics, study duration, and investment in visits and supplementary tests) from 489 kidney transplant candidates evaluated in 2020.

RESULTS

The comorbidity index was high (> 4 in 64.3%), with a mean of 5.6 ± 2.4. Part of the study population had certain characteristics that could hinder their access a kidney transplant: physical dependence (9.4%), emotional distress (33.5%), non-adherent behaviours (25.2%), or language barriers (9.4%). The median study duration was 6.6[3.4;14] months. The ratio of required visits to patients was 5.97:1, meaning an investment of €237.10 per patient, and the ratio of supplementary tests to patients was 3.5:1, meaning an investment of €402.96 per patient.

CONCLUSIONS

The study population can be characterised as complex due to their profile and their investment in terms of time, visits, supplementary tests, and direct costs. Management based on our results involves designing work-adaptation strategies to the needs of the study population, which can lead to increased patient satisfaction, shorter waiting times, and reduced costs.

Opportunities for Improving the Transplant Assessment and Education Process in British Columbia: Patient and Health Care Provider Perspective

Background

There are several steps patients and their health care providers must navigate to access kidney transplantation in British Columbia (BC).

Objective

We explored perceptions and experiences with the pretransplant process across BC to determine where process improvements can be made to enhance access to transplantation.

Design

Anonymous surveys were sent online and via post to health care providers (including nephrologists, registered nurses, and coordinators) and patients across BC.

Setting

Kidney care clinics, transplant regional clinics, and provincial transplant centers in BC.

Measurements

Surveys included Likert scale questions on the current pretransplant process and transplant education available in BC. The health provider survey focused on understanding the pretransplant process, knowledge, roles, and communication while the patient survey focused on patient education and experience of the pretransplant processes.

Results

A total of 100 health care providers and 146 patients responded. Seventy-six percent of health care providers understood their role and responsibility in the pretransplant process, while only 47% understood others' roles in the process. Fifty-nine percent of health care respondents felt adequately supported by the provincial donor and transplant teams. Seventy-one percent of registered nurses and 92% of nephrologists understood transplant eligibility. About 68% and 77% of nurses and nephrologists, respectively, reported having enough knowledge to discuss living donation with patients. Fifty percent of patients had received transplant education, of which 60% had a good grasp of the pretransplant clinical processes. Sixty-three percent felt their respective kidney teams had provided enough advice and tools to support them in finding a living donor. Fifty percent of patients reported feeling up to date with their status in the evaluation process.

Limitations

This analysis was conducted between December 2021 and June 2022 and may need to account for practice changes that occurred during the COVID-19 pandemic. Responses are from a selection of health care providers, thus acknowledging a risk of selection bias. Furthermore, we are not able to verify patients who reported receiving formal transplant education from their health care providers.

Conclusions

Exploring these themes suggests communication with regional clinics and transplant centers can be improved. In addition, patient and staff education can benefit from education on kidney transplantation and the pretransplant clinical processes. Our findings provide opportunities to develop strategies to actively address modifiable barriers in a patient's kidney transplantation journey.

Expanding the access to kidney transplantation: Strategies for kidney transplant programs

Kidney transplantation is the most successful kidney replacement therapy available, resulting in improved recipient survival and societal cost savings. Yet, nearly 70 years after the first successful kidney transplant, there are still numerous barriers and untapped opportunities that constrain the access to transplant. The literature describing these barriers is extensive, but the practices and processes to solve them are less clear. Solutions must be multidisciplinary and be the product of strong partnerships among patients, their networks, health care providers, and transplant programs. Transparency in the referral, evaluation, and listing process as well as organ selection are paramount to build such partnerships. Providing early culturally congruent and patient-centered education as well as maximizing the use of local resources to facilitate the transplant work up should be prioritized. Every opportunity to facilitate pre-emptive kidney transplantation and living donation must be taken. Promoting the use of telemedicine and kidney paired donation as standards of care can positively impact the work up completion and maximize the chances of a living donor kidney transplant.

Use of Donor-derived Cell-free DNA to Inform Tapering of Immunosuppression Therapy in Kidney Transplant Recipients: An Observational Study

Background

Immunosuppression therapy (IST) is required for allograft survival but can cause significant adverse effects. Donor-derived cell-free DNA (dd-cfDNA) is a validated noninvasive biomarker for active rejection in kidney transplant (KTx). Evidence supporting dd-cfDNA testing use in IST management is limited.

Methods

In this single-center observational study, dd-cfDNA testing was performed in 21 KTx patients considered good candidates for mycophenolic acid (MPA) reduction. Patients with dd-cfDNA <1% at the first visit (enrollment) had their MPA dosage reduced; those with dd-cfDNA ≥1% had their MPA dosage maintained. Patients were monitored with dd-cfDNA for 6 additional visits.

Results

Of 21 patients enrolled in the study, 17 were considered low risk for rejection by dd-cfDNA and underwent MPA reduction; 4 patients were considered high risk for rejection by dd-cfDNA and had their initial MPA dosage maintained. Of the 4 patients considered high risk for rejection by dd-cfDNA, 1 experienced chronic allograft nephropathy and graft loss, and another received an indication biopsy that showed no evidence of rejection. Of the 17 patients considered low risk for rejection by dd-cfDNA, none experienced allograft rejection. dd-cfDNA was used for surveillance in a 6-mo period following MPA reduction; no untoward results were noted.

Conclusions

This proof-of-concept study reports the use of dd-cfDNA to directly inform IST management in a cohort of KTx who were candidates for IST reduction.

Disparities Persist Among Hispanic Patients: Completing Evaluation, Waitlisting, and Receiving a Kidney Transplant

Background

Hispanic patients receive disproportionately fewer kidney transplants (KT) than non-Hispanic White (NHW) patients. In this observational study, we evaluated disparities in completing evaluation steps to KT among Hispanic patients.

Methods

Using medical records of Hispanic and NHW patients initiating evaluation at 4 transplant centers from January 2011 to March 2020, we performed sequential Cox models to compare Hispanic versus NHW patients reaching each step of the evaluation process until receiving a KT.

Results

Among all 5197 patients (Hispanic n = 2473; NHW n = 2724) initiating evaluation, Hispanic patients had 8% lower risk to be approved by the kidney pancreas (KP) committee than NHW patients (adjusted hazard ratio [aHR], 0.92; 95% confidence intervals (CI), 0.86-0.98; P = 0.015). Among 3492 patients approved by the KP committee, Hispanic patients had 13% lower risk to be waitlisted than NHW patients (aHR, 0.87; 95% CI, 0.81-0.94; P = 0.004). Among 3382 patients who were waitlisted, Hispanic patients had 11% lower risk than NHW patients to receive KT (aHR, 0.89; 95% CI, 0.81-0.97; P = 0.011). Among all patients initiating evaluation, Hispanic patients had a 16% lower risk than NHW patients to reach KT (aHR, 0.84; 95% CI, 0.76-0.92; P = 0.0002).

Conclusions

Our study found that disproportionately fewer Hispanic patients were approved by the KP committee, were waitlisted, and received a KT, particularly a living donor kidney transplant, than NHW patients. Closer oversight of the evaluation process may help patients overcome challenges in access to KT.

Implementation of the ASCENT Trial to Improve Transplant Waitlisting Access

Introduction

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

Methods

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

Results

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

Conclusion

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

Systems Connected to Inequities in Access to Kidney Transplantation and the Value of Intersectionality

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.

Intersectional race and gender disparities in kidney transplant access in the United States: a scoping review

BACKGROUND

Gender and racial disparities in kidney transplant access are well established, however how gender and race interact to shape access to kidney transplant is less clear. Therefore, we examined existing literature to assess what is known about the potential interaction of gender and race and the impact on access to kidney transplantation in the US.

METHODS

Following PRISMA guidelines, we conducted a scoping review and included quantitative and qualitative studies published in English between 1990 and May 31, 2023 among adult end-stage kidney disease patients in the US. All studies reported on access to specific transplant steps or perceived barriers to transplant access in gender and race subgroups, and the intersection between the two. We narratively synthesized findings across studies.

RESULTS

Fourteen studies met inclusion criteria and included outcomes of referral (n = 4, 29%), evaluation (n = 2, 14%), waitlisting (n = 4, 29%), transplantation (n = 5, 36%), provider perceptions of patient transplant candidacy (n = 3, 21%), and patient preferences and requests for a living donor (n = 5, 36%). Overall, we found that White men have the greatest access at all steps of the transplant process, from referral to eventual living or deceased donor transplantation. In contrast, women from racial or ethnic minorities tend to have the lowest access to kidney transplant, in particular living donor transplant, though this was not consistent across all studies.

CONCLUSIONS

Examining how racism and sexism interact to shape kidney transplant access should be investigated in future research, in order to ultimately shape policies and interventions to improve equity.

Referral and evaluation for kidney transplantation among patients with lupus nephritis-related end-stage kidney disease

OBJECTIVE

For the majority of patients with lupus nephritis-related end-stage kidney disease (LN-ESKD), kidney transplant is associated with better outcomes than dialysis. Access to kidney transplant requires an initial referral to a transplant center and medical evaluation prior to waitlisting. The study's objective was to examine access to these early steps in the kidney transplant process among patients with LN-ESKD.

METHODS

Adults who began treatment for ESKD in the Southeast, Northeast, New York, or Ohio River Valley U.S. regions from 1/1/2012 to 12/31/2019, followed through 6/30/2021, were identified from the United States Renal Data System. Referral and evaluation start data were collected from 28 of 48 transplant centers across these regions. The exposure was primary cause of ESKD (LN-ESKD vs other-ESKD). The outcomes were referral and evaluation start at a transplant center. Cox models quantified the association between LN-ESKD (vs other-ESKD) and referral and evaluation start.

RESULTS

Among 192,318 patients initiating treatment for ESKD, 0.4% had LN-ESKD. Over half (58%) of LN-ESKD patients were referred before study end, and among those referred, 66% started the evaluation. In adjusted analyses, patients with LN-ESKD were referred (HR: 1.09, 95% CI: 0.99, 1.19) and started the transplant evaluation (HR: 1.13, 95% CI: 1.00, 1.28) at a higher rate than patients with other-ESKD. Among referred patients with LN-ESKD, the median time from ESKD start to referral was 2.9 months (IQR: <1 to 11.7 months), which is similar to patients with other-ESKD (median 2.6 months, IQR: <1 to 8.8 months).

CONCLUSIONS

Among incident patients with ESKD, having a primary diagnosis of LN-ESKD versus other-ESKD is associated with higher rates of early transplant access outcomes. Despite this, patients with LN-ESKD (vs other-ESKD) are less likely to be preemptively referred (i.e., referred prior to ESKD start) for kidney transplant. While providers may no longer be delaying the early steps in the kidney transplantation process among this patient population, there is still room for improvement in the rates of preemptive referral. Access to kidney transplant referral prior to ESKD could result in increased transplant rates and better transplant outcomes for patients with LN-ESKD.

Racial Equity in Living Donor Kidney Transplant Centers, 2008-2018

Importance

It is unclear whether center-level factors are associated with racial equity in living donor kidney transplant (LDKT).

Objective

To evaluate center-level factors and racial equity in LDKT during an 11-year time period.

Design, Setting, and Participants

A retrospective cohort longitudinal study was completed in February 2023, of US transplant centers with at least 12 annual LDKTs from January 1, 2008, to December 31, 2018, identified in the Health Resources Services Administration database and linked to the US Renal Data System and the Scientific Registry of Transplant Recipients.

Main Outcomes and Measures

Observed and model-based estimated Black-White mean LDKT rate ratios (RRs), where an RR of 1 indicates racial equity and values less than 1 indicate a lower rate of LDKT of Black patients compared with White patients. Estimated yearly best-case center-specific LDKT RRs between Black and White individuals, where modifiable center characteristics were set to values that would facilitate access to LDKT.

Results

The final cohorts of patients included 394 625 waitlisted adults, of whom 33.1% were Black and 66.9% were White, and 57 222 adult LDKT recipients, of whom 14.1% were Black and 85.9% were White. Among 89 transplant centers, estimated yearly center-level RRs between Black and White individuals accounting for center and population characteristics ranged from 0.0557 in 2008 to 0.771 in 2018. The yearly median RRs ranged from 0.216 in 2016 to 0.285 in 2010. Model-based estimations for the hypothetical best-case scenario resulted in little change in the minimum RR (from 0.0557 to 0.0549), but a greater positive shift in the maximum RR from 0.771 to 0.895. Relative to the observed 582 LDKT in Black patients and 3837 in White patients, the 2018 hypothetical model estimated an increase of 423 (a 72.7% increase) LDKTs for Black patients and of 1838 (a 47.9% increase) LDKTs for White patients.

Conclusions and Relevance

In this cohort study of patients with kidney failure, no substantial improvement occurred over time either in the observed or the covariate-adjusted estimated RRs. Under the best-case hypothetical estimations, modifying centers' participation in the paired exchange and voucher programs and increased access to public insurance may contribute to improved racial equity in LDKT. Additional work is needed to identify center-level and program-specific strategies to improve racial equity in access to LDKT.

Health inequities in dialysis care: A scoping review

MAIN PROBLEM

We aim to look at potential gaps in current dialysis literature on inequities and explore future research that could contribute to more equitable care.

METHODS

Following guidelines from the Joanna Briggs Institute (JBI) and the Preferred Reporting Items for Systematic reviews and Meta Analyses extension for Scoping Reviews (PRISMA-ScR), we conducted a scoping review of health inequities in dialysis. PubMed and Ovid Embase were searched in July 2022 for articles published between 2016 and 2022 that examined at least one of the following NIH defined health inequities: race/ethnicity, sex/gender, LGBTQ+ identity, underserved rural populations, education level, income, and occupation status. Frequencies of each health inequity as well as trends over time of the four most examined inequities were analyzed.

RESULTS

In our sample of 69 included studies, gaps were identified in LGBTQ+ identity and patient education. Inequities pertaining to race/ethnicity, sex/gender, underserved rural populations, and income were sufficiently reported. No trends between inequities investigated over time were identified.

CONCLUSIONS

Our scoping review examined current literature on health inequities pertaining to dialysis and found gaps concerning LGBTQ+ and patients with lower levels of education. To help fill these gaps, and possibly alleviate additional burden to these patients, we recommend cultural competency training for providers and dialysis center staff as well as community-based educational programs to improve dialysis patients' health literacy.

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

Rationale & Objective

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

Study Design

Retrospective cohort study.

Setting & Participants

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

Exposures

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

Outcomes

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

Analytical Approach

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

Results

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

Limitations

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

Conclusions

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

Plain-Language Summary

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Nominal Group Technique Study of Patients Who Identify as Black or African American and Access to Renal Transplantation

Introduction: Completion of the renal transplant evaluation has been associated with several barriers for patients who identify as Black or African American. This study sought to prioritize barriers to and motivators of completing the renal transplant evaluation. Methods/Approach: Semi-structured interviews and focus groups with a nominal group technique were used to generate priority scores. Transplant professionals (N = 23) were recruited from 9 transplant centers in the Mid-Atlantic, Mid-Western, and Southeastern parts of the United States. Black or African American identifying renal patients (N = 30) diagnosed with end-stage kidney disease were recruited from 1 transplant center in the Mid-Atlantic region. Findings: Priority scores were created to assess the quantitative data of participant rankings of top barriers and motivators. The most significant barriers identified by both patients and transplant professionals comprised financial constraints, insurance issues, difficulty navigating the healthcare system, transportation difficulties, and multiple health problems. Facilitators consisted of family/social support, transplant education, patient navigators, comprehensive insurance, and physician repertoire and investment. A qualitative description of the ranked factors resulted in themes classified as intrapersonal, health, socioeconomic, transplant-specific healthcare, and general healthcare. Conclusion: These findings provided vital information to transplant centers nationwide about assessing the influences of renal transplant evaluation completion. Achieving equity in access to transplantation for Black or African American renal patients requires multilayered approaches.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

National Institutes of Health ( NCT02879812 ).

PODCAST

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

Broad organ acceptance and equitable access to early kidney transplantation

BACKGROUND

Broad organ acceptance can increase early kidney transplantation (KTX) within <1-year of dialysis initiation while improving access inequity.

METHODS

Single-center data of adult isolated deceased-donor KTX recipients between 2013 and 2020 were stratified into three 2.5-year periods before-, early after-, and late after our center's deceased-donor organ acceptance practice change, excluding a 6-month implementation period. Outcomes were assessed within five recipient subgroups based on demographic and clinical characteristics.

RESULTS

Of 704 recipients, the frequency of early KTX was 22% pre-change, 36% early post-change, and 34% late post-change. Given similar post-change frequencies of early KTX, post-change eras were combined to improve analytic power of subgroup analyses. After the organ acceptance practice change (vs. pre-change), the likelihood of early KTX increased variably within historically underserved groups, including recipients who were older (37%-39%, p = .859), Black (10%-21%, p = .136), female (21%-37%, p = .034), diabetic (13%-32%, p = .010), and BMI≥35 kg/m² (20%-34%, p = .007). Despite the practice change, Black recipients continued to experience less early KTX compared to non-Black recipients. The likelihood of delayed graft function was significantly increased (p < .001), and 1-year creatinine was significantly higher (p < .001) post-practice change, but between-era risk-adjusted death-censored graft survival was similar.

CONCLUSIONS

Transition to broader donor acceptance was associated with more early KTXs among historically underserved patient subgroups. However, the effect was non-significant among Black recipients, suggesting the need for additional strategies to impact early transplant access for this population. Studies of broad organ acceptance are needed to examine both access and outcomes.

Perception of social inequities in the access to the kidney transplant waiting list by nephrology trainees: a national survey

BACKGROUND

Social inequalities in health are responsible for disparities in access to the kidney transplant waiting list (KTWL). The perception of disparities by nephrologists has consequences for the registration on the KTWL. The purposes of our study were to assess the perception of the factors implicated in the disparities in access to the KTWL by nephrology trainees and to assess the quality of the questionnaire.

METHODS

A questionnaire was developed to assess the perception of the determinants of the inequities in access to waitlisting. Continuous variables were described by median, 1st and 3rd quartiles. Categorical variables were described by frequencies and percentages. A principal component analysis and a hierarchical cluster analysis were performed to approach the correlation between the variables. A scree plot and a factor analysis were performed to determine the dimensions of the questionnaire. The internal consistency was estimated by Cronbach's coefficient.

RESULTS

The response rate was 98/110 (89%). The determinants of inequities in the access to KTWL not perceived by the nephrology trainees were "female sex", "income level" and "the centre provision to adapt the information to all of the patients" (18,3%, 36,7, 47% respectively). "Age", "being born abroad", "place of living", "education level", "transplant centre", "the health care provider" were determinants of disparities perceived by most of the trainees (85,7%, 75,5%, 82,6%, 78,6%, 73,5% et 78,5% respectively). Items related to the transplant centre were positively correlated, as well as "being born abroad", "education level" and "income level". The Cronbach's coefficient was 0,60.

CONCLUSION

Social inequalities in health are partially perceived by nephrology trainees. A teaching session could raise nephrologists' awareness of this issue and could help reduce the impact of these disparities on the course of ESKD (end-stage kidney disease) patients.

Values, Perspectives, and Experiences of Indigenous Māori Regarding Kidney Transplantation: A Qualitative Interview Study in Aotearoa/New Zealand

RATIONALE & OBJECTIVE

In Aotearoa/New Zealand, Indigenous Māori experience inequitable delivery of kidney transplantation despite disproportionately higher rates of kidney failure. This study describes Māori patients' and families' values, perspectives, and experiences related to kidney transplantation.

STUDY DESIGN

Qualitative interview study.

SETTING & PARTICIPANTS

We conducted 40 in-depth interviews of 40 Māori: 8 who had received a transplant, 20 with chronic kidney disease (which included 10 on the deceased donor transplant list, 9 who were interested in transplantation and not currently waitlisted or who were ineligible for waitlisting, and 1 who was not interested in transplantation), 4 live-kidney donors, and 8 family members including 6 who had experiences with donor assessment.

ANALYTICAL APPROACH

Data were analyzed inductively to generate themes and a conceptual framework.

RESULTS

We identified 5 major themes: actively seeking a kidney transplant; evolving attitudes toward traditional values and practices; being confronted by interpersonal and systemic racism; poor information and communication; and challenged by social determinants of health.

LIMITATIONS

Participants were recruited nationally through patient advocacy organizations and 1 regional kidney service. Potential participants unrelated to these groups or region could not be included.

CONCLUSIONS

Māori participants were highly motivated to seek kidney transplantation and were inspired by positive experiences through donating and receiving a kidney. However, they faced barriers including social determinants, racism, and lack of information that impacted both direct experiences of transplantation and access to transplantation services.

Gender Disparities in Kidney Transplantation Referral Vary by Age and Race: A Multiregional Cohort Study in the Southeast United States

Introduction

Men (vs. women) are more likely to be waitlisted or receive a kidney transplant. Whether gender disparities exist in earlier transplant steps (i.e., referral) and whether age, race, or obesity factors play a role are unknown.

Methods

Adults (18-80 years; N = 45,015) initiating dialysis in Georgia (GA), North Carolina (NC), or South Carolina (SC) (2012-2016) from the United States Renal Data System were linked to the Early Transplant Access Registry, with follow-up to December 2017. Using a mixed-effects logistic regression model adjusted for several patient characteristics, we assessed the association between gender and referral within 12 months, including interaction terms for age, race/ethnicity, and obesity.

Results

Overall, 37.0% and 41.5% of women and men, respectively, were referred within 12 months. In fully adjusted models, women (vs. men) were 14% less likely to be referred (odds ratio [OR]: 0.86; 95% CI: 0.82-0.90). Women (vs. men) aged 45 to 64 years and 65 to 80 years were 0.93 (0.87-0.99) and 0.72 (0.66-0.77) less likely to be referred, respectively. Women (vs. men) of non-Hispanic White and non-Hispanic Black race were 0.76 (0.71-0.82) and 0.93 (0.88-0.99) less likely to be referred, respectively. For other race (Hispanic, other) and age (18-44 years) subgroups, and all obesity subgroups, no gender differences in referral rates were observed.

Conclusion

In the Southeast, women are less likely to be referred for a transplant, and this disparity is specific to older non-Hispanic Black and White women. These findings have important implications for known gender disparities in upstream (i.e., waitlisting) transplant steps and in the design of interventions to reduce gender disparities in transplant.