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

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.

Racial disparities across multiple stages of the deceased organ donation process

Pervasive structural violence causes higher organ failure rates among Black Americans and an excess of Black potential deceased organ donors. Underuse of Black donors would exacerbate organ shortages that disproportionately harm Black transplant candidates. This study investigates racial differences in transit between distinct donation steps among 132 968 potential donors across 557 hospitals and 6 organ procurement organizations (OPOs) from 2015 through 2021. Multilevel multistate modeling with patient covariates and OPO random effects shows adjusted likelihoods (95% confidence interval) of non-Black versus Black patients transitioning from OPO referral to approach of 1.39 (1.35, 1.44), approach to authorization: 1.64 (1.56, 1.72), authorization to procurement: 1.10 (1.04, 1.16), and procurement to transplant: 1.00 (0.95, 1.06). Overall organ utilization rates for Black, Latino, White, and other OPO referrals were 5.89%, 8.18%, 6.79%, and 5.24%, respectively. Adjusting for patient covariates and hospital and OPO random effects, multilevel logistic models estimated that compared with Black patients, Latino, White, and other patients had odds ratios of organ utilization of 1.81 (1.61, 2.03), 3.19 (2.91, 3.50), and 1.24 (1.05, 1.47), respectively. Nationwide in 2022, donor conversion disparities likely lost more than 1700 donors-two-thirds of whom would have been Black. Achieving racial equity for transplant candidates will require reducing racial disparities in organ donation.