1
|
Koo DC, Scalise PN, Chiu MZ, Staffa SJ, Demehri FR, Cuenca AG, Kim HB, Lee EJ. Effect of citizenship status on access to pediatric liver and kidney transplantation. Am J Transplant 2024; 24:1868-1880. [PMID: 38908484 DOI: 10.1016/j.ajt.2024.06.008] [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: 11/28/2023] [Revised: 05/09/2024] [Accepted: 06/11/2024] [Indexed: 06/24/2024]
Abstract
Transplantation of non-US citizen residents remains controversial. We evaluate national trends in transplant activity among pediatric noncitizen residents (PNCR). Pediatric liver and kidney transplant data were obtained from the Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients. Data on transplanted organs, region, waitlist additions, procedures, and citizenship status were analyzed from 2012-2022. Rates of PNCR transplantation activity were compared with population rates from the US Census Bureau. On average, 713 ± 47 pediatric liver and 1039 ± 51 kidney patients were added to the waitlist, with 544 ± 32 liver and 742 ± 33 kidney transplants performed annually. Of these, PNCR comprised 1.5% and 3.3% of liver and kidney waitlist additions and 1.5% and 2.9% of liver and kidney transplant procedures, respectively. There were no significant changes in waitlist or transplant activity nationwide over the study period. There was a significant geographic variation in the percentage of waitlist additions and transplants across the United Network for Organ Sharing regions among the PNCR for liver and kidney transplantation. This is the first study to evaluate national trends in transplantation activity among PNCRs. The significant regional variation in transplantation activity for PNCR may suggest multilevel structural and systemic barriers to transplant accessibility.
Collapse
Affiliation(s)
- Donna C Koo
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - P Nina Scalise
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Megan Z Chiu
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alex G Cuenca
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Pediatric Transplant Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Pediatric Transplant Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Eliza J Lee
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Pediatric Transplant Center, Boston Children's Hospital, Boston, Massachusetts, USA.
| |
Collapse
|
2
|
Nunez M, Abbasi A, McEnhill M, Brennan J, Shappell T, Kinnier S, Winnicki E, Stock P. Long-Term Impact of Immigration Status on Outcomes in Pediatric Kidney Transplant Recipients. Am J Transplant 2024:S1600-6135(24)00563-X. [PMID: 39278627 DOI: 10.1016/j.ajt.2024.09.008] [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: 04/06/2024] [Revised: 08/16/2024] [Accepted: 09/09/2024] [Indexed: 09/18/2024]
Abstract
This study aimed to investigate the effects of documentation status on pediatric kidney transplant outcomes in a single-center setting, emphasizing the significance of state and federal policies like Deferred Action for Childhood Arrivals (DACA) on patient outcomes. A cohort of 283 patients, including 48 undocumented individuals, who received their first kidney transplant as children between 1998 and 2011 was analyzed. There was no significant difference in unadjusted all-cause (p=0.91) and death-censored (p=0.38) graft survival between undocumented patients and US residents. Additionally, in the Cox proportional hazards model, immigration status was not significantly associated with all-cause graft survival (HR 0.87 95% CI 0.51-1.46, p=0.6). Telephone interviews were conducted with the undocumented cohort. 41/48 of the undocumented recipients were contacted. 95% had access to insurance with 68.3% on Medicaid or Medicare. DACA recipients exhibited higher employment rates (88% vs. 67%, p=0.11) and were more likely to complete a degree beyond high school (47.1% vs. 12.5%, p = 0.01). Immigration status did not impact long-term graft survival, suggesting eligibility expansions for state-funded insurance and DACA may improve access to transplant care for undocumented patients. Moreover, DACA recipients showed trends toward increased employment and education compared to non-DACA recipients.
Collapse
Affiliation(s)
- Miguel Nunez
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Ali Abbasi
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Marilyn McEnhill
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Jessica Brennan
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Taryn Shappell
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Sarah Kinnier
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Erica Winnicki
- Division of Nephrology, Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Peter Stock
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
| |
Collapse
|
3
|
Xu K, Dor A, Mohanty S, Han J, Parvathinathan G, Braggs-Gresham JL, Held PJ, Roberts JP, Vaughan W, Tan JC, Scandling JD, Chertow GM, Busque S, Cheng XS. The Medical Costs of Determining Eligibility and Waiting for a Kidney Transplantation. Med Care 2024; 62:521-529. [PMID: 38889200 PMCID: PMC11226385 DOI: 10.1097/mlr.0000000000002028] [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] [Indexed: 06/20/2024]
Abstract
BACKGROUND Recent efforts to increase access to kidney transplant (KTx) in the United States include increasing referrals to transplant programs, leading to more pretransplant services. Transplant programs reconcile the costs of these services through the Organ Acquisition Cost Center (OACC). OBJECTIVE The aim of this study was to determine the costs associated with pretransplant services by applying microeconomic methods to OACC costs reported by transplant hospitals. RESEARCH DESIGN, SUBJECTS, AND MEASURES For all US adult kidney transplant hospitals from 2013 through 2018 (n=193), we crosslinked the total OACC costs (at the hospital-fiscal year level) to proxy measures of volumes of pretransplant services. We used a multiple-output cost function, regressing total OACC costs against proxy measures for volumes of pretransplant services and adjusting for patient characteristics, to calculate the marginal cost of each pretransplant service. RESULTS Over 1015 adult hospital-years, median OACC costs attributable to the pretransplant services were $5 million. Marginal costs for the pretransplant services were: initial transplant evaluation, $9k per waitlist addition; waitlist management, $2k per patient-year on the waitlist; deceased donor offer management, $1k per offer; living donor evaluation, procurement and follow-up: $26k per living donor. Longer time on dialysis among patients added to the waitlist was associated with higher OACC costs at the transplant hospital. CONCLUSIONS To achieve the policy goals of more access to KTx, sufficient funding is needed to support the increase in volume of pretransplant services. Future studies should assess the relative value of each service and explore ways to enhance efficiency.
Collapse
Affiliation(s)
- Kunyao Xu
- George Washington University, Milken Institute School of Public Health, Washington DC
| | - Avi Dor
- George Washington University, Milken Institute School of Public Health, Washington DC
- National Bureau of Economics Research
| | | | - Jialin Han
- University of British Columbia, Division of Nephrology, Vancouver BC Canada
| | - Gomathy Parvathinathan
- Stanford University School of Medicine, Department of Medicine, Division of Nephrology, Palo Alto CA
| | | | - Philip J. Held
- Stanford University School of Medicine, Department of Medicine, Division of Nephrology, Palo Alto CA
| | - John P. Roberts
- University of California San Francisco, Department of Surgery, Division of Transplant Surgery, San Francisco CA
| | | | - Jane C. Tan
- Stanford University School of Medicine, Department of Medicine, Division of Nephrology, Palo Alto CA
| | - John D. Scandling
- Stanford University School of Medicine, Department of Medicine, Division of Nephrology, Palo Alto CA
| | - Glenn M. Chertow
- Stanford University School of Medicine, Department of Medicine, Division of Nephrology, Palo Alto CA
| | - Stephan Busque
- Stanford University School of Medicine, Department of Medicine, Division of Nephrology, Palo Alto CA
| | - Xingxing S. Cheng
- Stanford University School of Medicine, Department of Medicine, Division of Nephrology, Palo Alto CA
| |
Collapse
|
4
|
Stock PG, Nagral S, Rondeau E, Gawronska S, Groverman J, Barbari A, Coates PT, Domínguez-Gil B, Fadhil R, Malyszko J, Niño Murcia A. Transplantation in the Context of Migration and Refugees: A Summary of the DICG and TTS Ethics Committee Workshop, Buenos Aires, Argentina, September 2022. Transplantation 2024; 108:1476-1487. [PMID: 38383953 DOI: 10.1097/tp.0000000000004918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Global conflicts and humanitarian crises have resulted in an unprecedented number of refugees and migrants. This challenges the limited resources of health care systems and jeopardizes the availability of transplant care for these deserving migrants and refugees. This was the basis for a workshop held during the Congress of the Transplantation Society (Buenos Aires, 2022). We elaborate on the proceedings of the workshop entitled "Transplantation in the Context of Migration and Refugees," organized by the Ethics Committee of The Transplantation Society and Declaration of Istanbul Custodian Group. Transplant providers from around the world shared strategies of how each region has responded to providing access to care for refugees and migrants in need of transplant services. The potential exploitation of this vulnerable group leading to illicit organ removal was addressed for each region. The Transplantation Society, Declaration of Istanbul Custodian Group, and global transplant community should continue to focus on the status of refugees and migrants and collaborate on strategies to provide access to transplant care for this deserving population. Global cooperation will be essential to provide vigilant oversight to prevent exploitation of this vulnerable population.
Collapse
Affiliation(s)
- Peter G Stock
- Department of Transplant Surgery, University of California San Francisco, San Francisco, CA
- Ethics Committee of The Transplantation Society, Montreal, QC, Canada
| | - Sanjay Nagral
- Department of Surgical Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, India
- Declaration of Istanbul Custodian Group (DICG), Montreal, QC, Canada
| | - Eric Rondeau
- Declaration of Istanbul Custodian Group (DICG), Montreal, QC, Canada
- Soins intensifs nephrologiques et Rein aigu, hôpital Tenon, Paris, France
| | - Sylwia Gawronska
- United Nations Office on Drugs and Crime (UNODC), Regional Office for Southeast Asia and the Pacific (ROSEAP), Bangkok, Thailand
| | | | - Antoine Barbari
- Department of Nephrology, Rafik Hariri University Hospital, Beirut, Lebanon
| | - P Toby Coates
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Faculty of Health and Medical Sciences, University of Adelaide, SA, Australia
| | - Beatriz Domínguez-Gil
- Ethics Committee of The Transplantation Society, Montreal, QC, Canada
- Organización Nacional de Trasplantes, Madrid, Spain
| | - Riadh Fadhil
- Ethics Committee of The Transplantation Society, Montreal, QC, Canada
- Qatar Organ Donation Centre, Hamad Medical Corporation, Doha, Qatar
| | - Jolanta Malyszko
- Declaration of Istanbul Custodian Group (DICG), Montreal, QC, Canada
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Alejandro Niño Murcia
- Ethics Committee of The Transplantation Society, Montreal, QC, Canada
- Department of Transplantation Surgery, Colombiana de Trasplantes, Bogotá, Colombia
| |
Collapse
|
5
|
Birtan D, Akpinar A. Ethical challenges in organ transplants for refugees in a healthcare system. Nurs Ethics 2024:9697330241230528. [PMID: 38321969 DOI: 10.1177/09697330241230528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND Several ethical issues are associated with providing living organ transplantation services, and there is limited information on these issues faced by the teams providing service to refugees or asylum seekers. AIM To determine the challenges healthcare professionals face in organ transplant centers providing services to Syrians under temporary protection status and discern whether these difficulties align with ethical issues in living organ transplantation. RESEARCH DESIGN This study employed a qualitative design and conducted individual semi-structured, in-depth interviews with 18 transplant team members in Istanbul between September and November 2022. Data analysis was based on Braun and Clarke's thematic analysis. PARTICIPANTS AND RESEARCH CONTEXT The participants comprised 18 healthcare professionals, including 6 physicians and 12 nurses working in organ transplant teams in Istanbul. ETHICAL CONSIDERATIONS The University's Ethics Committee provided approval. Participants were informed regarding confidentiality and signed an informed consent form. RESULTS Three themes emerged from the data on ethical issues faced by organ transplantation services to Syrians: (a) beneficence or double equipoise, (b) autonomy, and (c) justice. Transplant teams experience problems related to preserving double equipoise in the provision of living donor organ transplantation because of language barriers, poor socioeconomic conditions, and cultural factors, which increases transplant teams' individual and indirect social burden. Although problems arise from the language barrier when obtaining informed consent in the autonomy theme, institutional and national policies in preventing donor abuse have a comforting effect. Health workers had the least problems with the justice theme, wherein national health policies are determined. CONCLUSION Fewer issues related to autonomy and justice were reported in providing organ transplantation services to Syrians, with the most intense reported issues being maintaining double equipoise. The results revealed the need to develop institutional, national, and international policies with individual solutions to prevent difficulties healthcare professionals face in this process.
Collapse
Affiliation(s)
- Deniz Birtan
- Kocaeli University
- İstanbul University-Cerrahpaşa
| | - Aslihan Akpinar
- Department of History of Medicine and Ethics, School of Medicine, Kocaeli University, Kocaeli
| |
Collapse
|
6
|
Rizzolo K, Rockey N, Camacho C, Gardner C, Giusti S, Cervantes L. The Transplant Experience for Undocumented Immigrant Patients Formerly Receiving Emergency Dialysis and Caregivers. JAMA Netw Open 2024; 7:e2354602. [PMID: 38421652 PMCID: PMC10905299 DOI: 10.1001/jamanetworkopen.2023.54602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/30/2023] [Indexed: 03/02/2024] Open
Abstract
Importance Individuals of undocumented immigration status with kidney failure face barriers to receiving transplants due to lack of health insurance despite no regulatory barriers. Little is known about the perspectives on kidney transplant among individuals with undocumented immigration status with kidney failure who relied on emergency hemodialysis. Objective To examine the overall experiences of transplant among transplant recipients of undocumented immigration status who previously relied on emergency hemodialysis and their family caregivers. Design, Setting, and Participants In this qualitative study, semistructured 1-to-1 interviews were conducted with transplant recipients who had previously received emergency hemodialysis and transitioned to scheduled dialysis and their primary caregivers living in Denver, Colorado, between May 1, 2022, and March 31, 2023, in English or Spanish. Main Outcomes and Measures Themes and subthemes regarding the experience of transplant as an undocumented immigrant previously receiving emergency hemodialysis were identified. Interview transcripts were translated, deidentified, and then analyzed using thematic analysis. Results A total of 25 participants including 15 transplant recipients (5 [33.3%] female and 10 [66.7%] male; mean [SD] age, 49.5 [9.8] years) and 10 caregivers (7 [70.0%] female and 3 [30.0%] male; mean [SD] age, 44.5 [22.3] years) participated. Six themes were reported: limited kidney replacement therapy education while receiving emergency hemodialysis (lack of awareness of kidney disease and treatment options and discriminatory kidney replacement therapy education due to immigration status), hope for transplant once receiving scheduled dialysis (prospect of transplant through scheduled dialysis, family and quality of life as transplant motivators), transplant education and health insurance after transition to scheduled dialysis (inadequate transplant education in dialysis clinic, peer-to-peer transplant education, and peer-to-peer communication regarding availability of private health insurance), uncertainty during transplant evaluation (difficulty navigating the evaluation and wait-listing process, lack of communication regarding timeline, and concern for family limiting living donation), posttransplant improvements (ability to work after transplant is critically important given immigration status, autonomy with transplant improves mental health, and vigilance in maintaining transplant), and transplant facilitators (self-advocacy, spirituality and optimism, and peer support). Conclusions and Relevance This qualitative study of transplant recipients of undocumented immigration status and their caregivers found that individuals formerly receiving emergency dialysis are excluded from education and access to transplant, and peer support throughout the transplant process helped with education and motivation to pursue transplant. These findings may be used to implement improvements in access to support and education for patients of undocumented immigration status with kidney failure, especially in areas where scheduled dialysis is not available.
Collapse
Affiliation(s)
- Katherine Rizzolo
- Section of Nephrology, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Nathan Rockey
- Department of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Claudia Camacho
- Department of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Colin Gardner
- University of Colorado Medical School, University of Colorado Anschutz Medical Campus, Aurora
| | - Sixto Giusti
- Department of Transplant, University of Colorado Anschutz Medical Campus, Aurora
| | - Lilia Cervantes
- Department of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora
| |
Collapse
|
7
|
Isgor Z, Johnson T, Cmunt K, Lange-Maia BS. Illinois Transplant Fund Experience: Is It a Pathway to Increased Transplant Access for Hispanic Patients With Kidney Failure? Kidney Med 2024; 6:100742. [PMID: 38162539 PMCID: PMC10757032 DOI: 10.1016/j.xkme.2023.100742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Rationale & Objective The Illinois Transplant Fund, established in 2015, provides private health insurance premium support for noncitizen patients with kidney failure in Illinois and thus allows them to qualify for kidney transplants. Our objective was to describe trends in kidney transplant volumes over time to inform the development of a hypothesis regarding the impact of the Illinois Transplant Fund on kidney transplant volumes for adult Hispanic patients with kidney failure in Illinois, especially noncitizen patients. Study Design Retrospective study. Setting & Population We used data on the annual number of kidney transplants and kidney failure prevalence aggregated to the national and state levels from the Organ Procurement and Transplantation Network and United States Renal Data System, respectively. Outcomes The annual number of transplants as a percentage of prevalent kidney failure cases among adults over time from 2010 to 2020 by race/ethnicity for all payer and private insurance-paid transplants and the annual number of transplants by citizenship status (for Hispanic patients only) were examined for the United States (US), Illinois, and 6 selected US states. Analytical Approach Descriptive study. Results From pre- to post-Illinois Transplant Fund, the average annual number of transplants as a percentage of the average annual prevalent kidney failure cases for Hispanic adults increased by 4% in Illinois while the same figure increased by 33% for privately insured transplants. Limitations The observations reported in this paper cannot be interpreted as evidence for the program's impact. Conclusions Observed trends suggest plausibility of developing a hypothesis that Illinois Transplant Fund's introduction may have contributed to improvement in kidney transplantation access for Hispanic patients in Illinois, especially noncitizens, but cannot constitute evidence in support of or against this hypothesis. Future research should test whether the Illinois Transplant Fund improved access to kidney transplants for noncitizens with kidney failure. Plain-Language Summary Health policies regarding kidney transplant access for undocumented residents vary widely by state. The Illinois Transplant Fund (ITF) provides financial support for health insurance premiums, so undocumented patients with kidney failure in Illinois can qualify for a kidney transplant. In this study, we reported kidney transplant trends in Illinois before and after the creation of the ITF along with kidney transplant trends in the US overall and selected states that share similarities to Illinois.
Collapse
Affiliation(s)
- Zeynep Isgor
- Department of Health Systems Management, College of Health Sciences, Rush University, Chicago, IL, USA
| | - Tricia Johnson
- Department of Health Systems Management, College of Health Sciences, Rush University, Chicago, IL, USA
| | - Kevin Cmunt
- Gift of Hope Organ and Tissue Donor Network and Illinois Transplant Fund, Itasca, IL, USA
| | - Brittney S. Lange-Maia
- Department of Family & Preventive Medicine and Rush Alzheimer’s Disease Center, Rush University, Chicago, IL, USA
| |
Collapse
|
8
|
Gely YI, Esqueda-Medina M, Johnson TJ, Arias-Pelayo ML, Cortes NA, Isgor Z, Lynch EB, Lange-Maia BS. Experiences With Kidney Transplant Among Undocumented Immigrants in Illinois: A Qualitative Study. Kidney Med 2023; 5:100644. [PMID: 37235043 PMCID: PMC10206204 DOI: 10.1016/j.xkme.2023.100644] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
Rationale & Objective Noncitizen, undocumented patients with kidney failure have few treatment options in many states, although Illinois allows for patients to receive a transplant regardless of citizenship status. Little information exists about the experiences of noncitizen patients pursuing kidney transplantation. We sought to understand how access to kidney transplantation affects patients, their family, health care providers, and the health care system. Study Design A qualitative study with virtually conducted semistructured interviews. Setting & Participants Participants were transplant and immigration stakeholders (physicians, transplant center and community outreach professionals), and patients who have received assistance through the Illinois Transplant Fund (listed for or received transplant; patients could complete the interview with a family member). Analytical Approach Interview transcripts were coded using open coding and were analyzed using thematic analysis methods with an inductive approach. Results We interviewed 36 participants: 13 stakeholders (5 physicians, 4 community outreach stakeholders, and 4 transplant center professionals), 16 patients, and 7 partners. The following seven themes were identified: (1) devastation from kidney failure diagnosis, (2) resource needs for care, (3) communication barriers to care, (4) importance of culturally competent health care providers, (5) negative impacts of policy gaps, (6) new chance at life after transplant, and (7) recommendations for improving care. Limitations The patients we interviewed were not representative of noncitizen patients with kidney failure overall or in other states. The stakeholders were also not representative of health care providers because they were generally well informed on kidney failure and immigration issues. Conclusions Although patients in Illinois can access kidney transplants regardless of citizenship status, access barriers, and health care policy gaps continue to negatively affect patients, families, health care professionals, and the health care system. Necessary changes for promoting equitable care include comprehensive policies to increase access, diversifying the health care workforce, and improving communication with patients. These solutions would benefit patients with kidney failure regardless of citizenship.
Collapse
Affiliation(s)
- Yumiko I. Gely
- Rush Medical College, Rush University Medical Center, Chicago, IL
| | - Maritza Esqueda-Medina
- Department of Family and Preventive Medicine, Rush University Medical Center, Chicago, IL
| | - Tricia J. Johnson
- Department of Health Systems Management, Rush University Medical Center, Chicago, IL
| | | | - Nancy A. Cortes
- Rush Medical College, Rush University Medical Center, Chicago, IL
| | - Zeynep Isgor
- Department of Health Systems Management, Rush University Medical Center, Chicago, IL
| | - Elizabeth B. Lynch
- Department of Family and Preventive Medicine, Rush University Medical Center, Chicago, IL
| | - Brittney S. Lange-Maia
- Department of Family and Preventive Medicine, Rush University Medical Center, Chicago, IL
- Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, IL
| |
Collapse
|
9
|
Ordaya EE, Shaughnessy M, Elkin B, Husmann RL, Stauffer JC, Luengas EM, Chang BH, Tessier KM, Walker PF, Stauffer WM. Transplantation and immigration: Comparing infectious complications and outcomes between foreign-born and US-born kidney transplant recipients in Minnesota. Transpl Infect Dis 2023; 25:e14039. [PMID: 36856346 PMCID: PMC10085839 DOI: 10.1111/tid.14039] [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: 08/26/2022] [Revised: 01/22/2023] [Accepted: 02/09/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Foreign-born kidney transplant recipients (FBKTRs) are at increased risk for reactivation of latent infections that may impact outcomes. We aimed to compare the etiology of infections and outcomes between FBKTR and United States KTRs (USKTR). METHODS We performed a retrospective study of patients who underwent kidney transplantation between January 1, 2014 and December 31, 2018 at two transplant centers in Minnesota. Frequency and etiology of infections as well as outcomes (graft function, rejection, and patient survival) at 1-year post-transplant between FBKTR and USKTR were compared. RESULTS Of the 573 transplant recipients, 124 (21.6%) were foreign-born and 449 (78.4%) US-born. At least one infection occurred in 411 (71.7%) patients (38.2% bacterial, 55% viral, 9.4% fungal). Viral infections were more frequent in FBKTR, particularly BK viremia (38.7% vs. 21.2%, p < .001). No statistical differences were found for bacterial or fungal infections; no parasitic infections were identified in either group. No geographically-restricted infections were noted aside from a single case of Madura foot in a FBKTR. Rejection episodes were more common in USKTR (p = .037), but stable/improving graft function (p = .976) and mortality (p = .451) at 1-year posttransplantation were similar in both groups. After adjusting for covariates, previous transplantation was associated with a higher number of infections (IRR 1.35, 95% confidence intervals 1.05-1.73, p = .020). CONCLUSION Although viral infections were more frequent in FBKTR, overall frequency and etiology of most infections and outcomes were similar between FBKTR and USKTR suggesting that comprehensive transplant care is providing timely prevention, diagnosis, and treatment of latent infections in FBKTR.
Collapse
Affiliation(s)
- Eloy E. Ordaya
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - Megan Shaughnessy
- Department of Medicine, Hennepin HealthCare, Minneapolis, Minnesota
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Baila Elkin
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Rachel L. Husmann
- Department of Medicine, Hennepin HealthCare, Minneapolis, Minnesota
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Jacob C. Stauffer
- School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | | | - Bickey H. Chang
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Katelyn M. Tessier
- Masonic Cancer Center, Biostatistics Core, University of Minnesota, Minneapolis, Minnesota
| | - Patricia F. Walker
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- HealthPartners Institute, Minneapolis, Minnesota
| | - William M. Stauffer
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota
- School of Public Health, University of Minnesota, Minneapolis, Minnesota
- Human Migration and Health, Center for Global Health and Social Responsibility, Minneapolis, Minnesota
| |
Collapse
|
10
|
Thongprayoon C, Vaitla P, Jadlowiec CC, Leeaphorn N, Mao SA, Mao MA, Qureshi F, Kaewput W, Qureshi F, Tangpanithandee S, Krisanapan P, Pattharanitima P, Acharya PC, Nissaisorakarn P, Cooper M, Cheungpasitporn W. Distinct Phenotypes of Non-Citizen Kidney Transplant Recipients in the United States by Machine Learning Consensus Clustering. MEDICINES (BASEL, SWITZERLAND) 2023; 10:medicines10040025. [PMID: 37103780 PMCID: PMC10144541 DOI: 10.3390/medicines10040025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 03/24/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Better understanding of the different phenotypes/subgroups of non-U.S. citizen kidney transplant recipients may help the transplant community to identify strategies that improve outcomes among non-U.S. citizen kidney transplant recipients. This study aimed to cluster non-U.S. citizen kidney transplant recipients using an unsupervised machine learning approach; Methods: We conducted a consensus cluster analysis based on recipient-, donor-, and transplant- related characteristics in non-U.S. citizen kidney transplant recipients in the United States from 2010 to 2019 in the OPTN/UNOS database using recipient, donor, and transplant-related characteristics. Each cluster's key characteristics were identified using the standardized mean difference. Post-transplant outcomes were compared among the clusters; Results: Consensus cluster analysis was performed in 11,300 non-U.S. citizen kidney transplant recipients and identified two distinct clusters best representing clinical characteristics. Cluster 1 patients were notable for young age, preemptive kidney transplant or dialysis duration of less than 1 year, working income, private insurance, non-hypertensive donors, and Hispanic living donors with a low number of HLA mismatch. In contrast, cluster 2 patients were characterized by non-ECD deceased donors with KDPI <85%. Consequently, cluster 1 patients had reduced cold ischemia time, lower proportion of machine-perfused kidneys, and lower incidence of delayed graft function after kidney transplant. Cluster 2 had higher 5-year death-censored graft failure (5.2% vs. 9.8%; p < 0.001), patient death (3.4% vs. 11.4%; p < 0.001), but similar one-year acute rejection (4.7% vs. 4.9%; p = 0.63), compared to cluster 1; Conclusions: Machine learning clustering approach successfully identified two clusters among non-U.S. citizen kidney transplant recipients with distinct phenotypes that were associated with different outcomes, including allograft loss and patient survival. These findings underscore the need for individualized care for non-U.S. citizen kidney transplant recipients.
Collapse
Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Pradeep Vaitla
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | | | - Napat Leeaphorn
- Renal Transplant Program, University of Missouri-Kansas City School of Medicine/Saint Luke's Health System, Kansas City, MO 64108, USA
| | - Shennen A Mao
- Division of Transplant Surgery, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Michael A Mao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Fahad Qureshi
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand
| | - Fawad Qureshi
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Supawit Tangpanithandee
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Pajaree Krisanapan
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand
| | - Pattharawin Pattharanitima
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine Thammasat University, Pathum Thani 12120, Thailand
| | - Prakrati C Acharya
- Division of Nephrology, Texas Tech Health Sciences Center El Paso, El Paso, TX 79905, USA
| | - Pitchaphon Nissaisorakarn
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Matthew Cooper
- Medstar Georgetown Transplant Institute, Georgetown University School of Medicine, Washington, DC 21042, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| |
Collapse
|
11
|
Eguchi N, Tantisattamo E, Chung D, Reddy UG, Ferrey A, Dafoe D, Ichii H. Outcomes Among Undocumented Immigrant Kidney Transplant Recipients in California. JAMA Netw Open 2023; 6:e2254660. [PMID: 36780162 PMCID: PMC9926318 DOI: 10.1001/jamanetworkopen.2022.54660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
IMPORTANCE There are over 2 million undocumented immigrants (UI) in California, where currently, all individuals regardless of immigration status have access to kidney transplant. There is a medical perception that UI face a higher risk of transplant failure due to language barriers and lack of access to immunosuppressive medication and health care when compared with US residents (UR). OBJECTIVE To elucidate the kidney transplant outcomes of UI at an academic medical center in California. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted from a single transplant center during an 8-year study period. Patients who received a kidney transplant at the University of California, Irvine, between January 1, 2012, and September 1, 2019, were included in this study. Data were analyzed from October 2020 to August 2021. EXPOSURES The primary exposure of this study was citizenship status. UI were defined as immigrants residing in the US without permission or legal documentation. MAIN OUTCOMES AND MEASURES The primary end point was all-cause graft loss defined as the return to dialysis, need for a second kidney transplant, or death. The secondary end points of this study were all-cause mortality and rejection. All-cause mortality between the 2 groups was compared using multiple Cox proportional hazard regression analysis. Other transplant outcomes, including all-cause graft loss and acute rejection, were examined by competing risks regressions with mortality and mortality plus graft loss serving as competing risks, respectively. RESULTS Of all 446 consecutive kidney transplant recipients, the mean (SD) age was 47 (13) years; 261 patients (59%) were male, and 114 (26%) were UI. During a median (IQR) follow-up time of 3.39 (0.04-8.11) years, 6 UI and 48 UR experienced all-cause graft loss. UR had a 192% (hazard ratio, 2.92; 95% CI, 1.21-6.85; P = .01) and 343% (hazard ratio, 4.34; 95% CI, 1.05-18.69; P = .04) significantly increased unadjusted risk for all-cause graft loss and all-cause mortality, respectively. These results became nonsignificant and were mostly attenuated when adjusted for age and ethnicity. Finally, there was no difference in incidence rate of kidney allograft rejection between the 2 groups (UR, 3.5 per 100 person-years vs UI, 2.4 per 100 person-years; rate ratio, 1.45; 95% CI, 0.90-5.05; P = .08). CONCLUSIONS AND RELEVANCE This single-center cohort study found that kidney transplant outcomes of UI were not inferior to those of UR. Across the US, however, UI have consistently had unequal access to transplantation. These findings suggest that extending kidney transplants to UI is safe and does not portend worse outcomes. As a result, denying transplant according to immigration status not only results in higher costs but also worse end stage kidney disease outcomes for an already underserved population.
Collapse
Affiliation(s)
| | - Ekamol Tantisattamo
- Division of Nephrology and Hypertension, Department of Medicine, University of California, Irvine
| | - Dean Chung
- Department of Surgery, University of California, Irvine
| | - Uttam G. Reddy
- Division of Nephrology and Hypertension, Department of Medicine, University of California, Irvine
| | - Antoney Ferrey
- Division of Nephrology and Hypertension, Department of Medicine, University of California, Irvine
| | - Donald Dafoe
- Department of Surgery, University of California, Irvine
| | | |
Collapse
|
12
|
Delman AM, Shah SA, Cuffy MC. Equitable Policies and Center-Level Commitment May Be Associated With Improved Access to Kidney Transplantation for Undocumented Immigrants. JAMA Netw Open 2023; 6:e2254666. [PMID: 36780166 DOI: 10.1001/jamanetworkopen.2022.54666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Affiliation(s)
- Aaron M Delman
- Cincinnati Research in Outcomes and Safety in Surgery Research Group, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery Research Group, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Madison C Cuffy
- Cincinnati Research in Outcomes and Safety in Surgery Research Group, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
13
|
Martin DE, Fadhil RAS, Więcek A. Ethical Aspects of Kidney Donation and Transplantation for Migrants. Semin Nephrol 2022; 42:151271. [PMID: 36577643 DOI: 10.1016/j.semnephrol.2022.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Migrants represent a large and diverse population globally that includes international refugees, stateless persons, expatriate workers, and more. Many migrants face significant barriers in accessing health care, especially scarce and costly resources such as dialysis and kidney transplantation. Improving equity of access to these kidney replacement therapies for migrant populations may present a range of complex ethical dilemmas, particularly in the setting of crises and when considering the use of residency status and citizenship as eligibility criteria for access to treatment. In this article, we discuss ethical obligations to provide kidney care for migrants, the implications of the self-sufficiency concept with regard to access to deceased donation and transplantation, factors that may influence evaluation of the risks and benefits of transplantation for migrants with insecure access to care, and the vulnerability of migrants to organ trafficking. We also present a set of general recommendations to assist in preventing and managing ethical dilemmas when making decisions about policy or practice regarding kidney care for migrants.
Collapse
Affiliation(s)
| | - Riadh A S Fadhil
- Qatar Organ Donation Center, Hamad Medical Corporation, Doha, Qatar; Weill Cornell College of Medicine - Doha, Qatar
| | - Andrzej Więcek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| |
Collapse
|
14
|
Cervantes L, Rizzolo K, Klassen D. Organ Procurement and Transplant Equity Among US Residents: The 5% Guideline. Am J Kidney Dis 2021; 80:139-142. [PMID: 34974030 DOI: 10.1053/j.ajkd.2021.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/21/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Lilia Cervantes
- Division of Hospital Medicine, Denver Health; Office of Research, Denver Health; Division of General Internal Medicine, University of Colorado Anschutz Medical Campus.
| | - Katherine Rizzolo
- Department of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus
| | - David Klassen
- Office of the Chief Medical Officer, United Network for Organ Sharing, Richmond, Virginia
| |
Collapse
|
15
|
Lange-Maia BS, Johnson TJ, Gely YI, Ansell DA, Cmunt JK, Lynch EB. End Stage Kidney Disease in Non-citizen Patients: Epidemiology, Treatment, and an Update to Policy in Illinois. J Immigr Minor Health 2021; 24:1557-1563. [PMID: 34773520 DOI: 10.1007/s10903-021-01303-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 11/30/2022]
Abstract
End-stage kidney disease (ESKD) is common in the U.S. There is no cure, and survival requires either dialysis or kidney transplant. Medicare provides coverage for most ESKD patients in the U.S., though non-citizens are excluded from most current policies providing standard ESKD care, especially regarding kidney transplants. Despite being eligible to be organ donors, non-citizens often have few avenues to be organ recipients-a major equity problem. Overall, transplants are cost-saving compared to dialysis, and non-citizens have comparable outcomes to the general population. We reviewed the literature regarding the vastly different policies across the U.S., with a focus on current Illinois policy, including updates regarding Illinois legislation which passed in 2014 providing non-citizens to receive coverage for transplants. Unfortunately, despite legislation providing avenues for transplants, funds were not allocated, and the bill has not had the impact that was expected when initially passed. We outline opportunities for improving current policies.
Collapse
Affiliation(s)
- Brittney S Lange-Maia
- Department of Preventive Medicine, Rush University Medical Center, Chicago, IL, USA. .,Center for Community Health Equity, Rush University Medical Center, Chicago, IL, USA. .,Rush University Medical Center, 1750 W. Harrison St. Suite 1000, Chicago, IL, 60612, USA.
| | - Tricia J Johnson
- Center for Community Health Equity, Rush University Medical Center, Chicago, IL, USA.,Department of Health Systems Management, Rush University, Chicago, IL, USA
| | - Yumiko I Gely
- Rush Medical College, Rush University Medical Center, Chicago, IL, USA
| | - David A Ansell
- Center for Community Health Equity, Rush University Medical Center, Chicago, IL, USA.,Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - J Kevin Cmunt
- Gift of Hope Organ and Tissue Donor Network and Illinois Transplant Fund, Itasca, IL, USA
| | - Elizabeth B Lynch
- Department of Preventive Medicine, Rush University Medical Center, Chicago, IL, USA.,Center for Community Health Equity, Rush University Medical Center, Chicago, IL, USA
| |
Collapse
|
16
|
Rizzolo K, Cervantes L. Barriers and Solutions to Kidney Transplantation for the Undocumented Latinx Community with Kidney Failure. Clin J Am Soc Nephrol 2021; 16:1587-1589. [PMID: 34556499 PMCID: PMC8499002 DOI: 10.2215/cjn.03900321] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Katherine Rizzolo
- Department of Nephrology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Lilia Cervantes
- Department of Medicine and Office of Research, Denver Health, Denver, Colorado,Division of General Internal Medicine and Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| |
Collapse
|
17
|
Luce MS, Kleber KT, Abdallah AC, Basmaci UN, Perez RV, Troppmann C. Outcomes of Kidney Transplant in Undocumented Immigrants. JAMA Surg 2021; 156:1063-1064. [PMID: 34319374 DOI: 10.1001/jamasurg.2021.2870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- M Siobhan Luce
- Department of Surgery, UC Davis School of Medicine, Sacramento, California
| | - Kara T Kleber
- Department of Surgery, UC Davis School of Medicine, Sacramento, California
| | | | | | - Richard V Perez
- Department of Surgery, UC Davis School of Medicine, Sacramento, California
| | | |
Collapse
|
18
|
Yu E, Wightman A. Pediatric kidney transplant in undocumented immigrants: An American perspectives. Pediatr Transplant 2021; 25:e13788. [PMID: 32721077 DOI: 10.1111/petr.13788] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/18/2020] [Accepted: 06/19/2020] [Indexed: 01/31/2023]
Abstract
Kidney transplant in undocumented immigrants remains controversial. While in the United States the National Organ Transplant Act does not prohibit inclusion of these patients as transplant candidates, legislative and financial barriers and ethical concerns remain. The purpose of this article was to review the legal and financial barriers to kidney transplant for children with ESKD who are undocumented immigrants and consider arguments for and against inclusion of these children as kidney transplant candidates. While this discussion is largely restricted to the experience in the United States and its unique healthcare system, the themes and ideas may be more generalizable to the experience in many high-income countries. We conclude that access to kidney transplant is legal, ethically justifiable, and clearly in the best interest of these children. Transplant professionals should continue to advocate for changes in policy and greater resources to support these patients.
Collapse
Affiliation(s)
- Elizabeth Yu
- Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Aaron Wightman
- Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, Washington, USA
| |
Collapse
|
19
|
Sinnenberg L, Machado SR, Ostrominski JW, Stehlik J, Mehra MR, Vaduganathan M. Citizenship Status and Cardiothoracic Organ Transplantation in the United States. Circ Heart Fail 2020; 13:e007788. [PMID: 33161731 DOI: 10.1161/circheartfailure.120.007788] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lauren Sinnenberg
- Department of Medicine (L.S., J.W.O.), Brigham and Women's Hospital, Boston, MA
| | - Sara R Machado
- Cardiovascular Division (M.R.M., M.V.), Brigham and Women's Hospital, Boston, MA.,Department of Health Policy, London School of Economics and Political Science, London, United Kingdom (S.R.M.)
| | - John W Ostrominski
- Department of Medicine (L.S., J.W.O.), Brigham and Women's Hospital, Boston, MA
| | - Josef Stehlik
- Division of Cardiology, University of Utah School of Medicine, Salt Lake City (J.S.)
| | | | - Muthiah Vaduganathan
- Cardiovascular Division (M.R.M., M.V.), Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
20
|
Rizzolo K, Cervantes L. Immigration status and end-stage kidney disease: Role of policy and access to care. Semin Dial 2020; 33:513-522. [PMID: 33089565 DOI: 10.1111/sdi.12919] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Immigration status is an important mitigating factor in determining the provision of dialysis and kidney-related care. Immigrants make up the largest uninsured group in the country. For immigrants with end-stage kidney disease (ESKD), dialysis access varies by insurance type and by state, leading to great variability in the availability of kidney care. In some states, undocumented immigrants may only qualify for hemodialysis when critically ill (emergency hemodialysis), which is associated with higher mortality, hospital length of stay, and cost, in addition to an emotional burden on patients, their caregivers, and healthcare professionals. Barriers to effective care for immigrants with ESKD include immigration status, insurance access, and availability of pre-end stage kidney disease care, vascular access, and transplant. Effective strategies for improving dialysis care for immigrants include advocacy at the state and federal level, broadening definitions under Emergency Medicaid, and improving benefits for home therapies and transplantation options.
Collapse
Affiliation(s)
- Katherine Rizzolo
- Division of Renal Disease and Hypertension, University of Colorado, Aurora, CO, USA
| | - Lilia Cervantes
- Division of Hospital Medicine and Office of Research, Denver Health, Denver, CO, USA.,Division of General Internal Medicine and Hospital Medicine, University of Colorado, Aurora, CO, USA
| |
Collapse
|
21
|
Cervantes L, Johnson T, Hill A, Earnest M. Offering Better Standards of Dialysis Care for Immigrants: The Colorado Example. Clin J Am Soc Nephrol 2020; 15:1516-1518. [PMID: 32444395 PMCID: PMC7536747 DOI: 10.2215/cjn.01190120] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Lilia Cervantes
- Division of Hospital Medicine and Office of Research, Denver Health, Denver, Colorado .,Division of General Internal Medicine and Hospital Medicine, Univeristy of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Tracy Johnson
- Department of Health Care Policy and Financing, Denver, Colorado
| | - Aubrey Hill
- Center for Health Progress, Denver, Colorado
| | - Mark Earnest
- Divsion of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| |
Collapse
|
22
|
Charnaya O, Verghese P, Goldberg A, Ladin K, Porteny T, Lantos JD. Access to Transplantation for Undocumented Pediatric Patients. Pediatrics 2020; 146:peds.2019-3692. [PMID: 32591437 DOI: 10.1542/peds.2019-3692] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2019] [Indexed: 11/24/2022] Open
Abstract
Clinicians in the United States today regularly face dilemmas about health disparities. Many patients and families cannot afford the medical care that doctors recommend. These problems are most stark when the medical care that is needed is lifesaving and expensive and involves scarce resources. Transplants are the best example of this. The most ethically disturbing situations occur when an undocumented immigrant child needs a transplant. We present such a case and analyze the ethical, legal, and policy issues that arise.
Collapse
Affiliation(s)
- Olga Charnaya
- Division of Pediatric Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Priya Verghese
- Division of Pediatric Nephrology, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, Minnesota
| | - Aviva Goldberg
- Section of Nephrology, Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Keren Ladin
- Research on Ethics, Aging, and Community Health Lab and.,Departments of Occupational Therapy and Community Health, School of Arts and Sciences, Tufts University, Medford, Massachusetts; and
| | | | - John D Lantos
- Bioethics Center, Children's Mercy Hospital, Kansas City, Missouri
| |
Collapse
|
23
|
Hemodialysis care for undocumented immigrants with end-stage renal disease in the United States. Curr Opin Nephrol Hypertens 2020; 28:615-620. [PMID: 31403475 DOI: 10.1097/mnh.0000000000000543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Across the United States, significant variation exists in the provision of care of undocumented immigrants with end-stage renal disease (ESRD), with some states providing standard dialysis, and other states providing emergency-only hemodialysis (EoHD). RECENT FINDINGS EoHD is associated with higher morbidity and mortality compared with standard hemodialysis. EoHD is also associated with higher healthcare utilization, resulting in more emergency department visits, more days spent in the hospital, and higher healthcare costs. Undocumented immigrants with ESRD who rely on EoHD also experience crippling and potentially fatal physical symptoms as well as psychosocial suffering, with some patients describing recurrent near-death experiences. Clinicians who provide EoHD to undocumented patients report experiencing moral distress and symptoms of professional burnout because of providing care that they perceive as unethical and far below the standard of care. SUMMARY Undocumented immigrants with ESRD who rely on EoHD have worse health outcomes and quality of life compared with patients who receive standard hemodialysis. EoHD is also more costly to the healthcare system. Healthcare policy reform is critical as more research demonstrates the worse clinical outcomes and higher costs of EoHD.
Collapse
|
24
|
Welles CC, Cervantes L. Barriers to providing optimal dialysis care for undocumented immigrants: Policy challenges and solutions. Semin Dial 2020; 33:52-57. [DOI: 10.1111/sdi.12846] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Christine C. Welles
- Department of Medicine Denver Health and Hospital Authority Denver CO USA
- Department of Medicine University of Colorado School of Medicine Aurora CO USA
| | - Lilia Cervantes
- Department of Medicine Denver Health and Hospital Authority Denver CO USA
- Department of Medicine University of Colorado School of Medicine Aurora CO USA
- Office of Research Denver Health and Hospital Authority Denver CO USA
| |
Collapse
|
25
|
Douthit NT, Old C. Renal Replacement Therapy for Undocumented Immigrants: Current Models with Medical, Financial, and Physician Perspectives-a Narrative Review. J Gen Intern Med 2019; 34:2246-2253. [PMID: 31388913 PMCID: PMC6816691 DOI: 10.1007/s11606-019-05237-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 09/12/2018] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
Abstract
Renal replacement therapy is guaranteed for all US citizens with end-stage renal disease (ESRD). Undocumented immigrants with ESRD are a particularly vulnerable subset of renal failure patients. There is no federal legislation for these patients except for the requirement to treat them during "emergency medical conditions" and federal legislation excluding them from the guarantee of renal replacement therapy described above. Different states have developed different methods for dealing with this problem, with variation in management even addressed on a center by center basis. This review of the original studies published in the literature reveals the medical, ethical, and financial problems with this situation. These patients frequently have delayed presentation to care, poor access to routine care, increased complications, increased utilization of services, and increased morbidity and mortality in an emergent dialysis model compared to chronic outpatient care. They present an ethical dilemma for practitioners who know they are providing substandard care and occasionally making decisions on how to allocate resources. Emergent dialysis is associated with inadequate reimbursement, increased threat to sustained unemployment, and an overburdening of our healthcare infrastructure. This practice puts patients at risk, places an unfair ethical burden on providers and is financially unsustainable. Special considerations described for kidney transplant and peritoneal dialysis are considered and considerations for a new model are reviewed in the paper. Ultimately accommodations must be made with the input of government, healthcare practitioners, and facilities needs to be reached to protect these vulnerable patients.
Collapse
Affiliation(s)
- Nathan T Douthit
- Brookwood Baptist Health Medical Education, Birmingham, AL, USA.
| | - Christopher Old
- Brookwood Baptist Health Medical Education, Birmingham, AL, USA
| |
Collapse
|
26
|
Greenberg R, Ballesteros-Gallego F, Allard J, Fortin MC. Organ Transplantation for Foreign Nationals in Canada: A Survey of Transplant Professionals. Can J Kidney Health Dis 2019; 6:2054358119859530. [PMID: 31308952 PMCID: PMC6607567 DOI: 10.1177/2054358119859530] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/09/2019] [Indexed: 12/17/2022] Open
Abstract
Background: Transplantation for foreign nationals (non-citizens and non-residents) (FNs) in Canada is a complex issue. Currently, there are no Canadian guidelines for the provision of organ transplantation for FNs, and no empirical data on this issue or on transplant professionals’ practices are available. Objective: This project aimed to gather empirical data on transplant professionals’ perspectives and practices regarding transplantation for FNs. Design: Survey research design. Setting: A Web-based survey of members of the Canadian Society of Transplantation (CST). Participants: All members of the CST were invited to participate between April and June 2016. Measurements: Multiple-choice questions were developed to capture participants’ attitudes toward different fictitious clinical scenarios in which an FN needed a transplant, their experiences with FNs, their attitude toward FNs in need of transplantation, their knowledge about relevant institutional and organ donation organization (ODO) policies, and their perspectives on a quota. There were two questions with a five-point Likert scale to measure respondents’ agreement with statements related to possible policy options and arguments for and against transplantation for FNs. There was one open-ended question about the content of transplant programs’ policies on transplantation for FNs. Methods: Descriptive statistical analysis were performed. Results: A total of 87 transplant professionals completed the survey. Over the 4-year period from 2012 to 2016, 47.1% of respondents dealt with at least one situation of listing or performing a transplant for an FN. Only 19.5% of respondents reported that their transplant program had a policy about transplantation for FNs and 59.7% did not know if their ODO had such a policy. When asked about policy options, 47.5% disagreed with a policy of no transplantation for FNs and 41.4% agreed with offering transplantation for FNs in some circumstances (including life-saving and non–life-saving organs). Study participants agreed that transplantation should not be offered to FNs traveling to Canada specifically for transplantation, that FNs should not be transplanted with organs not suitable for Canadian citizens and that there should not be a transplantation quota for FNs. Participants also seem to be more inclined to offer transplantation of life-saving organs, particularly for children. Limitations: The major limitation of this study is the low response rate of transplant professionals to this survey. Conclusion: This is the first study to describe Canadian transplant professionals’ perspectives on transplantation for FNs. The findings of this study will be of interest for future policy development on access to transplantation for FNs. Further studies are needed to gather various key stakeholders’ perspectives on this issue, as well as to analyze the legal and ethical issues and the economics, to develop future policies.
Collapse
Affiliation(s)
- Rebecca Greenberg
- Department of Bioethics, Mount Sinai Hospital, Toronto, ON, Canada.,Department of Paediatrics, Faculty of Medicine, University of Toronto, ON, Canada.,The Canadian Donation and Transplant Research Program, Edmonton, AB, Canada
| | - Fabián Ballesteros-Gallego
- The Canadian Donation and Transplant Research Program, Edmonton, AB, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada
| | - Julie Allard
- The Canadian Donation and Transplant Research Program, Edmonton, AB, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada
| | - Marie-Chantal Fortin
- The Canadian Donation and Transplant Research Program, Edmonton, AB, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada.,Université de Montréal, QC, Canada
| |
Collapse
|
27
|
Cervantes L, Grafals M, Rodriguez RA. The United States Needs a National Policy on Dialysis for Undocumented Immigrants With ESRD. Am J Kidney Dis 2019; 71:157-159. [PMID: 29389384 DOI: 10.1053/j.ajkd.2017.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/06/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Lilia Cervantes
- Denver Health, Denver, CO; University of Colorado School of Medicine, Colorado, Denver, CO.
| | - Monica Grafals
- University of Colorado School of Medicine, Colorado, Denver, CO
| | | |
Collapse
|
28
|
Cervantes L, Mundo W, Powe NR. The Status of Provision of Standard Outpatient Dialysis for US Undocumented Immigrants with ESKD. Clin J Am Soc Nephrol 2019; 14:1258-1260. [PMID: 31171588 PMCID: PMC6682810 DOI: 10.2215/cjn.03460319] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Lilia Cervantes
- Department of Medicine, Denver Health and .,Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - William Mundo
- University of Colorado School of Medicine, Aurora, Colorado
| | - Neil R Powe
- Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, California; and.,Department of Medicine, University of California, San Francisco, California
| |
Collapse
|
29
|
|
30
|
Zhang HH, Cortés-Penfield NW, Mandayam S, Niu J, Atmar RL, Wu E, Chen D, Zamani R, Shah MK. Dialysis Catheter-related Bloodstream Infections in Patients Receiving Hemodialysis on an Emergency-only Basis: A Retrospective Cohort Analysis. Clin Infect Dis 2019; 68:1011-1016. [PMID: 29986016 PMCID: PMC6399430 DOI: 10.1093/cid/ciy555] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/07/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND An estimated 6500 undocumented immigrants with end-stage renal disease (ESRD) live in the United States. Those living in states that do not provide undocumented immigrants scheduled hemodialysis receive intermittent hemodialysis only when life-threatening conditions arise. Little is known about catheter-related bloodstream infections (CRBSIs) in this population. METHODS We conducted a retrospective cohort study of emergency-only hemodialysis patients in the Harris Health System in Houston, Texas, between January 2012 and December 2015. We assessed CRBSI risk factors including demographics, comorbidities, and duration and frequency of hemodialysis. We investigated the microbiologic etiology of these infections, rates of recurrent CRBSI, and associated morbidity and mortality. RESULTS The cohort included 329 patients; 90% were Hispanic, 60% had diabetes, and the average age was 51 years. A total of 101 CRBSIs occurred, with a rate of 0.84 infections per 1000 catheter-days. Cirrhosis and duration of hemodialysis during the study period were associated with increased risk of CRBSI. Seventeen CRBSIs were recurrent; infection with gram-positive bacteria predicted recurrence. Adherence to catheter-related infection guidelines was improved by infectious diseases consultation and associated with fewer recurrent infections. CRBSI was associated with prolonged hospitalization (mean, 15 days), composite complication rate of 8%, and a 4% mortality rate. CONCLUSIONS Patients receiving emergency-only hemodialysis via tunneled catheters have a high CRBSI rate compared with infection rates previously reported in patients receiving scheduled maintenance hemodialysis. Increased CRSBI risk likely contributes to the increased morbidity and mortality seen in ESRD patients receiving emergency-only hemodialysis.
Collapse
Affiliation(s)
- Hal H Zhang
- Department of Medicine, Baylor College of Medicine, Houston
| | | | - Sreedhar Mandayam
- Department of Medicine, Baylor College of Medicine, Houston
- Department of Medicine, Section of Nephrology, Baylor College of Medicine, Houston
| | - Jingbo Niu
- Department of Medicine, Section of Nephrology, Baylor College of Medicine, Houston
| | - Robert L Atmar
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston
| | - Eric Wu
- Department of Medicine, Baylor College of Medicine, Houston
| | - Daniel Chen
- Department of Pediatrics, University of Texas Southwestern, Dallas
| | - Roya Zamani
- Department of Medicine, Baylor College of Medicine, Houston
| | - Maulin K Shah
- Department of Medicine, Section of Nephrology, Baylor College of Medicine, Houston
- Section of Nephrology, Veterans Affairs Medical Center, Houston, Texas
| |
Collapse
|
31
|
Poulakou G, Len O, Akova M. Immigrants as donors and transplant recipients: specific considerations. Intensive Care Med 2019; 45:401-403. [DOI: 10.1007/s00134-019-05534-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/14/2019] [Indexed: 10/27/2022]
|
32
|
Desai N, Lora CM, Lash JP, Ricardo AC. CKD and ESRD in US Hispanics. Am J Kidney Dis 2018; 73:102-111. [PMID: 29661541 DOI: 10.1053/j.ajkd.2018.02.354] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 02/08/2018] [Indexed: 12/23/2022]
Abstract
Hispanics are the largest racial/ethnic minority group in the United States, and they experience a substantial burden of kidney disease. Although the prevalence of chronic kidney disease (CKD) is similar or slightly lower in Hispanics than non-Hispanic whites, the age- and sex-adjusted prevalence rate of end-stage renal disease is almost 50% higher in Hispanics compared with non-Hispanic whites. This has been attributed in part to faster CKD progression among Hispanics. Furthermore, Hispanic ethnicity has been associated with a greater prevalence of cardiovascular disease risk factors, including obesity and diabetes, as well as CKD-related complications. Despite their less favorable socioeconomic status, which often leads to limited access to quality health care, and their high comorbid condition burden, the risk for mortality among Hispanics appears to be lower than for non-Hispanic whites. This survival paradox has been attributed to a complex interplay between sociocultural and psychosocial factors, as well as other factors. Future research should focus on evaluating the long-term impact of these factors on patient-centered and clinical outcomes. National policies are needed to improve access to and quality of health care among Hispanics with CKD.
Collapse
Affiliation(s)
- Nisa Desai
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Claudia M Lora
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - James P Lash
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Ana C Ricardo
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL.
| |
Collapse
|