Nonmedical barriers to early steps in kidney transplantation among underrepresented groups in the United States

Interviews With Lay Caregivers About Their Experiences Supporting Patients Throughout Kidney Transplantation

Introduction: Lay caregivers provide essential support to patients throughout the kidney transplant process, pretransplant through discharge. Sparse data exists about kidney transplant caregiver experience and facilitators of caregiver engagement. The aim of this study was to explore and describe lay caregivers' accounts of supporting a patient before and early after kidney transplantation. Methods: Caregivers of recent kidney transplant recipients were individually interviewed about their experiences, coping strategies, and perspectives of center-specific support approaches for patients and caregivers in a single transplant center. Results: Inductive content analysis of transcribed interviews with 23 caregivers revealed 6 domain areas: visit preparation, initial evaluation, caregiver role discussion, exposure to support resources, transplant preparedness, and coping styles. Caregivers used and appreciated information offered by the transplant center, including materials directed to the patient. They recommended repeating information, online access, and adding video to complement print resources. They valued and requested information directed to them, both within passive materials and communication with providers. Social network interactions were helpful for practical, emotional, and informational support. Support group reminders and connection pathways to peers were suggested for both patients and caregivers. Conclusion: Findings highlight steps that can be taken by transplant centers and may stimulate caregiver engagement. Featuring caregiver-focused information and communication more prominently may support caregivers to improve patient progress in navigating kidney transplantation.

High Prevalence of Adverse Social Determinants of Health in Dialysis Access Creation Patients in a Safety-Net Setting

BACKGROUND

Patients receiving dialysis access surgery are often exposed to adverse social determinants of health (SDH) that negatively impact their care. Our goal was to characterize these factors experienced by our arteriovenous dialysis access patients and identify differences in health outcomes based on their SDH.

METHODS

We performed a retrospective cohort study of all patients who underwent dialysis access creation (2017-2021) and were screened for SDH at a clinical visit (using THRIVE survey) implemented at an urban, safety-net hospital institution within 1 year of access creation. Demographics, procedural details, early postoperative outcomes, survey responses, and referral to our hospital's preventive food pantry were recorded. Univariable analysis and multivariable analyses were performed to assess for associations with key health outcomes.

RESULTS

There were 190 patients who responded to the survey within 1 year of their operation. At least 1 adverse SDH was identified in 42 (22%) patients. Normalized to number of respondents for each question, adverse SDH identified were difficulty obtaining transportation to medical appointments (18%), food insecurity (16%), difficulty affording utilities (13%), difficulty affording medication (12%), unemployed and seeking employment (9%), unstable housing (7%), difficulty caring for family/friends (6%), and desiring more education (5%). There were 71 (37%) patients who received food pantry referrals. Mean age was 60 years and 38% of patients were female and 64% were Black. More than half of patients (57%) had a tunneled dialysis catheter (TDC) at the time of access creation. Dialysis accesses created were brachiocephalic (39%), brachiobasilic (25%), radiocephalic fistulas (16%), and arteriovenous grafts (14%). Thirty-day emergency department (ED) visits, 30-day readmissions, and 90-day mortality occurred in 23%, 21%, and 2%, respectively. On univariable and multivariable analyses, any adverse SDH determined on survey and food pantry referral were not associated with preoperative dialysis through TDCs, receiving nonautogenous dialysis access, 30-day ED visits and readmissions, or 90-day mortality.

CONCLUSION

Nearly a quarter of dialysis access surgery patients at a safety-net hospital experienced adverse SDH and more than one-third received a food pantry referral. Most common difficulties experienced include difficulty obtaining transportation to medical appointments, food insecurity, and difficulty paying for utilities and medication. Although there were no differences in postoperative outcomes, the high prevalence of these adverse SDH warrants prioritization of resources in this population to ensure healthy equity and further investigation into their effects on health outcomes.

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.

Disparities in Kidney Transplant Waitlisting Among Young Patients Without Medical Comorbidities

Importance

Disparities in kidney transplant referral and waitlisting contribute to disparities in kidney disease outcomes. Whether these differences are rooted in population differences in comorbidity burden is unclear.

Objective

To examine whether disparities in kidney transplant waitlisting were present among a young, relatively healthy cohort of patients unlikely to have medical contraindications to kidney transplant.

Design, Setting, and Participants

This retrospective cohort study used the US Renal Data System Registry to identify patients with end-stage kidney disease who initiated dialysis between January 1, 2005, and December 31, 2019. Patients who were older than 40 years, received a preemptive transplant, were preemptively waitlisted, or had documented medical comorbidities other than hypertension or smoking were excluded, yielding an analytic cohort of 52 902 patients. Data were analyzed between March 1, 2022, and February 1, 2023.

Main Outcome(s) and Measure(s)

Kidney transplant waitlisting after dialysis initiation.

Results

Of 52 902 patients (mean [SD] age, 31 [5] years; 31 132 [59%] male; 3547 [7%] Asian/Pacific Islander, 20 782 [39%] Black/African American, and 28 006 [53%] White) included in the analysis, 15 840 (30%) were waitlisted for a kidney transplant within 1 year of dialysis initiation, 11 122 (21%) were waitlisted between 1 and 5 years after dialysis initiation, and 25 940 (49%) were not waitlisted by 5 years. Patients waitlisted within 1 year of dialysis initiation were more likely to be male, to be White, to be employed full time, and to have had predialysis nephrology care. There were large state-level differences in the proportion of patients waitlisted within 1 year (median, 33%; range, 15%-58%). In competing risk regression, female sex (adjusted subhazard ratio [SHR], 0.92; 95% CI, 0.90-0.94), Hispanic ethnicity (SHR, 0.77; 95% CI, 0.75-0.80), and Black race (SHR, 0.66; 95% CI, 0.64-0.68) were all associated with lower waitlisting after dialysis initiation. Unemployment (SHR, 0.47; 95% CI, 0.45-0.48) and part-time employment (SHR, 0.74; 95% CI, 0.70-0.77) were associated with lower waitlisting compared with full-time employment, and more than 1 year of predialysis nephrology care, compared with none, was associated with greater waitlisting (SHR, 1.51; 95% CI, 1.46-1.56).

Conclusions and Relevance

This retrospective cohort study found that fewer than one-third of patients without major medical comorbidities were waitlisted for a kidney transplant within 1 year of dialysis initiation, with sociodemographic disparities in waitlisting even in this cohort of young, relatively healthy patients unlikely to have a medical contraindication to transplantation. Transplant policy changes are needed to increase transparency and address structural barriers to waitlist access.

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.

The impact of neighborhood social disadvantage on presentation and management of first-time hemodialysis access surgery patients

OBJECTIVES

The impact of social determinants of health on the presentation, management, and outcomes of patients requiring hemodialysis (HD) arteriovenous (AV) access creation have not been well-characterized. The Area Deprivation Index (ADI) is a validated measure of aggregate community-level social determinants of health disparities experienced by members living within a community. Our goal was to examine the effect of ADI on health outcomes for first-time AV access patients.

METHODS

We identified patients who underwent first-time HD access surgery in the Vascular Quality Initiative between July 2011 to May 2022. Patient zip codes were correlated with an ADI quintile, defined as quintile 1 (Q1) to quintile 5 (Q5) from least to most disadvantaged. Patients without ADI were excluded. Preoperative, perioperative, and postoperative outcomes considering ADI were analyzed.

RESULTS

There were 43,292 patients analyzed. The average age was 63 years, 43% were female, 60% were of White race, 34% were of Black race, 10% were of Hispanic ethnicity, and 85% received autogenous AV access. Patient distribution by ADI quintile was as follows: Q1 (16%), Q2 (18%), Q3 (21%), Q4 (23%), and Q5 (22%). On multivariable analysis, the most disadvantaged quintile (Q5) was associated with lower rates of autogenous AV access creation (OR, 0.82; 95% confidence interval [CI], 0.74-0.90; P < .001), preoperative vein mapping (OR, 0.57; 95% CI, 0.45-0.71; P < .001), access maturation (OR, 0.82; 95% CI, 0.71-0.95; P = .007), and 1-year survival (OR, 0.81; 95% CI, 0.71-0.91; P = .001) compared with Q1. Q5 was associated with higher 1-year intervention rates than Q1 on univariable analysis, but not on multivariable analysis.

CONCLUSIONS

The patients undergoing AV access creation who were most socially disadvantaged (Q5) were more likely to experience lower rates of autogenous access creation, obtaining vein mapping, access maturation, and 1-year survival compared with the most socially advantaged (Q1). Improvement in preoperative planning and long-term follow-up may be an opportunity for advancing health equity in this population.

Social Determinants of Health Impacting Access to Renal Dialysis for Racial/Ethnic Minorities

Although widespread, the burden of disease presented by chronic kidney disease (CKD) is not equally distributed among all demographics. Examining the social determinants of health (SDOH) that relate to barriers to renal dialysis care in CKD can help to prevent future disparities. There has not been a study addressing the social factors that create barriers to care for ethnic minority patients with CKD. The aim of this scoping review is to address the SDOH that affects access to renal dialysis for ethnic minority patients in the United States. This study was based on the protocol published by the Joanna Briggs Institute. A total of 349 studies were identified from PubMed, EBSCOhost, and Embase. Each article was screened against population, concept, and context criteria in order to be considered for inclusion. The population was determined to be adults of all genders from underrepresented minority populations. The selected concept was SDOH. The context of this study was the United States population. From the articles selected by the search criteria, neighborhood of residence, mental health care access, glomerular filtration rate (GFR) methodology, socioeconomic status (SES), language barriers, immigration status, and military rank were identified as SDOH affecting access to renal dialysis care. While this study identified four social determinants, more research is needed for the investigation of other possible SDOH contributing to disparities related to CKD and access to renal dialysis care.

Taking a "Care Pathway/Whole Systems" Approach to Equality Diversity Inclusion (EDI) in Organ Donation and Transplantation in Relation to the Needs of "Ethnic/Racial/Migrant" Minority Communities: A Statement and a Call for Action

International evidence shows variation in organ donation and transplantation (ODT) based upon a range of patient characteristics. What is less well understood is the impact of patient "ethnicity/race/immigration background," as these terms are defined and intended differently across countries. We also know that these characteristics do not operate in isolation but intersect with a range of factors. In this paper, we propose a framework that seeks to clarify the definition of the key terms "ethnicity/race/migrant" and to review how these communities are operationalized across European studies about inequities in ODT. Further, patients and the public wish to see Equality Diversity Inclusion (EDI) approaches in their everyday lives, not just in relation to ODT. We propose a 'care pathway/whole-systems' approach to ODT encompassing culturally competent public health interventions for a) the prevention and management of chronic diseases, b) improvements in public engagement for the promotion of the culture of ODT and enhancements in end-of-life care, through to c) enhanced likelihood of successful transplant among migrant/ethnic minority communities. Our framework recognizes that if we truly wish to take an EDI approach to ODT, we need to adopt a more social, human and holistic approach to examining questions around patient ethnicity.

Experiences With Kidney Transplant Among Undocumented Immigrants in Illinois: A Qualitative Study

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.

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.

Using Community-Based Participatory Research to Create Animated Videos to Attenuate Disparities in Access to Kidney Transplant Information

Introduction: Community-based participatory research and animated video offer promising approaches to attenuate disparities in access to kidney transplant information. Project Aims: We refined an evidence-based animated video curriculum (Kidney Transplant and Donation Information Made Easy) designed for diverse individuals, that is currently being trialed to advance kidney transplant access among referred patients at a single transplant center, to further accommodate information needs in earlier stages of the path to transplant (pre-referral) and to enhance fit for Black and Hispanic people. Design: We describe formation of an academic-community partnership and the application of qualitative research methods and partnership discussions to refine the Kidney Transplant and Donation Information Made Easy videos. A simple content analysis was undertaken of intervention refinement transcriptions, minutes, and meeting notes. Results: We formed a community steering committee and advisory board of local members predominantly of minoritized race or ethnicity. Full engagement with community members is evident in the program's adaptation process. Essential refinement elements were adaptation of 17 original videos and iterative development of 8 new videos with the community, conducting parallel cognitive interviews of an expanded sample of stakeholders, maintaining the theoretical grounding of Elaboration Theory, communication/multimedia learning best practices, and self-efficacy framework, and doing Spanish-language translation. Conclusions: Applying community-based participatory research principles and qualitative methods, we produced a culturally grounded adaptation of the Kidney Transplant and Donation Information Made Easy videos that provides information about kidney transplantation from primary care to transplantation. This approach is likely to strengthen our community partnership and eventual community acceptance of the intervention during the implementation phase. Challenges were achieving consensus and adding Spanish-language translation.

Contribution of Estimates of Glomerular Filtration to the Extensive Disparities in Preemptive Listing for Kidney Transplant

Introduction

The use of race coefficients in equations for estimated glomerular filtration rate (eGFR) may have contributed to racial disparities in access to preemptive (without dialysis exposure) kidney transplantation (Ktx).

Methods

In this retrospective national cohort study of incident kidney transplant candidates in the United States from 2001 to 2019, we describe temporal trends and racial disparities in preemptive listing and the distribution of eGFR at listing, using eGFR as reported and after removing the race coefficient for Black candidates.

Results

Among 511,686 candidates, preemptive listing increased over time, from 18% in 2001 to 33% in 2019. Non-Black candidates were listed preemptively nearly twice as frequently as Black candidates in 2019 (38% vs. 21% preemptive) and at higher eGFR values (median 15.6 vs. 15.0 ml/min per 1.73 m²). After adjusting for candidate characteristics, including listing eGFR without the race coefficient, preemptive Black candidates still had significantly lower odds of preemptive deceased donor (DD) kidney transplantation compared to non-Black candidates (odds ratio 0.87, 95% confidence interval: 0.78-0.98).

Conclusions

Over the last 2 decades, Black patients were consistently less likely to be listed preemptively and were listed at lower eGFR values. Adjusting for listing eGFR with the race coefficient computationally removed did not eliminate the racial disparity, suggesting that additional efforts are needed to achieve equity in preemptive transplantation beyond adopting race-free eGFR equations.

A comparison of deprivation indices and application to transplant populations

The choice of deprivation index can influence conclusions drawn regarding the extent of deprivation within a community and the identification of the most deprived communities in the United States. This study aimed to determine the degree of correlation among deprivation indices commonly used to characterize transplant populations. We used a retrospective cohort consisting of adults listed for liver or kidney transplants between 2008 and 2018 to compare 4 deprivation indices: neighborhood deprivation index, social deprivation index (SDI), area deprivation index, and social vulnerability index. Pairwise correlation between deprivation indices by transplant referral regions was measured using Spearman correlations of population-weighted medians and upper quartiles. In total, 52 individual variables were used among the 4 deprivation indices with 25% overlap. For both organs, the correlation between the population-weighted 75th percentile of the deprivation indices by transplant referral region was highest between SDI and social vulnerability index (liver and kidney, 0.93) and lowest between area deprivation index and SDI (liver, 0.19 and kidney, 0.15). The choice of deprivation index affects the applicability of research findings across studies examining the relationship between social risk and clinical outcomes. Appropriate application of these measures to transplant populations requires careful index selection based on the intended use and included variable relevance.

Trends in utilization of laparoscopic colectomy according to race: an analysis of the NIS database

BACKGROUND

Laparoscopic colectomy has been associated with improved recovery and decreased complications when compared to an open approach. Consequently, the rates of laparoscopic colectomy have increased. Race has been identified as a factor that influences a patient's likelihood of undergoing laparoscopic colectomy. Therefore, the purpose of this study is to analyze the rates of laparoscopic colectomy stratified by race over time.

METHODS

Patients were selected using procedure codes for colectomy within the National Inpatient Sample (NIS) database from 2009 to 2018. The primary independent variable was race (Black, BL; Hispanic, HI; White, WH), and the primary outcome was surgical approach (laparoscopic vs open). Covariates included age, sex, case complexity, insurance status, income, year of surgery, urbanicity, region, bedsize, and teaching status. We examined the univariable association of race with laparoscopic vs open colectomy with chi-square. We used multivariable logistic regression to examine the association of race with procedure type adjusting for covariates. All analyses were done using SAS (version 9.4, Cary, NC) with p < .05 considered significant.

RESULTS

267,865 patients (25,000 BL, 19,685 HI, and 223,180 WH) were identified. Laparoscopy was used in 47% of cases, and this varied significantly by race (BL 44%, HI 49%, WH 47%, p < .0001). After adjusting for covariates, Black patients had significantly lower adjusted odds of undergoing laparoscopic colectomy vs White patients (aOR 0.92, p < 0.0001). Utilization of laparoscopy was similar in Hispanic compared to White patients (aOR 1.00, p = 0.9667). Racial disparity in the adjusted odds of undergoing laparoscopic colectomy was persistent over time.

CONCLUSION

Race was independently associated with the rate of laparoscopic colectomy, with Black patients less likely to receive laparoscopic surgery than White patients. This disparity persisted over a decade. Attention should be paid to increasing the rates of laparoscopic colectomy in under-represented populations in order to optimize surgical care and address racial disparities.

Preliminary feasibility of animated video education designed to empower patients' referral to kidney transplantation

BACKGROUND

Referral for kidney transplantation is influenced by patient education; digital technologies can enhance broad information accessibility. This single-group study tested the feasibility and acceptability of patient-centered self-directed educational animated videos to improve mediators of kidney transplant referral.

METHODS

Community-based adults with chronic kidney disease stage ≥4 invited from a clinical registry or self-responding to flyers viewed eight sequential videos (19:36 min total duration) remotely on their own device. Change in kidney transplant knowledge, concerns, and confidence talking about kidney transplantation to doctors was assessed with self-report surveys before and immediately after viewing. Program feedback was assessed by survey and self-selected exit interview.

RESULTS

Viewers of the video set (n = 50) demonstrated increases in mean kidney transplantation knowledge by +22%, confidence discussing with their doctor by +6%, and reductions in concerns by -2%. Knowledge results were consistent across age, race, and literacy level. Over 90% indicated positive ratings on understanding, engaging, and helpfulness. In post-study interviews viewers indicated the videos promoted confidence in obtaining a kidney transplant and none reported that the 19-min duration of the home education was too long.

CONCLUSION

The animated video education is promising to improve diverse individuals' knowledge, concerns, and communication confidence about kidney transplantation and is highly acceptable.

Geographic hot spots of kidney transplant candidates wait-listed post-dialysis

INTRODUCTION

Preemptive wait-listing of deceased donor kidney transplant (DDKT) candidates before maintenance dialysis increases the likelihood of transplantation and improves outcomes among transplant patients. Previous studies have identified substantial disparities in rates of preemptive listing, but a gap exists in examining geographic sources of disparities, particularly for sub-regional units. Identifying small area hot spots where delayed listing is particularly prevalent may more effectively inform both health policy and regionally appropriate interventions.

METHODS

We conducted a retrospective cohort study utilizing 2010-2020 Scientific Registry of Transplant Recipients (SRTR) data for all DDKT candidates to examine overall and race-stratified geospatial hot spots of post-dialysis wait-listing in U.S. zip code tabulation areas (ZCTA). Three geographic clustering methods were utilized to identify robust statistically significant hot spots of post-dialysis wait-listing.

RESULTS

Novel sub-regional hot spots were identified in the southeast, southwest, Appalachia, and California, with a majority existing in the southeast. Race-stratified results were more nuanced, but broadly reflected similar patterns. Comparing transplant candidates in hot spots to candidates in non-clusters indicated a strong association between residence in hot spots and high area deprivation (OR: 6.76, 95%CI: 6.52-7.02), indicating that improving access healthcare in these areas may be particularly beneficial.

CONCLUSION

Our study identified overall and race-stratified hot spots with low rates of preemptive wait list placement in the U.S., which may be useful for prospective healthcare policy and interventions via targeting of these narrowly defined geographical areas.

Movement is Life-Optimizing Patient Access to Total Joint Arthroplasty: Chronic Kidney Disease Disparities

Approximately 15% of the American adults have chronic kidney disease (CKD). Rates of CKD are higher in underserved communities: It is highest in African Americans (16%) and Hispanic individuals (14%). African Americans are more than 3 times as likely compared with their White counterparts to develop end-stage kidney disease, requiring dialysis or a kidney transplant. Rates of CKD are higher in the geriatric and socioeconomic disadvantaged populations, groups with higher rates of hip and knee osteoarthritis and with comorbidities, including obesity, diabetes mellitus, heart disease, and hypertension. CKD of any stage is associated with increased postoperative readmission, complications, and mortality. Patients on hemodialysis after total joint arthroplasty are at increased risk for complications, including periprosthetic joint infection, and given the reduction in risk after kidney transplant, there is varying opinion regarding whether patients on hemodialysis are safe arthroplasty candidates.

Perpetuating Disparity: Failure of the Kidney Transplant System to Provide the Most Kidney Transplants to Communities With the Greatest Need

BACKGROUND

The burden of end-stage kidney disease (ESKD) and kidney transplant rates vary significantly across the United States. This study aims to examine the mismatch between ESKD burden and kidney transplant rates from a perspective of spatial epidemiology.

METHODS

US Renal Data System data from 2015 to 2017 on incident ESKD and kidney transplants per 1000 incident ESKD cases was analyzed. Clustering of ESKD burden and kidney transplant rates at the county level was determined using local Moran's I and correlated to county health scores. Higher percentile county health scores indicated worse overall community health.

RESULTS

Significant clusters of high-ESKD burden tended to coincide with clusters of low kidney transplant rates, and vice versa. The most common cluster type had high incident ESKD with low transplant rates (377 counties). Counties in these clusters had the lowest overall mean transplant rate (61.1), highest overall mean ESKD incidence (61.3), and highest mean county health scores percentile (80.9%, P <0.001 vs all other cluster types). By comparison, counties in clusters with low ESKD incidence and high transplant rates (n=359) had the highest mean transplant rate (110.6), the lowest mean ESKD incidence (28.9), and the lowest county health scores (20.2%). All comparisons to high-ESKD/low-transplant clusters were significant at P value <0.001.

CONCLUSION

There was a significant mismatch between kidney transplant rates and ESKD burden, where areas with the greatest need had the lowest transplant rates. This pattern exacerbates pre-existing disparities, as disadvantaged high-ESKD regions already suffer from worse access to care and overall community health, as evidenced by the highest county health scores in the study.

A Population Health Approach to Transplant Access: Challenging the Status Quo

Transplant referral and evaluation are critical steps to waitlisting yet remain an elusive part of the transplant process. Despite calls for more data collection on pre-waitlisting steps, there are currently no national surveillance data to aid in understanding the causes and potential solutions for the extreme variation in access to transplantation. As population health scientists, epidemiologists, clinicians, and ethicists we submit that the transplant community has an obligation to better understand disparities in transplant access as a first necessary step to effectively mitigating these inequities. Our position is grounded in a population health approach, consistent with several new overarching national policy and quality initiatives. The purpose of this Perspective is to (1) provide an overview of how a population health approach should inform current multisystem policies impacting kidney transplantation and demonstrate how these efforts could be enhanced with national data collection on pre-waitlisting steps; (2) demonstrate the feasibility and concrete next steps for pre-waitlisting data collection; and (3) identify potential opportunities to use these data to implement effective population-level interventions, policies, and quality measures to improve equity in access to kidney transplantation.

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

BACKGROUND

In the United States (US), barriers in access to later steps in the kidney transplantation process (i.e. waitlisting) have been well documented. Barriers in access to earlier steps (i.e. referral and evaluation) are less well described due to the lack of national surveillance data. In this review, we summarize the available literature on non-medical barriers in access to kidney transplant referral and evaluation.

METHODS

Following PRISMA guidelines, we conducted a scoping review of the literature through June 3, 2021. We included all studies (quantitative and qualitative) reporting on barriers to kidney transplant referral and evaluation in the US published from 1990 onwards in English and among adult end-stage kidney disease (ESKD) patients (PROSPERO registration number: CRD42014015027). We narratively synthesized results across studies.

RESULTS

We retrieved information from 33 studies published from 1990 to 2021 (reporting data between 1990 and 2018). Most studies (n = 28, 85%) described barriers among patient populations, three (9%) among provider populations, and two (6%) included both patients and providers. Key barriers were identified across multiple levels and included patient- (e.g. demographic, socioeconomic, sociocultural, and knowledge), provider- (e.g. miscommunication, staff availability, provider perceptions and attitudes), and system- (e.g. geography, distance to care, healthcare logistics) level factors.

CONCLUSIONS

A multi-pronged approach (e.g. targeted and systemwide interventions, and policy change) implemented at multiple levels of the healthcare system will be necessary to reduce identified barriers in access to early kidney transplant steps. Collection of national surveillance data on these early kidney transplant steps is also needed to enhance our understanding of barriers to referral and evaluation.

Editorial: Disparities in transplantation access and outcomes: mind the gap!

Organ transplantation still remains a problem of supply and demand and presents multiple ethical challenges to our society. Despite numerous targeted interventions and policy reforms, women, underrepresented minorities and patients with low socioeconomic status (SES) continue to have unequal access to transplant. The purpose of this special edition is to highlight disparities in access to transplantation and posttransplant outcomes. Acknowledging that these disparities exist is the first step toward interventions aimed at mitigating this long-standing inequity. This issue provides 10 articles that give the background and summarize relevant literature describing these disparities and identify potential areas of intervention. Most of the data relates to the United States but may reflect patterns encounter in most societies. Each manuscript was written by leaders of international teams in the field of patient advocacy, public health or outcome research in transplantation.