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Racial and Ethnic Disparities in Kidney Transplant Access Within a Theoretical Context of Medical Eligibility. Transplantation 2020; 104:1437-1444. [PMID: 31568216 DOI: 10.1097/tp.0000000000002962] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Non-Hispanic black (NHB) and Hispanic patients have lower access to kidney transplantation compared to non-Hispanic whites (NHWs). We examined whether differences in the prevalence of comorbidities that affect eligibility for transplant contribute to disparities in receipt of transplantation. METHODS We performed a retrospective study of 986 019 adults who started dialysis between 2005 and 2014, according to the United States Renal Data System. We compared prevalence of comorbidities that could influence transplant eligibility by race/ethnicity. We examined time to first transplant by race/ethnicity in this overall cohort and in a very healthy sub-cohort without conditions that could be contraindications to transplantation. RESULTS During 2.3 years of mean follow-up, 64 892 transplants occurred. NHBs and Hispanics had a lower prevalence of medical barriers to transplantation at the time of dialysis initiation than NHWs, including age >70 years (26% in NHB versus 47% in NHW) and malignancy (4% in Hispanics versus 10% in NHWs). Access to transplant was 65% lower (95% CI, 0.33-0.37) in NHBs and 43% lower (95% CI, 0.54-0.62) in Hispanics (versus NHWs) in the first year after end-stage renal disease, but by Year 4, access to transplantation was not statistically significantly different between Hispanics or NHBs (versus NHWs). In our very healthy cohort, racial and ethnic disparities in access to transplantation persisted up to Year 5 in NHBs and Year 4 in Hispanics after end-stage renal disease onset. CONCLUSIONS Differences in medical eligibility do not appear to explain racial/ethnic disparities in receipt of kidney transplantation and may mask the actual magnitude of the inequities that are present.
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Ku E, Yang W, McCulloch CE, Feldman HI, Go AS, Lash J, Bansal N, He J, Horwitz E, Ricardo AC, Shafi T, Sondheimer J, Townsend RR, Waikar SS, Hsu CY. Race and Mortality in CKD and Dialysis: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis 2019; 75:394-403. [PMID: 31732235 DOI: 10.1053/j.ajkd.2019.08.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 08/02/2019] [Indexed: 01/13/2023]
Abstract
RATIONALE & OBJECTIVES Few studies have investigated racial disparities in survival among dialysis patients in a manner that considers risk factors and mortality during the phase of kidney disease before maintenance dialysis. Our objective was to explore racial variations in survival among dialysis patients and relate them to racial differences in comorbid conditions and rates of death in the setting of kidney disease not yet requiring dialysis therapy. STUDY DESIGN Retrospective cohort study. SETTINGS & PARTICIPANTS 3,288 black and white participants in the Chronic Renal Insufficiency Cohort (CRIC), none of whom were receiving dialysis at enrollment. EXPOSURE Race. OUTCOME Mortality. ANALYTIC APPROACH Cox proportional hazards regression was used to examine the association between race and mortality starting at: (1) time of dialysis initiation and (2) entry into the CRIC. RESULTS During 7.1 years of median follow-up, 678 CRIC participants started dialysis. Starting from the time of dialysis initiation, blacks had lower risk for death (unadjusted HR, 0.67; 95% CI, 0.51-0.87) compared with whites. Starting from baseline CRIC enrollment, the strength of the association between some risk factors and dialysis was notably stronger for whites than blacks. For example, the HR for dialysis onset in the presence (vs absence) of heart failure at CRIC enrollment was 1.30 (95% CI, 1.01-1.68) for blacks versus 2.78 (95% CI, 1.90-4.50) for whites, suggesting differential severity of these risk factors by race. When we included deaths occurring both before and after dialysis, risk for death was higher among blacks (vs whites) starting from CRIC enrollment (HR, 1.41; 95% CI, 1.22-1.64), but this finding was attenuated in adjusted models (HR, 1.08; 95% CI, 0.91-1.28). LIMITATIONS Residual confounding. CONCLUSIONS The apparent survival advantage among blacks over whites treated with dialysis may be attributed to selected transition of a subset of whites with more severe comorbid conditions onto dialysis.
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Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA; Division of Pediatric Nephrology, Department of Pediatrics, University of California San Francisco, San Francisco, CA.
| | - Wei Yang
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Harold I Feldman
- Division of Nephrology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alan S Go
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA; Division of Research, Kaiser Permanente Northern California, San Francisco, CA
| | - James Lash
- Division of Nephrology, Department of Medicine, University of Illinois, Chicago, IL
| | - Nisha Bansal
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA
| | - Ed Horwitz
- Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland OH
| | - Ana C Ricardo
- Division of Nephrology, Department of Medicine, University of Illinois, Chicago, IL
| | - Tariq Shafi
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | | | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sushrut S Waikar
- Division of Nephrology, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Renal Section, Department of Medicine, Boston University Medical Center, Boston, MA
| | - Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA
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Andreoni KA, Formica RN. Whose kidney is it anyway? The complexities of sharing deceased donor kidneys. Am J Transplant 2014; 14:2204-5. [PMID: 25220132 DOI: 10.1111/ajt.12865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 05/27/2014] [Accepted: 06/06/2014] [Indexed: 01/25/2023]
Affiliation(s)
- K A Andreoni
- Department of Surgery, University of Florida, Gainesville, FL; United Network of Organ Sharing, Richmond, VA
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