Understanding disparities in transplantation: do social networks provide the missing clue?

Safety and efficacy of a reduced frequency viral monitoring strategy for Epstein-Barr virus, cytomegalovirus, and BK polyomavirus post-kidney transplant: A quality assurance initiative

BACKGROUND

There is variability in recommended viral monitoring protocols after kidney transplant. In response to increased demand for laboratory testing during the COVID-19 pandemic, the Transplant Manitoba Adult Kidney Program updated its monitoring protocols for cytomegalovirus (CMV), Epstein-Barr virus (EBV), and BK polyomavirus (BKV) to a reduced frequency.

METHODS

This single-center nested case-control study evaluated 252 adult kidney transplant recipients transplanted from 2015 to 2021, with the updated protocols effective on March 19th 2020. Cases included recipients transplanted after the protocol update who developed CMV, EBV, and BKV DNAemia and were matched to controls with DNAemia transplanted prior to the protocol update. The primary outcome was the difference in maximum DNA load titers between cases and matched controls. Secondary outcomes included time to initial DNAemia detection and DNAemia clearance. Safety outcomes of tissue-invasive viral disease were described.

RESULTS

There were 216 recipients transplanted preupdate and 36 recipients postupdate. There was no difference between cases and controls in maximum or first DNA load titers for EBV, CMV, or BKV. Cases experienced earlier EBV DNAemia detection (26 (IQR 8, 32) vs. 434 (IQR 96, 1184) days, p = .005). Median follow-up was significantly longer for recipients transplanted preupdate (4.3 vs. 1.3 years, p < .0001). After adjusting for follow-up time, there was no difference in DNAemia clearance or tissue-invasive viral disease.

CONCLUSION

Our findings suggest that reduced frequency viral monitoring protocols may be safe and cost-effective. This quality assurance initiative should be extended to detect longer-term and tissue-invasive disease outcomes.

Neighborhood Segregation and Access to Live Donor Kidney Transplantation

Importance

Identifying the mechanisms of structural racism, such as racial and ethnic segregation, is a crucial first step in addressing the persistent disparities in access to live donor kidney transplantation (LDKT).

Objective

To assess whether segregation at the candidate's residential neighborhood and transplant center neighborhood is associated with access to LDKT.

Design, Setting, and Participants

In this cohort study spanning January 1995 to December 2021, participants included non-Hispanic Black or White adult candidates for first-time LDKT reported in the US national transplant registry. The median (IQR) follow-up time for each participant was 1.9 (0.6-3.0) years.

Main Outcome and Measures

Segregation, measured using the Theil H method to calculate segregation tertiles in zip code tabulation areas based on the American Community Survey 5-year estimates, reflects the heterogeneity in neighborhood racial and ethnic composition. To quantify the likelihood of LDKT by neighborhood segregation, cause-specific hazard models were adjusted for individual-level and neighborhood-level factors and included an interaction between segregation tertiles and race.

Results

Among 162 587 candidates for kidney transplant, the mean (SD) age was 51.6 (13.2) years, 65 141 (40.1%) were female, 80 023 (49.2%) were Black, and 82 564 (50.8%) were White. Among Black candidates, living in a high-segregation neighborhood was associated with 10% (adjusted hazard ratio [AHR], 0.90 [95% CI, 0.84-0.97]) lower access to LDKT relative to residence in low-segregation neighborhoods; no such association was observed among White candidates (P for interaction = .01). Both Black candidates (AHR, 0.94 [95% CI, 0.89-1.00]) and White candidates (AHR, 0.92 [95% CI, 0.88-0.97]) listed at transplant centers in high-segregation neighborhoods had lower access to LDKT relative to their counterparts listed at centers in low-segregation neighborhoods (P for interaction = .64). Within high-segregation transplant center neighborhoods, candidates listed at predominantly minority neighborhoods had 17% lower access to LDKT relative to candidates listed at predominantly White neighborhoods (AHR, 0.83 [95% CI, 0.75-0.92]). Black candidates residing in or listed at transplant centers in predominantly minority neighborhoods had significantly lower likelihood of LDKT relative to White candidates residing in or listed at transplant centers located in predominantly White neighborhoods (65% and 64%, respectively).

Conclusions

Segregated residential and transplant center neighborhoods likely serve as a mechanism of structural racism, contributing to persistent racial disparities in access to LDKT. To promote equitable access, studies should assess targeted interventions (eg, community outreach clinics) to improve support for potential candidates and donors and ultimately mitigate the effects of segregation.

A Social Network Analysis of Hemodialysis Clinics: Attitudes Toward Living Donor Kidney Transplant among Influential Patients

Key Points

Hemodialysis clinic social networks spread attitudes and behaviors toward kidney transplants. Identifying and characterizing influential patients is a first step in future hemodialysis clinic social network interventions to promote kidney transplantation.

Background

Hemodialysis clinics help develop patient social networks that may spread kidney transplant (KT) attitudes and behaviors. Identifying influential social network members is an important first step to increase KT rates. We mapped the social networks of two hemodialysis facilities to identify which patients were influential using in-degree centrality as a proxy for popularity and influence.

Methods

In this cross-sectional study, we performed a sociocentric social network analysis of patients on hemodialysis in two geographically and demographically different hemodialysis facilities. Statistical and social network analyses were performed using R statistical software.

Results

More patients at facility 1 (N =71) were waitlisted/evaluating living donor KT (50.7% versus 20.0%, P = 0.021), considered KT as very important (70.4% versus 45.0%, P = 0.019), and knew people who received a successful KT (1.0 versus 0.0, P = 0.003). Variables predicting relationship formation at facility 1 were the same shift (β =1.87, 95% confidence interval [CI] [1.19 to 2.55]; P < 0.0001), same sex (β =0.51, 95% CI [0.01 to 1.00]; P = 0.045), younger age (β =−0.03, 95% CI [−0.05 to −0.01]; P = 0.004), different lengths of time on hemodialysis (β =−0.49, 95% CI [−0.86 to −0.12]; P = 0.009), and knowing more people who received a successful KT (β =0.12, 95% CI [0.03 to 0.21]; P = 0.009). Predictive variables at facility 2 (N =40) were the same race (β =2.52, 95% CI [0.39 to 4.65]; P = 0.021) and knowing fewer people with successful KT (β =−0.92, 95% CI [−1.82 to −0.02]; P = 0.045). In-degree centrality was higher at facility 1 (1.1±1.2) compared with facility 2 (0.6±0.9).

Conclusions

Social networks differed between the hemodialysis clinics in structure and prevalent transplant attitudes. Influential patients at facility 1 (measured by in-degree centrality) had positive attitudes toward KT, whereas influential patients at facility 2 had negative attitudes.

Dialysis Patients' Social Networks and Living Donation Offers

Rationale & Objective

Most living kidney donors are members of a hemodialysis patient's social network. Network members are divided into core members, those strongly connected to the patient and other members; and peripheral members, those weakly connected to the patient and other members. We identify how many hemodialysis patients' network members offered to become kidney donors, whether these offers were from core or peripheral network members, and whose offers the patients accepted.

Study Design

A cross-sectional interviewer-administered hemodialysis patient social network survey.

Setting & Participants

Prevalent hemodialysis patients in 2 facilities.

Predictors

Network size and constraint, a donation from a peripheral network member.

Outcomes

Number of living donor offers, accepting an offer.

Analytical Approach

We performed egocentric network analyses for all participants. Poisson regression models evaluated associations between network measures and number of offers. Logistic regression models determined the associations between network factors and accepting a donation offer.

Results

The mean age of the 106 participants was 60 years. Forty-five percent were female, and 75% self-identified as Black. Fifty-two percent of participants received at least one living donor offer (range 1-6); 42% of the offers were from peripheral members. Participants with larger networks received more offers (incident rate ratio [IRR], 1.26; 95% CI, 1.12-1.42; P = 0.001), including networks with more peripheral members (constraint, IRR, 0.97; 95% CI, 0.96-0.98; P < 0.001). Participants who received a peripheral member offer had 3.6 times greater odds of accepting an offer (OR, 3.56; 95% CI, 1.15-10.8; P = 0.02) than those who did not receive a peripheral member offer.

Limitations

A small sample of only hemodialysis patients.

Conclusions

Most participants received at least one living donor offer, often from peripheral network members. Future living donor interventions should focus on both core and peripheral network members.

The company we keep. Using hemodialysis social network data to classify patients' kidney transplant attitudes with machine learning algorithms

BACKGROUND

Hemodialysis clinic patient social networks may reinforce positive and negative attitudes towards kidney transplantation. We examined whether a patient's position within the hemodialysis clinic social network could improve machine learning classification of the patient's positive or negative attitude towards kidney transplantation when compared to sociodemographic and clinical variables.

METHODS

We conducted a cross-sectional social network survey of hemodialysis patients in two geographically and demographically different hemodialysis clinics. We evaluated whether machine learning logistic regression models using sociodemographic or network data best predicted the participant's transplant attitude. Models were evaluated for accuracy, precision, recall, and F1-score.

RESULTS

The 110 surveyed participants' mean age was 60 ± 13 years old. Half (55%) identified as male, and 74% identified as Black. At facility 1, 69% of participants had a positive attitude towards transplantation whereas at facility 2, 45% of participants had a positive attitude. The machine learning logistic regression model using network data alone obtained a higher accuracy and F1 score than the sociodemographic and clinical data model (accuracy 65% ± 5% vs. 61% ± 7%, F1 score 76% ± 2% vs. 70% ± 7%). A model with a combination of both sociodemographic and network data had a higher accuracy of 74% ± 3%, and an F1-score of 81% ± 2%.

CONCLUSION

Social network data improved the machine learning algorithm's ability to classify attitudes towards kidney transplantation, further emphasizing the importance of hemodialysis clinic social networks on attitudes towards transplant.

Caregiver perspectives on the everyday medical and social needs of long-term pediatric liver transplant patients

Using in-depth interviews, we sought to characterize the everyday medical and social needs of pediatric liver transplant caregivers to inform the future design of solutions to improve care processes. Participants (parents/caregivers of pediatric liver transplant recipients) completed a survey (assessing socioeconomic status, economic hardship, health literacy, and social isolation). We then asked participants to undergo a 60-min virtual, semistructured qualitative interview to understand the everyday medical and social needs of the caregiver and their household. We intentionally oversampled caregivers who reported a social or economic hardship on the survey. Transcripts were analyzed using thematic analysis and organized around the Capability, Opportunity, Motivation-Behavior model. A total of 18 caregivers participated. Of the participants, 50% reported some form of financial strain, and about half had less than 4 years of college education. Caregivers had high motivation and capability in executing transplant-related tasks but identified several opportunities for improving care. Caregivers perceived the health system to lack capability in identifying and intervening on specific family social needs. Caregiver interviews revealed multiple areas in which family supports could be strengthened, including (1) managing indirect costs of prolonged hospitalizations (e.g., food, parking), (2) communicating with employers to support families' needs, (3) coordinating care across hospital departments, and (4) clarifying care team roles in helping families reduce both medical and social barriers. This study highlights the caregiver perspective on barriers and facilitators to posttransplant care. Future work should identify whether these themes are present across transplant centers. Caregiver perspectives should help inform future interventions aimed at improving long-term outcomes for children after liver transplantation.

Patient perceptions by race of educational animations about living kidney donation made for a diverse population

Introduction

This qualitative study sought to identify potential design and delivery alterations to inform cultural adaptation of educational animations about living donor kidney transplantation (LDKT)–previously developed for a diverse population–to better fit Black Americans’ needs.

Methods

We conducted a secondary analysis of 88 transcripts derived from interviews and focus groups conducted with diverse target users (62 kidney failure patients, 36 prior/potential donors, and 11 care partners) to develop 12 animations about LDKT, named KidneyTIME. Statements were abstracted and coded pertaining to cognitive and communication barriers to LDKT, and the perceived value of using the videos to learn and share the information with social network members using content analysis. Incidence counts of each content code were also calculated to assess differences between Black and non-Black patients.

Results

Cognitive barrier codes included lack of knowledge, ambivalence, and concern for donor. Communication barrier codes included reluctance and difficulty talking about LDKT. Cognitive facilitating codes included attention-getting, efficient learning, manageable content, emotional impact, and new knowledge. Communication facilitating codes included delivery through many dissemination channels and broadly shareable. Compared to non-black patients (n = 33) Black patients (n = 29) more often stated concern for donor and reluctance/difficulty talking about LDKT as barriers, and less often stated efficient learning and manageable content as facilitators.

Conclusion

Findings highlight the value of LDKT informational content that is visually appealing, digestible, non-threatening, and highly shareable. Heterogeneity may exist when considering access and intervention preferences in using KidneyTIME videos and highlight a potential for further cultural targeting or tailoring.

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.

Liver Transplantation in the Time of a Pandemic: A Widening of the Racial and Socioeconomic Health Care Gap During COVID-19

OBJECTIVE

During the initial wave of the COVID-19 pandemic, organ transplantation was classified a CMS Tier 3b procedure which should not be postponed. The differential impact of the pandemic on access to liver transplantation was assessed.

SUMMARY BACKGROUND DATA

Disparities in organ access and transplant outcomes among vulnerable populations have served as obstacles in liver transplantation.

METHODS

Using UNOS STARfile data, adult waitlisted candidates were identified from March 1, 2020 to November 30, 2020 (n = 21,702 pandemic) and March 1, 2019 to November 30, 2019 (n = 22,797 pre-pandemic), and further categorized and analyzed by time periods: March to May (Period 1), June to August (Period 2), and September to November (Period 3). Comparisons between pandemic and pre-pandemic groups included: Minority status, demographics, diagnosis, MELD, insurance type, and transplant center characteristics. Liver transplant centers (n = 113) were divided into tertiles by volume (small, medium, large) for further analyses. Multivariable logistic regression was fitted to assess odds of transplant. Competing risk regression was used to predict probability of removal from the waitlist due to transplantation or death and sickness. Additional temporal analyses were performed to assess changes in outcomes over the course of the pandemic.

RESULTS

During Period 1 of the pandemic, Minorities showed greater reduction in both listing (-14% vs -12% Whites), and transplant (-15% vs -7% Whites), despite a higher median MELD at transplant (23 vs 20 Whites, P < 0.001). Of candidates with public insurance, Minorities demonstrated an 18.5% decrease in transplants during Period 1 (vs -8% Whites). Although large programs increased transplants during Period 1, accounting for 61.5% of liver transplants versus 53.4% pre-pandemic (P < 0.001), Minorities constituted significantly fewer transplants at these programs during this time period (27.7% pandemic vs 31.7% pre-pandemic, P = 0.04). Although improvements in disparities in candidate listings, removals, and transplants were observed during Periods 2 and 3, the adjusted odds ratio of transplant for Minorities was 0.89 (95% CI 0.83-0.96, P = 0.001) over the entire pandemic period.

CONCLUSIONS

COVID-19's effect on access to liver transplantation has been ubiquitous. However, Minorities, especially those with public insurance, have been disproportionately affected. Importantly, despite the uncertainty and challenges, our systems have remarkable resiliency, as demonstrated by the temporal improvements observed during Periods 2 and 3. As the pandemic persists, and the aftermath ensues, health care systems must consciously strive to identify and equitably serve vulnerable populations.

Gender and race/ethnicity differences in living kidney donor demographics: Preference or disparity?

In the United States, women are over-represented and Blacks are under-represented as living kidney donors. A traditional bioethics approach would state that as long as living donors believe that the benefits of participation outweigh the risks and harms (beneficence) and they give a voluntary and informed consent, then the demographics reflect a mere difference in preferences. Such an analysis, however, ignores the social, economic and cultural determinants as well as various forms of structural discrimination (e.g., racism, sexism) that may imply that the distribution is less voluntary than may appear initially. The distribution also raises justice concerns regarding the fair recruitment and selection of living donors. We examine the differences in living kidney donor demographics using a vulnerabilities analysis and argue that these gender and racial differences may not reflect mere preferences, but rather, serious justice concerns that need to be addressed at both the individual and systems level.

A Quality Improvement Intervention to Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) in Patients With Chronic Kidney Disease: Clinical Research Protocol of a Cluster-Randomized Clinical Trial

Background:

Many patients with kidney failure will live longer and healthier lives if they receive a kidney transplant rather than dialysis. However, multiple barriers prevent patients from accessing this treatment option.

Objective:

To determine if a quality improvement intervention provided in chronic kidney disease (CKD) programs (vs. usual care) enables more patients with no recorded contraindications to kidney transplant to complete more steps toward receiving a kidney transplant.

Design:

This protocol describes a pragmatic 2-arm, parallel-group, open-label, registry-based, cluster-randomized clinical trial—the Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) trial.

Setting:

All 26 CKD programs in Ontario, Canada, with a trial start date of November 1, 2017. The original end date of March 31, 2021 (3.4 years) has been extended to December 31, 2021 (4.1 years) due to the COVID-19 pandemic.

Participants:

During the trial, the 26 CKD programs are expected to care for more than 10 000 adult patients with CKD (including patients approaching the need for dialysis and patients receiving dialysis) with no recorded contraindications to a kidney transplant.

Intervention:

Programs were randomly allocated to provide a quality improvement intervention or usual care. The intervention has 4 main components: (1) local quality improvement teams and administrative support; (2) tailored education and resources for staff, patients, and living kidney donor candidates; (3) support from kidney transplant recipients and living kidney donors; and (4) program-level performance reports and oversight by program leaders.

Primary Outcome:

The primary outcome is the number of key steps completed toward receiving a kidney transplant analyzed at the cluster level (CKD program). The following 4 unique steps per patient will be counted: (1) patient referred to a transplant center for evaluation, (2) at least one living kidney donor candidate contacts a transplant center for an intended recipient and completes a health history questionnaire to begin their evaluation, (3) patient added to the deceased donor transplant wait list, and (4) patient receives a kidney transplant from a living or deceased donor.

Planned Primary Analysis:

Study data will be obtained from Ontario’s linked administrative healthcare databases. An intent-to-treat analysis will be conducted comparing the primary outcome between randomized groups using a 2-stage approach. First stage: residuals are obtained from fitting a regression model to individual-level variables ignoring intervention and clustering effects. Second stage: residuals from the first stage are aggregated at the cluster level as the outcome.

Limitations:

It may not be possible to isolate independent effects of each intervention component, the usual care group could adopt intervention components leading to contamination bias, and the relatively small number of clusters could mean the 2 arms are not balanced on all baseline prognostic factors.

Conclusions:

The EnAKT LKD trial will provide high-quality evidence on whether a multi-component quality improvement intervention helps patients complete more steps toward receiving a kidney transplant.

Trial registration:

Clinicaltrials.gov; identifier: NCT03329521.

Does Whom Patients Sit Next to during Hemodialysis Affect Whether They Request a Living Donation?

Background

The seating arrangement of in-center hemodialysis is conducive to patients forming a relationship and a social network. We examined how seating in the in-center hemodialysis clinic affected patients forming relationships, whether patients formed relationships with others who have similar transplant behaviors (homophily), and whether these relationships influenced patients (social contagion) to request a living donation from family and friends outside of the clinic.

Methods

In this 30-month, prospective cohort study, we observed the relationships of 46 patients on hemodialysis in a hemodialysis clinic. Repeated participant surveys assessed in-center transplant discussions and living-donor requests. A separable temporal exponential random graph model estimated how seating, demographics, in-center transplant discussions, and living-donor requests affected relationship formation via sociality and homophily. We examined whether donation requests spread via social contagion using a susceptibility-infected model.

Results

For every seat apart, the odds of participants forming a relationship decreased (OR, 0.74; 95% CI, 0.61 to 0.90; P=0.002). Those who requested a living donation tended to form relationships more than those who did not (sociality, OR, 1.6; 95% CI, 1.02 to 2.6; P=0.04). Participants who discussed transplantation in the center were more likely to form a relationship with another participant who discussed transplantation than with someone who did not discuss transplantation (homophily, OR, 1.9; 95% CI, 1.03 to 3.5; P=0.04). Five of the 36 susceptible participants made a request after forming a relationship with another patient.

Conclusions

Participants formed relationships with those they sat next to and had similar transplant behaviors. The observed increase in in-center transplant discussions and living-donation requests by the members of the hemodialysis-clinic social network was not because of social contagion. Instead, participants who requested a living donation were more social, formed more relationships within the clinic, and discussed transplantation with each other as a function of health-behavior homophily.

Association of Racial Disparities With Access to Kidney Transplant After the Implementation of the New Kidney Allocation System

Importance

Inactive patients on the kidney transplant wait-list have a higher mortality. The implications of this status change on transplant outcomes between racial/ethnic groups are unknown.

Objectives

To determine if activity status changes differ among races/ethnicities and levels of sensitization, and if these differences are associated with transplant probability after implementation of the Kidney Allocation System.

Design, Setting, and Participants

A multistate model was constructed from the Organ Procurement and Transplantation Network kidney transplant database (December 4, 2014, to September 8, 2016). The time interval followed Kidney Allocation System implementation and provided at least 1-year follow-up for all patients. The model calculated probabilities between active and inactive status and the following competing risk outcomes: living donor transplant, deceased donor transplant, and death/other. This retrospective cohort study included 42 558 patients on the Organ Procurement and Transplantation Network kidney transplant wait-list following Kidney Allocation System implementation. To rule out time-varying confounding from relisting, analysis was limited to first-time registrants. Owing to variations in listing practices, primary center listing data were used for dually listed patients. Individuals listed for another organ or pancreatic islets were excluded. Analysis began July 2017.

Main Outcome and Measures

Probabilities were determined for transitions between active and inactive status and the following outcome states: active to living donor transplant, active to deceased donor transplant, active to death/other, inactive to living donor transplant, inactive to deceased donor transplant, and inactive to death/other.

Results

The median (interquartile range) age at listing was 55.0 (18.0-89.0) years, and 26 535 of 42 558 (62.4%) were men. White individuals were 43.3% (n = 18 417) of wait-listed patients, while black and Hispanic individuals made up 27.8% (n = 11 837) and 19.5% (n = 8296), respectively. Patients in the calculated plasma reactive antibody categories of 0% or 1% to 79% showed no statistically significant difference in transplant probability among races/ethnicities. White individuals had an advantage in transplant probability over black individuals in calculated plasma reactive antibody categories of 80% to 89% (hazard ratio [HR], 1.8 [95% CI, 1.4-2.2]) and 90% or higher (HR, 2.4 [95% CI, 2.1-2.6]), while Hispanic individuals had an advantage over black individuals in the calculated plasma reactive antibody group of 90% or higher (HR, 2.5 [95% CI, 2.1-2.8]). Once on the inactive list, white individuals were more likely than Hispanic individuals (HR, 1.2 [95% CI, 1.17-1.3]) or black individuals (HR, 1.4 [95% CI, 1.3-1.4]) to resolve issues for inactivity resulting in activation.

Conclusions and Relevance

For patients who are highly sensitized, there continues to be less access to kidney transplant in the black population after the implementation of the Kidney Allocation System. Health disparities continue after listing where individuals from minority groups have greater difficulty in resolving issues of inactivity.

Should Lack of Social Support Prevent Access to Organ Transplantation?

Transplantation programs commonly rely on clinicians' judgments about patients' social support (care from friends or family) when deciding whether to list them for organ transplantation. We examine whether using social support to make listing decisions for adults seeking transplantation is morally legitimate, drawing on recent data about the evidence-base, implementation, and potential impacts of the criterion on underserved and diverse populations. We demonstrate that the rationale for the social support criterion, based in the principle of utility, is undermined by its reliance on tenuous evidence. Moreover, social support requirements may reinforce transplant inequities, interfere in patients' personal relationships, and contribute to biased and inconsistent listing procedures. As such, accommodating the needs of patients with limited social support would better balance ethical commitments to equity, utility, and respect for persons in transplantation. We suggest steps for researchers, transplantation programs, and policymakers to improve fair use of social support in transplantation.

Excluding patients from transplant due to social support: Results from a national survey of transplant providers

Social support is used to determine transplant eligibility despite lack of an evidence base and vague regulatory guidance. It is unknown how many patients are disqualified from transplantation due to inadequate support, and whether providers feel confident using these subjective criteria to determine eligibility. Transplant providers (n = 551) from 202 centers estimated that, on average, 9.6% (standard deviation = 9.4) of patients evaluated in the prior year were excluded due to inadequate support. This varied significantly by United Network for Organ Sharing region (7.6%-12.2%), and by center (21.7% among top quartile). Significantly more providers used social support in listing decisions than believed it ought to be used (86.3% vs 67.6%). Nearly 25% believed that using social support in listing determinations was unfair or were unsure; 67.3% felt it disproportionately impacted patients of low socioeconomic status. Overall, 42.4% were only somewhat or not at all confident using social support to determine transplant suitability. Compared to surgical/medical transplant providers, psychosocial providers had 2.13 greater odds of supporting the criteria (P = .03). Furthermore, 69.2% supported revised guidelines for use of social support in listing decisions. Social support criteria should be reconsidered in light of the limited evidence, potential for disparities, practice variation, low provider confidence, and desire for revised guidelines.

How important is social support in determining patients' suitability for transplantation? Results from a National Survey of Transplant Clinicians

BACKGROUND

National guidelines require programmes use subjective assessments of social support when determining transplant suitability, despite limited evidence linking it to outcomes. We examined how transplant providers weigh the importance of social support for kidney transplantation compared with other factors, and variation by clinical role and personal beliefs.

METHODS

The National survey of the American Society of Transplant Surgeons and the Society of Transplant Social Work in 2016. Using a discrete choice approach, respondents compared two hypothetical patient profiles and selected one for transplantation. Conditional logistic regression estimated the relative importance of each factor; results were stratified by clinical role (psychosocial vs medical/surgical providers) and beliefs (outcomes vs equity).

RESULTS

Five hundred and eighy-four transplant providers completed the survey. Social support was the second most influential factor among transplant providers. Providers were most likely to choose a candidate who had social support (OR=1.68, 95% CI 1.50 to 1.86), always adhered to a medical regimen (OR=1.64, 95% CI 1.46 to 1.88), and had a 15 years life expectancy with transplant (OR=1.61, 95% CI 1.42 to 1.85). Psychosocial providers were more influenced by adherence and quality of life compared with medical/surgical providers, who were more influenced by candidates' life expectancy with transplant (p<0.05). For providers concerned with avoiding organ waste, social support was the most influential factor, while it was the least influential for clinicians concerned with fairness (p<0.05).

CONCLUSIONS

Social support is highly influential in listing decisions and may exacerbate transplant disparities. Providers' beliefs and reliance on social support in determining suitability vary considerably, raising concerns about transparency and justice.

Is social support associated with post-transplant medication adherence and outcomes? A systematic review and meta-analysis

Although social support is used to determine transplant eligibility, the relationship between social support, medication adherence, and survival among transplant recipients remains unclear. We estimated the relationship between social support and post-transplant medication adherence and outcomes using 10 electronic databases from inception to January 2016. Study quality was assessed and all review stages were conducted independently by 2 reviewers. Systematic review and meta-analysis were conducted. Thirty-two studies (9102 participants) met inclusion criteria: 21 assessed medication adherence (5197 participants), and 13 assessed clinical outcomes (3905 participants). Among high quality studies, neither social support nor marital status was predictive of medication adherence or post-transplant outcomes. Social support was not associated with medication adherence. It was associated with superior post-transplant outcomes, but the relationship was not significant among high quality studies. Compared to unmarried recipients, married recipients were more likely to adhere to medication post-transplant, but this relationship was not significant among high quality studies. Marital status was not significantly associated with transplant success. Social support is weakly and inconsistently associated with post-transplant adherence and outcomes. Larger prospective studies using consistent and validated measures are needed to justify the use of inadequate social support as a contraindication to transplantation.

Hemodialysis Clinic Social Networks, Sex Differences, and Renal Transplantation

This study describes patient social networks within a new hemodialysis clinic and models the association between social network participation and kidney transplantation. Survey and observational data collected between August 2012 and February 2015 were used to observe the formation of a social network of 46 hemodialysis patients in a newly opened clinic. Thirty-two (70%) patients formed a social network, discussing health (59%) and transplantation (44%) with other patients. While transplant-eligible women participated in the network less often than men (56% vs. 90%, p = 0.02), women who participated discussed their health more often than men (90% vs. 45.5%, p = 0.02). Patients in the social network completed a median of two steps toward transplantation compared with a median of 0 for socially isolated patients (p = 0.003). Patients also completed more steps if network members were closely connected (β = 2.23, 95% confidence interval [CI] 0.16-4.29, p = 0.03) and if network members themselves completed more steps (β = 2.84, 95% CI 0.11-5.57, p = 0.04). The hemodialysis clinic patient social network had a net positive effect on completion of transplant steps, and patients who interacted with each other completed a similar number of steps.

Ethnic Background Is a Potential Barrier to Living Donor Kidney Transplantation in Canada: A Single-Center Retrospective Cohort Study

BACKGROUND

We examined if African or Asian ethnicity was associated with lower access to kidney transplantation (KT) in a Canadian setting.

METHODS

Patients referred for KT to the Toronto General Hospital from January 1, 2003, to December 31, 2012, who completed social work assessment, were included (n = 1769). The association between ethnicity and the time from referral to completion of KT evaluation or receipt of a KT were examined using Cox proportional hazards models.

RESULTS

About 54% of the sample was white, 13% African, 11% East Asian, and 11% South Asian; 7% had "other" (n = 121) ethnic background. African Canadians (hazard ratio [HR], 0.75; 95% CI: 0.62-0.92]) and patients with "other" ethnicity (HR, 0.71; 95% CI, 0.55-0.92) were less likely to complete the KT evaluation compared with white Canadians, and this association remained statistically significant in multivariable adjusted models. Access to KT was significantly reduced for all ethnic groups assessed compared with white Canadians, and this was primarily driven by differences in access to living donor KT. The adjusted HRs for living donor KT were 0.35 (95% CI, 0.24-0.51), 0.27 (95% CI, 0.17-0.41), 0.43 (95% CI, 0.30-0.61), and 0.34 (95% CI, 0.20-0.56) for African, East or South Asian Canadians and for patients with "other" ethnic background, respectively.

CONCLUSIONS

Similar to other jurisdictions, nonwhite patients face barriers to accessing KT in Canada. This inequity is very substantial for living donor KT. Further research is needed to identify if these inequities are due to potentially modifiable barriers.

Pregnancy-Induced Sensitization Promotes Sex Disparity in Living Donor Kidney Transplantation

The presence of sex disparity in living donor kidney transplantation (LDKT) remains controversial. To determine if women fall behind men in LDKT evaluation, we performed an intention to treat study of 2587 candidates listed for kidney transplant at a single transplant center over 7 years. We found that women and men kidney transplant candidates engaged an equivalent type and number of prospective living donors. However, sex-specific differences in sensitization history and histocompatibility reduced the rate of LDKT for women by 30%. Pregnancy-induced incompatibility with spouse donors was limiting given that spouses were among the individuals most likely to complete donation. Notably, participation in a kidney paired exchange program eliminated sex-based differences in LDKT. Collectively, these data suggest that pregnancy is a formidable biologic barrier for women and contributes uniquely to sex disparity in LDKT. Targeted efforts to improve transplant center participation in paired kidney exchanges may increase sex equity in LDKT.

Access to Kidney Transplantation among HIV-Infected Waitlist Candidates

BACKGROUND AND OBJECTIVES

Kidney transplantation among HIV-infected patients with ESRD confers a significant survival benefit over remaining on dialysis. Given the high mortality burden associated with dialysis, understanding access to kidney transplantation after waitlisting among HIV+ candidates is warranted.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Data from the Scientific Registry of Transplant Recipients were linked to Intercontinental Marketing Statistics pharmacy fills (January 1, 2001 to October 1, 2012) so that we could identify and study 1636 HIV+ (defined as having filled one or more antiretroviral medications unique to HIV treatment) and 72,297 HIV- kidney transplantation candidates.

RESULTS

HIV+ waiting list candidates were more often young (<50 years old: 62.7% versus 37.6%; P<0.001), were more often men (75.2% versus 59.3%; P<0.001), were more often black (73.6% versus 27.9%; P<0.001), had longer time on dialysis (years: 2.5 versus 0.8; P<0.001), were more often coinfected with hepatitis C virus (9.0% versus 3.9%; P<0.001), and were less likely to remain active on the waiting list (37.7% versus 49.4%; P<0.001). Waitlist mortality among HIV+ candidates was similar compared with HIV- candidates (adjusted hazard ratio, 1.03; 95% confidence interval, 0.89 to 1.20; P=0.67). In contrast, likelihood of living donor kidney transplantation was 47% lower (adjusted hazard ratio, 0.53; 95% confidence interval, 0.44 to 0.64; P<0.001), and there was a trend toward lower likelihood of deceased donor kidney transplantation (adjusted hazard ratio, 0.87; 95% confidence interval, 0.74 to 1.01; P=0.07) compared with in HIV- candidates.

CONCLUSIONS

Our findings highlight the need for additional study to better understand disparities in access to kidney transplantation, particularly living donor kidney transplantation, among HIV+ kidney waitlist candidates.

Making house calls increases living donor inquiries and evaluations for blacks on the kidney transplant waiting list

BACKGROUND

Blacks receive live donor kidney transplant (LDKT) less often than patients of all other races. We evaluated the effectiveness of educational interventions in removing barriers to LDKT for blacks.

METHODS

Patients were randomized to three interventions in which health educator(s) delivered an intervention to (a) the patient and his/her guests in the patient's home (house calls [HC], n=54), (b) clusters of patients and their guests in the transplant center (group based [GB], n=49), and (c) the individual patient alone in the transplant center (individual counseling [IC], n=49).

RESULTS

At the 2-year endpoint, 15% (n=8), 8% (n=4), and 6% (n=3) of HC, GB, and IC patients, respectively, received LDKT (P=0.30). Patients in the HC group were more likely than patients in the GB and IC groups to have at least one donor inquiry (82% vs. 61% vs. 47%, P=0.001) and evaluation (65% vs. 39% vs. 27%, P<0.001). Patients in the HC group also were more likely to have higher knowledge, fewer concerns, and higher willingness to talk to others about donation 6 weeks after intervention.

CONCLUSIONS

These findings underscore the importance of including the patient's social network in LDKT education and the potential of the HC intervention to reduce racial disparity in LDKT rates.

Readiness of wait-listed black patients to pursue live donor kidney transplant

CONTEXT

For adults with end-stage kidney disease, live donor kidney transplant (LDKT) has better outcomes than long-term dialysis and deceased donor kidney transplant. However, black patients receive LDKT at a much lower rate than adults of any other race or ethnicity.

OBJECTIVE

To examine the LDKT readiness stage of black patients on the transplant waiting list and its association with LDKT knowledge, concerns, and willingness.

DESIGN

Cross-sectional analysis of baseline data from a randomized controlled trial to improve knowledge and reduce concerns about LDKT.Patients and Setting-One hundred fifty-two black patients on the kidney transplant waiting list at a single transplant center in the northeastern United States.

MAIN OUTCOME MEASURES

LDKT readiness stage, knowledge, concerns, and willingness to talk to others about living donation.

RESULTS

Sixty percent of patients were not considering or not yet ready to pursue LDKT, and only 11% had taken action to talk to family members or friends about the possibility of living kidney donation. Patients in later stages of LDKT readiness (ie, who had talked to others about donation or were preparing to do so) had significantly more knowledge (P<.001), fewer concerns (P=.002), and more willingness (P=.001) to talk to others about living donation than those in earlier readiness stages.

CONCLUSIONS

The large percentage of black patients who are in the earlier stages of LDKT readiness may account for the low rate of LDKT in this patient population at our transplant center. Innovative and tailored LDKT educational strategies for black patients are needed to help reduce racial disparities in LDKT.

The RaDIANT community study protocol: community-based participatory research for reducing disparities in access to kidney transplantation

BACKGROUND

The Southeastern United States has the lowest kidney transplant rates in the nation, and racial disparities in kidney transplant access are concentrated in this region. The Southeastern Kidney Transplant Coalition (SEKTC) of Georgia, North Carolina, and South Carolina is an academic and community partnership that was formed with the mission to improve access to kidney transplantation and reduce disparities among African American (AA) end stage renal disease (ESRD) patients in the Southeastern United States.

METHODS/DESIGN

We describe the community-based participatory research (CBPR) process utilized in planning the Reducing Disparities In Access to kidNey Transplantation (RaDIANT) Community Study, a trial developed by the SEKTC to reduce health disparities in access to kidney transplantation among AA ESRD patients in Georgia, the state with the lowest kidney transplant rates in the nation. The SEKTC Coalition conducted a needs assessment of the ESRD population in the Southeast and used results to develop a multicomponent, dialysis facility-randomized, quality improvement intervention to improve transplant access among dialysis facilities in GA. A total of 134 dialysis facilities are randomized to receive either: (1) standard of care or "usual" transplant education, or (2) the multicomponent intervention consisting of transplant education and engagement activities targeting dialysis facility leadership, staff, and patients within dialysis facilities. The primary outcome is change in facility-level referral for kidney transplantation from baseline to 12 months; the secondary outcome is reduction in racial disparity in transplant referral.

DISCUSSION

The RaDIANT Community Study aims to improve equity in access to kidney transplantation for ESRD patients in the Southeast.

TRIAL REGISTRATION

Clinicaltrials.gov number NCT02092727.

Health literacy of living kidney donors and kidney transplant recipients

BACKGROUND

Health literacy (HL) may be a mediator for known socioeconomic and racial disparities in living kidney donation.

METHODS

We evaluated the associations of patient and demographic characteristics with HL in living kidney donors (LD), living donor kidney transplant recipients (LDR), and deceased donor recipients (DDR) in a single-center retrospective review of patients undergoing kidney donation or transplantation from September 2010 to July 2012. HL and demographic data were collected. HL was assessed via the Short Literacy Survey (SLS) comprising three self-reported screening questions scored using the five-point Likert scale (low, moderate, high). Chi-square and logistic regression were used to test factors associated with lower HL.

RESULTS

The sample included 360 adults (105 LD, 103 LDR, and 152 DDR; 46±14 years; 70% white; 56% male; 14±3 years of education). HL scores were skewed (49% high, 41% moderate, and 10% low). The distribution of HL categories differed significantly among groups (P=0.019). After controlling for age, race, sex, education, and a race-education interaction term, DDR was more likely to have moderate or low HL than LDR (OR, 1.911; 95% CI, 1.096-3.332; P=0.022).

CONCLUSION

Overall, living donors had high HL. The distribution of low, moderate, and high HL differed significantly between LD, DDR, and LDR. DDR had a higher likelihood of having low HL than LDR. Screening kidney transplant candidates and donors for lower HL may identify barriers to living donation. Future interventions addressing HL may be important to increase living donation and reduce disparities.

Of kin and kidneys: do kinship networks contribute to racial disparities in living donor kidney transplantation?

In the United States, racial disparities in kidney transplantation are large and especially stark for living donor transplants. Medical researchers frequently attribute this to the availability of medically compatible living kidney donors, who are usually kin. This paper evaluates this hypothesis by testing whether African American transplant candidates likely have lesser access to suitable living donors in their kinship networks than white candidates. This paper evaluates this hypothesis using a simulation design. Contrary to prior research on this topic, this simulation analysis concludes that black-white disparities in living donor kidney transplantation are unlikely to be the result of group differences in the availability of suitable donors. Although individual white kin are individually more likely to be suitable donors, African Americans' larger average kinship networks compensate for this difference.

Accountability for end-stage organ care: implications of geographic variation in access to kidney transplantation

BACKGROUND

The provision of effective surgical care for end-stage renal disease (ESRD) requires efficient evaluation and transplantation. Prior assessments of transplant access have focused primarily on waitlisted patients rather than the overall populations served by "accountable" providers of transplant services.

METHODS

Novel transplant referral regions (TRRs) were defined using United Network for Organ Sharing registry data for 301,092 kidney transplant listings to assign zip codes to "accountable" transplant programs. Subsequently, risk-adjusted observed to expected (O:E) rates of listing and transplant procedures were calculated for each TRR. Finally, the impact of variation in TRR listing and transplant rates on mortality was assessed for ESRD patients <60 years old diagnosed between 2000 and 2008.

RESULTS

In total, 113 TRRs were defined, 51% of which included >1 transplant center. The likelihood of being evaluated and listed for transplant varied significantly between TRRs (risk-adjusted O:E, 0.58-1.95). Variation was greater for the overall transplant rate (0.62-2.19), living donor transplantation (0.36-3.08), and donation after cardiac death transplant (0-15.4) than for standard criteria donors (0.64-2.86). Mortality was decreased for ESRD patients living in TRRs in the highest tertile of listings (hazard ratio, 0.89; P < .0001) and transplantation (0.90; P < .0001).

CONCLUSION

Residence in a TRR with care delivery systems that increase access to transplant services is associated with significant, risk-adjusted decreases in ESRD-related mortality. Transplant centers should continue to focus on improving access to care within the communities they serve.

Prominent impact of community risk factors on kidney transplant candidate processes and outcomes

Numerous factors impact patients' health beyond traditional clinical characteristics. We evaluated the association of risk factors in kidney transplant patients' communities with outcomes prior to transplantation. The primary exposure variable was a community risk score (range 0-40) derived from multiple databases and defined by factors including prevalence of comorbidities, access and quality of healthcare, self-reported physical and mental health and socioeconomic status for each U.S. county. We merged data with the Scientific Registry of Transplant Recipients (SRTR) and utilized risk-adjusted models to evaluate effects of community risk for adult candidates listed 2004-2010 (n = 209 198). Patients in highest risk communities were associated with increased mortality (adjusted hazard ratio [AHR] = 1.22, 1.16-1.28), decreased likelihood of living donor transplantation (adjusted odds ratio [AOR] = 0.90, 0.85-0.94), increased waitlist removal for health deterioration (AHR = 1.36, 1.22-1.51), decreased likelihood of preemptive listing (AOR = 0.85, 0.81-0.88), increased likelihood of inactive listing (AOR = 1.49, 1.43-1.55) and increased likelihood of listing for expanded criteria donor kidneys (AHR = 1.19, 1.15-1.24). Associations persisted with adjustment for rural-urban location; furthermore the independent effects of rural-urban location were largely eliminated with adjustment for community risk. Average community risk varied widely by region and transplant center (median = 21, range 5-37). Community risks are powerful factors associated with processes of care and outcomes for transplant candidates and may be important considerations for developing effective interventions and measuring quality of care of transplant centers.

A web-based application for initial screening of living kidney donors: development, implementation and evaluation

Most centers utilize phone or written surveys to screen candidates who self-refer to be living kidney donors. To increase efficiency and reduce resource utilization, we developed a web-based application to screen kidney donor candidates. The aim of this study was to evaluate the use of this web-based application. Method and time of referral were tabulated and descriptive statistics summarized demographic characteristics. Time series analyses evaluated use over time. Between January 1, 2011 and March 31, 2012, 1200 candidates self-referred to be living kidney donors at our center. Eight hundred one candidates (67%) completed the web-based survey and 399 (33%) completed a phone survey. Thirty-nine percent of donors accessed the application on nights and weekends. Postimplementation of the web-based application, there was a statistically significant increase (p < 0.001) in the number of self-referrals via the web-based application as opposed to telephone contact. Also, there was a significant increase (p = 0.025) in the total number of self-referrals post-implementation from 61 to 116 per month. An interactive web-based application is an effective strategy for the initial screening of donor candidates. The web-based application increased the ability to interface with donors, process them efficiently and ultimately increased donor self-referral at our center.

Finding a living kidney donor: experiences of New Zealand renal patients

A living donor kidney transplant (LDKT) is the preferred treatment for many people with end stage renal failure but there is a significant and growing gap between the number of people who might benefit from a transplant and those who receive one in New Zealand. International research suggests a range of barriers for patients in the journey to LDKT. One hundred and ninety-three patients on the New Zealand waiting list for a kidney transplant responded to a postal survey about live transplantation. While many patients are willing to discuss LDKT with family and friends, most are reluctant to go on to ask others directly to consider live donation. Patients who have not discussed LDKT with others are significantly less likely to have received even one offer from a potential donor. Pākehā and Māori are more likely to have received an offer to donate and to have had someone go on to be tested for compatibility than either Pacific or Other ethnic groups. Information gaps, ineffective donor recruitment strategies, donor incompatibility and donor medical unsuitability appear to be major barriers to LDKT. Many barriers are amenable to intervention and the implications for policy and practice are discussed. What is known about the topic? International studies suggest donor recruitment is difficult for patients and is a major barrier to LDKT. Incompatibility and medical unsuitability are barriers for many willing potential donors. There is no previous patient-centred NZ research on the barriers to living donor kidney transplantation (LDKT). What does this paper add? The paper provides evidence about patterns of donor recruitment activity amongst NZ patients, and suggests a strong relationship between discussing LDKT with family and friends, and receiving offers from potential donors. Asking potential donors directly to consider donation, as opposed to just discussing LDKT in general, does not seem to be associated with receiving more offers. Differences among ethnic groups can be seen. What are the implications for practitioners? Many of the barriers to LDKT are amenable to intervention, and possible options, such as support for donor recruitment and boosting NZ’s paired exchange scheme, are identified.

Center-level factors and racial disparities in living donor kidney transplantation

BACKGROUND

On average, African Americans attain living donor kidney transplantation (LDKT) at decreased rates compared with their non-African American counterparts. However, center-level variations in this disparity or the role of center-level factors is unknown.

STUDY DESIGN

Observational cohort study.

SETTING & PARTICIPANTS

247,707 adults registered for first-time kidney transplants from 1995-2007 as reported by the Scientific Registry of Transplant Recipients.

PREDICTORS

Patient-level factors (age, sex, body mass index, insurance status, education, blood type, and panel-reactive antibody level) were adjusted for in all models. The association of center-level characteristics (number of candidates, transplant volume, LDKT volume, median time to transplant, percentage of African American candidates, percentage of prelisted candidates, and percentage of LDKT) and degree of racial disparity in LDKT was quantified.

OUTCOMES

Hierarchical multivariate logistic regression models were used to derive center-specific estimates of LDKT attainment in African American versus non-African American candidates.

RESULTS

Racial parity was not seen at any of the 275 transplant centers in the United States. At centers with the least racial disparity, African Americans had 35% lower odds of receiving LDKT; at centers with the most disparity, African Americans had 76% lower odds. Higher percentages of African American candidates (interaction term, 0.86; P = 0.03) and prelisted candidates (interaction term, 0.80; P = 0.001) at a given center were associated with increased racial disparity at that center. Higher rates of LDKT (interaction term, 1.25; P < 0.001) were associated with less racial disparity.

LIMITATIONS

Some patient-level factors are not captured, including a given patient's pool of potential donors. Geographic disparities in deceased donor availability might affect LDKT rates. Center-level policies and practices are not captured.

CONCLUSIONS

Racial disparity in attainment of LDKT exists at every transplant center in the country. Centers with higher rates of LDKT attainment for all races had less disparity; these high-performing centers might provide insights into policies that might help address this disparity.

Racial disparities in pediatric access to kidney transplantation: does socioeconomic status play a role?

Racial disparities persist in access to renal transplantation in the United States, but the degree to which patient and neighborhood socioeconomic status (SES) impacts racial disparities in deceased donor renal transplantation access has not been examined in the pediatric and adolescent end-stage renal disease (ESRD) population. We examined the interplay of race and SES in a population-based cohort of all incident pediatric ESRD patients <21 years from the United States Renal Data System from 2000 to 2008, followed through September 2009. Of 8452 patients included, 30.8% were black, 27.6% white-Hispanic, 44.3% female and 28.0% lived in poor neighborhoods. A total of 63.4% of the study population was placed on the waiting list and 32.5% received a deceased donor transplant. Racial disparities persisted in transplant even after adjustment for SES, where minorities were less likely to receive a transplant compared to whites, and this disparity was more pronounced among patients 18-20 years. Disparities in access to the waiting list were mitigated in Hispanic patients with private health insurance. Our study suggests that racial disparities in transplant access worsen as pediatric patients transition into young adulthood, and that SES does not explain all of the racial differences in access to kidney transplantation.

Rational rationing or discrimination: balancing equity and efficiency considerations in kidney allocation

After 6 years of deliberation, the Organ Procurement and Transplantation Network recently released a concept document proposing changes to the kidney allocation algorithm, sparking a heated debate about priority-setting of scarce health resources and discrimination. Proponents of the proposal argue that it will result in an additional 15,223 life years following transplant annually for recipients, yet the benefit will not be equally distributed and will likely benefit younger patients. Critics argue that the new model will promote age discrimination and may lead to a further decrease in live kidney donation. If true, these concerns could undermine fairness and damage public trust in the organ allocation system. We address these objections and consider their merit, highlighting both benefits and shortcomings of the proposal. We argue that, despite weaknesses of the proposal and the importance of maintaining consistency in patient and provider expectations over time, the proposal represents a needed first step in balancing equity and efficiency.

Social Adaptability Index predicts access to kidney transplantation

Identifying the group of subjects prone to disparities in access to kidney transplantation is important for developing potential interventions. Data from the United States Renal Data System (January 1, 1990-September 1, 2007; n = 3407) were used to study association between the Social Adaptability Index (SAI; based upon employment, marital status, education, income, and substance abuse) and outcomes (time to being placed on the waiting list and time to being transplanted once listed). Patients were 56.9 ± 16.1 yr old, 54.2% men, 64.2% white, and 50.4% had diabetes. SAI was higher in whites (7.4 ± 2.4) than African Americans (6.5 ± 2.6) [ANOVA, p < 0.001] and greater in men (7.4 ± 2.4) than in women (6.7 ± 2.5) [T-test, p < 0.001]. In multivariate model, greater SAI (range 0-12) was associated with increased likelihood of being placed on the waiting list (hazard ratio [HR] 1.19 [95% CI 1.15-1.23] per each point of increase in SAI, p < 0.001) and greater likelihood of receiving a transplant once listed (HR of 1.06 [95% CI 1.03-1.09] per point of increase in SAI, p < 0.001). Similar trends were observed in most of the subgroups (based upon race, sex, diabetic status, age, comorbidities, and donor type). SAI is associated with access to renal transplantation in patients with end-stage renal disease; it may be used to indentify individuals at risk of healthcare disparities.

Racial and ethnic disparities in kidney transplantation

Success of renal transplantation, as a viable alternative to dialysis, has been tempered by long-standing racial disparities. Ethnic minorities have less access to transplantation, are less likely to be listed for transplantation, and experience a higher rate of graft failure. Reasons for the existing racial disparities at various stages of the transplantation process are complex and multi-factorial. They include a combination of behavioral, social, environmental, and occupational factors, as well as potential intended or unintended discrimination within the healthcare system. Immunologic factors such as human leukocyte antigen matching, composition of the organ donor pool, and patient immune response, all of which affect post-transplantation graft rejection rates and patient survival, also contribute to health disparities between ethnic groups.

Association of marital status with access to renal transplantation

In this report we evaluated the association of marital status with access to renal transplantation. We analyzed data from the USRDS. In patients with ESRD aged ≥ 27 (mean age of first marriage in the US), we analyzed the association of marital status with two outcomes: (1) likelihood of being placed on the waiting list for renal transplantation or first transplant, (2) likelihood of receiving kidney transplant in patients already listed. We analyzed marital status as a categorical variable: (1) not married (including never been married and widowed); (2) divorced or separated; and (3) currently married. Subgroups based on age, race, sex, donor type and diabetic status were also analyzed. After adjustments for the included independent variables and compared to individuals never married or widowed, those who were divorced/separated (HR 1.55, p < 0.001) and currently married (HR 1.54, p < 0.001) had a higher likelihood of being placed on the transplant waiting list. Once listed, married individuals had higher chances of getting transplanted as well (HR 1.28, p = 0.033). This trend was consistent in most of the subgroups studied. We demonstrated that being married is associated with better access to renal transplantation compared to those who were never married/widowed.

Barriers to living donor kidney transplantation among black or older transplant candidates

BACKGROUND AND OBJECTIVES

Lower rates of living donor kidney transplant (LDKT) among transplant candidates who are black or older may stem from lower likelihoods of (1) recruiting potential living donors or (2) potential donors actually donating (donor "conversion").

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A single-center, retrospective cohort study was performed to determine race, age, and gender differences in LDKT, donor recruitment, and donor conversion.

RESULTS

Of 1617 kidney transplant candidates, 791 (48.9%) recruited at least one potential living donor, and 452 (28.0%) received LDKTs. Black transplant candidates, versus non-blacks, were less likely to receive LDKTs (20.5% versus 30.6%, relative risk [RR] = 0.67), recruit potential living donors (43.9% versus 50.7%, RR = 0.86), and receive LDKTs if they had potential donors (46.8% versus 60.3%, RR = 0.78). Transplant candidates ≥60 years, versus candidates 18 to <40 years old, were less likely to receive LDKTs (15.1% versus 43.2%, RR = 0.35), recruit potential living donors (34.0% versus 64.6%, RR = 0.53), and receive LDKTs if they had potential donors (44.5% versus 66.8%, RR = 0.67). LDKT and donor recruitment did not differ by gender. Race and age differences persisted in multivariable logistic regression models. Among 339 candidates who recruited potential donors but did not receive LDKTs, blacks (versus non-blacks) were more likely to have potential donors who failed to donate because of a donor-related reason (86.9% versus 72.5%).

CONCLUSIONS

Black or older kidney transplant candidates were less likely to receive LDKTs because of lower likelihoods of donor recruitment and donor conversion.