1
|
Gaynor JJ, Guerra G, Vianna R, Tabbara MM, Graell EL, Ciancio G. Competing Risks Analysis of Kidney Transplant Waitlist Outcomes: Two Important Statistical Perspectives. Kidney Int Rep 2024; 9:1580-1589. [PMID: 38899174 PMCID: PMC11184382 DOI: 10.1016/j.ekir.2024.01.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/19/2024] [Indexed: 06/21/2024] Open
Abstract
Modern competing risks analysis has 2 primary goals in clinical epidemiology as follows: (i) to maximize the clinician's knowledge of etiologic associations existing between potential predictor variables and various cause-specific outcomes via cause-specific hazard models, and (ii) to maximize the clinician's knowledge of noteworthy differences existing in cause-specific patient risk via cause-specific subdistribution hazard models (cumulative incidence functions [CIFs]). A perfect application exists in analyzing the following 4 distinct outcomes after listing for a deceased donor kidney transplant (DDKT): (i) receiving a DDKT, (ii) receiving a living donor kidney transplant (LDKT), (iii) waitlist removal due to patient mortality or a deteriorating medical condition, and (iv) waitlist removal due to other reasons. It is important to realize that obtaining a complete understanding of subdistribution hazard ratios (HRs) is simply not possible without first having knowledge of the multivariable relationships existing between the potential predictor variables and the cause-specific hazards (perspective #1), because the cause-specific hazards form the "building blocks" of CIFs. In addition, though we believe that a worthy and practical alternative to estimating the median waiting-time-to DDKT is to ask, "what is the conditional probability of the patient receiving a DDKT, given that he or she would not previously experience one of the competing events (known as the cause-specific conditional failure probability)," only an appropriate estimator of this conditional type of cumulative incidence should be used (perspective #2). One suggested estimator, the well-known "one minus Kaplan-Meier" approach (censoring competing events), simply does not represent any probability in the presence of competing risks and will almost always produce biased estimates (thus, it should never be used).
Collapse
Affiliation(s)
- Jeffrey J. Gaynor
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine; Miami, Florida, USA
| | - Giselle Guerra
- Department of Medicine, Miami Transplant Institute, University of Miami Miller School of Medicine; Miami, Florida, USA
| | - Rodrigo Vianna
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine; Miami, Florida, USA
| | - Marina M. Tabbara
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine; Miami, Florida, USA
| | - Enric Lledo Graell
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine; Miami, Florida, USA
| | - Gaetano Ciancio
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine; Miami, Florida, USA
| |
Collapse
|
2
|
Sandal S, Ahn J, Chen Y, Thompson V, Purnell TS, Cantarovich M, Clark-Cutaia MN, Wu W, Suri R, Segev DL, McAdams-DeMarco M. Differences in Racial and Ethnic Disparities Between First and Repeat Kidney Transplantation. Transplantation 2024:00007890-990000000-00761. [PMID: 38771099 DOI: 10.1097/tp.0000000000005051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Recent data suggest patients with graft failure had better access to repeat kidney transplantation (re-KT) than transplant-naive dialysis accessing first KT. This was postulated to be because of better familiarity with the transplant process and healthcare system; whether this advantage is equitably distributed is not known. We compared the magnitude of racial/ethnic disparities in access to re-KT versus first KT. METHODS Using United States Renal Data System, we identified 104 454 White, Black, and Hispanic patients with a history of graft failure from 1995 to 2018, and 2 357 753 transplant-naive dialysis patients. We used adjusted Cox regression to estimate disparities in access to first and re-KT and whether the magnitude of these disparities differed between first and re-KT using a Wald test. RESULTS Black patients had inferior access to both waitlisting and receiving first KT and re-KT. However, the racial/ethnic disparities in waitlisting for (adjusted hazard ratio [aHR] = 0.77; 95% confidence interval [CI], 0.74-0.80) and receiving re-KT (aHR = 0.61; 95% CI, 0.58-0.64) was greater than the racial/ethnic disparities in first KT (waitlisting: aHR = 0.91; 95% CI, 0.90-0.93; Pinteraction = 0.001; KT: aHR = 0.68; 95% CI, 0.64-0.72; Pinteraction < 0.001). For Hispanic patients, ethnic disparities in waitlisting for re-KT (aHR = 0.83; 95% CI, 0.79-0.88) were greater than for first KT (aHR = 1.14; 95% CI, 1.11-1.16; Pinteraction < 0.001). However, the disparity in receiving re-KT (aHR = 0.76; 95% CI, 0.72-0.80) was similar to that for first KT (aHR = 0.73; 95% CI, 0.68-0.79; Pinteraction = 0.55). Inferences were similar when restricting the cohorts to the Kidney Allocation System era. CONCLUSIONS Unlike White patients, Black and Hispanic patients with graft failure do not experience improved access to re-KT. This suggests that structural and systemic barriers likely persist for racialized patients accessing re-KT, and systemic changes are needed to achieve transplant equity.
Collapse
Affiliation(s)
- Shaifali Sandal
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - JiYoon Ahn
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yusi Chen
- Department of Surgery, NYU Grossman School of Medicine and Langone Health, New York, NY
| | - Valerie Thompson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tanjala S Purnell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, NYU Grossman School of Medicine and Langone Health, New York, NY
| | - Marcelo Cantarovich
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | | | - Wenbo Wu
- Department of Population Health, NYU Grossman School of Medicine and Langone Health, New York, NY
| | - Rita Suri
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Dorry L Segev
- Department of Surgery, NYU Grossman School of Medicine and Langone Health, New York, NY
- Department of Population Health, NYU Grossman School of Medicine and Langone Health, New York, NY
| | - Mara McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine and Langone Health, New York, NY
- Department of Population Health, NYU Grossman School of Medicine and Langone Health, New York, NY
| |
Collapse
|
3
|
Isgor Z, Johnson T, Cmunt K, Lange-Maia BS. Illinois Transplant Fund Experience: Is It a Pathway to Increased Transplant Access for Hispanic Patients With Kidney Failure? Kidney Med 2024; 6:100742. [PMID: 38162539 PMCID: PMC10757032 DOI: 10.1016/j.xkme.2023.100742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Rationale & Objective The Illinois Transplant Fund, established in 2015, provides private health insurance premium support for noncitizen patients with kidney failure in Illinois and thus allows them to qualify for kidney transplants. Our objective was to describe trends in kidney transplant volumes over time to inform the development of a hypothesis regarding the impact of the Illinois Transplant Fund on kidney transplant volumes for adult Hispanic patients with kidney failure in Illinois, especially noncitizen patients. Study Design Retrospective study. Setting & Population We used data on the annual number of kidney transplants and kidney failure prevalence aggregated to the national and state levels from the Organ Procurement and Transplantation Network and United States Renal Data System, respectively. Outcomes The annual number of transplants as a percentage of prevalent kidney failure cases among adults over time from 2010 to 2020 by race/ethnicity for all payer and private insurance-paid transplants and the annual number of transplants by citizenship status (for Hispanic patients only) were examined for the United States (US), Illinois, and 6 selected US states. Analytical Approach Descriptive study. Results From pre- to post-Illinois Transplant Fund, the average annual number of transplants as a percentage of the average annual prevalent kidney failure cases for Hispanic adults increased by 4% in Illinois while the same figure increased by 33% for privately insured transplants. Limitations The observations reported in this paper cannot be interpreted as evidence for the program's impact. Conclusions Observed trends suggest plausibility of developing a hypothesis that Illinois Transplant Fund's introduction may have contributed to improvement in kidney transplantation access for Hispanic patients in Illinois, especially noncitizens, but cannot constitute evidence in support of or against this hypothesis. Future research should test whether the Illinois Transplant Fund improved access to kidney transplants for noncitizens with kidney failure. Plain-Language Summary Health policies regarding kidney transplant access for undocumented residents vary widely by state. The Illinois Transplant Fund (ITF) provides financial support for health insurance premiums, so undocumented patients with kidney failure in Illinois can qualify for a kidney transplant. In this study, we reported kidney transplant trends in Illinois before and after the creation of the ITF along with kidney transplant trends in the US overall and selected states that share similarities to Illinois.
Collapse
Affiliation(s)
- Zeynep Isgor
- Department of Health Systems Management, College of Health Sciences, Rush University, Chicago, IL, USA
| | - Tricia Johnson
- Department of Health Systems Management, College of Health Sciences, Rush University, Chicago, IL, USA
| | - Kevin Cmunt
- Gift of Hope Organ and Tissue Donor Network and Illinois Transplant Fund, Itasca, IL, USA
| | - Brittney S. Lange-Maia
- Department of Family & Preventive Medicine and Rush Alzheimer’s Disease Center, Rush University, Chicago, IL, USA
| |
Collapse
|
4
|
Brand S, Daga S, Mistry K, Morsy M, Bagul A, Hamer R, Malik S. Sikh and Muslim perspectives on kidney transplantation: phase 1 of the DiGiT project - a qualitative descriptive study. BMJ Open 2023; 13:e059668. [PMID: 38040423 PMCID: PMC10693862 DOI: 10.1136/bmjopen-2021-059668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 10/06/2023] [Indexed: 12/03/2023] Open
Abstract
OBJECTIVES Kidney transplantation offers patients better quality of life and survival compared with dialysis. The risk of end stage renal disease is higher among ethnic minorities and they experience longer wait times on transplant lists. This inequality stems from a high need for kidney transplantation combined with a low rate of deceased donation among ethnic minority groups. This study aimed to explore the perspectives around living donor kidney transplantation of members of the Sikh and Muslim communities with an aim to develop a digital intervention to overcome any barriers. DESIGN A qualitative descriptive study using in person focus groups. SETTING University Teaching Hospital and Transplant Centre. PARTICIPANTS Convenience sampling of participants from the transplant population. Three focus groups were held with 20 participants, all were of South Asian ethnicity belonging to the Sikh and Muslim communities. METHODS Interviews were digitally audio-recorded and transcribed verbatim; transcripts were analysed thematically. RESULTS Four themes were identified: (a) religious issues; (b) lack of knowledge within the community; (c) time; (d) cultural identification with transplantation. CONCLUSIONS Not only is the information given and when it is delivered important, but also the person giving the information is crucial to enhance consideration of live donor kidney transplantation. Information should be in a first language where possible and overtly align to religious considerations. A more integrated approach to transplantation counselling should be adopted which includes healthcare professionals and credible members of the target cultural group. TRIAL REGISTRATION NUMBER NCT04327167.
Collapse
Affiliation(s)
- Sarah Brand
- Department of Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sunil Daga
- Department of Nephrology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kirit Mistry
- South Asian Health Action Charity, Leicester, UK
| | - Mohamed Morsy
- Department of Nephrology and Transplantation, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Atul Bagul
- Department of Nephrology and Transplantation, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Rizwan Hamer
- Department of Renal Transplantation and Nephrology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Shafi Malik
- Department of Nephrology and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| |
Collapse
|
5
|
Rha B, See I, Dunham L, Kutty PK, Moccia L, Apata IW, Ahern J, Jung S, Li R, Nadle J, Petit S, Ray SM, Harrison LH, Bernu C, Lynfield R, Dumyati G, Tracy M, Schaffner W, Ham DC, Magill SS, O’Leary EN, Bell J, Srinivasan A, McDonald LC, Edwards JR, Novosad S. Vital Signs: Health Disparities in Hemodialysis-Associated Staphylococcus aureus Bloodstream Infections - United States, 2017-2020. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2023; 72:153-159. [PMID: 36757874 PMCID: PMC9925139 DOI: 10.15585/mmwr.mm7206e1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Introduction Racial and ethnic minorities are disproportionately affected by end-stage kidney disease (ESKD). ESKD patients on dialysis are at increased risk for Staphylococcus aureus bloodstream infections, but racial, ethnic, and socioeconomic disparities associated with this outcome are not well described. Methods Surveillance data from the 2020 National Healthcare Safety Network (NHSN) and the 2017-2020 Emerging Infections Program (EIP) were used to describe bloodstream infections among patients on hemodialysis (hemodialysis patients) and were linked to population-based data sources (CDC/Agency for Toxic Substances and Disease Registry [ATSDR] Social Vulnerability Index [SVI], United States Renal Data System [USRDS], and U.S. Census Bureau) to examine associations with race, ethnicity, and social determinants of health. Results In 2020, 4,840 dialysis facilities reported 14,822 bloodstream infections to NHSN; 34.2% were attributable to S. aureus. Among seven EIP sites, the S. aureus bloodstream infection rate during 2017-2020 was 100 times higher among hemodialysis patients (4,248 of 100,000 person-years) than among adults not on hemodialysis (42 of 100,000 person-years). Unadjusted S. aureus bloodstream infection rates were highest among non-Hispanic Black or African American (Black) and Hispanic or Latino (Hispanic) hemodialysis patients. Vascular access via central venous catheter was strongly associated with S. aureus bloodstream infections (NHSN: adjusted rate ratio [aRR] = 6.2; 95% CI = 5.7-6.7 versus fistula; EIP: aRR = 4.3; 95% CI = 3.9-4.8 versus fistula or graft). Adjusting for EIP site of residence, sex, and vascular access type, S. aureus bloodstream infection risk in EIP was highest in Hispanic patients (aRR = 1.4; 95% CI = 1.2-1.7 versus non-Hispanic White [White] patients), and patients aged 18-49 years (aRR = 1.7; 95% CI = 1.5-1.9 versus patients aged ≥65 years). Areas with higher poverty levels, crowding, and lower education levels accounted for disproportionately higher proportions of hemodialysis-associated S. aureus bloodstream infections. Conclusions and implications for public health practice Disparities exist in hemodialysis-associated S. aureus infections. Health care providers and public health professionals should prioritize prevention and optimized treatment of ESKD, identify and address barriers to lower-risk vascular access placement, and implement established best practices to prevent bloodstream infections.
Collapse
|
6
|
Adejare AA, Duncan HJ, Motz RG, Shah S, Thakar CV, Eckman MH. Implementing a Health Utility Assessment Platform to Acquire Health Utilities in a Hemodialysis Outpatient Setting: Feasibility Study. JMIR Form Res 2022; 6:e33562. [PMID: 35900828 PMCID: PMC9377480 DOI: 10.2196/33562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 06/14/2022] [Accepted: 06/24/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with end-stage kidney disease (ESKD) wait roughly 4 years for a kidney transplant. A potential way to reduce wait times is using hepatitis C virus (HCV)-viremic kidneys. OBJECTIVE As preparation for developing a shared decision-making tool to assist patients with ESKD with the decision to accept an HCV-viremic kidney transplant, our initial goal was to assess the feasibility of using The Gambler II, a health utility assessment tool, in an ambulatory dialysis clinic setting. Our secondary goals were to collect health utilities for patients with ESKD and to explore whether the use of race-matched versus race-mismatched exemplars impacted the knowledge gained during the assessment process. METHODS We used The Gambler II to elicit utilities for the following ESKD-related health states: hemodialysis, kidney transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney. We created race exemplar video clips describing these health states and randomly assigned patients into the race-matched or race-mismatched video arms. We obtained utilities for these 3 health states from each patient, and we evaluated knowledge about ESKD and HCV-associated health conditions with pre- and postintervention knowledge assessments. RESULTS A total of 63 patients with hemodialysis from 4 outpatient Dialysis Center Inc sites completed the study. Mean adjusted standard gamble utilities for hemodialysis, transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney were 82.5, 89, and 75.5, respectively. General group knowledge assessment scores improved by 10 points (P<.05) following utility assessment process. The use of race-matched exemplars had little effect on the results of the knowledge assessment of patients. CONCLUSIONS Using The Gambler II to collect utilities for patients with ESKD in an ambulatory dialysis clinic setting proved feasible. In addition, educational information about health states provided as part of the utility assessment process tool improved patients' knowledge and understanding about ESKD-related health states and implications of organ transplantation with HCV-viremic kidneys. A wide variation in patient health state utilities reinforces the importance of incorporating patients' preferences into decisions regarding use of HCV-viremic kidneys for transplantation.
Collapse
Affiliation(s)
- Adeboye A Adejare
- Department of Biomedical Informatics, University of Cincinnati, Cincinnati, OH, United States
| | - Heather J Duncan
- Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, OH, United States
| | - R Geoffrey Motz
- Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, OH, United States
| | - Silvi Shah
- Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, OH, United States
| | - Charuhas V Thakar
- Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, OH, United States
| | - Mark H Eckman
- Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH, United States
| |
Collapse
|
7
|
Pande M, Grafals M, Rizzolo K, Pomfret E, Kendrick J. Reducing disparities in kidney transplantation for Spanish-speaking patients through creation of a dedicated center. BMC Nephrol 2022; 23:251. [PMID: 35840913 PMCID: PMC9283817 DOI: 10.1186/s12882-022-02879-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/04/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction Hispanic Americans receive disproportionately fewer organ transplants than non-Hispanic whites. In 2018, the Hispanic Kidney Transplant Program (HKTP) was established as at the University of Colorado Hospital (UCH). The purpose of this quality improvement study was to examine the effect of this culturally sensitive program in reducing disparities in kidney transplantation. Methods We performed a mixed-methods analysis of data from 436 Spanish-speaking patients referred for transplant to UCH between 2015 and 2020. We compared outcomes for patients referred between 2015–2017 (n = 156) to those referred between 2018–2020 (n = 280). Semi-structured phone interviews were conducted with 6 patients per time period and with 6 nephrology providers in the Denver Metro Area. Patients and providers were asked to evaluate communication, transplant education, and overall experience. Results When comparing the two time periods, there was a significant increase in the percentage of patients being referred (79.5% increase, p-0.008) and evaluated for transplant (82.4% increase, p = 0.02) during 2018–2020. While the number of committee reviews and number waitlisted increased during 2018–2020, it did not reach statistical significance (82.9% increase, p = 0.37 and 79.5% increase, p = 0.75, respectively. During patient and provider interviews, we identified 4 themes reflecting participation in the HKTP: improved communication, enhanced patient education, improved experience and areas for advancement. Overall, patients and providers reported a positive experience with the HKTP and noted improved patient understanding of the transplantation process. Conclusions The establishment of the HKTP is associated with a significant increase in Spanish-speaking Hispanic patients being referred and evaluated for kidney transplantation.
Collapse
Affiliation(s)
- Madhura Pande
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Monica Grafals
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Colorado Center for Transplant Care, Research and Education (CCTCARE), Aurora, CO, USA
| | - Katherine Rizzolo
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Elizabeth Pomfret
- Colorado Center for Transplant Care, Research and Education (CCTCARE), Aurora, CO, USA.,Division of Transplant Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jessica Kendrick
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| |
Collapse
|
8
|
McGill RL, Saunders MR, Hayward AL, Chapman AB. Health Disparities in Autosomal Dominant Polycystic Kidney Disease (ADPKD) in the United States. Clin J Am Soc Nephrol 2022; 17:976-985. [PMID: 35725555 PMCID: PMC9269641 DOI: 10.2215/cjn.00840122] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/14/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Autosomal dominant polycystic kidney disease (ADPKD) occurs at conception and is often diagnosed decades prior to kidney failure. Nephrology care and transplantation access should be independent of race and ethnicity. However, institutional racism and barriers to health care may affect patient outcomes in ADPKD. We sought to ascertain the effect of health disparities on outcomes in ADPKD by examining age at onset of kidney failure and access to preemptive transplantation and transplantation after dialysis initiation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Retrospective cohort analyses of adults with ADPKD in the United States Renal Data System from January 2000 to June 2018 were merged to US Census income data and evaluated by self-reported race and ethnicity. Age at kidney failure was analyzed in a linear model, and transplant rates before and after dialysis initiation were analyzed in logistic and proportional hazards models in Black and Hispanic patients with ADPKD compared with White patients with ADPKD. RESULTS A total of 41,485 patients with ADPKD were followed for a median of 25 (interquartile range, 5-54) months. Mean age was 56±12 years; 46% were women, 13% were Black, and 10% were Hispanic. Mean ages at kidney failure were 55±13, 53±12, and 57±12 years for Black patients, Hispanic patients, and White patients, respectively. Odds ratios for preemptive transplant were 0.33 (95% confidence interval, 0.29 to 0.38) for Black patients and 0.50 (95% confidence interval, 0.44 to 0.56) for Hispanic patients compared with White patients. Transplant after dialysis initiation was 0.61 (95% confidence interval, 0.58 to 0.64) for Black patients and 0.78 (95% confidence interval, 0.74 to 0.83) for Hispanic patients. CONCLUSIONS Black and Hispanic patients with ADPKD reach kidney failure earlier and are less likely to receive a kidney transplant preemptively and after initiating dialysis compared with White patients with ADPKD.
Collapse
Affiliation(s)
- Rita L McGill
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Milda R Saunders
- Section of General Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | | | - Arlene B Chapman
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
| |
Collapse
|
9
|
DeBlasio RN, Myaskovsky L, DiMartini AF, Croswell E, Posluszny DM, Puttarajappa C, Switzer GE, Shapiro R, DeVito Dabbs AJ, Tevar AD, Hariharan S, Dew MA. The Combined Roles of Race/Ethnicity and Substance Use in Predicting Likelihood of Kidney Transplantation. Transplantation 2022; 106:e219-e233. [PMID: 35135973 PMCID: PMC9169160 DOI: 10.1097/tp.0000000000004054] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Racial/ethnic minorities face known disparities in likelihood of kidney transplantation. These disparities may be exacerbated when coupled with ongoing substance use, a factor also reducing likelihood of transplantation. We examined whether race/ethnicity in combination with ongoing substance use predicted incidence of transplantation. METHODS Patients were enrolled between March 2010 and October 2012 at the time of transplant evaluation. Substance use data were retrieved from transplant evaluations. Following descriptive analyses, the primary multivariable analyses evaluated whether, relative to the referent group (White patients with no substance use), racial/ethnic minority patients using any substances at the time of evaluation were less likely to receive transplants by the end of study follow-up (August 2020). RESULTS Among 1152 patients, 69% were non-Hispanic White, 23% non-Hispanic Black, and 8% Other racial/ethnic minorities. White, Black, and Other patients differed in percentages of current tobacco smoking (15%, 26%, and 18%, respectively; P = 0.002) and illicit substance use (3%, 8%, and 9%; P < 0.001) but not heavy alcohol consumption (2%, 4%, and 1%; P = 0.346). Black and Other minority patients using substances were each less likely to receive transplants than the referent group (hazard ratios ≤0.45, P ≤ 0.021). Neither White patients using substances nor racial/ethnic minority nonusers differed from the referent group in transplant rates. Additional analyses indicated that these effects reflected differences in waitlisting rates; once waitlisted, study groups did not differ in transplant rates. CONCLUSIONS The combination of minority race/ethnicity and substance use may lead to unique disparities in likelihood of transplantation. To facilitate equity, strategies should be considered to remove any barriers to referral for and receipt of substance use care in racial/ethnic minorities.
Collapse
Affiliation(s)
- Richelle N DeBlasio
- Department of Psychiatry, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Larissa Myaskovsky
- Department of Internal Medicine, Center for Healthcare Equity in Kidney Disease, University of New Mexico School of Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Andrea F DiMartini
- Department of Psychiatry, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Emilee Croswell
- Department of Psychiatry, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Donna M Posluszny
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA
| | | | - Galen E Switzer
- Department of Psychiatry, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Ron Shapiro
- Mount Sinai Recanati/Miller Transplantation Institute, Icahn School of Medicine, New York, NY
| | | | - Amit D Tevar
- Department of Surgery and Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Sundaram Hariharan
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- Department of Surgery and Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
- Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA
- Departments of Psychology, Epidemiology, and Biostatistics, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
10
|
A scoping review of inequities in access to organ transplant in the United States. Int J Equity Health 2022; 21:22. [PMID: 35151327 PMCID: PMC8841123 DOI: 10.1186/s12939-021-01616-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 12/24/2021] [Indexed: 02/06/2023] Open
Abstract
Background Organ transplant is the preferred treatment for end-stage organ disease, yet the majority of patients with end-stage organ disease are never placed on the transplant waiting list. Limited access to the transplant waiting list combined with the scarcity of the organ pool result in over 100,000 deaths annually in the United States. Patients face unique barriers to referral and acceptance for organ transplant based on social determinants of health, and patients from disenfranchised groups suffer from disproportionately lower rates of transplantation. Our objective was to review the literature describing disparities in access to organ transplantation based on social determinants of health to integrate the existing knowledge and guide future research. Methods We conducted a scoping review of the literature reporting disparities in access to heart, lung, liver, pancreas and kidney transplantation based on social determinants of health (race, income, education, geography, insurance status, health literacy and engagement). Included studies were categorized based on steps along the transplant care continuum: referral for transplant, transplant evaluation and selection, living donor identification/evaluation, and waitlist outcomes. Results Our search generated 16,643 studies, of which 227 were included in our final review. Of these, 34 focused on disparities in referral for transplantation among patients with chronic organ disease, 82 on transplant selection processes, 50 on living donors, and 61 on waitlist management. In total, 15 studies involved the thoracic organs (heart, lung), 209 involved the abdominal organs (kidney, liver, pancreas), and three involved multiple organs. Racial and ethnic minorities, women, and patients in lower socioeconomic status groups were less likely to be referred, evaluated, and added to the waiting list for organ transplant. The quality of the data describing these disparities across the transplant literature was variable and overwhelmingly focused on kidney transplant. Conclusions This review contextualizes the quality of the data, identifies seminal work by organ, and reports gaps in the literature where future research on disparities in organ transplantation should focus. Future work should investigate the association of social determinants of health with access to the organ transplant waiting list, with a focus on prospective analyses that assess interventions to improve health equity. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01616-x.
Collapse
|
11
|
Serrano Rodríguez P, Szempruch KR, Strassle PD, Gerber DA, Desai CS. Potential to Mitigate Disparities in Access to Kidney Transplant in the Hispanic/Latino Population With a Specialized Clinic: Single Center Study Representing Single State Data. Transplant Proc 2021; 53:1798-1802. [PMID: 33985800 DOI: 10.1016/j.transproceed.2021.03.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND We sought to evaluate potential disparities in kidney transplant rates in a single state in the United States. We studied the potential to mitigate disparities with a specialized clinic using it as a model presentation. METHODS Based on data from the United States Renal Data System and Organ Procurement and Transplantation Network, we estimated the yearly end-stage renal disease and waitlist addition, stratified by race/ethnicity from 2000 to 2018. Institution rates were analyzed similarly, and the implementation of a focused Latino clinic was evaluated. RESULTS The number of patients added to the national transplant waitlist has increased by 40% in non-Latino whites and by 160% in Latinos from 2000 to 2017. Comparing the period from 2000 to 2004 to 2015 to 2018 in North Carolina, the waitlist increased for Latino patients by 482% and non-Latino whites by 23%. One year after a designated Latino transplant clinic at our institution, there was a 125% increase in the number of Latino referrals for kidney transplant evaluation, a 142% increase in the number of waitlisted Latino patients, and an increase in kidney transplants of 145%. CONCLUSION With the increasing number of patients in the Latino community who are diagnosed with end-stage renal disease, there is a direct benefit for a culturally competent program that addresses access to transplants.
Collapse
Affiliation(s)
- Pablo Serrano Rodríguez
- Department of Surgery, Division of Abdominal Transplant Surgery, University of North Carolina, Chapel Hill, North Carolina.
| | - Kristen R Szempruch
- Department of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Paula D Strassle
- Department of Surgery, Division of Abdominal Transplant Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - David A Gerber
- Department of Surgery, Division of Abdominal Transplant Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Chirag S Desai
- Department of Surgery, Division of Abdominal Transplant Surgery, University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|
12
|
Hu A, Stewart C, Craig JC, Wyburn K, Pleass H, Kanellis J, Lim WH, Yang J, Wong G. Jurisdictional inequalities in deceased donor kidney allocation in Australia. Kidney Int 2021; 100:49-54. [PMID: 33961869 DOI: 10.1016/j.kint.2021.04.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/28/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Anne Hu
- Faculty of Science, School of Mathematics and Science, University of Sydney, Sydney, Australia
| | - Cameron Stewart
- Sydney Law School, University of Sydney, Camperdown, Sydney, New South Wales, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Kate Wyburn
- Department of Renal and Transplantation Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Henry Pleass
- Faculty of Health and Medical Science, University of Western Australia, Perth, Australia
| | - John Kanellis
- Department of Nephrology, Monash Health and Centre for Inflammatory Diseases, Melbourne, Australia; Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Wai H Lim
- Specialty of Surgery, University of Sydney, Camperdown, Sydney, New South Wales, Australia
| | - Jean Yang
- Faculty of Science, School of Mathematics and Science, University of Sydney, Sydney, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Camperdown, New South Wales, Australia; Centre for Kidney Research, Kids Research Institute, The Children's Hospital at Westmead, Sydney, New South Wales, Australia; Centre for Transplant and Renal Research, Westmead Hospital, Sydney, New South Wales, Australia.
| |
Collapse
|
13
|
Whelan AM, Johansen KL, Brar S, McCulloch CE, Adey DB, Roll GR, Grimes B, Ku E. Association between Longer Travel Distance for Transplant Care and Access to Kidney Transplantation and Graft Survival in the United States. J Am Soc Nephrol 2021; 32:1151-1161. [PMID: 33712528 PMCID: PMC8259680 DOI: 10.1681/asn.2020081242] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 01/06/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Transplant candidates may gain an advantage by traveling to receive care at a transplant center that may have more favorable characteristics than their local center. Factors associated with longer travel distance for transplant care and whether the excess travel distance (ETD) is associated with access to transplantation or with graft failure are unknown. METHODS This study of adults in the United States wait-listed for kidney transplantation in 1995-2015 used ETD, defined as distance a patient traveled beyond the nearest transplant center for initial waiting list registration. We used linear regression to examine patient and center characteristics associated with ETD and Fine-Gray models to examine the association between ETD (modeled as a spline) and time to deceased or living donor transplantation or graft failure. RESULTS Of 373,365 patients, 11% had an ETD≥50 miles. Traveling excess distance was more likely among patients who were of non-Black race or those whose nearest transplant center had lower annual living donor transplant volume. At an ETD of 50 miles, we observed a lower likelihood of deceased donor transplantation (subhazard ratio [SHR], 0.85; 95% confidence interval [95% CI], 0.84 to 0.87) but higher likelihood of living donor transplantation (SHR, 1.14; 95% CI, 1.12 to 1.16) compared with those who received care at their nearest center. ETD was weakly associated with higher risk of graft failure. CONCLUSIONS Patients who travel excess distances for transplant care have better access to living donor but not deceased donor transplantation and slightly higher risk of graft failure. Traveling excess distances is not clearly associated with better outcomes, especially if living donors are unavailable.
Collapse
Affiliation(s)
- Adrian M. Whelan
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
| | - Kirsten L. Johansen
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
- Division of Nephrology, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Sandeep Brar
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Deborah B. Adey
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
| | - Garrett R. Roll
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, California
| | - Barbara Grimes
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Elaine Ku
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
- Division of Pediatric Nephrology, Department of Pediatrics, University of California, San Francisco, California
| |
Collapse
|
14
|
Schold JD, Mohan S, Huml A, Buccini LD, Sedor JR, Augustine JJ, Poggio ED. Failure to Advance Access to Kidney Transplantation over Two Decades in the United States. J Am Soc Nephrol 2021; 32:913-926. [PMID: 33574159 PMCID: PMC8017535 DOI: 10.1681/asn.2020060888] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 12/02/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Extensive research and policies have been developed to improve access to kidney transplantation among patients with ESKD. Despite this, wide variation in transplant referral rates exists between dialysis facilities. METHODS To evaluate the longitudinal pattern of access to kidney transplantation over the past two decades, we conducted a retrospective cohort study of adult patients with ESKD initiating ESKD or placed on a transplant waiting list from 1997 to 2016 in the United States Renal Data System. We used cumulative incidence models accounting for competing risks and multivariable Cox models to evaluate time to waiting list placement or transplantation (WLT) from ESKD onset. RESULTS Among the study population of 1,309,998 adult patients, cumulative 4-year WLT was 29.7%, which was unchanged over five eras. Preemptive WLT (prior to dialysis) increased by era (5.2% in 1997-2000 to 9.8% in 2013-2016), as did 4-year WLT incidence among patients aged 60-70 (13.4% in 1997-2000 to 19.8% in 2013-2016). Four-year WLT incidence diminished among patients aged 18-39 (55.8%-48.8%). Incidence of WLT was substantially lower among patients in lower-income communities, with no improvement over time. Likelihood of WLT after dialysis significantly declined over time (adjusted hazard ratio, 0.80; 95% confidence interval, 0.79 to 0.82) in 2013-2016 relative to 1997-2000. CONCLUSIONS Despite wide recognition, policy reforms, and extensive research, rates of WLT following ESKD onset did not seem to improve in more than two decades and were consistently reduced among vulnerable populations. Improving access to transplantation may require more substantial interventions.
Collapse
Affiliation(s)
- Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians & Surgeons, New York, New York,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Anne Huml
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Laura D. Buccini
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - John R. Sedor
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Emilio D. Poggio
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
15
|
Ku E, Whelan AM, McCulloch CE, Lee B, Niemann CU, Roll GR, Grimes BA, Johansen KL. Weighing the waitlist: Weight changes and access to kidney transplantation among obese candidates. PLoS One 2020; 15:e0242784. [PMID: 33253253 PMCID: PMC7703917 DOI: 10.1371/journal.pone.0242784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 11/10/2020] [Indexed: 12/14/2022] Open
Abstract
High body mass index is a known barrier to access to kidney transplantation in patients with end-stage kidney disease. The extent to which weight and weight changes affect access to transplantation among obese candidates differentially by race/ethnicity has received little attention. We included 10 221 obese patients waitlisted for kidney transplantation prior to end-stage kidney disease onset between 1995–2015. We used multinomial logistic regression models to examine the association between race/ethnicity and annualized change in body mass index (defined as stable [-2 to 2 kg/m2/year], loss [>2 kg/m2/year] or gain [>2 kg/m2/year]). We then used Fine-Gray models to examine the association between weight changes and access to living or deceased donor transplantation by race/ethnicity, accounting for the competing risk of death. Overall, 29% of the cohort lost weight and 7% gained weight; 46% received a transplant. Non-Hispanic blacks had a 24% (95% CI 1.12–1.38) higher odds of weight loss and 22% lower odds of weight gain (95% CI 0.64–0.95) compared with non-Hispanic whites. Hispanics did not differ from whites in their odds of weight loss or weight gain. Overall, weight gain was associated with lower access to transplantation (HR 0.88 [95% CI 0.79–0.99]) compared with maintenance of stable weight, but weight loss was not associated with better access to transplantation (HR 0.96 [95% CI 0.90–1.02]), although this relation differed by baseline body mass index and for recipients of living versus deceased donor organs. For example, weight loss was associated with improved access to living donor transplantation (HR 1.24 [95% CI 1.07–1.44]) in whites but not in blacks or Hispanics. In a cohort of obese patients waitlisted before dialysis, blacks were more likely to lose weight and less likely to gain weight compared with whites. Weight loss was only associated with improved access to living donor transplantation among whites. Further studies are needed to understand the reasons for the observed associations.
Collapse
Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California, United States of America
- Division of Pediatric Nephrology, Department of Pediatrics, University of California, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States of America
- * E-mail:
| | - Adrian M. Whelan
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California, United States of America
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States of America
| | - Brian Lee
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California, United States of America
| | - Claus U. Niemann
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, United States of America
| | - Garrett R. Roll
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, California, United States of America
| | - Barbara A. Grimes
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States of America
| | - Kirsten L. Johansen
- Division of Nephrology, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, United States of America
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
| |
Collapse
|
16
|
Sloan CE, Zhong J, Mohottige D, Hall R, Diamantidis CJ, Boulware LE, Wang V. Fragmentation of care as a barrier to optimal ESKD management. Semin Dial 2020; 33:440-448. [PMID: 33128300 DOI: 10.1111/sdi.12929] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 10/04/2020] [Indexed: 12/15/2022]
Abstract
Caring for patients with end-stage kidney disease (ESKD) in the United States is challenging, due in part to the complex epidemiology of the disease's progression as well as the ways in which care is delivered. As CKD progresses toward ESKD, the number of comorbidities increases and care involves multiple healthcare providers from multiple subspecialties. This occurs in the context of a fragmented US healthcare delivery system that is traditionally siloed by provider specialty, organization, as well as systems of payment and administration. This article describes the role of care fragmentation in the delivery of optimal ESKD care and identifies research gaps in the evidence across the continuum of care. We then consider the impact of care fragmentation on ESKD care from the patient and health system perspectives and explore opportunities for system-level interventions aimed at improving care for patients with ESKD.
Collapse
Affiliation(s)
- Caroline E Sloan
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Judy Zhong
- Duke University Trinity College of Arts & Sciences, Durham, NC, USA
| | | | - Rasheeda Hall
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Clarissa J Diamantidis
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Leight E Boulware
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Virginia Wang
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
17
|
Ahmad MU, Eves MM. The structural conundrum of parolees and kidney transplantation. Clin Transplant 2020; 34:e14104. [PMID: 32997842 DOI: 10.1111/ctr.14104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/11/2020] [Accepted: 09/22/2020] [Indexed: 11/30/2022]
Abstract
In the United States, there are a large number of incarcerated individuals, resulting in high numbers of previously incarcerated individuals out on parole undergoing reentry into society. An aging prison population translates to an older parolee population and increased incidence of kidney disease requiring either long-term dialysis or transplantation. This paper argues that due to challenges specific to the parolee population as well as societal biases and priorities, Transplant Centers and healthcare professionals face an ethical imperative to attend to the needs of parolees as a class and take steps to address challenges related to access to Centers for renal transplantation evaluation for this disadvantaged group. It will first review the regulatory context of kidney transplantation and highlight the specific ways it effects parolees. The paper will then discuss the broader social context of parolee reentry into society and barriers faced by parolees in this process. This ethical analysis examines the complexity of these issues, and deliberates on ways to balance the competing priorities of justice, respect for this patient population as individuals and as a disadvantaged class, and the societal interests regarding organ allocation and considerable economic burdens of end-stage renal disease on parolees, the justice system, and the public.
Collapse
Affiliation(s)
- Mahwish U Ahmad
- Center for Bioethics, Cleveland Clinic, Cleveland, OH, USA.,Department of Bioethics, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Margot M Eves
- Center for Bioethics, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
18
|
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.
Collapse
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
| | | |
Collapse
|
19
|
Impact of Rural Residence on Kidney Transplant Rates Among Waitlisted Candidates in the VA Transplant Programs. Transplantation 2019; 103:1945-1952. [PMID: 31343570 DOI: 10.1097/tp.0000000000002624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although proportionally more veterans live in rural areas compared to nonveterans, the impact of rurality status on kidney transplantation (KTP) access among veterans is unknown. Our objective was to study KTP rates among veterans listed for KTP and to compare the impact of rurality status on KTP rates among veterans and nonveterans. METHODS Retrospective cohort study of adult patients waitlisted per the United Network for Organ Sharing from January 2000 to December 2014. Patient characteristics were compared using Chi-square or t tests, as appropriate, by veteran status and patient rurality. Multivariable competing-risks Cox regression was performed. RESULTS The study sample included 3281 veterans receiving care in Veteran Health Administration transplant programs and 445 177 nonveterans. Veterans, compared to nonveterans, were older (57 versus 50 y; P < 0.001), more likely to be male (96% versus 60%; P < 0.001) or diabetic at waitlisting (51% versus 41%; P < 0.001), and less likely be an urban resident (79% versus 84%; P < 0.001). Among veterans, dialysis duration prior to registration was longer among urban compared to all other rurality types (810 ± 22.1 d versus 632 to 702 ± 41.6 to 77.6 d; P = 0.02). In multivariate competing risks models, there was no evidence that the hazard of transplant among veterans differs by residential rurality. CONCLUSIONS Among waitlisted veterans served by Veteran Health Administration transplant programs, residential rurality status does not portend longer waiting time for KTP.
Collapse
|
20
|
Moise R, Meca A, Schwartz SJ, Unger JB, Lorenzo-Blanco EI, Cano MÁ, Szapocznik J, Piña-Watson B, Rosiers SED, Baezconde-Garbanati L, Soto DW, Pattarroyo M, Villamar JA, Lizzi KM. The use of cultural identity in predicting health lifestyle behaviors in Latinx immigrant adolescents. CULTURAL DIVERSITY & ETHNIC MINORITY PSYCHOLOGY 2019; 25:371-378. [PMID: 30335406 PMCID: PMC6472997 DOI: 10.1037/cdp0000229] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES This study explored whether cultural identity predicts health lifestyle behaviors. METHOD Participants included 302 recently immigrated (<5 years in the U.S.) Latinx adolescents (53% boys; mean age 14.51 years at baseline) from Miami and Los Angeles. Participants completed cultural identity measures at baseline and 1-year post baseline. A path analysis was used to estimate associations between cultural identities (ethnic, national, and bicultural) and health lifestyle behaviors (physical activity, diet, and sleep hygiene). RESULTS Ethnic identity positively predicted diet. Results also indicated a significant interaction between ethnic and national identity on sleep hygiene. Specifically, when national identity was high (+1 SD), ethnic identity positively predicted sleep hygiene. CONCLUSION This study focuses on health lifestyle behaviors such as physical activity, diet, and sleep hygiene in this population. Results highlight the need to explore the protective nature of cultural identity retention in relation to health lifestyle behaviors in Latinx adolescents. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
Collapse
Affiliation(s)
- Rhoda Moise
- University of Miami Miller School of Medicine, Department of Public Health Sciences, Miami, Florida
| | - Alan Meca
- Old Dominion University, Department of Psychology, Norfolk, VA
| | - Seth J. Schwartz
- University of Miami Miller School of Medicine, Department of Public Health Sciences, Miami, Florida
| | - Jennifer B. Unger
- University of Southern California, Department of Institute for Health Promotion & Disease Prevention, Los Angeles, California
| | | | - Miguel Ángel Cano
- Florida International University, Department of Epidemiology, Miami, Florida
| | - José Szapocznik
- University of Miami Miller School of Medicine, Department of Public Health Sciences, Miami, Florida
| | - Brandy Piña-Watson
- Texas Tech University, Department of Counseling Psychology, Lubbock, Texas
| | | | - Lourdes Baezconde-Garbanati
- University of Southern California, Department of Institute for Health Promotion & Disease Prevention, Los Angeles, California
| | - Daniel W. Soto
- University of Southern California, Department of Institute for Health Promotion & Disease Prevention, Los Angeles, California
| | - Monica Pattarroyo
- University of Southern California, Department of Institute for Health Promotion & Disease Prevention, Los Angeles, California
| | - Juan A. Villamar
- Northwestern University, Department of Preventive Medicine, Chicago, Illinois
| | - Karina M. Lizzi
- University of Michigan, Department of Internal Medicine, Ann Arbor, Michigan
| |
Collapse
|
21
|
Zhang X, Melanson TA, Plantinga LC, Basu M, Pastan SO, Mohan S, Howard DH, Hockenberry JM, Garber MD, Patzer RE. Racial/ethnic disparities in waitlisting for deceased donor kidney transplantation 1 year after implementation of the new national kidney allocation system. Am J Transplant 2018; 18:1936-1946. [PMID: 29603644 PMCID: PMC6105401 DOI: 10.1111/ajt.14748] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 02/26/2018] [Accepted: 03/20/2018] [Indexed: 01/25/2023]
Abstract
The impact of a new national kidney allocation system (KAS) on access to the national deceased-donor waiting list (waitlisting) and racial/ethnic disparities in waitlisting among US end-stage renal disease (ESRD) patients is unknown. We examined waitlisting pre- and post-KAS among incident (N = 1 253 100) and prevalent (N = 1 556 954) ESRD patients from the United States Renal Data System database (2005-2015) using multivariable time-dependent Cox and interrupted time-series models. The adjusted waitlisting rate among incident patients was 9% lower post-KAS (hazard ratio [HR]: 0.91; 95% confidence interval [CI], 0.90-0.93), although preemptive waitlisting increased from 30.2% to 35.1% (P < .0001). The waitlisting decrease is largely due to a decline in inactively waitlisted patients. Pre-KAS, blacks had a 19% lower waitlisting rate vs whites (HR: 0.81; 95% CI, 0.80-0.82); following KAS, disparity declined to 12% (HR: 0.88; 95% CI, 0.85-0.90). In adjusted time-series analyses of prevalent patients, waitlisting rates declined by 3.45/10 000 per month post-KAS (P < .001), resulting in ≈146 fewer waitlisting events/month. Shorter dialysis vintage was associated with greater decreases in waitlisting post-KAS (P < .001). Racial disparity reduction was due in part to a steeper decline in inactive waitlisting among minorities and a greater proportion of actively waitlisted minority patients. Waitlisting and racial disparity in waitlisting declined post-KAS; however, disparity remains.
Collapse
Affiliation(s)
- Xingyu Zhang
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
| | - Taylor A. Melanson
- Department of Health Policy & Management, Rollins School of Public Health, Atlanta, GA
| | - Laura C. Plantinga
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA
- Department of Medicine, Renal Division, Emory University School of Medicine
| | - Mohua Basu
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
| | - Stephen O. Pastan
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
- Department of Medicine, Renal Division, Emory University School of Medicine
| | - Sumit Mohan
- Department of Medicine, Columbia University College of Physicians and Surgeons, Department of Epidemiology, Mailman School of Public Health, New York
| | - David H. Howard
- Department of Health Policy & Management, Rollins School of Public Health, Atlanta, GA
| | - Jason M. Hockenberry
- Department of Health Policy & Management, Rollins School of Public Health, Atlanta, GA
| | - Michael D. Garber
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA
| | - Rachel E. Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA
- Department of Medicine, Renal Division, Emory University School of Medicine
| |
Collapse
|
22
|
Dzobo K, Thomford NE, Senthebane DA, Shipanga H, Rowe A, Dandara C, Pillay M, Motaung KSCM. Advances in Regenerative Medicine and Tissue Engineering: Innovation and Transformation of Medicine. Stem Cells Int 2018; 2018:2495848. [PMID: 30154861 PMCID: PMC6091336 DOI: 10.1155/2018/2495848] [Citation(s) in RCA: 184] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/22/2018] [Accepted: 07/08/2018] [Indexed: 02/08/2023] Open
Abstract
Humans and animals lose tissues and organs due to congenital defects, trauma, and diseases. The human body has a low regenerative potential as opposed to the urodele amphibians commonly referred to as salamanders. Globally, millions of people would benefit immensely if tissues and organs can be replaced on demand. Traditionally, transplantation of intact tissues and organs has been the bedrock to replace damaged and diseased parts of the body. The sole reliance on transplantation has created a waiting list of people requiring donated tissues and organs, and generally, supply cannot meet the demand. The total cost to society in terms of caring for patients with failing organs and debilitating diseases is enormous. Scientists and clinicians, motivated by the need to develop safe and reliable sources of tissues and organs, have been improving therapies and technologies that can regenerate tissues and in some cases create new tissues altogether. Tissue engineering and/or regenerative medicine are fields of life science employing both engineering and biological principles to create new tissues and organs and to promote the regeneration of damaged or diseased tissues and organs. Major advances and innovations are being made in the fields of tissue engineering and regenerative medicine and have a huge impact on three-dimensional bioprinting (3D bioprinting) of tissues and organs. 3D bioprinting holds great promise for artificial tissue and organ bioprinting, thereby revolutionizing the field of regenerative medicine. This review discusses how recent advances in the field of regenerative medicine and tissue engineering can improve 3D bioprinting and vice versa. Several challenges must be overcome in the application of 3D bioprinting before this disruptive technology is widely used to create organotypic constructs for regenerative medicine.
Collapse
Affiliation(s)
- Kevin Dzobo
- Cape Town Component, International Centre for Genetic Engineering and Biotechnology (ICGEB) and UCT Medical Campus, Wernher and Beit Building (South), Anzio Road, Observatory 7925, Cape Town, South Africa
- Division of Medical Biochemistry and Institute of Infectious Disease and Molecular Medicine, Department of Integrative Biomedical Sciences, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa
| | - Nicholas Ekow Thomford
- Pharmacogenetics Research Group, Division of Human Genetics, Department of Pathology and Institute of Infectious Diseases and Molecular medicine, Faculty of Health Sciences, University of Cape Town, Observatory 7925, Cape Town, South Africa
| | - Dimakatso Alice Senthebane
- Cape Town Component, International Centre for Genetic Engineering and Biotechnology (ICGEB) and UCT Medical Campus, Wernher and Beit Building (South), Anzio Road, Observatory 7925, Cape Town, South Africa
- Division of Medical Biochemistry and Institute of Infectious Disease and Molecular Medicine, Department of Integrative Biomedical Sciences, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa
| | - Hendrina Shipanga
- Cape Town Component, International Centre for Genetic Engineering and Biotechnology (ICGEB) and UCT Medical Campus, Wernher and Beit Building (South), Anzio Road, Observatory 7925, Cape Town, South Africa
- Division of Medical Biochemistry and Institute of Infectious Disease and Molecular Medicine, Department of Integrative Biomedical Sciences, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa
| | - Arielle Rowe
- Cape Town Component, International Centre for Genetic Engineering and Biotechnology (ICGEB) and UCT Medical Campus, Wernher and Beit Building (South), Anzio Road, Observatory 7925, Cape Town, South Africa
| | - Collet Dandara
- Pharmacogenetics Research Group, Division of Human Genetics, Department of Pathology and Institute of Infectious Diseases and Molecular medicine, Faculty of Health Sciences, University of Cape Town, Observatory 7925, Cape Town, South Africa
| | - Michael Pillay
- Department of Biotechnology, Faculty of Applied and Computer Sciences, Vaal University of Technology, Vanderbijlpark 1900, South Africa
| | | |
Collapse
|
23
|
Mohan S, Chiles MC, Patzer RE, Pastan SO, Husain SA, Carpenter DJ, Dube GK, Crew RJ, Ratner LE, Cohen DJ. Factors leading to the discard of deceased donor kidneys in the United States. Kidney Int 2018; 94:187-198. [PMID: 29735310 PMCID: PMC6015528 DOI: 10.1016/j.kint.2018.02.016] [Citation(s) in RCA: 164] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 01/31/2018] [Accepted: 02/01/2018] [Indexed: 01/22/2023]
Abstract
The proportion of deceased donor kidneys procured for transplant but subsequently discarded has been growing steadily in the United States, but factors contributing to the rising discard rate remain unclear. To assess the reasons for and probability of organ discard we assembled a cohort of 212,305 deceased donor kidneys recovered for transplant from 2000-2015 in the SRTR registry that included 36,700 kidneys that were discarded. 'Biopsy Findings' (38.2%) was the most commonly reported reason for discard. The median Kidney Donor Risk Index of discarded kidneys was significantly higher than transplanted organs (1.78 vs 1.12), but a large overlap in the quality of discarded and transplanted kidneys was observed. Kidneys of donors who were older, female, Black, obese, diabetic, hypertensive or HCV-positive experienced a significantly increased odds of discard. Kidneys from donors with multiple unfavorable characteristics were more likely to be discarded, whereas unilaterally discarded kidneys had the most desirable donor characteristics and the recipients of their partner kidneys experienced a one-year death-censored graft survival rate over 90%. There was considerable geographic variation in the odds of discard across the United States, which further supports the notion that factors beyond organ quality contributed to kidney discard. Thus, while the discard of a small fraction of organs procured from donors may be inevitable, the discard of potentially transplantable kidneys needs to be avoided. This will require a better understanding of the factors contributing to organ discard in order to remove the disincentives to utilize less-than-ideal organs for transplantation.
Collapse
Affiliation(s)
- Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA.
| | - Mariana C Chiles
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Emory University, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Stephen O Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Emory University, Atlanta, Georgia, USA
| | - S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Dustin J Carpenter
- Department of Surgery, Division of Transplantation, Columbia University Medical Center, New York, New York, USA
| | - Geoffrey K Dube
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - R John Crew
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - Lloyd E Ratner
- Department of Surgery, Division of Transplantation, Columbia University Medical Center, New York, New York, USA
| | - David J Cohen
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| |
Collapse
|
24
|
Desai N, Lora CM, Lash JP, Ricardo AC. CKD and ESRD in US Hispanics. Am J Kidney Dis 2018; 73:102-111. [PMID: 29661541 DOI: 10.1053/j.ajkd.2018.02.354] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 02/08/2018] [Indexed: 12/23/2022]
Abstract
Hispanics are the largest racial/ethnic minority group in the United States, and they experience a substantial burden of kidney disease. Although the prevalence of chronic kidney disease (CKD) is similar or slightly lower in Hispanics than non-Hispanic whites, the age- and sex-adjusted prevalence rate of end-stage renal disease is almost 50% higher in Hispanics compared with non-Hispanic whites. This has been attributed in part to faster CKD progression among Hispanics. Furthermore, Hispanic ethnicity has been associated with a greater prevalence of cardiovascular disease risk factors, including obesity and diabetes, as well as CKD-related complications. Despite their less favorable socioeconomic status, which often leads to limited access to quality health care, and their high comorbid condition burden, the risk for mortality among Hispanics appears to be lower than for non-Hispanic whites. This survival paradox has been attributed to a complex interplay between sociocultural and psychosocial factors, as well as other factors. Future research should focus on evaluating the long-term impact of these factors on patient-centered and clinical outcomes. National policies are needed to improve access to and quality of health care among Hispanics with CKD.
Collapse
Affiliation(s)
- Nisa Desai
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Claudia M Lora
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - James P Lash
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Ana C Ricardo
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL.
| |
Collapse
|
25
|
Gander JC, Plantinga L, Zhang R, Mohan S, Pastan SO, Patzer RE. United States Dialysis Facilities With a Racial Disparity in Kidney Transplant Waitlisting. Kidney Int Rep 2017; 2:963-968. [PMID: 29270504 PMCID: PMC5733744 DOI: 10.1016/j.ekir.2017.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/15/2017] [Accepted: 05/19/2017] [Indexed: 10/26/2022] Open
Affiliation(s)
- Jennifer C Gander
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laura Plantinga
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Rebecca Zhang
- Department of Biostatistics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Stephen O Pastan
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Emory Transplant Center, Atlanta, Georgia, USA
| | - Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Biostatistics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia, USA.,Emory Transplant Center, Atlanta, Georgia, USA
| |
Collapse
|
26
|
Kidney Transplantation Rates Across Glomerulonephritis Subtypes in the United States. Transplantation 2017; 101:2636-2647. [DOI: 10.1097/tp.0000000000001657] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
27
|
Huml AM, Albert JM, Thornton JD, Sehgal AR. Outcomes of Deceased Donor Kidney Offers to Patients at the Top of the Waiting List. Clin J Am Soc Nephrol 2017; 12:1311-1320. [PMID: 28751577 PMCID: PMC5544513 DOI: 10.2215/cjn.10130916] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 05/02/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Transplant centers may accept or refuse deceased-donor kidneys that are offered to their patients at the top of the waiting list. We sought to determine the outcomes of deceased-donor kidney offers and their association with characteristics of waitlisted patients and organ donors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We examined all 7 million deceased-donor adult kidney offers in the United States from 2007 to 2012 that led to eventual transplantation. Data were obtained from the national organ allocation system through the United Network of Organ Sharing. The study cohort consisted of 178,625 patients waitlisted for a deceased-donor kidney transplant and 31,230 deceased donors. We evaluated offers made to waitlisted patients and their outcomes (transplantation or specific reason for refusal). RESULTS Deceased-donor kidneys were offered a median of seven times before being accepted for transplantation. The most common reasons for refusal of an offer were donor-related factors, e.g., age or organ quality (3.2 million offers, 45.0%), and transplant center bypass, e.g., minimal acceptance criteria not met (3.2 million offers, 44.0%). After adjustment for characteristics of waitlisted patients, organ donors, and transplant centers, male (odds ratio [OR], 0.93; 95% confidence interval [95% CI], 0.91 to 0.95) and Hispanic (OR, 0.96; 95% CI, 0.93 to 0.99) waitlisted patients were less likely to have an offer accepted than female and white patients, respectively. The likelihood of offer acceptance varied greatly across transplant centers (interquartile ratio, 2.28). CONCLUSIONS Transplant centers frequently refuse deceased-donor kidneys. Such refusals differ by patient and donor characteristics, may contribute to disparities in access to transplantation, and vary greatly across transplant centers. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_07_27_Huml.mp3.
Collapse
Affiliation(s)
- Anne M Huml
- Center for Reducing Health Disparities and
- Divisions of Nephrology and
- Division of Nephrology, Department of Medicine, University Hospitals, Cleveland, Ohio
| | - Jeffrey M Albert
- Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio
| | - J Daryl Thornton
- Center for Reducing Health Disparities and
- Pulmonary and Critical Care Medicine, Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio; and
| | - Ashwini R Sehgal
- Center for Reducing Health Disparities and
- Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio
- Divisions of Nephrology and
| |
Collapse
|
28
|
Giwa S, Lewis JK, Alvarez L, Langer R, Roth AE, Church GM, Markmann JF, Sachs DH, Chandraker A, Wertheim JA, Rothblatt M, Boyden ES, Eidbo E, Lee WPA, Pomahac B, Brandacher G, Weinstock DM, Elliott G, Nelson D, Acker JP, Uygun K, Schmalz B, Weegman BP, Tocchio A, Fahy GM, Storey KB, Rubinsky B, Bischof J, Elliott JAW, Woodruff TK, Morris GJ, Demirci U, Brockbank KGM, Woods EJ, Ben RN, Baust JG, Gao D, Fuller B, Rabin Y, Kravitz DC, Taylor MJ, Toner M. The promise of organ and tissue preservation to transform medicine. Nat Biotechnol 2017; 35:530-542. [PMID: 28591112 PMCID: PMC5724041 DOI: 10.1038/nbt.3889] [Citation(s) in RCA: 298] [Impact Index Per Article: 42.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 04/28/2017] [Indexed: 02/06/2023]
Abstract
The ability to replace organs and tissues on demand could save or improve millions of lives each year globally and create public health benefits on par with curing cancer. Unmet needs for organ and tissue preservation place enormous logistical limitations on transplantation, regenerative medicine, drug discovery, and a variety of rapidly advancing areas spanning biomedicine. A growing coalition of researchers, clinicians, advocacy organizations, academic institutions, and other stakeholders has assembled to address the unmet need for preservation advances, outlining remaining challenges and identifying areas of underinvestment and untapped opportunities. Meanwhile, recent discoveries provide proofs of principle for breakthroughs in a family of research areas surrounding biopreservation. These developments indicate that a new paradigm, integrating multiple existing preservation approaches and new technologies that have flourished in the past 10 years, could transform preservation research. Capitalizing on these opportunities will require engagement across many research areas and stakeholder groups. A coordinated effort is needed to expedite preservation advances that can transform several areas of medicine and medical science.
Collapse
Affiliation(s)
- Sebastian Giwa
- Organ Preservation Alliance, NASA Research Park, Moffett Field, California, USA
- Sylvatica Biotech, Inc., Charleston, South Carolina, USA
- Ossium Health, San Francisco, California, USA
| | - Jedediah K Lewis
- Organ Preservation Alliance, NASA Research Park, Moffett Field, California, USA
| | - Luis Alvarez
- Regenerative Biology Research Group, Cancer and Developmental Biology Laboratory, National Cancer Institute, Bethesda, Maryland, USA
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Department of Chemistry and Life Science, United States Military Academy, West Point, New York, USA
| | - Robert Langer
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Alvin E Roth
- Department of Economics, Stanford University, Stanford, California, USA
| | - George M Church
- Department of Genetics, Harvard Medical School, Boston, Massachusetts, USA
| | - James F Markmann
- Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David H Sachs
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York, USA
| | - Anil Chandraker
- American Society of Transplantation, Mt. Laurel, New Jersey, USA
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason A Wertheim
- American Society of Transplant Surgeons, Arlington Virginia, USA
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Edward S Boyden
- MIT Media Lab and McGovern Institute, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Elling Eidbo
- Association of Organ Procurement Organizations, Vienna, Virginia, USA
| | - W P Andrew Lee
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David M Weinstock
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Gloria Elliott
- Department of Mechanical Engineering and Engineering Science, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
| | - David Nelson
- Department of Transplant Medicine, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, Oklahoma, USA
| | - Jason P Acker
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
- Society for Cryobiology, Baltimore, Maryland, USA
| | - Korkut Uygun
- Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Boris Schmalz
- Organ Preservation Alliance, NASA Research Park, Moffett Field, California, USA
- Max Planck Institute of Psychiatry, Munich, Germany
| | - Brad P Weegman
- Organ Preservation Alliance, NASA Research Park, Moffett Field, California, USA
- Sylvatica Biotech, Inc., Charleston, South Carolina, USA
| | - Alessandro Tocchio
- Organ Preservation Alliance, NASA Research Park, Moffett Field, California, USA
- Department of Radiology, Stanford School of Medicine, Stanford, California, USA
| | - Greg M Fahy
- 21st Century Medicine, Fontana, California, USA
| | - Kenneth B Storey
- Institute of Biochemistry, Carleton University, Ottawa, Ontario, Canada
| | - Boris Rubinsky
- Department of Mechanical Engineering, University of California Berkeley, Berkeley, California, USA
| | - John Bischof
- Department of Mechanical Engineering, University of Minnesota, Minneapolis, Minnesota, USA
| | - Janet A W Elliott
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
- Department of Chemical and Materials Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Teresa K Woodruff
- Division of Obstetrics and Gynecology-Reproductive Science in Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Utkan Demirci
- Department of Radiology, Stanford School of Medicine, Stanford, California, USA
- Department of Electrical Engineering (by courtesy), Stanford, California, USA
| | | | - Erik J Woods
- Ossium Health, San Francisco, California, USA
- Society for Cryobiology, Baltimore, Maryland, USA
- Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Robert N Ben
- Department of Chemistry and Biomolecular Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - John G Baust
- Department of Biological Sciences, Binghamton University, State University of New York, Binghamton, New York, USA
| | - Dayong Gao
- Society for Cryobiology, Baltimore, Maryland, USA
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, USA
| | - Barry Fuller
- Division of Surgery &Interventional Science, University College Medical School, Royal Free Hospital Campus, London, UK
| | - Yoed Rabin
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | | | - Michael J Taylor
- Sylvatica Biotech, Inc., Charleston, South Carolina, USA
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
- Department of Surgery, University of Arizona, Tucson, Arizona, USA
| | - Mehmet Toner
- Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
29
|
Talamantes E, Norris KC, Mangione CM, Moreno G, Waterman AD, Peipert JD, Bunnapradist S, Huang E. Linguistic Isolation and Access to the Active Kidney Transplant Waiting List in the United States. Clin J Am Soc Nephrol 2017; 12:483-492. [PMID: 28183854 PMCID: PMC5338711 DOI: 10.2215/cjn.07150716] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 11/15/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Waitlist inactivity is a barrier to transplantation, because inactive candidates cannot receive deceased donor organ offers. We hypothesized that temporarily inactive kidney transplant candidates living in linguistically isolated communities would be less likely to achieve active waitlist status. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We merged Organ Procurement and Transplantation Network/United Network for Organ Sharing data with five-digit zip code socioeconomic data from the 2000 US Census. The cumulative incidence of conversion to active waitlist status, death, and delisting before conversion among 84,783 temporarily inactive adult kidney candidates from 2004 to 2012 was determined using competing risks methods. Competing risks regression was performed to characterize the association between linguistic isolation, incomplete transplantation evaluation, and conversion to active status. A household was determined to be linguistically isolated if all members ≥14 years old speak a non-English language and also, speak English less than very well. RESULTS A total of 59,147 candidates (70% of the study population) achieved active status over the study period of 9.8 years. Median follow-up was 110 days (interquartile range, 42-276 days) for activated patients and 815 days (interquartile range, 361-1244 days) for candidates not activated. The cumulative incidence of activation over the study period was 74%, the cumulative incidence of death before conversion was 10%, and the cumulative incidence of delisting was 13%. After adjusting for other relevant covariates, living in a zip code with higher percentages of linguistically isolated households was associated with progressively lower subhazards of activation both in the overall population (reference: <1% linguistically isolated households; 1%-4.9% linguistically isolated: subhazard ratio, 0.89; 95% confidence interval, 0.86 to 0.93; 5%-9.9% linguistically isolated: subhazard ratio, 0.83; 95% confidence interval, 0.80 to 0.87; 10%-19.9% linguistically isolated: subhazard ratio, 0.76; 95% confidence interval, 0.72 to 0.80; and ≥20% linguistically isolated: subhazard ratio, 0.71; 95% confidence interval, 0.67 to 0.76) and among candidates designated temporarily inactive due to an incomplete transplant evaluation. CONCLUSIONS Our findings indicate that candidates residing in linguistically isolated communities are less likely to complete candidate evaluations and achieve active waitlist status.
Collapse
Affiliation(s)
- Efrain Talamantes
- Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento, California
| | - Keith C. Norris
- Division of Nephrology, Department of Medicine
- Division of General Internal Medicine and Health Services, Department of Medicine, and
| | - Carol M. Mangione
- Division of General Internal Medicine and Health Services, Department of Medicine, and
| | | | - Amy D. Waterman
- Division of Nephrology, Department of Medicine
- Kidney Transplant Research Program, Division of Nephrology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; and
| | - John D. Peipert
- Division of Nephrology, Department of Medicine
- Kidney Transplant Research Program, Division of Nephrology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; and
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine
- Kidney Transplant Research Program, Division of Nephrology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; and
| | - Edmund Huang
- Division of Nephrology, Department of Medicine
- Kidney Transplant Research Program, Division of Nephrology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; and
- Division of Nephrology, Department of Medicine, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| |
Collapse
|
30
|
Are There Inequities in Treatment of End-Stage Renal Disease in Sweden? A Longitudinal Register-Based Study on Socioeconomic Status-Related Access to Kidney Transplantation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14020119. [PMID: 28134798 PMCID: PMC5334673 DOI: 10.3390/ijerph14020119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/13/2017] [Accepted: 01/20/2017] [Indexed: 11/29/2022]
Abstract
Socioeconomic status-related factors have been associated with access to kidney transplantation, yet few studies have investigated both individual income and education as determinates of access to kidney transplantation. Therefore, this study aims to explore the effects of both individual income and education on access to kidney transplantation, controlling for both medical and non-medical factors. We linked the Swedish Renal Register to national registers for a sample of adult patients who started Renal Replacement Therapy (RRT) in Sweden between 1 January 1995, and 31 December 2013. Using uni- and multivariate logistic models, we studied the association between pre-RRT income and education and likelihood of receiving kidney transplantation. For non-pre-emptive transplantation patients, we also used multivariate Cox proportional hazards regression analysis to assess the association between treatment and socioeconomic factors. Among the 16,215 patients in the sample, 27% had received kidney transplantation by the end of 2013. After adjusting for covariates, the highest income group had more than three times the chance of accessing kidney transplantation compared with patients in the lowest income group (odds ratio (OR): 3.22; 95% confidence interval (CI): 2.73–3.80). Patients with college education had more than three times higher chance of access to kidney transplantation compared with patients with mandatory education (OR: 3.18; 95% CI: 2.77–3.66). Neither living in the county of the transplantation center nor gender was shown to have any effect on the likelihood of receiving kidney transplantation. For non-pre-emptive transplantation patients, the results from Cox models were similar with what we got from logistic models. Sensitive analyses showed that results were not sensitive to different conditions. Overall, socioeconomic status-related inequities exist in access to kidney transplantation in Sweden. Additional studies are needed to explore the possible mechanisms and strategies to mitigate these inequities.
Collapse
|
31
|
Gordon EJ. Culturally Competent Strategies for Increasing Knowledge of Live Kidney Donation in the Hispanic Community. CURRENT TRANSPLANTATION REPORTS 2017. [DOI: 10.1007/s40472-017-0136-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
32
|
Olufajo OA, Adler JT, Yeh H, Zeliadt SB, Hernandez RA, Tullius SG, Backhus L, Salim A. Disparities in kidney transplantation across the United States: Does residential segregation play a role? Am J Surg 2017; 213:656-661. [PMID: 28228248 DOI: 10.1016/j.amjsurg.2016.10.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 10/07/2016] [Accepted: 10/21/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although residential segregation has been implicated in various negative health outcomes, its association with kidney transplantation has not been examined. METHODS Age- and sex-standardized kidney transplantation rates were calculated from the Scientific Registry of Transplant Recipients, 2000-2013. Population characteristics including segregation indices were derived from the 2010 U.S. Census data and the U.S. Renal Data System. Separate multivariable Poisson regression models were constructed to identify factors independently associated with kidney transplantation among Blacks and Whites. RESULTS Median age- and sex-standardized kidney transplantation rates were 114 per 100,000 for Blacks and 38 per 100,000 for Whites. 16.1% of the U.S. population lived in counties with high segregation. There was no difference in the kidney transplantation rates across the levels of segregation among Blacks and Whites. CONCLUSION Factors other than residential segregation may play roles in kidney transplantation disparities. Continued efforts to identify these factors may be beneficial in reducing transplantation disparities across the U.S. SUMMARY Using the Scientific Registry of Transplant Recipients and U.S. census data, we aimed to determine whether residential segregation was associated with kidney transplantation rates. We found that there was no association between residential segregation and kidney transplantation rates.
Collapse
Affiliation(s)
- Olubode A Olufajo
- Division of Trauma, Burn and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Joel T Adler
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Heidi Yeh
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Steven B Zeliadt
- Department of Health Services, University of Washington, Seattle, WA, USA
| | | | - Stefan G Tullius
- Division of Transplant Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Leah Backhus
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Ali Salim
- Division of Trauma, Burn and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA.
| |
Collapse
|
33
|
Ku E, McCulloch CE, Grimes BA, Johansen KL. Racial and Ethnic Disparities in Survival of Children with ESRD. J Am Soc Nephrol 2016; 28:1584-1591. [PMID: 28034898 DOI: 10.1681/asn.2016060706] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 10/17/2016] [Indexed: 12/19/2022] Open
Abstract
Observational studies have reported that black and Hispanic adults receiving maintenance dialysis survive longer than non-Hispanic white counterparts. Whether there are racial disparities in survival of children with ESRD is not clear. We compared mortality risk among non-Hispanic black, Hispanic, and non-Hispanic white children who started RRT between 1995 and 2011 and were followed through 2012. We examined all-cause mortality using adjusted Cox models. Of 12,123 children included for analysis, 1600 died during the median follow-up of 7.1 years. Approximately 25% of children were non-Hispanic black, and 26% of children were of Hispanic ethnicity. Non-Hispanic black children had a 36% higher risk of death (95% confidence interval [95% CI], 1.21 to 1.52) and Hispanic children had a 34% lower risk of death (95% CI, 0.57 to 0.77) than non-Hispanic white children. Adjustment for transplant as a time-dependent covariate abolished the higher risk of death in non-Hispanic black children (hazard ratio, 0.99; 95% CI, 0.88 to 1.12) but did not attenuate the finding of a lower risk of death in Hispanic children (hazard ratio, 0.59; 95% CI, 0.51 to 0.68). In conclusion, Hispanic children had lower mortality than non-Hispanic white children. Non-Hispanic black children had higher mortality than non-Hispanic white children, which was related to differences in access to transplantation by race. Parity in access to transplantation in children and improvements in strategies to prolong graft survival could substantially reduce disparities in mortality risk of non-Hispanic black children treated with RRT.
Collapse
Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine, .,Division of Pediatric Nephrology, Department of Pediatrics, and
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Barbara A Grimes
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | | |
Collapse
|
34
|
Ansell D, Pallok K, Guzman MD, Flores M, Oberholzer J. Illinois law opens door to kidney transplants for undocumented immigrants. Health Aff (Millwood) 2016; 34:781-7. [PMID: 25941279 DOI: 10.1377/hlthaff.2014.1192] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- David Ansell
- David Ansell is a primary care physician in the Department of Internal Medicine and senior vice president for system integration, both at Rush University Medical Center, in Chicago, Illinois
| | - Kristen Pallok
- Kristen Pallok is a medical student at Rush Medical College, in Chicago
| | - Marieli D Guzman
- Marieli D. Guzman is a research assistant in the Department of Preventive Medicine at Rush University Medical Center and a matriculating medical student
| | - Marycarmen Flores
- Marycarmen Flores is a senior at Bates College, in Lewiston, Maine, and a former summer health disparity intern at Rush University Medical Center
| | - Jose Oberholzer
- Jose Oberholzer is chief of abdominal transplant surgery in the Department of Surgery, College of Medicine, the University of Illinois at Chicago
| |
Collapse
|
35
|
Newman KL, Fedewa SA, Jacobson MH, Adams AB, Zhang R, Pastan SO, Patzer RE. Racial/Ethnic Differences in the Association Between Hospitalization and Kidney Transplantation Among Waitlisted End-Stage Renal Disease Patients. Transplantation 2016; 100:2735-2745. [PMID: 26845307 PMCID: PMC4972697 DOI: 10.1097/tp.0000000000001072] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Even after placement on the deceased donor waitlist, there are racial disparities in access to kidney transplant. The association between hospitalization, a proxy for health while waitlisted, and disparities in kidney transplant has not been investigated. METHODS We used United States Renal Data System Medicare-linked data on waitlisted end-stage renal disease patients between 2005 and 2009 with continuous enrollment in Medicare Parts A & B (n = 24 581) to examine the association between annual hospitalization rate and odds of receiving a deceased donor kidney transplant. We used multilevel mixed effects models to estimate adjusted odds ratios, controlling for individual-, transplant center-, and organ procurement organization-level clustering. RESULTS Blacks and Hispanics were more likely than whites to be hospitalized for circulatory system or endocrine, nutritional, and metabolic diseases (P < 0.001). After adjustment, compared with individuals not hospitalized, patients who were hospitalized frequently while waitlisted were less likely to be transplanted (>2 vs 0 hospitalizations/year adjusted odds ratios = 0.57; P < 0.001). Though blacks and Hispanics were more likely to be hospitalized than whites (P < 0.001), adjusting for hospitalization did not change estimated racial/ethnic disparities in kidney transplantation. CONCLUSIONS Individuals hospitalized while waitlisted were less likely to receive a transplant. However, hospitalization does not account for the racial disparity in kidney transplantation after waitlisting.
Collapse
Affiliation(s)
- Kira L Newman
- 1 Department of Epidemiology, Rollins School of Public Health, Atlanta, GA.2 Medical Scientist Training Program, Emory University School of Medicine, Atlanta, GA.3 Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA.4 Emory Transplant Center, Atlanta, GA.5 Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | | | | | | | | | | | | |
Collapse
|
36
|
Gordon EJ, Feinglass J, Carney P, Vera K, Olivero M, Black A, O'Connor KG, Baumgart JM, Caicedo JC. A Website Intervention to Increase Knowledge About Living Kidney Donation and Transplantation Among Hispanic/Latino Dialysis Patients. Prog Transplant 2016; 26:82-91. [PMID: 27136254 DOI: 10.1177/1526924816632124] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Hispanic dialysis patients often encounter barriers to learning about living kidney donation and transplantation. Effective culturally targeted interventions to increase knowledge are lacking. We developed a culturally targeted educational website to enhance informed treatment decision making for end-stage kidney disease. METHODS A pretest/posttest intervention study was conducted among adult Hispanic patients undergoing dialysis at 5 dialysis centers in Chicago, Illinois. Surveys included a 31-item, multiple-choice pretest/posttest of knowledge about kidney transplantation and living donation, attitudes about the website, Internet use, and demographics. The intervention entailed viewing 3 of 6 website sections for a total of 30 minutes. The pretest/posttest was administered immediately before and after the intervention. Participants completed a second posttest via telephone 3 weeks thereafter to assess knowledge retention, attitudes, and use of the website. RESULTS Sixty-three patients participated (96% participation rate). Website exposure was associated with a mean 17.1% same day knowledge score increase between pretest and posttest (P < .001). At 3 weeks, participants' knowledge scores remained 11.7% above pretest (P < .001). The greatest knowledge gain from pretest to 3-week follow-up occurred in the Treatment Options (P < .0001) and Cultural Beliefs and Myths (P < .0001) website sections. Most participants (95%) "agreed" or "strongly agreed" that they would recommend the website to other Hispanics. CONCLUSIONS Web-based education for patients undergoing dialysis can effectively increase Hispanics' knowledge about transplantation and living kidney donation. Study limitations include small sample size and single geographic region study. Dialysis facilities could enable website access as a method of satisfying policy requirements to provide education about kidney transplantation.
Collapse
Affiliation(s)
- Elisa J Gordon
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Joe Feinglass
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Paula Carney
- Department of Health Sciences, Chicago State University, Chicago, IL, USA
| | - Karina Vera
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Maria Olivero
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Anne Black
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Jessica MacLean Baumgart
- Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Juan Carlos Caicedo
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA Hispanic Transplant Program, Northwestern Memorial Hospital, Chicago, IL, USA
| |
Collapse
|
37
|
Sapir-Pichhadze R, Pintilie M, Tinckam KJ, Laupacis A, Logan AG, Beyene J, Kim SJ. Survival Analysis in the Presence of Competing Risks: The Example of Waitlisted Kidney Transplant Candidates. Am J Transplant 2016; 16:1958-66. [PMID: 26751409 DOI: 10.1111/ajt.13717] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 12/30/2015] [Accepted: 01/03/2016] [Indexed: 01/25/2023]
Abstract
Competing events (or risks) preclude the observation of an event of interest or alter the probability of the event's occurrence and are commonly encountered in transplant outcomes research. Transplantation, for example, is a competing event for death on the waiting list because receiving a transplant may significantly decrease the risk of long-term mortality. In a typical analysis of time-to-event data, competing events may be censored or incorporated into composite end points; however, the presence of competing events violates the assumption of "independent censoring," which is the basis of standard survival analysis techniques. The use of composite end points disregards the possibility that competing events may be related to the exposure in a way that is different from the other components of the composite. Using data from the Scientific Registry of Transplant Recipients, this paper reviews the principles of competing risks analysis; outlines approaches for analyzing data with competing events (cause-specific and subdistribution hazards models); compares the estimates obtained from standard survival analysis, which handle competing events as censoring events; discusses the appropriate settings in which each of the two approaches could be used; and contrasts their interpretation.
Collapse
Affiliation(s)
- R Sapir-Pichhadze
- Division of Nephrology and the Multi Organ Transplant Program, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada.,Centre for Outcomes Research and Evaluation (CORE), McGill University Health Centre, Montreal, Quebec, Canada.,Division of Nephrology, Department of Medicine, McGill University, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - M Pintilie
- Division of Biostatistics, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - K J Tinckam
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Departments of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - A Laupacis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Departments of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - A G Logan
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - J Beyene
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Population Health Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - S J Kim
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology and the Renal Transplant Program, St. Michael's Hospital, Toronto, Ontario, Canada
| |
Collapse
|
38
|
Choi JY, Kuo YF, Goodwin JS, Lee J. Association of EMR Adoption with Minority Health Care Outcome Disparities in US Hospitals. Healthc Inform Res 2016; 22:101-9. [PMID: 27200220 PMCID: PMC4871840 DOI: 10.4258/hir.2016.22.2.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 03/29/2016] [Accepted: 04/26/2016] [Indexed: 01/23/2023] Open
Abstract
Objectives Disparities in healthcare among minority groups can result in disparate treatments for similar severities of symptoms, unequal access to medical care, and a wide deviation in health outcomes. Such racial disparities may be reduced via use of an Electronic Medical Record (EMR) system. However, there has been little research investigating the impact of EMR systems on the disparities in health outcomes among minority groups. Methods This study examined the impact of EMR systems on the following four outcomes of black patients: length of stay, inpatient mortality rate, 30-day mortality rate, and 30-day readmission rate, using patient and hospital data from the Medicare Provider Analysis and Review and the Healthcare Information and Management Systems Society between 2000 and 2007. The difference-in-difference research method was employed with a generalized linear model to examine the association of EMR adoption on health outcomes for minority patients while controlling for patient and hospital characteristics. Results We examined the association between EMR adoption and the outcomes of minority patients, specifically black patients. However, after controlling for patient and hospital characteristics we could not find any significant changes in the four health outcomes of minority patients before and after EMR implementation. Conclusions EMR systems have been reported to support better coordinated care, thus encouraging appropriate treatment for minority patients by removing potential sources of bias from providers. Also, EMR systems may improve the quality of care provided to patients via increased responsiveness to care processes that are required to be more time-sensitive and through improved communication. However, we did not find any significant benefit for minority groups after EMR adoption.
Collapse
Affiliation(s)
- Jae-Young Choi
- Program in Healthcare Management, College of Business, Hallym University, Chuncheon, Korea
| | - Yong-Fang Kuo
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - James S Goodwin
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Jinhyung Lee
- Department of Economics, Sungkyunkwan University, Seoul, Korea
| |
Collapse
|
39
|
Tandon A, Wang M, Roe KC, Patel S, Ghahramani N. Nephrologists' likelihood of referring patients for kidney transplant based on hypothetical patient scenarios. Clin Kidney J 2016; 9:611-5. [PMID: 27478607 PMCID: PMC4957715 DOI: 10.1093/ckj/sfw031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/08/2016] [Indexed: 01/04/2023] Open
Abstract
Background There is wide variation in referral for kidney transplant and preemptive kidney transplant (PKT). Patient characteristics such as age, race, sex and geographic location have been cited as contributing factors to this disparity. We hypothesize that the characteristics of nephrologists interplay with the patients' characteristics to influence the referral decision. In this study, we used hypothetical case scenarios to assess nephrologists' decisions regarding transplant referral. Methods A total of 3180 nephrologists were invited to participate. Among those interested, 252 were randomly selected to receive a survey in which nephrologists were asked whether they would recommend transplant for the 25 hypothetical patients. Logistic regression models with single covariates and multiple covariates were used to identify patient characteristics associated with likelihood of being referred for transplant and to identify nephrologists' characteristics associated with likelihood of referring for transplant. Results Of the 252 potential participants, 216 completed the survey. A nephrologist's affiliation with an academic institution was associated with a higher likelihood of referral, and being ‘>10 years from fellowship’ was associated with lower likelihood of referring patients for transplant. Patient age <50 years was associated with higher likelihood of referral. Rural location and smoking history/chronic obstructive pulmonary disease were associated with lower likelihood of being referred for transplant. The nephrologist's affiliation with an academic institution was associated with higher likelihood of referring for preemptive transplant, and the patient having a rural residence was associated with lower likelihood of being referred for preemptive transplant. Conclusions The variability in transplant referral is related to patients' age and geographic location as well as the nephrologists' affiliation with an academic institution and time since completion of training. Future educational interventions should emphasize the benefits of kidney transplant and PKT for all population groups regardless of geographic location and age and should target nephrologists in non-academic settings who are 10 or more years from their fellowship training.
Collapse
Affiliation(s)
- Ankita Tandon
- Department of Medicine , Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Ming Wang
- Department of Public Health Sciences , Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Kevin C Roe
- Division of Nephrology, Department of Medicine , Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Surju Patel
- Division of Nephrology, Department of Medicine , Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Nasrollah Ghahramani
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA; Division of Nephrology, Department of Medicine, Pennsylvania State University College of Medicine, Hershey, PA, USA
| |
Collapse
|
40
|
O'Shaughnessy MM, Montez-Rath ME, Lafayette RA, Winkelmayer WC. Differences in initial treatment modality for end-stage renal disease among glomerulonephritis subtypes in the USA. Nephrol Dial Transplant 2015; 31:290-8. [PMID: 26610594 DOI: 10.1093/ndt/gfv386] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 10/12/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Kidney transplantation is the preferred treatment for end-stage renal disease (ESRD), while peritoneal dialysis affords certain benefits over hemodialysis. Distributions and determinants of first ESRD treatment modality have not been compared across glomerulonephritis (GN) subtypes. METHODS We identified all adult (18-75 years) patients with ESRD attributed to any of six GN subtypes [focal segmental glomerulosclerosis (FSGS), IgA nephropathy (IgAN), membranous nephropathy (MN), membranoproliferative GN (MPGN), lupus nephritis (LN) and vasculitis] who were first registered in the US Renal Data System (USRDS) between 1996 and 2011. We used multinomial logistic regression--adjusting for temporal, geographic, demographic, socioeconomic and comorbid factors--to determine odds ratios (ORs) with 95% confidence intervals (CIs) for transplantation versus hemodialysis, and for peritoneal dialysis versus hemodialysis, comparing other GN subtypes to IgAN. RESULTS Among the 75 278 patients studied, patients with comparator GN subtypes were significantly less likely than those with IgAN to receive either transplantation or peritoneal dialysis. After adjusting for potentially confounding covariates, patients with comparator primary GN subtypes (FSGS, MN, MPGN) were at least as likely to receive transplantation [FSGS OR 0.98 (95% CI 0.93-1.15), MN OR 1.19 (95% CI 1.01-1.39), MPGN OR 1.08 (95% CI 0.93-1.26)] or peritoneal dialysis [FSGS OR 1.05 (95% CI 0.98-1.12), MN OR 1.30 (95% CI 1.18-1.43), MPGN OR 0.95 (95% CI 0.85-1.06)] as patients with IgAN. Conversely, patients with the secondary GN subtypes LN and vasculitis remained significantly less likely to receive either modality [transplantation OR 0.49 (95% CI 0.43-0.56) for LN and 0.27 (95% CI 0.22-0.34) for vasculitis, peritoneal dialysis OR 0.76 (95% CI 0.70-0.82) for LN and 0.54 (95% CI 0.48-0.60) for vasculitis]. CONCLUSIONS Significant differences in ESRD treatment practice patterns are apparent among GN subtypes. To ensure equitable care for all patients, regardless of GN subtype, reasons for observed disparities should be elucidated and-if appropriate-eliminated.
Collapse
Affiliation(s)
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Richard A Lafayette
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
41
|
Kucirka LM, Segev DL. The Other Half of Informed Consent: Transplant Education Practices in Dialysis Centers. Clin J Am Soc Nephrol 2015; 10:1507-9. [PMID: 26292695 DOI: 10.2215/cjn.08280815] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Lauren M Kucirka
- Department of Surgery, Johns Hopkins School of Medicine, and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins School of Medicine, and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
42
|
Affiliation(s)
- Lauren M Kucirka
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland2Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Tanjala S Purnell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland2Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland2Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| |
Collapse
|
43
|
Patzer RE, Plantinga LC, Paul S, Gander J, Krisher J, Sauls L, Gibney EM, Mulloy L, Pastan SO. Variation in Dialysis Facility Referral for Kidney Transplantation Among Patients With End-Stage Renal Disease in Georgia. JAMA 2015; 314:582-94. [PMID: 26262796 PMCID: PMC4571496 DOI: 10.1001/jama.2015.8897] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Dialysis facilities in the United States are required to educate patients with end-stage renal disease about all treatment options, including kidney transplantation. Patients receiving dialysis typically require a referral for kidney transplant evaluation at a transplant center from a dialysis facility to start the transplantation process, but the proportion of patients referred for transplantation is unknown. OBJECTIVE To describe variation in dialysis facility-level referral for kidney transplant evaluation and factors associated with referral among patients initiating dialysis in Georgia, the US state with the lowest kidney transplantation rates. DESIGN, SETTING, AND PARTICIPANTS Examination of United States Renal Data System data from a cohort of 15,279 incident, adult (18-69 years) patients with end-stage renal disease from 308 Georgia dialysis facilities from January 2005 to September 2011, followed up through September 2012, linked to kidney transplant referral data collected from adult transplant centers in Georgia in the same period. MAIN OUTCOMES AND MEASURES Referral for kidney transplant evaluation within 1 year of starting dialysis at any of the 3 Georgia transplant centers was the primary outcome; placement on the deceased donor waiting list was also examined. RESULTS The median within-facility percentage of patients referred within 1 year of starting dialysis was 24.4% (interquartile range, 16.7%-33.3%) and varied from 0% to 75.0%. Facilities in the lowest tertile of referral (<19.2%) were more likely to treat patients living in high-poverty neighborhoods (absolute difference, 21.8% [95% CI, 14.1%-29.4%]), had a higher patient to social worker ratio (difference, 22.5 [95% CI, 9.7-35.2]), and were more likely nonprofit (difference, 17.6% [95% CI, 7.7%-27.4%]) compared with facilities in the highest tertile of referral (>31.3%). In multivariable, multilevel analyses, factors associated with lower referral for transplantation, such as older age, white race, and nonprofit facility status, were not always consistent with the factors associated with lower waitlisting. CONCLUSIONS AND RELEVANCE In Georgia overall, a limited proportion of patients treated with dialysis were referred for kidney transplant evaluation between 2005 and 2011, but there was substantial variability in referral among facilities. Variables associated with referral were not always associated with waitlisting, suggesting that different factors may account for disparities in referral.
Collapse
Affiliation(s)
- Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia2Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia3Emory Transplant Center, Atlanta, Georgia
| | - Laura C Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia4Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Jennifer Gander
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jenna Krisher
- Southeastern Kidney Council Inc of End Stage Renal Disease Network 6, Raleigh, North Carolina
| | - Leighann Sauls
- Southeastern Kidney Council Inc of End Stage Renal Disease Network 6, Raleigh, North Carolina
| | - Eric M Gibney
- Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, Georgia
| | - Laura Mulloy
- Division of Nephrology, Department of Medicine, Georgia Regents University, Augusta
| | - Stephen O Pastan
- Emory Transplant Center, Atlanta, Georgia4Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| |
Collapse
|
44
|
Tong A, Hanson CS, Chapman JR, Halleck F, Budde K, Josephson MA, Craig JC. 'Suspended in a paradox'-patient attitudes to wait-listing for kidney transplantation: systematic review and thematic synthesis of qualitative studies. Transpl Int 2015; 28:771-87. [PMID: 25847569 DOI: 10.1111/tri.12575] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 02/23/2015] [Accepted: 03/31/2015] [Indexed: 12/21/2022]
Abstract
Patients on waiting lists for kidney transplantation have higher mortality rates and have specific anxieties about their eligibility, process, and outcomes of wait-listing. We aimed to describe patient experiences and attitudes to wait-listing for kidney transplantation. Electronic databases were searched to September 2014. Thematic synthesis was used to analyze the findings. From 22 studies (n = 795 patients), we identified six themes: accepting the only option (chance to regain normality, avoiding guilt, impulsive decision-making); maintaining hope (determined optimism, appreciating a fortuitous gift, enduring for optimal outcomes, trust in clinical judgment); burden of testing (strenuous commitment, losing the battle, medical mistrust); permeating vulnerability (eligibility enigma, being threatened, angst of timing uncertainty, desperate urgency, living in limbo, spiraling doubt and disappointment, residual ambivalence); deprived of opportunity (unfairly dismissed, unexpected disqualification, self-resignation and acceptance, jealousy, suspicious of inequity); and moral guilt (awaiting someone's death, questioning deservingness). The waiting list offered hope of restored normality. However, the demands of workup, uncertainty about eligibility, and waiting times that exceeded expectations impelled patients to disillusionment, despair, and suspicion of inequity. Managing patient expectations and ensuring transparency of wait-listing and allocation decisions may allay patient disappointment and skepticism, to improve patient satisfaction and treatment outcomes.
Collapse
Affiliation(s)
- Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Camilla S Hanson
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Fabian Halleck
- Department of Nephrology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| |
Collapse
|
45
|
Ward FL, O'Kelly P, Donohue F, O'Haiseadha C, Haase T, Pratschke J, deFreitas DG, Johnson H, O'Seaghdha CM, Conlon PJ. The influence of socioeconomic status on patient survival on chronic dialysis. Hemodial Int 2015; 19:601-8. [PMID: 25854991 DOI: 10.1111/hdi.12295] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Socioeconomic status (SES) has been linked to worse end-stage kidney disease survival. The effect of SES on survival on chronic dialysis, including the impact of transplantation, was examined. A retrospective, observational study investigated the association of SES with dialysis patient survival, with censoring at time of transplantation. Adult patients commencing dialysis from 1990 to 2009 in an Irish tertiary center received a spatial SES score using the 2011 Pobal Haase-Pratschke Deprivation Index and were compared by quartile. Cox proportional hazard models and Kaplan-Meier survival analysis examined any association of SES with survival. The 1794 patients included had a median follow-up of 3.8 years. Patients in the lowest SES area quartile were significantly younger than the highest, mean age 56.7 vs. 59 years, P = 0.006, respectively. There was no association between SES area score and survival in an unadjusted model (hazard ratio [HR] 1.00, 95% confidence interval [CI] 0.99-1.01). Survival in the highest SES area quartile was superior to the lowest SES in a multivariable adjusted model including age, gender, and dialysis modality (HR 0.83, 95% CI 0.70-0.99, P = 0.04). These results were only mildly attenuated by censoring at time of transplantation (highest SES area quartile deprived vs. lowest SES area quartile, HR 0.85, 95% CI 0.70-1.03, P = 0.09). Superior patient survival was identified in the highest SES areas compared with the lowest following age-adjusted analyses, despite the older population in the most affluent areas. Further research should focus on identifying modifiable targets for intervention that account for this socioeconomic-related survival advantage.
Collapse
Affiliation(s)
- Frank L Ward
- Department of Transplantation and Renal Medicine, Beaumont Hospital, Dublin, Ireland
| | - Patrick O'Kelly
- Department of Transplantation and Renal Medicine, Beaumont Hospital, Dublin, Ireland
| | - Fionnuala Donohue
- Department of Public Health and Health Intelligence Unit, Dr Steevens Hospital, Dublin, Ireland
| | - Coilín O'Haiseadha
- Department of Public Health and Health Intelligence Unit, Dr Steevens Hospital, Dublin, Ireland
| | - Trutz Haase
- Social and Economic Consultants, Health Service Executive, Dublin, Ireland
| | - Jonathan Pratschke
- Social and Economic Consultants, Health Service Executive, Dublin, Ireland
| | - Declan G deFreitas
- Department of Transplantation and Renal Medicine, Beaumont Hospital, Dublin, Ireland
| | - Howard Johnson
- Department of Public Health and Health Intelligence Unit, Dr Steevens Hospital, Dublin, Ireland
| | - Conall M O'Seaghdha
- Department of Transplantation and Renal Medicine, Beaumont Hospital, Dublin, Ireland
| | - Peter J Conlon
- Department of Transplantation and Renal Medicine, Beaumont Hospital, Dublin, Ireland
| |
Collapse
|
46
|
Pérez-Sáez MJ, Prieto-Alhambra D, Barrios C, Crespo M, Redondo D, Nogués X, Díez-Pérez A, Pascual J. Increased hip fracture and mortality in chronic kidney disease individuals: the importance of competing risks. Bone 2015; 73:154-9. [PMID: 25549867 DOI: 10.1016/j.bone.2014.12.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 12/01/2014] [Accepted: 12/19/2014] [Indexed: 01/23/2023]
Abstract
BACKGROUND Many studies have shown a correlation between chronic kidney disease (CKD) and fracture. However, increased mortality in CKD patients is a competing risk scenario not accounted for in previous studies. Our aim was to investigate the true impact of CKD on hip fracture after accounting for a competing risk with death. METHODS We conducted a population-based cohort study to determine the impact of CKD on hip fractures in individuals aged ≥50years old registered in the SIDIAP(Q) database (representative of 1.9 million people in Catalonia, Spain). Cox regression was used to estimate hazard ratio (HR) for death and hip fracture according to CKD status. A competing risk (Fine and Gray) model was fitted to estimate sub-HR for hip fracture in CKD or CKD-free patients accounting for differential mortality. RESULTS A total of 873,073 (32,934 (3.8%) CKD) patients were observed for 3 years. During follow-up, 4,823 (14.6%) CKD and 36,328 (4.3%) CKD-free participants died (HR, 1.83 [95% CI, 1.78-1.89]), whilst 522 (1.59%) and 6,292 (0.75%) sustained hip fractures, respectively. Adjusted Cox models showed a significantly increased risk of hip fractures for the CKD group (HR, 1.16 [1.06-1.27]), but this association was attenuated in competing risk models accounting for mortality (SHR, 1.14 [1.03-1.27]). CONCLUSIONS Both death and hip fracture rates are increased (by 83% and 16%, respectively) in CKD patients. However, the association between CKD and hip fractures is attenuated when an excess of mortality is taken into account. A competing risk with death must be considered in future analyses of association between CKD and any health outcomes.
Collapse
Affiliation(s)
| | - Daniel Prieto-Alhambra
- Institut Mar d'Investigacions Mediques, Barcelona, Spain; Idiap Jordi Gol Primary Care Research Institute, Universitat Autonoma de Barcelona, Barcelona, Spain; Musculoskeletal Epidemiology Unit, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Clara Barrios
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Dolores Redondo
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Xavier Nogués
- Department of Internal Medicine, Hospital del Mar, Barcelona, Spain
| | - Adolfo Díez-Pérez
- Idiap Jordi Gol Primary Care Research Institute, Universitat Autonoma de Barcelona, Barcelona, Spain; Department of Internal Medicine, Hospital del Mar, Barcelona, Spain
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Idiap Jordi Gol Primary Care Research Institute, Universitat Autonoma de Barcelona, Barcelona, Spain
| |
Collapse
|
47
|
Lee J. The impact of health information technology on disparity of process of care. Int J Equity Health 2015; 14:34. [PMID: 25889891 PMCID: PMC4392633 DOI: 10.1186/s12939-015-0161-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 03/17/2015] [Indexed: 11/10/2022] Open
Abstract
Introduction Disparities in the quality of health care and treatment among racial or ethnic groups can result from unequal access to medical care, disparate treatments for similar severities of symptoms, and wide divergence in general health status among individuals. Such disparities may be eliminated through better use of health information technology (IT). Investment in health IT could foster better coordinated care, improve guideline compliance, and reduce the likelihood of redundant testing, thereby encouraging more equitable treatment for underprivileged populations. However, there is little research exploring the impact of health IT investment on disparities of process of care. Methodology This study examines the impact of health IT investment on waiting times – from admission to the date of first principle procedure – among different racial and ethnic groups, using patient and hospital data for the state of California collected from 2001 to 2007. The final sample includes 14,056,930 patients admitted with medical diseases to 316 unique, acute-care hospitals over a seven-year period. The linear random intercept and slope model was employed to examine the impacts of health IT investment on waiting time, while controlling for patient, disease, and hospital characteristics. Results Greater health IT investment was associated with shorter waiting times, and the reduction in waiting times was greater for non-White than for White patients. This indicates that minority populations could benefit from health IT investment with regard to process of care. Conclusion Investments in health IT may reduce disparities in process of care. Electronic supplementary material The online version of this article (doi:10.1186/s12939-015-0161-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Jinhyung Lee
- Department of Economics, Sungkyunkwan University, Seoul, Korea.
| |
Collapse
|
48
|
Adler JT, Hyder JA, Elias N, Nguyen LL, Markmann JF, Delmonico FL, Yeh H. Socioeconomic status and ethnicity of deceased donor kidney recipients compared to their donors. Am J Transplant 2015; 15:1061-7. [PMID: 25758952 DOI: 10.1111/ajt.13097] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 10/20/2014] [Accepted: 11/08/2014] [Indexed: 01/25/2023]
Abstract
Public perception and misperceptions of socioeconomic disparities affect the willingness to donate organs. To improve our understanding of the flow of deceased donor kidneys, we analyzed socioeconomic status (SES) and racial/ethnic gradients between donors and recipients. In a retrospective cohort study, traditional demographic and socioeconomic factors, as well as an SES index, were compared in 56,697 deceased kidney donor and recipient pairs transplanted between 2007 and 2012. Kidneys were more likely to be transplanted in recipients of the same racial/ethnic group as the donor (p < 0.001). Kidneys tended to go to recipients of lower SES index (50.5% of the time, p < 0.001), a relationship that remained after adjusting for other available markers of donor organ quality and SES (p < 0.001). Deceased donor kidneys do not appear to be transplanted from donors of lower SES to recipients of higher SES; this information may be useful in counseling potential donors and their families regarding the distribution of their organ gifts.
Collapse
Affiliation(s)
- J T Adler
- Center for Surgery and Public Health at Brigham and Women's Hospital, Boston, MA; Division of Transplant Surgery, Massachusetts General Hospital, Boston, MA
| | | | | | | | | | | | | |
Collapse
|
49
|
Abstract
OBJECTIVE To evaluate the impact of market competition on patient mortality and graft failure after kidney transplantation. BACKGROUND Kidneys are initially allocated within 58 donation service areas (DSAs), which have varying numbers of transplant centers. Market competition is generally considered beneficial. METHODS The Scientific Registry of Transplant Recipients database was queried and the Herfindahl-Hirschman index (HHI), a measure of market competition, was calculated for each DSA from 2003 to 2012. Receipt of low-quality kidneys (Kidney Donor Profile Index ≥ 85) was modeled with multivariable logistic regression, and Cox proportional hazards models were created for graft failure and patient mortality. RESULTS A total of 127,355 adult renal transplants were performed. DSAs were categorized as 7 no (HHI = 1), 17 low (HHI = 0.52-0.97), 17 medium (HHI = 0.33-0.51), or 17 high (HHI = 0.09-0.32) competition. For deceased donor kidney transplantation, increasing market competition was significantly associated with mortality [hazard ratio (HR): 1.11, P = 0.01], graft failure (HR: 1.18, P = 0.0001), and greater use of low-quality kidneys (odds ratio = 1.39, P < 0.0001). This was not true for living donor kidney transplantation (mortality HR: 0.94, P = 0.48; graft failure HR: 0.99, P = 0.89). Competition was associated with longer waitlists (P = 0.04) but not with the number of transplants per capita in a DSA (P = 0.21). CONCLUSIONS Increasing market competition is associated with increased patient mortality and graft failure and the use of riskier kidneys. These results may represent more aggressive transplantation and tolerance of greater risk for patients who otherwise have poor alternatives. Market competition should be better studied to ensure optimal outcomes.
Collapse
|
50
|
The Preferences and Perspectives of Nephrologists on Patients’ Access to Kidney Transplantation. Transplantation 2014; 98:682-91. [DOI: 10.1097/tp.0000000000000336] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|