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Maclay LM, Yu M, Amaral S, Adler JT, Sandoval PR, Ratner LE, Schold JD, Mohan S, Husain SA. Disparities in Access to Timely Waitlisting Among Pediatric Kidney Transplant Candidates. Pediatrics 2024:e2024065934. [PMID: 39086359 DOI: 10.1542/peds.2024-065934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Kidney transplantation with minimal or no dialysis exposure provides optimal outcomes for children with end-stage kidney disease. We sought to understand disparities in timely access to transplant waitlisting. METHODS We conducted a retrospective, registry-based cohort study of candidates ages 3 to 17 added to the US kidney transplant waitlist 2015 to 2019. We defined "preemptive waitlisting" as waitlist addition before receiving dialysis and compared demographics of candidates based on preemptive status. We used competing risk regression to determine the association between preemptive waitlisting and transplantation. We then identified waitlist additions age >18 who initiated dialysis as children, thereby missing pediatric allocation prioritization, and evaluated the association between waitlisting with pediatric prioritization and transplantation. RESULTS Among 4506 pediatric candidates, 48% were waitlisted preemptively. Female sex, Hispanic ethnicity, Black race, and public insurance were associated with lower adjusted relative risk of preemptive waitlisting. Preemptive listing was not associated with time from waitlist activation to transplantation (adjusted hazard ratio 0.94, 95% confidence interval 0.87-1.02). Among transplant recipients waitlisted preemptively, 68% had no pretransplant dialysis, whereas recipients listed nonpreemptively had median 1.6 years of dialysis at transplant. Among 415 candidates initiating dialysis as children but waitlisted as adults, transplant rate was lower versus nonpreemptive pediatric candidates after waitlist activation (adjusted hazard ratio 0.54, 95% confidence interval 0.44-0.66). CONCLUSIONS Disparities in timely waitlisting are associated with differences in pretransplant dialysis exposure despite no difference in time to transplant after waitlist activation. Young adults who experience delays may miss pediatric prioritization, highlighting an area for policy intervention.
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Affiliation(s)
- Lindsey M Maclay
- Departments of Medicine, Division of Nephrology
- Columbia University Renal Epidemiology Group, New York, New York
| | - Miko Yu
- Departments of Medicine, Division of Nephrology
- Columbia University Renal Epidemiology Group, New York, New York
| | - Sandra Amaral
- Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joel T Adler
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - P Rodrigo Sandoval
- Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Lloyd E Ratner
- Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Jesse D Schold
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora
- Department of Epidemiology, School of Public Health, University of Colorado - Anschutz Medical Campus, Aurora
| | - Sumit Mohan
- Departments of Medicine, Division of Nephrology
- Columbia University Renal Epidemiology Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Syed Ali Husain
- Departments of Medicine, Division of Nephrology
- Columbia University Renal Epidemiology Group, New York, New York
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Wang C, Garg AX, Luo B, Kim SJ, Knoll G, Yohanna S, Treleaven D, McKenzie S, Ip J, Cooper R, Elliott L, Naylor KL. Defining pre-emptive living kidney donor transplantation as a quality indicator. Am J Transplant 2024; 24:1445-1455. [PMID: 38395149 DOI: 10.1016/j.ajt.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/31/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024]
Abstract
Quality indicators in kidney transplants are needed to identify care gaps and improve access to transplants. We used linked administrative health care databases to examine multiple ways of defining pre-emptive living donor kidney transplants, including different patient cohorts and censoring definitions. We included adults from Ontario, Canada with advanced chronic kidney disease between January 1, 2013, to December 31, 2018. We created 4 unique incident patient cohorts, varying the eligibility by the risk of progression to kidney failure and whether individuals had a recorded contraindication to kidney transplant (eg, home oxygen use). We explored the effect of 4 censoring event definitions. Across the 4 cohorts, size varied substantially from 20 663 to 9598 patients, with the largest reduction (a 43% reduction) occurring when we excluded patients with ≥1 recorded contraindication to kidney transplantation. The incidence rate (per 100 person-years) of pre-emptive living donor kidney transplant varied across cohorts from 1.02 (95% CI: 0.91-1.14) for our most inclusive cohort to 2.21 (95% CI: 1.96-2.49) for the most restrictive cohort. Our methods can serve as a framework for developing other quality indicators in kidney transplantation and monitoring and improving access to pre-emptive living donor kidney transplants in health care systems.
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Affiliation(s)
- Carol Wang
- Division of Nephrology, Western University, London, Ontario, Canada.
| | - Amit X Garg
- Division of Nephrology, Western University, London, Ontario, Canada; ICES, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
| | - Bin Luo
- ICES, Ontario, Canada; Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
| | - S Joseph Kim
- Division of Nephrology and the Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Gregory Knoll
- University of Ottawa, Department of Medicine (Nephrology) and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Seychelle Yohanna
- Division of Nephrology, McMaster University, Hamilton, Ontario, Canada
| | - Darin Treleaven
- Division of Nephrology, McMaster University, Hamilton, Ontario, Canada
| | | | - Jane Ip
- Ontario Renal Network, Ontario Health, Ontario, Canada
| | - Rebecca Cooper
- Ontario Renal Network, Ontario Health, and Trillium Gift of Life Network, Ontario Health, Canada
| | - Lori Elliott
- Ontario Renal Network, Ontario Health, Ontario, Canada
| | - Kyla L Naylor
- ICES, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
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Shrestha S, Haq K, Malhotra D, Patel DM. Care of Adults with Advanced Chronic Kidney Disease. J Clin Med 2024; 13:4378. [PMID: 39124645 PMCID: PMC11313041 DOI: 10.3390/jcm13154378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/23/2024] [Accepted: 07/23/2024] [Indexed: 08/12/2024] Open
Abstract
Chronic kidney disease (CKD) impacts over 10% of the global population. Adults with CKD face significant morbidity and mortality. As kidney disease progresses, the risk of adverse outcomes increases. Here, we present an overview of strategies to care for adults with advanced CKD (stage 4-5 CKD, not receiving kidney replacement therapy). We aim to guide clinicians through several aspects of CKD care, ranging from recommended laboratory assessments to interdisciplinary support for patients as they plan for kidney replacement therapy (dialysis, transplantation, or conservative management). We incorporate considerations of health equity and person-centered care, empowering clinicians to deliver high-quality care to people with CKD.
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Affiliation(s)
| | | | | | - Dipal M. Patel
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA (D.M.)
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4
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Kaur R, Schick-Makaroff K, Dang P, Sasaki A, Neves P, Mucsi I, Gill J. Navigating Living Kidney Donation and Transplantation Among South Asian Canadians: The ACTION Project. Am J Kidney Dis 2024; 83:750-761.e1. [PMID: 38242424 DOI: 10.1053/j.ajkd.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 11/02/2023] [Accepted: 11/14/2023] [Indexed: 01/21/2024]
Abstract
RATIONALE & OBJECTIVE South Asian (SA) Canadians with kidney failure have a 50%-77% lower likelihood of kidney transplant and are less likely to identify potential living donors (LDs). This study aimed to identify health system-, patient-, and community-level barriers and facilitators for accessing LD kidney transplantation in the SA community to inform the development of health system- and community-level interventions to address barriers. STUDY DESIGN Qualitative study. SETTING & PARTICIPANTS 20 SA recipients of an LD or deceased-donor kidney transplant, 10 SA LDs, and 41 general SA community members. ANALYTICAL APPROACH In-depth multilingual interviews were conducted with recipients and LDs. Gender-, language-, and age-stratified focus groups were conducted with general SA community members. Summative content analysis was used to analyze the data. RESULTS Hesitancy in approaching potential donors, fear about the health of potential LDs, information gaps, language barriers, and challenges evaluating out-of-country donors were highlighted as significant barriers by recipients, and financial concerns and information gaps were identified by donors. Cultural barriers in the SA community were highlighted by donors, recipients, and community members as critical factors when considering donation and transplant; women and elderly SA Canadians highlighted nuanced challenges. Participants reported generally a favorable perception of their health care teams, citing SA representation in the teams as important to providing culturally and linguistically sensitive care. LIMITATIONS Limited geographic, race, and cultural representation and reliance on virtual data collection. CONCLUSIONS This study highlights several culturally relevant barriers to donation and transplant that are potentially modifiable through patient-, health system-, and community-focused engagement and education.
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Affiliation(s)
- Reetinder Kaur
- Providence Health Care Research Institute, Vancouver, BC, Canada
| | | | - Phuc Dang
- Providence Health Care Research Institute, Vancouver, BC, Canada
| | - Ayumi Sasaki
- Providence Health Care Research Institute, Vancouver, BC, Canada
| | - Paula Neves
- Centre for Living Organ Donation, University Health Network, Toronto, ON, Canada
| | - Istvan Mucsi
- Ajmera Transplant Center, University Health Network, Toronto, ON, Canada; Division of Nephrology, University of Toronto, Toronto, ON, Canada
| | - Jagbir Gill
- Division of Nephrology, Department of Medicine, and Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, BC, Canada.
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Ly L, Zhu D, Schaubel DE, Woodside KJ, Sung RS. Impact of delayed listing after initiating kidney transplant evaluation on transplant outcomes. Clin Transplant 2024; 38:e15319. [PMID: 38683684 DOI: 10.1111/ctr.15319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 03/20/2024] [Accepted: 04/08/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVE Longer end-stage renal disease time has been associated with inferior kidney transplant outcomes. However, the contribution of transplant evaluation is uncertain. We explored the relationship between time from evaluation to listing (ELT) and transplant outcomes. METHODS This retrospective study included 2535 adult kidney transplants from 2000 to 2015. Kaplan-Meier survival curves, log-rank tests, and Cox regression models were used to compare transplant outcomes. RESULTS Patient survival for both deceased donor (DD) recipients (p < .001) and living donor (LD) recipients (p < .0001) was significantly higher when ELT was less than 3 months. The risks of ELT appeared to be mediated by other risks in DD recipients, as adjusted models showed no associated risk of graft loss or death in DD recipients. For LD recipients, ELT remained a risk factor for patient death after covariate adjustment. Each month of ELT was associated with an increased risk of death (HR = 1.021, p = .04) but not graft loss in LD recipients in adjusted models. CONCLUSIONS Kidney transplant recipients with longer ELT times had higher rates of death after transplant, and ELT was independently associated with an increased risk of death for LD recipients. Investigations on the impact of pretransplant evaluation on post-transplant outcomes can inform transplant policy and practice.
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Affiliation(s)
- Lisa Ly
- Department of Urology, Temple University, Philadelphia, Pennsylvania, USA
| | - Danting Zhu
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology and Bioinformatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Randall S Sung
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Gordon EJ, Lee J, Kang R, Uriarte J, Caicedo JC. Disparities Persist Among Hispanic Patients: Completing Evaluation, Waitlisting, and Receiving a Kidney Transplant. Transplant Direct 2024; 10:e1595. [PMID: 38414978 PMCID: PMC10898667 DOI: 10.1097/txd.0000000000001595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/10/2024] [Indexed: 02/29/2024] Open
Abstract
Background Hispanic patients receive disproportionately fewer kidney transplants (KT) than non-Hispanic White (NHW) patients. In this observational study, we evaluated disparities in completing evaluation steps to KT among Hispanic patients. Methods Using medical records of Hispanic and NHW patients initiating evaluation at 4 transplant centers from January 2011 to March 2020, we performed sequential Cox models to compare Hispanic versus NHW patients reaching each step of the evaluation process until receiving a KT. Results Among all 5197 patients (Hispanic n = 2473; NHW n = 2724) initiating evaluation, Hispanic patients had 8% lower risk to be approved by the kidney pancreas (KP) committee than NHW patients (adjusted hazard ratio [aHR], 0.92; 95% confidence intervals (CI), 0.86-0.98; P = 0.015). Among 3492 patients approved by the KP committee, Hispanic patients had 13% lower risk to be waitlisted than NHW patients (aHR, 0.87; 95% CI, 0.81-0.94; P = 0.004). Among 3382 patients who were waitlisted, Hispanic patients had 11% lower risk than NHW patients to receive KT (aHR, 0.89; 95% CI, 0.81-0.97; P = 0.011). Among all patients initiating evaluation, Hispanic patients had a 16% lower risk than NHW patients to reach KT (aHR, 0.84; 95% CI, 0.76-0.92; P = 0.0002). Conclusions Our study found that disproportionately fewer Hispanic patients were approved by the KP committee, were waitlisted, and received a KT, particularly a living donor kidney transplant, than NHW patients. Closer oversight of the evaluation process may help patients overcome challenges in access to KT.
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Affiliation(s)
- Elisa J. Gordon
- Department of Surgery, and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN
| | - Jungwha Lee
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Raymond Kang
- Center for Community Health, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jefferson Uriarte
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Juan Carlos Caicedo
- Department of Surgery, Division of Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL
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Gompers A, Rossi A, Harding JL. Intersectional race and gender disparities in kidney transplant access in the United States: a scoping review. BMC Nephrol 2024; 25:36. [PMID: 38273245 PMCID: PMC10811805 DOI: 10.1186/s12882-023-03453-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 12/30/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Gender and racial disparities in kidney transplant access are well established, however how gender and race interact to shape access to kidney transplant is less clear. Therefore, we examined existing literature to assess what is known about the potential interaction of gender and race and the impact on access to kidney transplantation in the US. METHODS Following PRISMA guidelines, we conducted a scoping review and included quantitative and qualitative studies published in English between 1990 and May 31, 2023 among adult end-stage kidney disease patients in the US. All studies reported on access to specific transplant steps or perceived barriers to transplant access in gender and race subgroups, and the intersection between the two. We narratively synthesized findings across studies. RESULTS Fourteen studies met inclusion criteria and included outcomes of referral (n = 4, 29%), evaluation (n = 2, 14%), waitlisting (n = 4, 29%), transplantation (n = 5, 36%), provider perceptions of patient transplant candidacy (n = 3, 21%), and patient preferences and requests for a living donor (n = 5, 36%). Overall, we found that White men have the greatest access at all steps of the transplant process, from referral to eventual living or deceased donor transplantation. In contrast, women from racial or ethnic minorities tend to have the lowest access to kidney transplant, in particular living donor transplant, though this was not consistent across all studies. CONCLUSIONS Examining how racism and sexism interact to shape kidney transplant access should be investigated in future research, in order to ultimately shape policies and interventions to improve equity.
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Affiliation(s)
- Annika Gompers
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA, 30322, USA.
| | - Ana Rossi
- Piedmont Transplant Institute, 1968 Peachtree Rd NW Building 77, Atlanta, GA, 30309, USA
| | - Jessica L Harding
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA, 30322, USA
- Department of Surgery, Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA, 30322, USA
- Health Services Research Center, Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA, 30322, USA
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McElroy LM, Mohottige D, Cooper A, Sanoff S, Davis LA, Collins BH, Gordon EJ, Wang V, Boulware LE. Improving Health Equity in Living Donor Kidney Transplant: Application of an Implementation Science Framework. Transplant Proc 2024; 56:68-74. [PMID: 38184377 DOI: 10.1016/j.transproceed.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 12/19/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Interventions to improve racial equity in access to living donor kidney transplants (LDKT) have focused primarily on patients, ignoring the contributions of clinicians, transplant centers, and health system factors. Obtaining access to LDKT is a complex, multi-step process involving patients, their families, clinicians, and health system functions. An implementation science framework can help elucidate multi-level barriers to achieving racial equity in LDKT and guide the implementation of interventions targeted at all levels. METHODS We adopted the Pragmatic Robust Implementation and Sustainability Model (PRISM), an implementation science framework for racial equity in LDKT. The purpose was to provide a guide for assessment, inform intervention design, and support planning for the implementation of interventions. RESULTS We applied 4 main PRISM domains to racial equity in LDKT: Organizational Characteristics, Program Components, External Environment, and Patient Characteristics. We specified elements within each domain that consider perspectives of the health system, transplant center, clinical staff, and patients. CONCLUSION The applied PRISM framework provides a foundation for the examination of multi-level influences across the entirety of LDKT care. Researchers, quality improvement staff, and clinicians can use the applied PRISM framework to guide the assessment of inequities, support collaborative intervention development, monitor intervention implementation, and inform resource allocation to improve equity in access to LDKT.
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Affiliation(s)
- Lisa M McElroy
- Department of Surgery, Duke University, Durham, North Carolina; Department of Population Health Sciences, Duke University, Durham, North Carolina.
| | | | - Alexandra Cooper
- Social Science Research Institute, Duke University, Durham, North Carolina
| | - Scott Sanoff
- Department of Medicine, Duke University, Durham, North Carolina
| | - LaShara A Davis
- Department of Surgery and J.C. Walter Jr. Transplant Center, Houston Methodist Hospital, Houston, Texas
| | | | - Elisa J Gordon
- Department of Surgery, Vanderbilt University, Nashville, Tennessee
| | - Virginia Wang
- Department of Population Health Sciences, Duke University, Durham, North Carolina; Department of Medicine, Duke University, Durham, North Carolina
| | - L Ebony Boulware
- Department of Population Health Sciences, Duke University, Durham, North Carolina; Department of Medicine, Duke University, Durham, North Carolina
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McPherson L, Plantinga LC, Howards PP, Kramer M, Pastan SO, Patzer RE. Referral and evaluation for kidney transplantation among patients with lupus nephritis-related end-stage kidney disease. Lupus 2024; 33:48-57. [PMID: 38019182 PMCID: PMC10842868 DOI: 10.1177/09612033231219739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
OBJECTIVE For the majority of patients with lupus nephritis-related end-stage kidney disease (LN-ESKD), kidney transplant is associated with better outcomes than dialysis. Access to kidney transplant requires an initial referral to a transplant center and medical evaluation prior to waitlisting. The study's objective was to examine access to these early steps in the kidney transplant process among patients with LN-ESKD. METHODS Adults who began treatment for ESKD in the Southeast, Northeast, New York, or Ohio River Valley U.S. regions from 1/1/2012 to 12/31/2019, followed through 6/30/2021, were identified from the United States Renal Data System. Referral and evaluation start data were collected from 28 of 48 transplant centers across these regions. The exposure was primary cause of ESKD (LN-ESKD vs other-ESKD). The outcomes were referral and evaluation start at a transplant center. Cox models quantified the association between LN-ESKD (vs other-ESKD) and referral and evaluation start. RESULTS Among 192,318 patients initiating treatment for ESKD, 0.4% had LN-ESKD. Over half (58%) of LN-ESKD patients were referred before study end, and among those referred, 66% started the evaluation. In adjusted analyses, patients with LN-ESKD were referred (HR: 1.09, 95% CI: 0.99, 1.19) and started the transplant evaluation (HR: 1.13, 95% CI: 1.00, 1.28) at a higher rate than patients with other-ESKD. Among referred patients with LN-ESKD, the median time from ESKD start to referral was 2.9 months (IQR: <1 to 11.7 months), which is similar to patients with other-ESKD (median 2.6 months, IQR: <1 to 8.8 months). CONCLUSIONS Among incident patients with ESKD, having a primary diagnosis of LN-ESKD versus other-ESKD is associated with higher rates of early transplant access outcomes. Despite this, patients with LN-ESKD (vs other-ESKD) are less likely to be preemptively referred (i.e., referred prior to ESKD start) for kidney transplant. While providers may no longer be delaying the early steps in the kidney transplantation process among this patient population, there is still room for improvement in the rates of preemptive referral. Access to kidney transplant referral prior to ESKD could result in increased transplant rates and better transplant outcomes for patients with LN-ESKD.
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Affiliation(s)
- Laura McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Laura C. Plantinga
- Divisions of Rheumatology and Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Penelope P. Howards
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Michael Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Stephen O. Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E. Patzer
- Division of Transplantation, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
- Regenstrief Institute, Indianapolis, IN
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Chesnaye NC, Carrero JJ, Hecking M, Jager KJ. Differences in the epidemiology, management and outcomes of kidney disease in men and women. Nat Rev Nephrol 2024; 20:7-20. [PMID: 37985869 DOI: 10.1038/s41581-023-00784-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 11/22/2023]
Abstract
Improved understanding of differences in kidney disease epidemiology, management and outcomes in men and women could help nephrologists to better meet the needs of their patients from a sex- and gender-specific perspective. Evidence of sex differences in the risk and outcomes of acute kidney injury is mixed and dependent on aetiology. Women have a higher prevalence of chronic kidney disease (CKD) stages 3-5 than men, whereas men have a higher prevalence of albuminuria and hence CKD stages 1-2. Men show a faster decline in kidney function, progress more frequently to kidney failure and have higher mortality and risk of cardiovascular disease than women. However, the protective effect of female sex is reduced with CKD progression. Women are less likely than men to be aware of, screened for and diagnosed with CKD, started on antiproteinuric medication and referred to nephrologist care. They also consistently report a poorer health-related quality of life and a higher symptom burden than men. Women experience greater barriers than men to access the waiting list for kidney transplantation, particularly with respect to older age and obesity. However, women also have longer survival than men after transplantation, which may partly explain the comparable prevalence of transplantation between the sexes.
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Affiliation(s)
- Nicholas C Chesnaye
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Manfred Hecking
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Kitty J Jager
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Amsterdam, Netherlands.
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands.
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von Samson-Himmelstjerna FA, Kolbrink B, Kakavand N, Zacharias HU, Schulte K. The German Transplantation Registry Reveals Deficiencies in the Listing Process for Kidney Transplantation. Kidney Int Rep 2023; 8:2701-2708. [PMID: 38106602 PMCID: PMC10719593 DOI: 10.1016/j.ekir.2023.09.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/28/2023] [Accepted: 09/25/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction The time from dialysis onset to enrollment on the kidney waiting list (listing time) is a crucial step on the path to receiving a kidney allograft; however, this process has received very little research attention in the Eurotransplant (ET) area. Methods We retrospectively analyzed data from the German transplantation registry, including patients who were on the waiting list for a first kidney transplant in Germany between 2006 and 2016. Listing time was evaluated using a mixed linear model. The outcomes on the kidney waiting list were assessed using competing risk analyses. Results We assessed a total of 43,955 patients. Listing occurred at a higher pace in patients receiving living donor transplantations (median 0.4 years from dialysis onset) than in deceased donor transplantations (Eurotransplant Kidney Allocation System [ETKAS] 1.1 years, European Senior Program [ESP] 1.4 years, Acceptable Mismatch program 1.3 years), with 28.5% of living donor transplantations performed preemptively. There was only modest variation in listing time between the transplant centers. Patients with a history of viral infection, high immunization; hemodialysis patients; and patients with a higher body mass index (BMI) had a delayed listing process. Two of 3 patients listed in the ETKAS, excluding those with potential bonus points (pediatric, other organ transplantations), were eventually transplanted. Older patients, male patients, patients with blood type O, and patients with diabetic nephropathy as the underlying renal disease had the highest risk not to proceed to transplantation. Conclusion Although long waiting times remain the biggest hurdle for transplantation in Germany, there is ample room for improvement of the listing process.
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Affiliation(s)
| | - Benedikt Kolbrink
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Nassim Kakavand
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Helena U. Zacharias
- Peter L. Reichertz Institute for Medical Informatics of TU Braunschweig and Hannover Medical School, Hannover Medical School, Hannover, Germany
| | - Kevin Schulte
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Kiel, Germany
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McPherson LJ, Di M, Adams AA, Plantinga L, Pastan SO, Patzer RE. Geographic Differences in Racial Disparities in Access to Kidney Transplantation. Kidney Int Rep 2023; 8:2474-2477. [PMID: 38025234 PMCID: PMC10658202 DOI: 10.1016/j.ekir.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 06/17/2023] [Accepted: 08/02/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Laura J. McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Mengyu Di
- Regenstrief Institute, Indianapolis, Indiana, USA
| | - Ayrenne A. Adams
- Department of Medicine, Division of General Internal Medicine and Innovation, New York University Grossman School of Medicine, New York, New York, USA
| | - Laura Plantinga
- Divisions of Rheumatology and Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Stephen O. Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rachel E. Patzer
- Regenstrief Institute, Indianapolis, Indiana, USA
- Department of Surgery, Division of Transplantation, Indiana University School of Medicine, Indianapolis, Indiana, USA
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13
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Buford J, Retzloff S, Wilk AS, McPherson L, Harding JL, Pastan SO, Patzer RE. Race, Age, and Kidney Transplant Waitlisting Among Patients Receiving Incident Dialysis in the United States. Kidney Med 2023; 5:100706. [PMID: 37753250 PMCID: PMC10518364 DOI: 10.1016/j.xkme.2023.100706] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
Rationale & Objective Patients with kidney failure from racial and ethnic minority groups and older patients have reduced access to the transplant waitlist relative to White and younger patients. Although racial disparities in the waitlisting group have declined after the 2014 kidney allocation system change, whether there is intersectionality of race and age in waitlisting access is unknown. Study Design Retrospective cohort study. Setting & Participants 439,455 non-Hispanic White and non-Hispanic Black US adults initiating dialysis between 2015 and 2019 were identified from the United States Renal Data System, and followed through 2020. Exposures Patient race and ethnicity (non-Hispanic White and non-Hispanic Black) and age group (18-29, 30-49, 50-64, and 65-80 years). Outcomes Placement on the United Network for Organ Sharing deceased donor waitlist. Analytical Approach Age- and race-stratified waitlisting rates were compared. Multivariable Cox proportional hazards models, censored for death, examined the association between race and waitlisting, and included interaction term for race and age. Results Over a median follow-up period of 1 year, the proportion of non-Hispanic White and non-Hispanic Black patients waitlisted was 20.7% and 20.5%, respectively. In multivariable models, non-Hispanic Black patients were 14% less likely to be waitlisted (aHR, 0.86, 95% CI, 0.77-0.95). Relative differences between non-Hispanic Black and non-Hispanic White patients were different by age group. Non-Hispanic Black patients were 27%, 12%, and 20% less likely to be waitlisted than non-Hispanic White patients for ages 18-29 years (aHR, 0.73; 95% CI, 0.61-0.86), 50-64 (aHR, 0.88; 95% CI, 0.80-0.98), and 65-80 years (aHR, 0.80; 95% CI, 0.71-0.90), respectively, but differences were attenuated among patients aged 30-49 years (aHR, 0.89; 95% CI, 0.77-1.02). Limitations Race and ethnicity data is physician reported, residual confounding, and analysis is limited to non-Hispanic White and non-Hispanic Black patients. Conclusions Racial disparities in waitlisting exist between non-Hispanic Black and non-Hispanic White individuals and are most pronounced among younger patients with kidney failure. Results suggest that interventions to address inequalities in waitlisting may need to be targeted to younger patients with kidney failure. Plain-Language Summary Research has shown that patients from racial and ethnic minority groups and older patients have reduced access to transplant waitlisting relative to White and younger patients; nevertheless, how age impacts racial disparities in waitlisting is unknown. We compared waitlisting between non-Hispanic Black and non-Hispanic White patients with incident kidney failure, within age strata, using registry data for 439,455 US adults starting dialysis (18-80 years) during 2015-2019. Overall, non-Hispanic Black patients were less likely to be waitlisted and relative differences between the two racial groups differed by age. After adjusting for patient-level factors, the largest disparity in waitlisting was observed among adults aged 18-29 years. These results suggest that interventions should target younger adults to reduce disparities in access to kidney transplant waitlisting.
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Affiliation(s)
- Jade Buford
- Regenstrief Institute, Indianapolis, Indiana
| | - Samantha Retzloff
- HIV Surveillance Branch (HSB), Division of HIV Prevention (DHP), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adam S. Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Laura McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Jessica L. Harding
- Department of Epidemiology, Rollins School of Public Health, Emory University, Emory University, Emory University School of Medicine, Atlanta, Georgia
- Division of Transplantation, Department of Surgery, Emory University, Emory University School of Medicine, Atlanta, Georgia
- Health Services Research Center, Emory University School of Medicine, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Stephen O. Pastan
- Department of Medicine, Renal Division, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E. Patzer
- Regenstrief Institute, Indianapolis, Indiana
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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14
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Thongprayoon C, Tangpanithandee S, Jadlowiec CC, Mao SA, Mao MA, Vaitla P, Acharya PC, Leeaphorn N, Kaewput W, Pattharanitima P, Suppadungsuk S, Krisanapan P, Nissaisorakarn P, Cooper M, Craici IM, Cheungpasitporn W. Characteristics of Kidney Transplant Recipients with Prolonged Pre-Transplant Dialysis Duration as Identified by Machine Learning Consensus Clustering: Pathway to Personalized Care. J Pers Med 2023; 13:1273. [PMID: 37623523 PMCID: PMC10455164 DOI: 10.3390/jpm13081273] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 08/26/2023] Open
Abstract
Longer pre-transplant dialysis duration is known to be associated with worse post-transplant outcomes. Our study aimed to cluster kidney transplant recipients with prolonged dialysis duration before transplant using an unsupervised machine learning approach to better assess heterogeneity within this cohort. We performed consensus cluster analysis based on recipient-, donor-, and transplant-related characteristics in 5092 kidney transplant recipients who had been on dialysis ≥ 10 years prior to transplant in the OPTN/UNOS database from 2010 to 2019. We characterized each assigned cluster and compared the posttransplant outcomes. Overall, the majority of patients with ≥10 years of dialysis duration were black (52%) or Hispanic (25%), with only a small number (17.6%) being moderately sensitized. Within this cohort, three clinically distinct clusters were identified. Cluster 1 patients were younger, non-diabetic and non-sensitized, had a lower body mass index (BMI) and received a kidney transplant from younger donors. Cluster 2 recipients were older, unsensitized and had a higher BMI; they received kidney transplant from older donors. Cluster 3 recipients were more likely to be female with a higher PRA. Compared to cluster 1, cluster 2 had lower 5-year death-censored graft (HR 1.40; 95% CI 1.16-1.71) and patient survival (HR 2.98; 95% CI 2.43-3.68). Clusters 1 and 3 had comparable death-censored graft and patient survival. Unsupervised machine learning was used to characterize kidney transplant recipients with prolonged pre-transplant dialysis into three clinically distinct clusters with variable but good post-transplant outcomes. Despite a dialysis duration ≥ 10 years, excellent outcomes were observed in most recipients, including those with moderate sensitization. A disproportionate number of minority recipients were observed within this cohort, suggesting multifactorial delays in accessing kidney transplantation.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (S.S.); (P.K.); (I.M.C.); (W.C.)
| | - Supawit Tangpanithandee
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (S.S.); (P.K.); (I.M.C.); (W.C.)
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10540, Thailand
| | - Caroline C. Jadlowiec
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Shennen A. Mao
- Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ 85054, USA;
| | - Michael A. Mao
- Division of Transplant Surgery, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Pradeep Vaitla
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Prakrati C. Acharya
- Division of Nephrology, Texas Tech Health Sciences Center El Paso, El Paso, TX 79905, USA;
| | - Napat Leeaphorn
- Renal Transplant Program, University of Missouri-Kansas City School of Medicine/Saint Luke’s Health System, Kansas City, MO 64108, USA;
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand;
| | - Pattharawin Pattharanitima
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine Thammasat University, Pathum Thani 12120, Thailand;
| | - Supawadee Suppadungsuk
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (S.S.); (P.K.); (I.M.C.); (W.C.)
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10540, Thailand
| | - Pajaree Krisanapan
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (S.S.); (P.K.); (I.M.C.); (W.C.)
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine Thammasat University, Pathum Thani 12120, Thailand;
- Division of Nephrology, Department of Internal Medicine, Thammasat University Hospital, Pathum Thani 12120, Thailand
| | - Pitchaphon Nissaisorakarn
- Deparment of Medicine, Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA;
| | - Matthew Cooper
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA;
| | - Iasmina M. Craici
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (S.S.); (P.K.); (I.M.C.); (W.C.)
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (S.S.); (P.K.); (I.M.C.); (W.C.)
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15
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Longley RM, Harnedy LE, Ghanime PM, Arroyo-Ariza D, Deary EC, Daskalakis E, Sadang KG, West J, Huffman JC, Celano CM, Amonoo HL. Peer support interventions in patients with kidney failure: A systematic review. J Psychosom Res 2023; 171:111379. [PMID: 37270909 PMCID: PMC10340538 DOI: 10.1016/j.jpsychores.2023.111379] [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: 03/10/2023] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Peer support has been associated with improved health-related outcomes (e.g., psychological well-being and treatment adherence) among patients with serious, chronic conditions, including kidney disease. Yet, there is little existing research evaluating the effects of peer support programs on health outcomes among patients with kidney failure being treated with kidney replacement therapy. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we conducted a systematic review using five databases to assess the effects of peer support programs on health-related outcomes (e.g., physical symptoms, depression) among patients with kidney failure undergoing kidney replacement therapy. RESULTS Peer support in kidney failure was assessed across 12 studies (eight randomized controlled trials, one quasi-experimental controlled trial, and three single-arm trials) with 2893 patients. Three studies highlighted the links between peer support and improved patient engagement with care, while one found peer support did not significantly impact engagement. Three studies showed associations between peer support and improvements in psychological well-being. Four studies underscored the effects of peer support on self-efficacy and one on treatment adherence. CONCLUSIONS Despite preliminary evidence of the positive associations between peer support and health-related outcomes among patients with kidney failure, peer support programs for this patient population remain poorly understood and underutilized. Further rigorous prospective and randomized studies are needed to evaluate how peer support can be optimized and incorporated into clinical care for this vulnerable patient population.
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Affiliation(s)
- Regina M Longley
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Lauren E Harnedy
- Massachusetts General Hospital, Department of Psychiatry, Boston, MA, United States of America
| | - Pia Maria Ghanime
- Massachusetts General Hospital, Department of Psychiatry, Boston, MA, United States of America
| | - Daniel Arroyo-Ariza
- Massachusetts General Hospital, Department of Psychiatry, Boston, MA, United States of America
| | - Emma C Deary
- Brigham and Women's Hospital, Department of Psychiatry, Boston, MA, United States of America
| | - Elizabeth Daskalakis
- Brigham and Women's Hospital, Department of Psychiatry, Boston, MA, United States of America
| | - Katrina G Sadang
- University of California San Francisco School of Medicine, San Francisco, CA, United States of America
| | - Jason West
- Brigham and Women's Hospital, Department of Psychiatry, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Jeff C Huffman
- Massachusetts General Hospital, Department of Psychiatry, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Christopher M Celano
- Massachusetts General Hospital, Department of Psychiatry, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Hermioni L Amonoo
- Brigham and Women's Hospital, Department of Psychiatry, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care, Boston, MA, United States of America.
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16
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Cron DC, Tsai TC, Patzer RE, Husain SA, Xiang L, Adler JT. The Association of Dialysis Facility Payer Mix With Access to Kidney Transplantation. JAMA Netw Open 2023; 6:e2322803. [PMID: 37432684 PMCID: PMC10336615 DOI: 10.1001/jamanetworkopen.2023.22803] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/25/2023] [Indexed: 07/12/2023] Open
Abstract
Importance Insurance coverage for patients with end-stage kidney disease has shifted toward more commercially insured patients at dialysis facilities. The associations among insurance status, facility-level payer mix, and access to kidney transplantation are unclear. Objective To determine the association of dialysis facility commercial payer mix and 1-year incidence of wait-listing for kidney transplantation, and to delineate the association of commercial insurance at the patient vs facility level. Design, Setting, and Participants This retrospective population-based cohort study used data from the United States Renal Data System from 2013 to 2018. Participants included patients aged 18 to 75 years initiating chronic dialysis between 2013 and 2017, excluding patients with a prior kidney transplant or with major contraindications to kidney transplant. Data were analyzed from August 2021 and May 2023. Exposure Dialysis facility commercial payer mix, calculated as the proportion of patients with commercial insurance per facility. Main Outcomes and Measures The primary outcome was patients added to a waiting list for kidney transplant within 1 year of dialysis initiation. Multivariable Cox regression, censoring for death, was used to adjust for patient-level (demographic, socioeconomic, and medical) and facility-level factors. Results A total of 233 003 patients (97 617 [41.9%] female patients; mean [SD] age, 58.0 [12.1] years) across 6565 facilities met inclusion criteria. Participants included 70 062 Black patients (30.1%), 42 820 Hispanic patients (18.4%), 105 368 White patients (45.2%), and 14 753 patients (6.3%) who identified as another race or ethnicity (eg, American Indian or Alaskan Native, Asian, Native Hawaiian or Pacific Islander, and multiracial). Of 6565 dialysis facilities, the mean (SD) commercial payer mix was 21.2% (15.6 percentage points). Patient-level commercial insurance was associated with increased incidence of wait-listing (adjusted hazard ratio [aHR], 1.86; 95% CI, 1.80-1.93; P < .001). At the facility-level and before covariate adjustment, higher commercial payer mix was associated with increased wait-listing (fourth vs first payer mix quartile [Q]: HR, 1.79; 95% CI, 1.67-1.91; P < .001). However, after covariate-adjustment, including adjusting for patient-level insurance status, commercial payer mix was not significantly associated with outcome (Q4 vs Q1: aHR, 1.02; 95% CI, 0.95-1.09; P = .60). Conclusions and Relevance In this national cohort study of patients newly initiated on chronic dialysis, although patient-level commercial insurance was associated with higher access to the kidney transplant waiting lists, there was no independent association of facility-level commercial payer mix with patients being added to waiting lists for transplant. As the landscape of insurance coverage for dialysis evolves, the potential downstream impact on access to kidney transplant should be monitored.
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Affiliation(s)
- David C. Cron
- Department of Surgery, Massachusetts General Hospital, Boston
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Thomas C. Tsai
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Rachel E. Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Medicine, Emory Medical School, Atlanta, Georgia
| | - Syed A. Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology Group, New York, New York
| | - Lingwei Xiang
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Joel T. Adler
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Transplantation, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin
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17
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Fritz K, Hong J, Basdeo D, Byrnes K, Cordoba A, Dunn K, Haider U, Kashif M, Lee N, Mohamed Nuhuman AS, Santos R, Jacobs RJ. United Network for Organ Sharing (UNOS) Database Analysis of Factors Associated With Kidney Transplant Time on Waiting List. Cureus 2023; 15:e34679. [PMID: 36909033 PMCID: PMC9997046 DOI: 10.7759/cureus.34679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 02/06/2023] [Indexed: 02/09/2023] Open
Abstract
INTRODUCTION In the United States (U.S.), African Americans and other minority groups have longer wait times for kidney transplantation than Caucasians. To date, many studies analyzing time spent on the waitlist for each race/ethnicity have been done. However, there are few to no studies examining waitlist time after the 2019 policy changes to the geographic distribution of donated kidneys. METHODS Data collected from the National Organ Procurement and Transplantation Network database were used to analyze associations between race and time spent on the waitlist for a kidney transplant in the U.S. Additional sub-categorical data were analyzed to determine further associations and potential covariates, such as gender, age, citizenship, primary source of payment, region of transplant center, BMI, Kidney Donor Profile Index (KDPI), renal diagnosis, and presence/type of diabetes. Data were analyzed using odds ratios and validated by Bonferroni-Holm's corrected chi-square tests at confidence intervals of 95% to determine if there are statistically significant differences between transplant time spent on the waitlist and ethnicity, as well as age, diagnosis category, region of transplant center, and KDPI. RESULTS Statistically significant increased odds of remaining on the transplant list at two years existed for all non-white races/ethnicities, except those identifying as multiracial. Asian American candidates had the greatest odds of remaining on the waitlist greater than two years in comparison to white candidates: 1.51 times that of a patient categorized as white (odds ratio [OR] 1.51, confidence interval [CI] 1.44-1.57). African American/Black, (OR 1.38, CI 1.34-1.43) Pacific Islander (OR 1.38, CI 1.17-1.63), Hispanic candidates (OR 1.37, CI 1.32-1.41), and American Indian or Native Alaskan candidates (OR 1.23, CI 1.12-1.46) also had increased odds of remaining on the transplant waitlist greater than two years compared to white candidates. DISCUSSION In this study, ethnic disparities persisted as a barrier for non-white individuals receiving treatment for end-stage kidney disease, specifically in the context of time spent on the waitlist for a kidney transplant. Further research is needed regarding the causes of these disparities in time spent on the waitlist, such as cultural restrictions in organ donation, racial differences in parameters for organ match, and institutionalized racism in health care practitioners.
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Affiliation(s)
- Kristina Fritz
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Jennifer Hong
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Devina Basdeo
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Kimberly Byrnes
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Andres Cordoba
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Kylie Dunn
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Umbul Haider
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Mareena Kashif
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Nick Lee
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | | | | | - Robin J Jacobs
- Epidemiology and Public Health, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
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18
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How COVID-19 Outbreak Influenced Transplantation in Poland. J Clin Med 2023; 12:jcm12020461. [PMID: 36675390 PMCID: PMC9864929 DOI: 10.3390/jcm12020461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 12/22/2022] [Accepted: 01/04/2023] [Indexed: 01/09/2023] Open
Abstract
Announced by the World Health Organization in early 2020, the pandemic caused by SARS-CoV-2 infections has had a huge impact on healthcare systems around the world. Local and international authorities focused on implementing procedures to safeguard the health of the population. All regular daily activities were disrupted. Similar factors related to the global fight against the COVID-19 epidemic also had a large impact on transplantation activity. In this article, the authors present the number of patients qualified for transplantation, transplanted and waiting on the waiting list in Poland during the 2-year period of the pandemic. In the first year of the epidemic (2020), all transplantation figures dropped drastically, by as much as 20-30% compared with 2019. The most disturbing fact is that the number of transplants performed in 2022 is still lower than before the outbreak of the epidemic (2019 and earlier).
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19
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Paris L, Calvar E, Morello R, Lecouf A, Beaumier M, Lobbedez T, Châtelet V. Perception of social inequities in the access to the kidney transplant waiting list by nephrology trainees: a national survey. BMC Nephrol 2022; 23:394. [PMID: 36482319 PMCID: PMC9733200 DOI: 10.1186/s12882-022-03017-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Social inequalities in health are responsible for disparities in access to the kidney transplant waiting list (KTWL). The perception of disparities by nephrologists has consequences for the registration on the KTWL. The purposes of our study were to assess the perception of the factors implicated in the disparities in access to the KTWL by nephrology trainees and to assess the quality of the questionnaire. METHODS A questionnaire was developed to assess the perception of the determinants of the inequities in access to waitlisting. Continuous variables were described by median, 1st and 3rd quartiles. Categorical variables were described by frequencies and percentages. A principal component analysis and a hierarchical cluster analysis were performed to approach the correlation between the variables. A scree plot and a factor analysis were performed to determine the dimensions of the questionnaire. The internal consistency was estimated by Cronbach's coefficient. RESULTS The response rate was 98/110 (89%). The determinants of inequities in the access to KTWL not perceived by the nephrology trainees were "female sex", "income level" and "the centre provision to adapt the information to all of the patients" (18,3%, 36,7, 47% respectively). "Age", "being born abroad", "place of living", "education level", "transplant centre", "the health care provider" were determinants of disparities perceived by most of the trainees (85,7%, 75,5%, 82,6%, 78,6%, 73,5% et 78,5% respectively). Items related to the transplant centre were positively correlated, as well as "being born abroad", "education level" and "income level". The Cronbach's coefficient was 0,60. CONCLUSION Social inequalities in health are partially perceived by nephrology trainees. A teaching session could raise nephrologists' awareness of this issue and could help reduce the impact of these disparities on the course of ESKD (end-stage kidney disease) patients.
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Affiliation(s)
- Lucile Paris
- grid.411149.80000 0004 0472 0160Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la Côte de Nacre, 14 033 Caen Cedex 9, France ,Normandie Université, Unicaen, UFR de Médecine, 2 rue des Rochambelles, 14032 Caen Cedex, France
| | - Eve Calvar
- grid.411149.80000 0004 0472 0160Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la Côte de Nacre, 14 033 Caen Cedex 9, France ,Normandie Université, Unicaen, UFR de Médecine, 2 rue des Rochambelles, 14032 Caen Cedex, France ,U1086 INSERM – ANTICIPE – Centre Régional de Lutte Contre le Cancer, François Baclesse, Caen, France
| | - Rémy Morello
- grid.411149.80000 0004 0472 0160Plateforme de Méthodologie, CHU de Caen, Avenue de la Côte de Nacre, Niveau 3, CS 30001, 14033 Caen Cedex 9, France
| | - Angélique Lecouf
- grid.411149.80000 0004 0472 0160Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la Côte de Nacre, 14 033 Caen Cedex 9, France
| | - Mathilde Beaumier
- grid.411149.80000 0004 0472 0160Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la Côte de Nacre, 14 033 Caen Cedex 9, France ,Normandie Université, Unicaen, UFR de Médecine, 2 rue des Rochambelles, 14032 Caen Cedex, France ,U1086 INSERM – ANTICIPE – Centre Régional de Lutte Contre le Cancer, François Baclesse, Caen, France
| | - Thierry Lobbedez
- grid.411149.80000 0004 0472 0160Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la Côte de Nacre, 14 033 Caen Cedex 9, France ,Normandie Université, Unicaen, UFR de Médecine, 2 rue des Rochambelles, 14032 Caen Cedex, France ,U1086 INSERM – ANTICIPE – Centre Régional de Lutte Contre le Cancer, François Baclesse, Caen, France
| | - Valérie Châtelet
- grid.411149.80000 0004 0472 0160Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la Côte de Nacre, 14 033 Caen Cedex 9, France ,Normandie Université, Unicaen, UFR de Médecine, 2 rue des Rochambelles, 14032 Caen Cedex, France ,U1086 INSERM – ANTICIPE – Centre Régional de Lutte Contre le Cancer, François Baclesse, Caen, France
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20
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Johnson WR, Rega SA, Feurer ID, Karp SJ. Associations between social determinants of health and abdominal solid organ transplant wait-lists in the United States. Clin Transplant 2022; 36:e14784. [PMID: 35894259 DOI: 10.1111/ctr.14784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 07/07/2022] [Accepted: 07/17/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Societal factors that influence wait-listing for transplantation are complex and poorly understood. Social determinants of health (SDOH) affect rates of and outcomes after transplantation. METHODS This cross-sectional study investigated the impact of SDOH on additions to state-level, 2017-2018 kidney and liver wait-lists. Principal components analysis, starting with 127 variables among 3142 counties, was used to derive novel, comprehensive state-level composites, designated (1) health/economics and (2) community capital/urbanicity. Stepwise multivariate linear regression with backwards elimination (n = 51; 50 states and DC) tested the effects of these composites, Medicaid expansion, and center density on adult disease burden-adjusted wait-list additions. RESULTS SDOH related to increased community capital/urbanicity were independently associated with wait-listing (starting models: B = .40, P = .010 Kidney; B = .36, P = .038 Liver) (final models: B = .31, P = .027 Kidney, B = .34, P = .015 Liver). In contrast and surprisingly, no other covariates were associated with wait-listing (P ≥ .122). CONCLUSIONS These results suggest that deficits in community resources are important contributors to disparities in wait-list access. Our composite SDOH metrics may help identify at-risk communities, which can be the focus of local and national policy initiatives to improve access to organ transplantation.
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Affiliation(s)
- Wali R Johnson
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott A Rega
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Irene D Feurer
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Seth J Karp
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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21
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Chan NW, Moya-Mendez M, Henson JB, Zaribafzadeh H, Sendak MP, Bhavsar NA, Balu S, Kirk AD, McElroy LM. Social determinants of health data in solid organ transplantation: National data sources and future directions. Am J Transplant 2022; 22:2293-2301. [PMID: 35583111 PMCID: PMC9547872 DOI: 10.1111/ajt.17096] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/04/2022] [Accepted: 05/15/2022] [Indexed: 01/25/2023]
Abstract
Health equity research in transplantation has largely relied on national data sources, yet the availability of social determinants of health (SDOH) data varies widely among these sources. We sought to characterize the extent to which national data sources contain SDOH data applicable to end-stage organ disease (ESOD) and transplant patients. We reviewed 10 active national data sources based in the United States. For each data source, we examined patient inclusion criteria and explored strengths and limitations regarding SDOH data, using the National Institutes of Health PhenX toolkit of SDOH as a data collection instrument. Of the 28 SDOH variables reviewed, eight-core demographic variables were included in ≥80% of the data sources, and seven variables that described elements of social status ranged between 30 and 60% inclusion. Variables regarding identity, healthcare access, and social need were poorly represented (≤20%) across the data sources, and five of these variables were included in none of the data sources. The results of our review highlight the need for improved SDOH data collection systems in ESOD and transplant patients via: enhanced inter-registry collaboration, incorporation of standardized SDOH variables into existing data sources, and transplant center and consortium-based investigation and innovation.
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Affiliation(s)
- Norine W. Chan
- Duke University School of Medicine, Durham, North Carolina, USA,Duke Institute for Health Innovation, Durham, North Carolina, United States
| | | | - Jacqueline B. Henson
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Hamed Zaribafzadeh
- Duke Institute for Health Innovation, Durham, North Carolina, United States
| | - Mark P. Sendak
- Duke Institute for Health Innovation, Durham, North Carolina, United States
| | - Nrupen A. Bhavsar
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA,Department of Biostatistics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Suresh Balu
- Duke Institute for Health Innovation, Durham, North Carolina, United States
| | - Allan D. Kirk
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lisa M. McElroy
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA,Department of Population Health Sciences Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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22
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Impact of CYP3A5 Status on the Clinical and Financial Outcomes Among African American Kidney Transplant Recipients. Transplant Direct 2022; 8:e1379. [PMID: 36204191 PMCID: PMC9529042 DOI: 10.1097/txd.0000000000001379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/06/2022] Open
Abstract
Pharmacogenetic profiling of transplant recipients demonstrates that the marked variation in the metabolism of immunosuppressive medications, particularly tacrolimus, is related to genetic variants. Patients of African ancestry are less likely to carry loss-of-function (LoF) variants in the CYP3A5 gene and therefore retain a rapid metabolism phenotype and higher clearance of tacrolimus. Patients with this rapid metabolism typically require higher dosing to achieve therapeutic trough concentrations. This study aims to further characterize the impact of CYP3A5 genotype on clinical outcomes and financial expenditure.
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23
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Patzer RE, Adler JT, Harding JL, Huml A, Kim I, Ladin K, Martins PN, Mohan S, Ross-Driscoll K, Pastan SO. A Population Health Approach to Transplant Access: Challenging the Status Quo. Am J Kidney Dis 2022; 80:406-415. [PMID: 35227824 DOI: 10.1053/j.ajkd.2022.01.422] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/09/2022] [Indexed: 01/27/2023]
Abstract
Transplant referral and evaluation are critical steps to waitlisting yet remain an elusive part of the transplant process. Despite calls for more data collection on pre-waitlisting steps, there are currently no national surveillance data to aid in understanding the causes and potential solutions for the extreme variation in access to transplantation. As population health scientists, epidemiologists, clinicians, and ethicists we submit that the transplant community has an obligation to better understand disparities in transplant access as a first necessary step to effectively mitigating these inequities. Our position is grounded in a population health approach, consistent with several new overarching national policy and quality initiatives. The purpose of this Perspective is to (1) provide an overview of how a population health approach should inform current multisystem policies impacting kidney transplantation and demonstrate how these efforts could be enhanced with national data collection on pre-waitlisting steps; (2) demonstrate the feasibility and concrete next steps for pre-waitlisting data collection; and (3) identify potential opportunities to use these data to implement effective population-level interventions, policies, and quality measures to improve equity in access to kidney transplantation.
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Affiliation(s)
- Rachel E Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
| | - Joel T Adler
- Department of Surgery, Division of Organ Transplantation, University of Massachusetts, Worcester, Massachusetts; Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jessica L Harding
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Anne Huml
- Case Center for Reducing Health Disparities, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Irene Kim
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Keren Ladin
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts; Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, Massachusetts
| | - Paulo N Martins
- Department of Surgery, Division of Organ Transplantation, University of Massachusetts, Worcester, Massachusetts
| | - Sumit Mohan
- Departments of Medicine and Epidemiology, Columbia University, New York, New York
| | - Katie Ross-Driscoll
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Stephen O Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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24
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Schappe T, Peskoe S, Bhavsar N, Boulware LE, Pendergast J, McElroy LM. Geospatial Analysis of Organ Transplant Referral Regions. JAMA Netw Open 2022; 5:e2231863. [PMID: 36107423 PMCID: PMC9478781 DOI: 10.1001/jamanetworkopen.2022.31863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
IMPORTANCE System and center-level interventions to improve health equity in organ transplantation benefit from robust characterization of the referral population served by each transplant center. Transplant referral regions (TRRs) define geographic catchment areas for transplant centers in the US, but accurately characterizing the demographics of populations within TRRs using US Census data poses a challenge. OBJECTIVE To compare 2 methods of linking US Census data with TRRs-a geospatial intersection method and a zip code cross-reference method. DESIGN, SETTING, AND PARTICIPANTS This cohort study compared spatial congruence of spatial intersection and zip code cross-reference methods of characterizing TRRs at the census block level. Data included adults aged 18 years and older on the waiting list for kidney transplant from 2008 through 2018. EXPOSURES End-stage kidney disease. MAIN OUTCOMES AND MEASURES Multiple assignments, where a census tract or block group crossed the boundary between 2 hospital referral regions and was assigned to multiple different TRRs; misassigned area, the portion of census tracts or block groups assigned to a TRR using either method but fall outside of the TRR boundary. RESULTS In total, 102 TRRs were defined for 238 transplant centers. The zip code cross-reference method resulted in 4627 multiple-assigned census block groups (representing 18% of US land area assigned to TRRs), while the spatial intersection method eliminated this problem. Furthermore, the spatial method resulted in a mean and median reduction in misassigned area of 65% and 83% across all TRRs, respectively, compared with the zip code cross-reference method. CONCLUSIONS AND RELEVANCE In this study, characterizing populations within TRRs with census block groups provided high spatial resolution, complete coverage of the country, and balanced population counts. A spatial intersection approach avoided errors due to duplicative and incorrect assignments, and allowed more detailed and accurate characterization of the sociodemographics of populations within TRRs; this approach can enrich transplant center knowledge of local referral populations, assist researchers in understanding how social determinants of health may factor into access to transplant, and inform interventions to improve heath equity.
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Affiliation(s)
- Tyler Schappe
- Duke University, School of Medicine, Durham, North Carolina
| | - Sarah Peskoe
- Duke University, School of Medicine, Durham, North Carolina
| | - Nrupen Bhavsar
- Duke University, School of Medicine, Durham, North Carolina
| | | | | | - Lisa M McElroy
- Duke University, School of Medicine, Durham, North Carolina
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25
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Kadatz M, Lan JH, Brar S, Vaishnav S, Chang DT, Gill J, Gill JS. Transplantation of Patients With Long Dialysis Vintage in the Current Deceased Donor Kidney Allocation System (KAS). Am J Kidney Dis 2022; 80:319-329.e1. [PMID: 35311661 DOI: 10.1053/j.ajkd.2022.01.429] [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: 06/22/2021] [Accepted: 01/14/2022] [Indexed: 01/27/2023]
Abstract
RATIONALE & OBJECTIVE In 2014 the wait-time calculation for deceased donor kidney transplantation in the United States was changed from the date of first waitlisting to the date of first maintenance dialysis treatment with the aim of minimizing disparities in access to transplantation. This study examined the impact of this policy on access to transplantation, patient survival, and transplant outcomes among patients treated with maintenance dialysis for a prolonged duration before waitlisting. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Patients identified in the US Renal Data System between 2008 and 2018 aged 18-70 years and in the 95th percentile of dialysis treatment duration (≥6.5 years) before waitlisting. EXPOSURE Waitlisting for transplantation before versus after implementation of the policy. OUTCOME Time from date of waitlisting to deceased donor transplantation and death, and from date of transplantation to all cause graft loss. ANALYTICAL APPROACH Univariate and multivariable time to event analyses. RESULTS Patients waitlisted after the policy change had a higher likelihood of deceased donor transplantation (HR, 3.12 [95% CI, 2.90-3.37]) and lower risk of death (HR, 0.74 [95% CI, 0.63-0.87]). The risk of graft loss was lower in the post-kidney allocation system (KAS) cohort (HR, 0.66 [95% CI, 0.55-0.80]). The proportion of adult patients treated with dialysis ≥6.5 years who were never waitlisted for transplantation remained high (73%) and did not decrease after the policy implementation. LIMITATIONS Cannot determine causality in this observational study. CONCLUSIONS The policy change was associated with an increase in deceased donor transplantation and marked improvement in patient survival for patients waitlisted after long periods of dialysis treatment without decreasing the utility of available deceased donor kidney supply. The policy was not associated with increased waitlisting of this disadvantaged population.
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Affiliation(s)
- Matthew Kadatz
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - James H Lan
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, British Columbia, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Sandeep Brar
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, British Columbia, Canada; Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California
| | - Sakshi Vaishnav
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, British Columbia, Canada
| | - Doris T Chang
- Providence Health Research Institute, Vancouver, British Columbia, Canada
| | - Jagbir Gill
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, British Columbia, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada; School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada; Providence Health Research Institute, Vancouver, British Columbia, Canada; Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada
| | - John S Gill
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, British Columbia, Canada; Providence Health Research Institute, Vancouver, British Columbia, Canada; Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada; Tufts Medical Center, Boston, Massachusetts.
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26
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Wilk AS, Drewry KM, Zhang R, Pastan SO, Thorsness R, Trivedi AN, Patzer RE. Treatment Patterns and Characteristics of Dialysis Facilities Randomly Assigned to the Medicare End-Stage Renal Disease Treatment Choices Model. JAMA Netw Open 2022; 5:e2225516. [PMID: 35930284 PMCID: PMC9356315 DOI: 10.1001/jamanetworkopen.2022.25516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
IMPORTANCE In 2021, Medicare launched the End-Stage Renal Disease Treatment Choices (ETC) model, which randomly assigned approximately 30% of dialysis facilities to new financial incentives to increase use of transplantation and home dialysis; these financial bonuses and penalties are calculated by comparing living-donor transplantation, transplant wait-listing, and home dialysis use in ETC-assigned facilities vs benchmarks from non-ETC-assigned (ie, control) facilities. Because model participation is randomly assigned, evaluators may attribute any downstream differences in outcomes to facility performance rather than any imbalance in baseline characteristics. OBJECTIVE To identify preintervention imbalances in dialysis facility characteristics that should be recognized in any ETC model evaluations. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study compared ETC-assigned and control dialysis facility characteristics in the United States from 2017 to 2018. A total of 6062 facilities were included. Data were analyzed from February 2021 to May 2022. EXPOSURES Assignment to the ETC model. MAIN OUTCOMES AND MEASURES Dialysis facilities' preintervention transplantations and home dialysis use, facility characteristics (notably, profit and chain status), patient demographic characteristics, and community socioeconomic characteristics. RESULTS Among 316 927 patients, with 6 178 855 attributed patient-months, the mean (SD) age in January 2017 was 59 (11) years, and 132 462 (42%) were female. Patients in ETC-assigned facilities had 9% (0.2 [95% CI, 0.1-0.2] percentage points) lower prevalence of living donor transplantation, 12% (3.2 [95% CI, 3.0-3.3] percentage points) lower prevalence of transplantation wait-listing, and 4% (0.4 [95% CI, 0.3-0.4] percentage points) lower prevalence of peritoneal dialysis use compared with control facilities. ETC-assigned facilities were 14% (5.1 [95% CI, 0.9-9.4] percentage points) more likely than control facilities to be owned by the second largest dialysis organization. Relative to control facilities, ETC-assigned facilities also treated 34% (6.6 [95% CI, 6.5-6.7] percentage point) fewer patients with Hispanic ethnicity and were located in communities with median household incomes that were 4% ($2500; 95% CI, $500-$4500) lower on average. CONCLUSIONS AND RELEVANCE In this study, dialysis facilities in ETC-assigned regions had lower preintervention prevalence of transplantation wait-listing, living donor transplantation, and peritoneal dialysis use, relative to control facilities. ETC-assigned and control facilities also differed with respect to other facility, patient, and community characteristics. Evaluators should account for these preintervention imbalances to minimize bias in their inferences about the model's association with postintervention outcomes.
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Affiliation(s)
- Adam S. Wilk
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kelsey M. Drewry
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | - Rebecca Zhang
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Stephen O. Pastan
- Emory University School of Medicine, Atlanta, Georgia
- Emory Transplant Center, Atlanta, Georgia
| | - Rebecca Thorsness
- Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| | - Amal N. Trivedi
- Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| | - Rachel E. Patzer
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
- Emory Transplant Center, Atlanta, Georgia
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27
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Sateesh J, Guha K, Dutta A, Sengupta P, Yalamanchili D, Donepudi NS, Surya Manoj M, Sohail SS. A comprehensive review on advancements in tissue engineering and microfluidics toward kidney-on-chip. BIOMICROFLUIDICS 2022; 16:041501. [PMID: 35992641 PMCID: PMC9385224 DOI: 10.1063/5.0087852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 07/19/2022] [Indexed: 06/15/2023]
Abstract
This review provides a detailed literature survey on microfluidics and its road map toward kidney-on-chip technology. The whole review has been tailored with a clear description of crucial milestones in regenerative medicine, such as bioengineering, tissue engineering, microfluidics, microfluidic applications in biomedical engineering, capabilities of microfluidics in biomimetics, organ-on-chip, kidney-on-chip for disease modeling, drug toxicity, and implantable devices. This paper also presents future scope for research in the bio-microfluidics domain and biomimetics domain.
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Affiliation(s)
| | - Koushik Guha
- Department of Electronics and Communication Engineering, National MEMS Design Centre, National Institute of Technology Silchar, Assam 788010, India
| | - Arindam Dutta
- Urologist, RG Stone Urology and Laparoscopic Hospital, Kolkata, West Bengal, India
| | | | | | - Nanda Sai Donepudi
- Medical Interns, Government Siddhartha Medical College, Vijayawada, India
| | - M. Surya Manoj
- Department of Electronics and Communication Engineering, National MEMS Design Centre, National Institute of Technology Silchar, Assam 788010, India
| | - Sk. Shahrukh Sohail
- Department of Electronics and Communication Engineering, National MEMS Design Centre, National Institute of Technology Silchar, Assam 788010, India
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28
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Wong D, Adjei-Bosompem T, Maxwell L, Melendez-Suarez J, Smith B, Boutin-Foster C. Factors influencing decision making for kidney transplantation among Black and Latino patients on dialysis: A qualitative study applying the social ecological model. Chronic Illn 2022; 18:286-294. [PMID: 32972238 DOI: 10.1177/1742395320959411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This qualitative study explored factors that may influence decisions regarding kidney transplantation among African-American and Latino adults on dialysis. METHODS Qualitative interviews were audio-recorded and transcribed. Open-coding techniques were used to identify concepts, categories, and themes. The Social Ecological Model (SEM) was used to organize themes and identify potential solutions across multiple levels (individual, interpersonal, community, and policy/health system). RESULTS Thirty-six patients were interviewed. Their mean age was 53 SD 12 years; 50% were female; and their duration on dialysis was 4.9 SD 6 years. Five themes emerged and were organized according to the levels of the SEM: 1) Fear about the outcomes of transplantation and 2) faith in God (individual level); 3) Family dynamics and reluctance to involve family in the decision making process (interpersonal level); 4) The experiences of friends and social networks (community level); and 5) Concerns about the social and economic impact of transplantation (policy and health system). DISCUSSION The application of a Social Ecological model in this study helped to illuminate the complex and multilevel factors that may influence the decisions for kidney transplantation. Future studies are needed to further explore how family members, social networks, faith communities, and policies/health systems influence the decision making process.
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Affiliation(s)
- Diandra Wong
- SUNY Downstate Health Sciences University, State University of New York, Brooklyn, USA
| | - Tina Adjei-Bosompem
- SUNY Downstate Health Sciences University, State University of New York, Brooklyn, USA
| | - Lakia Maxwell
- SUNY Downstate Health Sciences University, State University of New York, Brooklyn, USA
| | | | | | - Carla Boutin-Foster
- SUNY Downstate Health Sciences University, State University of New York, Brooklyn, USA
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29
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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.
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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
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30
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Abstract
Sex and gender often are used interchangeably, but are two distinct entities, with sex being the biological attribute and gender including the social, psychological, and cultural aspects of one's identity. Kidney transplantation has been proven to be the best treatment for end-stage kidney disease, improving both quality of life and life-expectancy for most patients. However, gender disparities in access to and outcomes of kidney transplantation remain despite the plethora of evidence showing the advantages of kidney transplantation to our patients. Data have shown that women are less likely to be waitlisted for a kidney transplant and to receive a deceased donor or a living donor kidney. On the other hand, women are more likely than men to become living kidney donors. Although some state the latter is the result of the female gender to nurture and care for loved ones, others believe this observation is because women often are incompatible with their spouse or child because pregnancy is a strong sensitizing event, which stems from the biological rather than the social differences between the sexes. Influence of sex and gender is not limited to access to kidney transplantation, but rather exist in other areas of transplant medicine, such as the difference observed in transplant outcomes between the sexes, variability in immunosuppression metabolism, and even in more contemporary areas such as recent data showing sex-based differences in outcomes of kidney transplant recipients with coronavirus disease-2019, with males having an increased incidence of acute kidney injury and death.
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Affiliation(s)
- Goni Katz-Greenberg
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Silvi Shah
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH.
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Steinberg Christofferson E, Ruzicka EB, Bolt M, Lyons E, Wachs M, Buchanan CL, Schmiege SJ, Monnin K. Understanding disparities and barriers associated with pediatric transplant evaluation and time to listing: Moving toward a more comprehensive picture. Pediatr Transplant 2022; 26:e14182. [PMID: 34738706 DOI: 10.1111/petr.14182] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 09/25/2021] [Accepted: 10/14/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Delayed time to listing (TTL) for pediatric transplant patients is associated with increased risks of mortality and morbidity. The full range of health disparities, sociodemographic factors, and other barriers associated with delays in listing in the pediatric transplant candidate evaluation process has not been fully examined. METHODS Retrospective chart reviews were conducted for 183 kidney, liver, and heart transplant candidates ages 0-18 who were referred for evaluation during 2012-2015. Demographic information and potential barriers (e g., social/medical factors, financial concerns) were gathered from pre-transplant evaluations and included in a comprehensive model to evaluate mechanisms that explain differences in TTL. Descriptive statistics, logistic regression models, Cox proportional hazards models, and path analysis were used for analyses. RESULTS Candidates included 26.8% heart, 33.3% liver, and 39.9% kidney patients. The most common barrier to listing was financial (71.6%), followed by caregiver psychological or substance use (57.9%), and medical problems (49.7%). Higher age, kidney, and liver organ type (relative to the heart), and presence of social, medical, administrative/motivation, and financial barriers were all directly associated with longer TTL. Public insurance was indirectly associated with TTL through social, administrative/motivation, and financial barriers. Organ type was indirectly associated with TTL through financial barriers. CONCLUSIONS Results suggest social problems, administrative issues, and financial issues act as mechanisms through which insurance type and liver transplant candidates face increased risk of delays in transplant listing time. There are numerous clinical implications and interventions that are warranted to reduce TTL among pediatric transplant candidates with co-occurring barriers.
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Affiliation(s)
- Elizabeth Steinberg Christofferson
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Pediatric Mental Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Elizabeth B Ruzicka
- Pediatric Mental Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Matthew Bolt
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Emma Lyons
- Pediatric Mental Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Michael Wachs
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Cindy L Buchanan
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Pediatric Mental Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sarah J Schmiege
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kara Monnin
- Department of Psychology, Nationwide Children's Hospital, Columbus, Ohio, USA
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32
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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.
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Kiberd BA, Vinson A, Acott PD, Tennankore KK. Optimal Sequencing of Deceased Donor and Live Donor Kidney Transplant Among Pediatric Patients With Kidney Failure. JAMA Netw Open 2022; 5:e2142331. [PMID: 34989796 PMCID: PMC8739763 DOI: 10.1001/jamanetworkopen.2021.42331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE In the US, live donor (LD) kidney transplant rates have decreased in pediatric recipients. Pediatric patients with kidney failure will likely need more than 1 kidney transplant during their lifetime, but the optimal sequence of transplant (ie, deceased donor [DD] followed by LD or vice versa) is not known. OBJECTIVE To determine whether pediatric recipients should first receive a DD allograft followed by an LD allograft (DD-LD sequence) or an LD allograft followed by a DD allograft (LD-DD sequence). DESIGN, SETTING, AND PARTICIPANTS This decision analytical model examined US pediatric patients with kidney failure included in the US Renal Data System 2019 Report who were waiting for a kidney transplant, received a transplant, or experienced graft failure. INTERVENTIONS Kidney transplant sequences of LD-DD vs DD-LD. MAIN OUTCOMES AND MEASURES Difference in projected life-years between the 2 sequence options. RESULTS Among patients included in the analysis, the LD-DD sequence provided more net life-years in those 5 years of age (1.82 [95% CI, 0.87-2.77]) and 20 years of age (2.23 [95% CI, 1.31-3.15]) compared with the DD-LD sequence. The net outcomes in patients 10 years of age (0.36 [95% CI, -0.51 to 1.23] additional life-years) and 15 years of age (0.64 [95% CI, -0.15 to 1.39] additional life-years) were not significantly different. However, for those aged 10 years, an LD-DD sequence was favored if eligibility for a second transplant was low (2.09 [95% CI, 1.20-2.98] additional life-years) or if the LD was no longer available (2.32 [95% CI, 1.52-3.12] additional life-years). For those aged 15 years, the LD-DD sequence was favored if the eligibility for a second transplant was low (1.84 [95% CI, 0.96-2.72] additional life-years) or if the LD was no longer available (2.49 [95% CI, 1.77-3.27] additional life-years). Access to multiple DD transplants did not compensate for missing the LD opportunity. CONCLUSIONS AND RELEVANCE These findings suggest that the decreased use of LD kidney transplants in pediatric recipients during the past 2 decades should be scrutinized. Given the uncertainty of future recipient eligibility for retransplant and future availability of an LD transplant, the LD-DD sequence is likely the better option. This strategy of an LD transplant first would not only benefit pediatric recipients but allow DD kidneys to be used by others who do not have an LD option.
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Affiliation(s)
- Bryce A. Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amanda Vinson
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Philip D. Acott
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
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Salmon EC, Barr LG, Hill DL, Shea JA, Amaral S. Caregiver perspectives of pre-transplant evaluation in children. Pediatr Nephrol 2022; 37:1897-1903. [PMID: 34985556 PMCID: PMC8727489 DOI: 10.1007/s00467-021-05354-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pre-transplant evaluation is mandated by Centers for Medicare and Medicaid Services, but there is wide institutional variation in implementation, and the family experience of the process is incompletely understood. Current literature largely focuses on adult transplant recipients. METHODS This qualitative study begins to fill the knowledge gap about family experience of the pre-transplant evaluation for children through interviews with caregivers at a large pediatric transplant center. RESULTS Prominent themes heard from caregivers include (1) the pre-transplant evaluation is overwhelming and emotional, (2) prior experiences and background knowledge frame the evaluation experience, and (3) frustration with communication among teams is common. CONCLUSIONS These findings are relevant to efforts by transplant centers to optimize information delivery, minimize concrete barriers, and address healthcare systems issues. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Eloise C Salmon
- University of Michigan, 1540 Hospital Drive, Ann Arbor, MI, 48109-4297, USA.
| | - Laura G Barr
- University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas L Hill
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Judy A Shea
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sandra Amaral
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
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35
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Mohottige D, McElroy LM, Boulware LE. A Cascade of Structural Barriers Contributing to Racial Kidney Transplant Inequities. Adv Chronic Kidney Dis 2021; 28:517-527. [PMID: 35367020 PMCID: PMC11200179 DOI: 10.1053/j.ackd.2021.10.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 10/17/2021] [Accepted: 10/27/2021] [Indexed: 11/11/2022]
Abstract
Stark racial disparities in access to and receipt of kidney transplantation, especially living donor and pre-emptive transplantation, have persisted despite decades of investigation and intervention. The causes of these disparities are complex, are inter-related, and result from a cascade of structural barriers to transplantation which disproportionately impact minoritized individuals and communities. Structural barriers contributing to racial transplant inequities have been acknowledged but are often not fully explored with regard to transplant equity. We describe longstanding racial disparities in transplantation, and we discuss contributing structural barriers which occur along the transplant pathway including pretransplant health care, evaluation, referral processes, and the evaluation of transplant candidates. We also consider the role of multilevel socio-contextual influences on these processes. We believe focused efforts which apply an equity lens to key transplant processes and systems are required to achieve greater structural competency and, ultimately, racial transplant equity.
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Affiliation(s)
- Dinushika Mohottige
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC; Center for Community and Population Health Improvement, Clinical and Translational Science Institute, Duke University School of Medicine, Durham, NC.
| | - Lisa M McElroy
- Division of Abdominal Transplant, Department of Surgery, Duke University School of Medicine, Durham, NC; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - L Ebony Boulware
- Center for Community and Population Health Improvement, Clinical and Translational Science Institute, Duke University School of Medicine, Durham, NC; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
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36
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Community Engagement to Improve Equity in Kidney Transplantation from the Ground Up: the Southeastern Kidney Transplant Coalition. CURRENT TRANSPLANTATION REPORTS 2021; 8:324-332. [DOI: 10.1007/s40472-021-00346-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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37
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Non-medical barriers in access to early steps of kidney transplantation in the United States - A scoping review. Transplant Rev (Orlando) 2021; 35:100654. [PMID: 34597944 DOI: 10.1016/j.trre.2021.100654] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND In the United States (US), barriers in access to later steps in the kidney transplantation process (i.e. waitlisting) have been well documented. Barriers in access to earlier steps (i.e. referral and evaluation) are less well described due to the lack of national surveillance data. In this review, we summarize the available literature on non-medical barriers in access to kidney transplant referral and evaluation. METHODS Following PRISMA guidelines, we conducted a scoping review of the literature through June 3, 2021. We included all studies (quantitative and qualitative) reporting on barriers to kidney transplant referral and evaluation in the US published from 1990 onwards in English and among adult end-stage kidney disease (ESKD) patients (PROSPERO registration number: CRD42014015027). We narratively synthesized results across studies. RESULTS We retrieved information from 33 studies published from 1990 to 2021 (reporting data between 1990 and 2018). Most studies (n = 28, 85%) described barriers among patient populations, three (9%) among provider populations, and two (6%) included both patients and providers. Key barriers were identified across multiple levels and included patient- (e.g. demographic, socioeconomic, sociocultural, and knowledge), provider- (e.g. miscommunication, staff availability, provider perceptions and attitudes), and system- (e.g. geography, distance to care, healthcare logistics) level factors. CONCLUSIONS A multi-pronged approach (e.g. targeted and systemwide interventions, and policy change) implemented at multiple levels of the healthcare system will be necessary to reduce identified barriers in access to early kidney transplant steps. Collection of national surveillance data on these early kidney transplant steps is also needed to enhance our understanding of barriers to referral and evaluation.
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38
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Doshi MD, Singh N, Hippen BE, Woodside KJ, Mohan P, Byford HL, Cooper M, Dadhania DM, Ainapurapu S, Lentine KL. Transplant Clinician Opinions on Use of Race in the Estimation of Glomerular Filtration Rate. Clin J Am Soc Nephrol 2021; 16:1552-1559. [PMID: 34620650 PMCID: PMC8499001 DOI: 10.2215/cjn.05490421] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/13/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Current race-based eGFR calculators assign a higher eGFR value to Black patients, which could affect the care of kidney transplant candidates and potential living donors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a survey of staff at adult kidney transplant centers in the United States (December 17, 2020 to February 28, 2021) to assess opinions on use of race-based eGFR equations for waitlisting and living donor candidate evaluation, availability of serum cystatin C testing and measured GFR, and related practices. RESULTS Respondents represented 57% (124 of 218) of adult kidney transplant programs, and the responding centers conducted 70% of recent kidney transplant volume. Most (93%) programs use serum creatinine-based eGFR for listing candidates. However, only 6% of respondents felt that current race-based eGFR calculators are appropriate, with desire for change grounded in concerns for promotion of health care disparities by current equations and inaccuracies in reporting of race. Most respondents (70%) believed that elimination of race would allow more preemptive waitlisting for Black patients, but a majority (79%) also raised concerns that such an approach could incur harms. More than one third of the responding programs lacked or were unsure of availability of testing for cystatin C or measured GFR. At this time, 40% of represented centers did not plan to remove race from eGFR calculators, 46% were planning to remove, and 15% had already done so. There was substantial variability in eGFR reporting and listing of multiracial patients with some Black ancestry. There was no difference in GFR acceptance thresholds for Black versus non-Black living donors. CONCLUSIONS This national survey highlights a broad consensus that extant approaches to GFR estimation are unsatisfactory, but it also identified a range of current opinions.
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Affiliation(s)
| | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana
| | | | | | - Prince Mohan
- Geisinger Medical Center, Danville, Pennsylvania
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39
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Nissaisorakarn P, Xiao H, Doshi MD, Singh N, Lentine KL, Rosas SE. Eliminating racial disparities in kidney transplantation. Clin Transplant 2021; 35:e14397. [PMID: 34174786 DOI: 10.1111/ctr.14397] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/16/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Pitchaphon Nissaisorakarn
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Huiling Xiao
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | | | - Neeraj Singh
- Willis Knighton Health System, Shreveport, LA, USA
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Sylvia E Rosas
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Kidney and Hypertension Unit, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts, USA
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40
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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.
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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
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Ouayogodé MH, Schnier KE. Patient selection in the presence of regulatory oversight based on healthcare report cards of providers: the case of organ transplantation. Health Care Manag Sci 2021; 24:160-184. [PMID: 33417173 PMCID: PMC7791538 DOI: 10.1007/s10729-020-09530-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 10/27/2020] [Indexed: 11/13/2022]
Abstract
Many healthcare report cards provide information to consumers but do not represent a constraint on the behavior of healthcare providers. This is not the case with the report cards utilized in kidney transplantation. These report cards became more salient and binding, with additional oversight, in 2007 under the Centers for Medicare and Medicaid Services Conditions of Participation. This research investigates whether the additional oversight based on report card outcomes influences patient selection via waiting-list registrations at transplant centers that meet regulatory standards. Using data from a national registry of kidney transplant candidates from 2003 through 2010, we apply a before-and-after estimation strategy that isolates the impact of a binding report card. A sorting equilibrium model is employed to account for center-level heterogeneity and the presence of congestion/agglomeration effects and the results are compared to a conditional logit specification. Our results indicate that patient waiting-list registrations change in response to the quality information similarly on average if there is additional regulation or not. We also find evidence of congestion effects when spatial choice sets are smaller: new patient registrations are less likely to occur at a center with a long waiting list when fewer options are available.
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Affiliation(s)
- Mariétou H. Ouayogodé
- School of Medicine and Public Health, Department of Population Health Sciences, University of Wisconsin-Madison, 610 Walnut St, Madison, WI 53726 USA
| | - Kurt E. Schnier
- School of Social Sciences, Humanities and Arts, University of California, Merced, 5200 North Lake Road, Merced, CA 95343 USA
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Pais P, Blydt-Hansen TD, Michael Raj JA, Dello Strologo L, Iyengar A. Low renal transplantation rates in children with end-stage kidney disease: A study of barriers in a low-resource setting. Pediatr Transplant 2021; 25:e13867. [PMID: 33058452 DOI: 10.1111/petr.13867] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 02/06/2023]
Abstract
After 2 decades as a low-cost transplant centre in India, our rates of kidney transplantation are low compared to the burden of end-stage kidney disease (ESKD). We performed this study to identify possible barriers inhibiting paediatric kidney transplant and to assess the outcomes of paediatric ESKD. A retrospective chart review of ESKD patients (2013 - 2018) at a tertiary paediatric nephrology centre was conducted. Medical/non-medical barriers to transplant were noted. Patient outcomes were classified as "continued treatment," "lost to follow-up (LTFU)" or "died." Of 155 ESKD patients (monthly income 218 USD [146, 365], 94% self-pay), only 30 (19%) were transplanted (28 living donor). Sixty-five (42%) were LTFU, 19 (12%) died, and 71 (46%) continued treatment. LTFU/death was associated with greater travel distance (300 km [60, 400] vs 110 km [20, 250] km, P < .0001) and lower monthly income (145 USD [101, 290] vs 290 USD [159, 681], P < .0001). Among those who continued treatment, 41 proceeded to transplant evaluation of whom 13 had no living donor and remained waitlisted for 27 months (15, 30). The remainder (n = 30) did not proceed to transplant due to unresolved medical issues (n = 10) or a lack of parental interest in pursuing transplant (n = 20). Barriers to transplantation in low-resource setting begin in ESKD. LTFU resulted in withdrawal of care and was associated with low socioeconomic status. Among those who continued treatment, transplant rates were higher but medical challenges and negative attitudes towards transplant and organ donation occurred.
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Affiliation(s)
- Priya Pais
- Department of Pediatric Nephrology, St John's Medical College, St John's National Academy of Health Sciences, Bangalore, India
| | - Tom D Blydt-Hansen
- Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, Canada
| | - John A Michael Raj
- Department of Biostatistics, St John's Medical College, St John's National Academy of Health Sciences, Bangalore, India
| | - Luca Dello Strologo
- Pediatric Nephrology and Renal Transplant Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Arpana Iyengar
- Department of Pediatric Nephrology, St John's Medical College, St John's National Academy of Health Sciences, Bangalore, India
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43
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Barth A, Szőllősi GJ, Nemes B. Factors Affecting Access to the Kidney Transplant Waiting List in Eastern Hungary. Transplant Proc 2021; 53:1418-1422. [PMID: 33640164 DOI: 10.1016/j.transproceed.2021.01.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Kidney transplantation is the best available treatment choice for patients suffering from end-stage renal disease; however, not all patients with end-stage renal disease have equal access to it. The aim of the study was to measure the factors that may influence access to the kidney transplant waiting list in eastern Hungary. A total of 254 patients with renal failure between 18 and 75 years old from 8 dialysis centers participated in the study. The factors associated with access to the waiting list were identified by univariate descriptive analysis and multivariate logistic regression analysis where the outcome variable was placement on the kidney transplant waiting list. Our findings demonstrates that patients registered on the waiting list were younger (odds ratio [OR] = 0.96; 95% confidence interval [CI], 0.94-0.98), were male (OR = 0.54; 95% CI, 0.30-0.98), were economically active (OR = 0.53; 95% CI, 0.29-0.98), and had greater knowledge in the field (OR = 1.17; 95% CI, 1.03-1.33). Disparity in access to the kidney transplant waiting list in Hungary does exist.
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Affiliation(s)
- Anita Barth
- Department of Transplantation, Institute of Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; Department of Nursing Science, Faculty of Health, University of Debrecen, Nyiregyhaza, Hungary; Doctoral School of Health Sciences, University of Debrecen, Debrecen, Hungary.
| | | | - Balázs Nemes
- Department of Transplantation, Institute of Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Wesselman H, Ford CG, Leyva Y, Li X, Chang CCH, Dew MA, Kendall K, Croswell E, Pleis JR, Ng YH, Unruh ML, Shapiro R, Myaskovsky L. Social Determinants of Health and Race Disparities in Kidney Transplant. Clin J Am Soc Nephrol 2021; 16:262-274. [PMID: 33509963 PMCID: PMC7863655 DOI: 10.2215/cjn.04860420] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 11/16/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Black patients have a higher incidence of kidney failure but lower rate of deceased- and living-donor kidney transplantation compared with White patients, even after taking differences in comorbidities into account. We assessed whether social determinants of health (e.g., demographics, cultural, psychosocial, knowledge factors) could account for race differences in receiving deceased- and living-donor kidney transplantation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Via medical record review, we prospectively followed 1056 patients referred for kidney transplant (2010-2012), who completed an interview soon after kidney transplant evaluation, until their kidney transplant. We used multivariable competing risk models to estimate the cumulative incidence of receipt of any kidney transplant, deceased-donor transplant, or living-donor transplant, and the factors associated with each outcome. RESULTS Even after accounting for social determinants of health, Black patients had a lower likelihood of kidney transplant (subdistribution hazard ratio, 0.74; 95% confidence interval, 0.55 to 0.99) and living-donor transplant (subdistribution hazard ratio, 0.49; 95% confidence interval, 0.26 to 0.95), but not deceased-donor transplant (subdistribution hazard ratio, 0.92; 95% confidence interval, 0.67 to 1.26). Black race, older age, lower income, public insurance, more comorbidities, being transplanted before changes to the Kidney Allocation System, greater religiosity, less social support, less transplant knowledge, and fewer learning activities were each associated with a lower probability of any kidney transplant. Older age, more comorbidities, being transplanted before changes to the Kidney Allocation System, greater religiosity, less social support, and fewer learning activities were each associated with a lower probability of deceased-donor transplant. Black race, older age, lower income, public insurance, higher body mass index, dialysis before kidney transplant, not presenting with a potential living donor, religious objection to living-donor transplant, and less transplant knowledge were each associated with a lower probability of living-donor transplant. CONCLUSIONS Race and social determinants of health are associated with the likelihood of undergoing kidney transplant.
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Affiliation(s)
- Hannah Wesselman
- Department of Biological Sciences, University of Notre Dame, Notre Dame, Indiana
| | - Christopher Graham Ford
- Center for Healthcare Equity in Kidney Disease, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Yuridia Leyva
- Center for Healthcare Equity in Kidney Disease, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Xingyuan Li
- Eli Lilly and Company, Indianapolis, Indiana
| | - Chung-Chou H. Chang
- Department of Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania,Department of Biostatistics, University of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - Kellee Kendall
- Department of Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - Emilee Croswell
- Department of Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - John R. Pleis
- Division of Research and Methodology, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
| | - Yue Harn Ng
- Department of Internal Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico
| | - Mark L. Unruh
- Department of Internal Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico
| | - Ron Shapiro
- Mount Sinai Recanati/Miller Transplantation Institute, Icahn School of Medicine, New York, New York
| | - Larissa Myaskovsky
- Center for Healthcare Equity in Kidney Disease, University of New Mexico Health Sciences Center, Albuquerque, New Mexico,Department of Internal Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico
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Kawaguchi ES, Shen JI, Suchard MA, Li G. Scalable Algorithms for Large Competing Risks Data. J Comput Graph Stat 2020; 30:685-693. [DOI: 10.1080/10618600.2020.1841650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Eric S. Kawaguchi
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - Jenny I. Shen
- Division of Nephrology and Hypertension, The Lundquist Institute at Harbor UCLA, Torrance, CA
- David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Marc A. Suchard
- Department of Biostatistics, University of California, Los Angeles, CA
- Department of Computational Medicine, University of California, Los Angeles, CA
- Department of Human Genetics, University of California, Los Angeles, CA
| | - Gang Li
- Department of Biostatistics, University of California, Los Angeles, CA
- Department of Computational Medicine, University of California, Los Angeles, CA
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46
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Kuppachi S, Norman SP, Lentine KL, Axelrod DA. Using race to estimate glomerular filtration and its impact in kidney transplantation. Clin Transplant 2020; 35:e14136. [PMID: 33232529 DOI: 10.1111/ctr.14136] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/22/2020] [Accepted: 10/27/2020] [Indexed: 12/19/2022]
Abstract
Since direct measurement of glomerular filtration rate (GFR) is time-consuming and more expensive, estimated GFR (eGFR) based on measured laboratory values is widely used to determine kidney function. Commonly used formulae to calculate eGFR are dependent on variables, which include filtration markers like serum creatinine and patient characteristics including race. Medical algorithms which utilize race are increasingly being scrutinized, as race is recognized to be a social construct rather than a biologic one. eGFR calculations have important implications for kidney transplantation, both in the listing of candidates as well as in the evaluation of potential kidney donors. This review considers the specific implications of race-based eGFR calculations on recipient evaluation and on decisions related to living kidney donation. We suggest a potential policy solution to ensure that racial and ethnic minority patients are not disadvantaged by eGFR as a result of current calculation methods.
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Affiliation(s)
- Sarat Kuppachi
- Department of Internal Medicine, Division of Nephrology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Silas P Norman
- Department of Internal Medicine, Division of Nephrology, University of Michigan Transplant Center, University of Michigan, Ann Arbor, MI, USA
| | - Krista L Lentine
- Department of Internal Medicine, Division of Nephrology, Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - David A Axelrod
- Department of Surgery, Division of Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Melk A, Schmidt BMW, Geyer S, Epping J. Sex disparities in dialysis initiation, access to waitlist, transplantation and transplant outcome in German patients with renal disease-A population based analysis. PLoS One 2020; 15:e0241556. [PMID: 33180815 PMCID: PMC7660568 DOI: 10.1371/journal.pone.0241556] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 10/18/2020] [Indexed: 12/31/2022] Open
Abstract
Background Renal transplantation access and outcome differ between men and women, but no analysis has considered all transition phases and transplant outcome using the same data set. We analyzed sex disparities in all phases of patients’ clinical path (progression to dialysis, waitlisting, transplantation, graft failure/death). Methods In a population based approach using health insurance data (2005–2013) we examined patients’ risk of changing from one phase to another applying Cox Proportional Hazards model. Results After adjusting for age and comorbidities, women had a 16% lower risk of progression to ESRD (HR/95%-CI: 0.84/0.79–0.88). Access to the waitlist was lowered by 18% in women compared to men (HR/95%-CI: 0.82/0.70–0.96). An age stratified analysis did not reveal differences in any age group. Once waitlisted, the chance to receive a transplant was identical (HR/95%-CI: 0.96/0.81–1.15). The risk of transplant failure/death was identical for both sexes (HR/95%-CI: 0.99/0.73–1.35), but the effect was modified by age: in younger women (18–45 years) the risk was twice as high compared to men (HR/95%-CI: 2.08/1.04–4.14), whereas the risk in elderly women (> 65 years) was only half the risk of men (HR/95%-CI: 0.47/0.24–0.93). Conclusion Sex disparities occurred at different steps in the history of patients with renal disease and affected progression to dialysis, waitlisting and transplantation outcome in a population with equal access to medical treatment.
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Affiliation(s)
- Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
- * E-mail:
| | | | - Siegfried Geyer
- Department of Medical Sociology, Hannover Medical School, Hannover, Germany
| | - Jelena Epping
- Department of Medical Sociology, Hannover Medical School, Hannover, Germany
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Abstract
Kidney transplantation is the ideal treatment option for patients with end-stage kidney disease (ESKD). Since there is clear mortality benefit to receiving a transplant regardless of comorbidities and age, the gold standard of care should focus on attaining kidney transplantation and minimizing, or better yet eliminating, time on dialysis. Unfortunately, only a small percentage of patients with ESKD receive a kidney transplant. Several barriers to kidney transplantation have been identified. Barriers can largely be grouped into three categories: patient-related, physician/provider-related, and system-related. Several barriers fall into multiple categories and play a role at various levels within the healthcare system. Acknowledging and understanding these barriers will allow transplant centers and dialysis facilities to make the necessary interventions to mitigate these disparities, optimize the transplant evaluation process, and improve patient outcomes. This review will discuss these barriers and potential interventions to increase access to kidney transplantation.
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49
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Arhuidese IJ, Holscher CM, Elemuo C, Parkerson GR, Johnson BL, Malas MB. Impact of Body Mass Index on Outcomes of Autogenous Fistulas for Hemodialysis Access. Ann Vasc Surg 2020; 68:192-200. [DOI: 10.1016/j.avsg.2020.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 11/25/2022]
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50
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Patzer RE, McPherson L, Wang Z, Plantinga LC, Paul S, Ellis M, DuBay DA, Wolf J, Reeves-Daniel A, Jones H, Zayas C, Mulloy L, Pastan SO. Dialysis facility referral and start of evaluation for kidney transplantation among patients treated with dialysis in the Southeastern United States. Am J Transplant 2020; 20:2113-2125. [PMID: 31981441 DOI: 10.1111/ajt.15791] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/02/2020] [Accepted: 01/19/2020] [Indexed: 01/25/2023]
Abstract
Variability in transplant access exists, but barriers to referral and evaluation are underexplored due to lack of national surveillance data. We examined referral for kidney transplantation evaluation and start of the evaluation among 34 857 incident, adult (18-79 years) end-stage kidney disease patients from 690 dialysis facilities in the United States Renal Data System from January 1, 2012 through August 31, 2016, followed through February 2018 and linked data to referral and evaluation data from nine transplant centers in Georgia, North Carolina, and South Carolina. Multivariable-adjusted competing risk analysis examined each outcome. The median within-facility cumulative percentage of patients referred for kidney transplantation within 1 year of dialysis at the 690 dialysis facilities in Network 6 was 33.7% (interquartile range [IQR]: 25.3%-43.1%). Only 48.3% of referred patients started the transplant evaluation within 6 months of referral. In multivariable analyses, factors associated with referral vs evaluation start among those referred at any time differed. For example, black, non-Hispanic patients had a higher rate of referral (hazard ratio [HR]: 1.22; 95% confidence interval [CI]: 1.18-1.27), but lower evaluation start among those referred (HR: 0.93; 95% CI: 0.88-0.98), vs white non-Hispanic patients. Barriers to transplant varied by step, and national surveillance data should be collected on early transplant steps to improve transplant access.
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Affiliation(s)
- Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Emory Transplant Center, Atlanta, Georgia, USA
| | - Laura McPherson
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Zhensheng Wang
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laura C Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Matthew Ellis
- Departments of Medicine and Surgery, Duke University, Durham, North Carolina, USA
| | - Derek A DuBay
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Joshua Wolf
- Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, Georgia, USA
| | | | - Heather Jones
- Vidant Medical Center, Greenville, North Carolina, USA
| | - Carlos Zayas
- Division of Nephrology, Department of Medicine, Augusta University, Augusta, Georgia, USA
| | - Laura Mulloy
- Division of Nephrology, Department of Medicine, Augusta University, Augusta, Georgia, USA
| | - Stephen O Pastan
- Emory Transplant Center, Atlanta, Georgia, USA.,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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