Black Race Is Associated With Higher Rates of Early‐Onset End‐Stage Renal Disease and Increased Mortality Following Liver Transplantation

Abstract

Black race is a risk factor for end-stage renal disease (ESRD). Racial disparities in the risks of early and long-term renal complications after liver transplantation (LT) have not been systematically studied. This study evaluated racial differences in the natural history of acute and chronic renal insufficiency after LT. This was a retrospective single-center cohort study of 763 non-Hispanic White and 181 Black LT recipients between 2008 and 2017. Black race was investigated as an independent predictor of the following outcomes: (1) receipt and duration of early post-LT hemodialysis and (2) time to post-LT ESRD. The interaction of race and post-LT ESRD on survival was also studied. Black recipients had higher rates of pre-LT hypertension (P < 0.001), but diabetes mellitus and renal function before LT were not different by race (all P > 0.05). Overall, 15.2% of patients required early hemodialysis immediately after LT with no difference by race (covariate-adjusted odds ratio, 0.89; P = 0.71). Early dialysis discontinuation was lower among Black recipients (covariate-adjusted hazard ratio [aHR], 0.47; P = 0.02), whereas their rate of post-LT ESRD was higher (aHR, 1.91; P = 0.005). Post-LT survival after ESRD was markedly worse for Black (aHR, 11.18; P < 0.001) versus White recipients (aHR, 5.83; P < 0.001; interaction P = 0.08). Although Black and White LT recipients had comparable pretransplant renal function, post-LT renal outcomes differed considerably, and the impact of ESRD on post-LT survival was greater for Black recipients. This study highlights the need for an individualized approach to post-LT management to improve outcomes for all patients.

Changes and mediators of survival disparity among Black liver transplant recipients in the United States

“…Fourth, variables were captured at LT, and post‐LT changes (e.g., interval post‐LT changes to insurance status 20 ) or behaviors 21 (e.g., health adherence, alcohol/tobacco use) were not evaluated. While we did adjust for a number of co‐morbidities at LT, other comorbidities are unknown in UNOS and may differ by race, particularly hypertension which is more common in Blacks and is associated with higher rates of renal insufficiency 22 . Differences in hypertension prevalence may contribute to survival differences for Blacks; however, a recent national study shows stable trends among young to mid‐aged US adults for the prevalence, awareness, treatment, and control of hypertension across racial groups 23 suggesting hypertension cannot account entirely for the increasing post‐LT survival disparity for Blacks over time.…”

“…While we did adjust for a number of co-morbidities at LT, other comorbidities are unknown in UNOS and may differ by race, particularly hypertension which is more common in Blacks and is associated with higher rates of renal insufficiency. 22 Differences in hypertension prevalence may contribute to survival differences for Blacks; however, a recent national study shows stable trends among young to mid-aged US adults for the prevalence, awareness, treatment, and control of hypertension across racial groups 23 suggesting hypertension cannot account entirely for the increasing post-LT survival disparity for Blacks over time. Finally, examining specific policy changes over the study period, including expansion of health insurance coverage by the Affordable Care Act, addition of sodium to the MELD allocation…”

Impact of Race‐Adjusted Glomerular Filtration Rate Estimation on Eligibility for Simultaneous Liver‐Kidney Transplantation

“…In comparing Black patients meeting SLKT criteria by race‐adjusted and race‐unadjusted eGFR formulas, there was no difference in waitlist mortality between the groups, suggesting that differences in key patient outcomes may manifest in the posttransplant setting. ( 2 ) Indeed, we found that a higher proportion of patients reclassified as meeting SLKT criteria via the CKD pathway without race adjustment required short‐term kidney transplantation. These are important points as the safety‐net policies that govern access to kidney transplantation after LTA also rely on eGFR.…”

“…( 12‐14 ) Finally, Black patients have in increased incidence of ESRD and need for dialysis after LTA, which was recently shown with national registry data. ( 2 )…”

“…Race adjustment in eGFR calculation is currently under scrutiny in light of the emerging data that Black patients have increased renal complications and higher rates of end‐stage renal disease (ESRD) after liver transplantation alone (LTA) compared with non‐Black patients. ( 2 ) Furthermore, recent data have suggested that removing the race adjustment from eGFR calculations in patients with cirrhosis did not adversely impact the ability to predict future AKI events or progression to CKD, suggesting that race adjustment in eGFR may be unnecessary in patients with cirrhosis. ( 3 ) There is biological plausibility to this idea, as historically eGFR was adjusted for Black race in part because of historic data suggesting differences in muscle mass.…”