Prominent Impact of Community Risk Factors on Kidney Transplant Candidate Processes and Outcomes

Abstract

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

Living Donor Kidney Transplantation

“…Lower household income is associated with more limited access to kidney transplantation, higher death rates on the waiting list, and lower rates of LDKT (6,39). Preemptive LDKT has the strongest correlation with patient higherincome status.…”

“…There is considerable regional variation in LDKT access and rates (6,39,58). At a surface level, and as depicted in Figure 3, LDKTs as a percentage of total kidney transplants vary considerably by United Network for Organ Sharing (UNOS) region in the United States (1).…”

Living-Donor Kidney Transplantation

“…On the basis of residence ZIP code and national registry data, both blacks and whites in lower-income areas were less likely to undergo LDKT (12)(13)(14). Since 2006, national living kidney donation rates have declined, a decrease some have ascribed in part to the downturn in the economic climate in the United States (1,12).…”

Mesenchymal stem cells for kidney transplantation

“…Whilst short term graft survival is improving and acute rejection rates are dropping long term graft survival rates remain a major focus for clinical improvement. There are many factors that can impact the prognosis of a kidney transplant, from graft or donor considerations [2,3] , factors involving the immunosuppressant regime [4,5] , and issues concerning the recipient [6,7] . Tissue typing and stringent exclusion criteria are implemented pre-transplant to reduce the risk of donor related problems [3] .…”

“…Tissue typing and stringent exclusion criteria are implemented pre-transplant to reduce the risk of donor related problems [3] . Issues with the recipient such as noncompliance and co-morbidity are much more difficult to manage and are often beyond a clinician's power to control [6,7] nisms has its benefits and disadvantages and tailoring a drug schedule has the potential to impact long term graft function and the quality of life of the recipient. However all current drugs are associated with a range of adverse effects including renal toxicity, opportunistic infections, development of malignancy and metabolic complications [5] .…”