Racial disparities in preemptive referral for kidney transplantation in Georgia

Gander, Jennifer C.; Zhang, Xingyu; Plantinga, Laura C.; Paul, Sudeshna; Basu, Mohua; Pastan, Stephen O.; Gibney, Eric M.; Hartmann, Erika; Mulloy, L; Zayas, Carlos; Patzer, Rachel E.

doi:10.1111/ctr.13380

Cited by 59 publications

(58 citation statements)

References 42 publications

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“…In general, the current study results confirmed that many of the associations that have been identified as barriers to initial kidney transplantation persist for evaluating access to repeat transplantation. Race and ethnicity were associated with preemptive listing for repeat transplantation, as has been demonstrated in prior studies evaluating access to primary transplantation . These results persisted with adjustment for demographic and clinical factors as well as indicators for socioeconomic status and social factors based on insurance type, educational attainment, and residential distress index.…”

Section: Discussionsupporting

confidence: 70%

“…Race and ethnicity were associated with preemptive listing for repeat transplantation, as has been demonstrated in prior studies evaluating access to primary transplantation. 9,22,23 These results persisted with adjustment for demographic and clinical factors as well as indicators for socioeconomic status and social factors based on insurance type, educational attainment, and residential distress index. The degree to which these differences are based on timely referral and identification of failing graft function and are amenable to interventions targeting access to care among ESRD patients is important to evaluate.…”

Section: Discussionmentioning

confidence: 84%

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Modest rates and wide variation in timely access to repeat kidney transplantation in the United States

Schold

Augustine

Huml

et al. 2020

American Journal of Transplantation

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Success of transplantation is not limited to initial receipt of a donor organ. Many kidney transplant recipients experience graft loss following initial transplantation and the benefits of expedited placement on the waiting list and retransplantation extend to this population. Factors associated with access to repeat transplantation may be unique given experience with the transplant process and prior viability as a candidate. We examined the incidence, risk factors, secular changes, and center‐level variation of preemptive relisting or transplantation (PRLT) for kidney transplant recipients in the United States with graft failure (not due to death) using Scientific Registry of Transplant Recipients data from 2007 to 2018 (n = 39 557). Overall incidence of PRLT was 15% and rates of relisting declined over time. Significantly lower PRLT was evident among patients who were African American and Hispanic, males, older, obese, publicly insured, had lower educational attainment, were diabetic, had longer dialysis time prior to initial transplant, shorter graft survival, longer distance to transplant center, and resided in distressed communities. There was significant variation in PRLT by center, median = 13%, 10th percentile = 6%, 90th percentile = 24%. Cumulatively, results indicate that despite prior access to transplantation, incidence of PRLT is modest with pronounced clinical, social, and center‐level sources of variation suggesting opportunities to improve preemptive care among patients with failing grafts.

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Section: Discussionsupporting

confidence: 70%

Section: Discussionmentioning

confidence: 84%

Modest rates and wide variation in timely access to repeat kidney transplantation in the United States

Schold

Augustine

Huml

et al. 2020

American Journal of Transplantation

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“…We extended this work to two distinct stages of the kidney transplant process and among a population who have overcome referral-related Table 3. Testing of mediation of SES, comorbidity, or SES and comorbidity on listing for kidney transplant within 1 year between black versus white patients with kidney failure (n53013) or receipt of transplant between black versus white kidney transplant candidates on the waitlist (n52068), using inverse odds ratio weighting and among a population who have started the transplant evaluation process disparities (4,(6)(7)(8)(9). It is at this point that transplant centers engage with candidates and have opportunities to influence the coordination of the transplant process (18,30).…”

Section: Discussionmentioning

confidence: 99%

“…These results should be considered in light of important limitations. Our cohort is a select group of candidates who have overcome significant barriers to be referred to and seen at transplant clinic (8,9). A majority of black candidates were recruited at one site and our sample size is modest (n53013).…”

Section: Discussionmentioning

confidence: 99%

“…Racial disparities persist throughout the kidney transplantation process (224), even as post-transplant outcome disparities are decreasing (5). Black adults who overcome disparities in referral for transplant (4,(6)(7)(8)(9) likely reflect a select population. Yet, they face continued disparities in listing for transplant (4,6,7,(10)(11)(12)(13) and receipt of transplant (3,4,6,7,(13)(14)(15)(16).…”

Section: Introductionmentioning

confidence: 99%

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Association of Socioeconomic Status and Comorbidities with Racial Disparities during Kidney Transplant Evaluation

Murphy

Jackson

Purnell

et al. 2020

CJASN

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Background and objectivesBlack patients referred for kidney transplantation have surpassed many obstacles but likely face continued racial disparities before transplant. The mechanisms that underlie these disparities are unclear. We determined the contributions of socioeconomic status (SES) and comorbidities as mediators to disparities in listing and transplant.Design, setting, participants, & measurementsWe studied a cohort (n=1452 black; n=1561 white) of patients with kidney failure who were referred for and started the transplant process (2009–2018). We estimated the direct and indirect effects of SES (self-reported income, education, and employment) and medical comorbidities (self-reported and chart-abstracted) as mediators of racial disparities in listing using Cox proportional hazards analysis with inverse odds ratio weighting. Among the 983 black and 1085 white candidates actively listed, we estimated the direct and indirect effects of SES and comorbidities as mediators of racial disparities on receipt of transplant using Poisson regression with inverse odds ratio weighting.ResultsWithin the first year, 876 (60%) black and 1028 (66%) white patients were waitlisted. The relative risk of listing for black compared with white patients was 0.76 (95% confidence interval [95% CI], 0.69 to 0.83); after adjustment for SES and comorbidity, the relative risk was 0.90 (95% CI, 0.83 to 0.97). The proportion of the racial disparity in listing was explained by SES by 36% (95% CI, 26% to 57%), comorbidity by 44% (95% CI, 35% to 61%), and SES with comorbidity by 58% (95% CI, 44% to 85%). There were 409 (42%) black and 496 (45%) white listed candidates transplanted, with a median duration of follow-up of 3.9 (interquartile range, 1.2–7.1) and 2.8 (interquartile range, 0.8–6.3) years, respectively. The incidence rate ratio for black versus white candidates was 0.87 (95% CI, 0.79 to 0.96); SES and comorbidity did not explain the racial disparity.ConclusionsSES and comorbidity partially mediated racial disparities in listing but not for transplant.

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Disparities in Kidney Transplant Waitlisting Among Young Patients Without Medical Comorbidities

Husain,

Yu,

King

et al. 2023

JAMA Intern Med

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ImportanceDisparities in kidney transplant referral and waitlisting contribute to disparities in kidney disease outcomes. Whether these differences are rooted in population differences in comorbidity burden is unclear.ObjectiveTo examine whether disparities in kidney transplant waitlisting were present among a young, relatively healthy cohort of patients unlikely to have medical contraindications to kidney transplant.Design, Setting, and ParticipantsThis retrospective cohort study used the US Renal Data System Registry to identify patients with end-stage kidney disease who initiated dialysis between January 1, 2005, and December 31, 2019. Patients who were older than 40 years, received a preemptive transplant, were preemptively waitlisted, or had documented medical comorbidities other than hypertension or smoking were excluded, yielding an analytic cohort of 52 902 patients. Data were analyzed between March 1, 2022, and February 1, 2023.Main Outcome(s) and Measure(s)Kidney transplant waitlisting after dialysis initiation.ResultsOf 52 902 patients (mean [SD] age, 31 [5] years; 31 132 [59%] male; 3547 [7%] Asian/Pacific Islander, 20 782 [39%] Black/African American, and 28 006 [53%] White) included in the analysis, 15 840 (30%) were waitlisted for a kidney transplant within 1 year of dialysis initiation, 11 122 (21%) were waitlisted between 1 and 5 years after dialysis initiation, and 25 940 (49%) were not waitlisted by 5 years. Patients waitlisted within 1 year of dialysis initiation were more likely to be male, to be White, to be employed full time, and to have had predialysis nephrology care. There were large state-level differences in the proportion of patients waitlisted within 1 year (median, 33%; range, 15%-58%). In competing risk regression, female sex (adjusted subhazard ratio [SHR], 0.92; 95% CI, 0.90-0.94), Hispanic ethnicity (SHR, 0.77; 95% CI, 0.75-0.80), and Black race (SHR, 0.66; 95% CI, 0.64-0.68) were all associated with lower waitlisting after dialysis initiation. Unemployment (SHR, 0.47; 95% CI, 0.45-0.48) and part-time employment (SHR, 0.74; 95% CI, 0.70-0.77) were associated with lower waitlisting compared with full-time employment, and more than 1 year of predialysis nephrology care, compared with none, was associated with greater waitlisting (SHR, 1.51; 95% CI, 1.46-1.56).Conclusions and RelevanceThis retrospective cohort study found that fewer than one-third of patients without major medical comorbidities were waitlisted for a kidney transplant within 1 year of dialysis initiation, with sociodemographic disparities in waitlisting even in this cohort of young, relatively healthy patients unlikely to have a medical contraindication to transplantation. Transplant policy changes are needed to increase transparency and address structural barriers to waitlist access.

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Racial disparities in preemptive referral for kidney transplantation in Georgia

Cited by 59 publications

References 42 publications

Modest rates and wide variation in timely access to repeat kidney transplantation in the United States

Modest rates and wide variation in timely access to repeat kidney transplantation in the United States

Association of Socioeconomic Status and Comorbidities with Racial Disparities during Kidney Transplant Evaluation

Disparities in Kidney Transplant Waitlisting Among Young Patients Without Medical Comorbidities

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