Association of Racial Disparities With Access to Kidney Transplant After the Implementation of the New Kidney Allocation System

Abstract

Inactive patients on the kidney transplant wait-list have a higher mortality. The implications of this status change on transplant outcomes between racial/ethnic groups are unknown.OBJECTIVES To determine if activity status changes differ among races/ethnicities and levels of sensitization, and if these differences are associated with transplant probability after implementation of the Kidney Allocation System. DESIGN, SETTING, AND PARTICIPANTSA multistate model was constructed from the Organ Procurement and Transplantation Network kidney transplant database (December 4, 2014, to September 8, 2016. The time interval followed Kidney Allocation System implementation and provided at least 1-year follow-up for all patients. The model calculated probabilities between active and inactive status and the following competing risk outcomes: living donor transplant, deceased donor transplant, and death/other. This retrospective cohort study included 42 558 patients on the Organ Procurement and Transplantation Network kidney transplant wait-list following Kidney Allocation System implementation. To rule out time-varying confounding from relisting, analysis was limited to first-time registrants. Owing to variations in listing practices, primary center listing data were used for dually listed patients. Individuals listed for another organ or pancreatic islets were excluded. Analysis began July 2017. MAIN OUTCOME AND MEASURESProbabilities were determined for transitions between active and inactive status and the following outcome states: active to living donor transplant, active to deceased donor transplant, active to death/other, inactive to living donor transplant, inactive to deceased donor transplant, and inactive to death/other. RESULTSThe median (interquartile range) age at listing was 55.0 (18.0-89.0) years, and 26 535 of 42 558 (62.4%) were men. White individuals were 43.3% (n = 18 417) of wait-listed patients, while black and Hispanic individuals made up 27.8% (n = 11 837) and 19.5% (n = 8296), respectively. Patients in the calculated plasma reactive antibody categories of 0% or 1% to 79% showed no statistically significant difference in transplant probability among races/ethnicities. White individuals had an advantage in transplant probability over black individuals in calculated plasma reactive antibody categories of 80% to 89% (hazard ratio [HR], 1.8 [95% CI, 1.4-2.2]) and 90% or higher (HR, 2.4 [95% CI, 2.1-2.6]), while Hispanic individuals had an advantage over black individuals in the calculated plasma reactive antibody group of 90% or higher (HR, 2.5 [95% CI, 2.1-2.8]). Once on the inactive list, white individuals were more likely than Hispanic individuals (HR, 1.2 [95% CI, 1.17-1.3]) or black individuals (HR, 1.4 [95% CI, 1.3-1.4]) to resolve issues for inactivity resulting in activation. CONCLUSIONS AND RELEVANCEFor patients who are highly sensitized, there continues to be less access to kidney transplant in the black population after the implementation of the Kidney Allocation System. Health disparities conti...

Cultural influences on willingness to donate organs among urban native Americans

“…Without a transplant, the median survival for an NA on dialysis has been quoted as less than three years . Issues such as wait‐list time and survival on dialysis are compounded in minority communities and have not greatly improved over recent years …”

“…Therefore, NAs waiting for an organ transplant will have a better chance of receiving one if there are large numbers of donors from their own racial/ethnic background . Importantly, the new kidney allocation system instituted in the United States in 2014 extends waiting times for organ allocation for people with diabetes, the disease afflicting the majority of NAs on the wait‐list, making it even harder to receive a deceased organ donation. Native Americans have been largely left out of studies assessing the new allocation system's effects on minority groups, though there have been some studies focusing on blacks and hispanics .…”

“…8 Issues such as wait-list time and survival on dialysis are compounded in minority communities and have not greatly improved over recent years. 4,13 Despite a demonstrated and growing need for renal replacement therapy and importantly, renal transplantation, the rate of deceased organ donation among NAs remains lower than the rate for the general population in the United States. 14…”

Implementation of a quality improvement strategy to increase outpatient kidney transplant referrals

“…Kidney transplantation remains the optimal treatment for patients who progress to end stage kidney disease (ESKD). Unfortunately, only approximately 14% of patients on dialysis are waitlisted for kidney transplantation [4] several barriers to timely kidney transplantation have been described, including medical and financial barriers [5,6], racial and ethnic disparities [7], and no identified living donor or donor evaluation delays [5]. Not surprisingly, both earlier timing of and presence of referral to kidney transplantation have been identified as predictors of preemptive kidney transplantation [5].…”

Measures of Inclusivity at Hospitals in the United States

“…1 They have less access to care, are less likely to receive treatment for chronic conditions, and are less likely to receive needed organ transplants. [2][3][4] Such disparities in care persist even when such factors as insurance status, income, age, comorbid conditions, and symptom expression are taken into account.…”