Health Disparities in Kidney Transplantation for African Americans

Harding, Kimberly; Mersha, Tesfaye B.; Pham, Phuong Thu; Waterman, Amy D.; Webb, Fern J.; Vassalotti, Joseph A.; Nicholas, Susanne B.

doi:10.1159/000479480

Cited by 71 publications

(75 citation statements)

References 65 publications

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“…Our study also suggests that among those who are listed, SES and comorbidity may have less influence on receipt of transplant. This is consistent with work that suggests immunologic concerns and availability of donor organs are important predictors for transplant (2,17). Prior national policies have focused on allocation stage of organ transplantation (32,33), yet disparities in transplantation may be widening between 1995 and 2014 (3) and within donor evaluation process (34).…”

Section: Discussionsupporting

confidence: 80%

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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Section: Discussionsupporting

confidence: 80%

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

Murphy

Jackson

Purnell

et al. 2020

CJASN

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“…Qualitative evidence highlighted several barriers for KTx among the Indigenous Americans including mistrust of the safety of the deceased organ, ethical concerns about the procurement process, fear of surgery, and concerns about maintaining the body whole to maintain spiritual balance [ 26 – 29 ]. Similar barriers were identified among Black Americans including mistrust of the medical team, fear of surgery, care coordination barriers and other cultural factors (such as perceived discrimination) [ 25 , 30 – 32 ]. Like the Indigenous Americans, the disparity in KTx access for Black Americans cannot be fully explained by medical or socioeconomic variables [ 3 ].…”

Section: Discussionmentioning

confidence: 79%

“…Optimizing care coordination between government funded tribal health services and specialty care such as transplant has been an ongoing quality effort [ 24 ]. The effect of lack of care coordination has been associated with disparity in KTx access for Black Americans [ 25 ].…”

Section: Discussionmentioning

confidence: 99%

Transplant center assessment of the inequity in the kidney transplant process and outcomes for the Indigenous American patients

et al. 2018

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BackgroundThe goal is to determine the delays and reduced rates of kidney transplant (KTx) for the Indigenous Americans and variables predictive of these outcomes at a large single transplant center.Methods300 Indigenous Americans and 300 non-Hispanic white American patients presenting for KTx evaluation from 2012–2016 were studied.ResultsCompared to whites, the Indigenous Americans had the following: more diabetes, dialysis, physical limitation and worse socioeconomic characteristics(p<0.01); median difference of 20 day delay from referral to KTx evaluation, 17 day delay from approval to UNOS listing and 126.5 longer delay on the waitlist compared to whites(p<0.001). Of the Indigenous Americans listed, more died, were removed, or were still waiting than transplanted compared to whites (p<0.001). Variables predictive of delay from referral to transplant evaluation included: Indigenous race, distance from transplant center, coronary artery disease, and time on dialysis (p<0.05). Cumulative incidence of waitlisting and KTx was lower for Indigenous Americans (p<0.0001). Independent predictors of decreased likelihood of waitlisting included age, peripheral vascular disease, no caregiver, physical limitation, and illegal drug use history (p<0.05). Variables predictive of lower likelihood of KTx included Indigenous race, percentage of time inactive on the waitlist, no caregiver, and O blood type.ConclusionsAmong patients referred and evaluated for KTx, the Indigenous American race was independently associated with significant delays in the KTx process after accounting for co-morbid and socioeconomic factors. Cardiovascular morbidity and physical limitation were identified as important determinants of delay and decreased likelihood of waitlisting. Further quantitative and qualitative work is needed to identify and intervene on modifiable barriers to improve access to KTx for the Indigenous Americans.

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“…Existing data have shown that minoritized groups such as African American and Hispanics are referred later for transplantation in their ESKD course. Proposed contributors include patient preferences, clinician biases, poor patient education, low socioeconomic status, more frequent contraindications to transplantation, inadequate health insurance, and immunologic factors [21]. Although the intervention clinic nephrology care was primarily delivered by fellows, the intervention could be applied to attending nephrology clinics and community clinics regardless of academic affiliation.…”

Section: Discussionmentioning

confidence: 99%

Implementation of a Quality Improvement Strategy to Increase Outpatient Kidney Transplant Referrals

Farouk

Atallah

Vassalotti

et al. 2020

Preprint

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Background: Kidney transplantation remains the optimal therapy for patients with end stage kidney disease (ESKD), though a small fraction of patients on dialysis are on organ waitlists. An important barrier to preemptive kidney transplantation and successful waitlisting is timely referral to a kidney transplant center. We implemented a quality improvement strategy to improve outpatient kidney transplant referrals in a single center academic outpatient nephrology clinic. Methods: Over a 3 month period (July 1 - September 30, 2016), we assessed the baseline kidney transplantation referral rate at our outpatient nephrology clinic for patients 18 - 75 years old with an estimated glomerular filtration rate (eGFR) of less than 20 mL/min/1.73m 2 (2 values over 90 days apart). Charts were manually reviewed by two reviewers to look for kidney transplant referrals and documentation of discussions about kidney transplantation. We then performed a root cause analysis to explore potential barriers to kidney transplantation. Our intervention began on July 1, 2017 and included the implementation of a column in the electronic medical record (EMR) which displayed the patient's last eGFR as part of the clinic schedule. Physicians were given a document listing their patients to be seen that day with an eGFR of < 20 mL/min/1.73m 2 . Results: 54 unique patients with eGFR ≤ 20 ml/min/1.73 m 2 were identified who were seen in the Clinic between July 1, 2016 and September 30, 2016. 29.6% (16) eligible patients were referred for kidney transplantation evaluation. 69.5% (37) of these patients were not referred for kidney transplant evaluation. 46.3% (25) did not have documentation regarding kidney transplant in the EMR. Following the intervention, 66 unique patients met criteria for eligibility for kidney transplant evaluation. Kidney transplant referrals increased to 60.6% (p < 0.001). Conclusions: Our pilot implementation study of a strategy to improve outpatient kidney transplant referrals showed that a free, simple, scalable intervention can significantly improve kidney transplant referrals in the outpatient setting Next steps include further study of the impact of early referral to kidney transplant centers on preemptive and living donor kidney transplantation as well as successful waitlisting.

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Health Disparities in Kidney Transplantation for African Americans

Cited by 71 publications

References 65 publications

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

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

Transplant center assessment of the inequity in the kidney transplant process and outcomes for the Indigenous American patients

Implementation of a Quality Improvement Strategy to Increase Outpatient Kidney Transplant Referrals

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