The Combined Roles of Race/Ethnicity and Substance Use in Predicting Likelihood of Kidney Transplantation

Abstract

Original Clinical Science-General Background. Racial/ethnic minorities face known disparities in likelihood of kidney transplantation. These disparities may be exacerbated when coupled with ongoing substance use, a factor also reducing likelihood of transplantation. We examined whether race/ethnicity in combination with ongoing substance use predicted incidence of transplantation. Methods. Patients were enrolled between March 2010 and October 2012 at the time of transplant evaluation. Substance use data were retrieved from transplant evaluations. Following descriptive analyses, the primary multivariable analyses evaluated whether, relative to the referent group (White patients with no substance use), racial/ethnic minority patients using any substances at the time of evaluation were less likely to receive transplants by the end of study follow-up (August 2020). Results. Among 1152 patients, 69% were non-Hispanic White, 23% non-Hispanic Black, and 8% Other racial/ethnic minorities. White, Black, and Other patients differed in percentages of current tobacco smoking (15%, 26%, and 18%, respectively; P = 0.002) and illicit substance use (3%, 8%, and 9%; P < 0.001) but not heavy alcohol consumption (2%, 4%, and 1%; P = 0.346). Black and Other minority patients using substances were each less likely to receive transplants than the referent group (hazard ratios ≤0.45, P ≤ 0.021). Neither White patients using substances nor racial/ethnic minority nonusers differed from the referent group in transplant rates. Additional analyses indicated that these effects reflected differences in waitlisting rates; once waitlisted, study groups did not differ in transplant rates. Conclusions. The combination of minority race/ethnicity and substance use may lead to unique disparities in likelihood of transplantation. To facilitate equity, strategies should be considered to remove any barriers to referral for and receipt of substance use care in racial/ethnic minorities.

Disparities in Kidney Transplant Waitlisting Among Young Patients Without Medical Comorbidities

“…Additionally, requiring centers to report why patients referred for transplant evaluation were denied waitlisting is necessary to understand the degree to which nonmedical contraindications to transplant—including subjective assessments of risk of posttransplant nonadherence or inadequate social support—are applied unevenly to patients with lower socioeconomic status and/or minority race . For example, prior investigations have shown that factors such as a history of substance use are more likely to cause Black kidney transplant candidates to be denied waitlisting compared with White candidates. The disparate application of these subjective criteria to the detriment of the candidacy of racially minoritized patients is an example of structural racism and is consistent with data from a broad range of health care scenarios demonstrating that implicit practitioner bias has detrimental impacts on the management and outcomes of minoritized patients …”

Recentering Accountability for Disparities in Kidney Transplant Access

“…Adding evidence to this finding is the prior demonstration that subjective assessments of relative contraindications to transplantation-such as substance use or low social support-are applied unequally by transplant centers to Black patients in a manner that deprives these patients of waitlist access. 6,7 Differential access to high-quality dialysis facilities with characteristics that may increase the likelihood of transplant referral, such as favorable staffing ratios of staff and social workers, might also influence the likelihood of receiving the educational counseling and support needed to initiate a complete a transplant evaluation.…”

Double Standards and Double Jeopardy: The Unintended Consequence of Policy Regarding Substance Use in Potential Kidney Transplant Candidates

“…The fact that substance use was more prevalent in minority patients in this study further compounds the degree of disparity, introducing a "double jeopardy" effect in which additional disadvantage is added to a group already with diminished access to transplant. 10 Having identified this disparity, we are now tasked with finding the best way to combat it. A reexamination of transplant center policies regarding marijuana use appears to be a reasonable place to start, given the prevalence of use and lack of clear and consistent evidence of harm.…”

“…As noted by the authors as well as Alhamad et al's, extra support and education must be marshaled on behalf of the most vulnerable populations with both a greater prevalence of substance use and less access to transplant. 8,10 Only when we can overcome the stigma attached to substance use and provide patients with the resources they need to overcome the barrier of dependence will we as a transplant community be able to achieve equity for our patients in this matter.…”

“…In this issue of Transplantation , DeBlasio et al 10 describe an insidious effect of blanket denial of transplantation to substance users. 10 In a single-center study examining 1152 patients referred for kidney transplant evaluation, the authors found that Black and other minority patients who used substances were less than half as likely to undergo transplantation than White nonusers. White substance users, on the other hand, had no significant difference in the cumulative incidence of transplantation from White nonusers, nor did Black and other minority nonusers.…”