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

Abstract

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.

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

“…These results strongly imply that factors beyond clinical factors have a strong association with timely preemptive care. The impact of broader accountable care or universal care models for attenuating racial disparities is not clear, but it is notable that inequities in income‐level and racial/ethnic disparities among kidney disease patients persist in countries with less fragmented organizational structure . In addition, patients who listed preemptively or early after ESRD initiation for primary transplantation had higher rates of PRLT, suggesting that factors such as seeking care proactively, access to providers, and disinclination to dialysis persist for access to repeat transplantation.…”

“…24,31 These associations may be ex- F I G U R E 3 Cumulative incidence of placement on the waiting list for kidney transplantation following graft failure from primary transplant by era (preemptive placements and deaths prior to graft failure are not included in cumulative incidence models; cumulative incidence function is based on 53% of centers with standardized re-lisƟng/transplant rates staƟsƟcally significantly < 1 34% of centers with standardized re-lisƟng/transplant rates staƟsƟcally significantly >1 Standardized incidence RaƟo that inequities in income-level and racial/ethnic disparities among kidney disease patients persist in countries with less fragmented organizational structure. [34][35][36][37][38][39] In addition, patients who listed preemptively or early after ESRD initiation for primary transplantation had higher rates of PRLT, suggesting that factors such as seeking care proactively, access to providers, and disinclination to dialysis persist for access to repeat transplantation.…”

Knowledge, Perception and Attitude of Indian Maintenance Hemodialysis Patients toward Renal Transplantation

“…North Indian population unlike their southern counterparts have lesser enthusiasm for diseased organ donation, primarily because of superstitions and lack of awareness. Other regions in the world too have their own set of unique challenges, like religious misbeliefs affect deceased donations in Islamic population, [12,13] racial bias affecting African Americans ESRD population, [14,15] and bias affected females and old aged MHD patients. [14][15][16] The pain and uncertainties of patient on deceased donor waiting list is heartbreaking.…”

Commentary: Do you live in a distressed community? How do you know? What does this mean? What are the risks? How do you get help?

“…Most, but not all, common medical and surgical disorders have worse outcomes in patients from distressed communities ( Table 1). [8][9][10][11][12][13][14][15][16][17][18][19][20][21] DOES LIVING IN A DISTRESSED COMMUNITY CAUSE WORSE OUTCOMES FROM SURGICAL PROCEDURES? Table 1 suggests that living in a distressed community is associated with worse outcomes from many medical disorders and from surgical interventions.…”

“…Kidney transplant 15 Breast cancer initial treatment 16 Lower extremity revascularization 17 Pancreatic cancer 18 CABG readmissions 19…”