Ethnic and Racial Disparities in Accessibility to Kidney Transplants

The researchers report systemic and individual barriers contribute to disparities across the kidney transplant care continuum. 

A recent study in The Lancet Regional Health-Americas analyzed ethnic and racial inequalities across the kidney transplantation (KT) care continuum. They assessed discrepancies in information, listing, and receipt of a kidney transplant following the 2015-2020 Kidney Allocation System in the United States (US).

Background

Health professionals consider renal transplantation as the most effective therapy for advanced renal illness. Transplantation improves the survival and living standard of renal disease patients.

Over the last 20 years, researchers have tried to eliminate ethnic and racial inequities in the renal transplantation care continuum, including addressing gaps in knowledge and introducing the 2014 Kidney Allocation System. However, preliminary data indicates that the measures have not considerably reduced ethnic and racial gaps.

Identifying the particular stages of the transplantation care continuum where discrepancies occur among minority groups is critical for attaining fairness. Intervention techniques suited to every ethnic and racial group are crucial to optimizing the allocation of resources and enhancing transplantation results on a large scale.

About the study

In the present study, researchers identified stages of the kidney transplant treatment continuum in which ethnic and racial inequities emerged after the implementation of the Kidney Allocation System.

The study included adults with advanced renal illness from January 2015 to December 2020, with follow-ups till December 10, 2021. The sample population comprised 637,951 individuals with advanced renal illness initiating dialysis (the dialysis population) and 98,561 listed for renal transplants (the listed population). Adults initiating dialysis quantified access to the listing. Adults listed for kidney transplantation quantified accessibility to transplants among listed individuals.

The study exposures included ethnicity and race (Asians, Blacks, Hispanics, and Whites). The study outcomes included the likelihood of listing after the dialysis initiation and the probability of renal transplant receipt after listing. The researchers assessed the outcomes using the US Renal Data Systems (USRDS).

The Centers for Medicare and Medicaid Services (CMS) report provided data on participants’ knowledge of KT choices during dialysis initiation, body mass index (BMI), job status, and comorbidities. The Organ Procurement and Transplantation Network (OPTN) and CMS provided waitlist data.

The team used modified Poisson regressions to quantify the adjusted prevalence ratios (aPRs) for receiving information on kidney transplantation. Specific-cause hazard models calculated the adjusted hazard ratios (aHR) of listing and receiving kidney transplants after listing.

Researchers adjusted for the following covariates: age, sex, BMI, comorbidities, dialysis year, listing year, Medicare coverage, cause of advanced renal illness, blood group, alcohol intake, tobacco use, and panel reactive antibodies.

The sensitivity analyses used fine and gray models and time-varying specific-cause hazard models. The study population comprised Medicare beneficiaries and individuals listed before initiating dialysis (pre-emptively listed individuals). The researchers analyzed Asian Americans, Pacific Islanders, and Native Hawaiians separately using a composite measure of transplant listing and receipt in the dialysis population.

Results

In the dialysis population, the mean participant age was 64 years; 42% were female, 5.4% were Asians, 26% were Blacks, and 52% were Whites. In the listed population, the mean age was 53 years; 37% were female, 7.7% were Asians, 25% were Blacks, and 49% were Whites. In both populations, diabetes mellitus and hypertension were the primary causes of advanced renal illness.

Blacks and Hispanics were modestly more likely to receive renal transplant information (aPR 1.0 for Blacks and Hispanics) than Whites. Asians had a higher listing (aHR, 1.2) but were less likely to receive kidney transplants (aHR, 0.6). Blacks and Hispanics had lower listings (aHR, 0.9 for Blacks and Hispanics) and were less likely to receive kidney transplants (aHR, 0.6 for Blacks and Hispanics).

Asians had an 18% higher probability of receiving a listing but had 44% less accessibility to kidney transplants than Whites. Blacks and Hispanics had lower rates of listing (Blacks: 13%; Hispanics: 14%) and renal transplantation (Blacks: 39%; Hispanics: 36%). Minoritized individuals had significantly lower rates of preemptive-type and live donor renal transplants than Whites.

The most significant inequalities among candidates were for live donor kidney transplantation, with five-year cumulative incidence rates of 30%, 16%, 11%, and 18% for Whites, Asians, Blacks, and Hispanics, respectively. Sensitivity analyses produced similar findings.

Conclusions

Based on the findings, the Kidney Allocation System has increased the chance of minoritized patients receiving information about kidney transplantation, but they still face barriers to undergoing the operation. These discrepancies are most likely due to a complex interaction of individual and systemic variables.

The study emphasizes the critical need for personalized treatments to address the distinct challenges encountered by each ethnic and racial group along the renal transplantation care continuum.

Future research should identify minority-specific problems, evaluate patient-provider interactions, and adopt ethnic and racial-specific interventions at critical stages of kidney transplant treatment to provide more equal access.