Racial disparities in access to transplant continue after implementation of new kidney allocation system
Despite implementation of the kidney allocation system, racial disparities continue in access to transplant, with white patients being more likely than black or Hispanic patients to resolve issues of inactivity on the waitlist, according to a recently published study.
“Disparities in access to health care continue after a person is listed for a kidney transplant,” Sanjay Kulkarni, MD, MHCM, FACS, associate professor of surgery and medicine, surgical director of the kidney transplant program, medical director of the Center for Living Organ Donors and scientific director of Yale Transplant Research at the Yale School of Medicine, told Healio/Nephrology. “This translates into a greater proportion of Hispanics and blacks that remain inactive on the kidney transplant waitlist and have a harder time becoming active compared to white patients. A waitlisted patient cannot receive kidney transplant offers while inactive, and inactive status is an independent predicator of death on the waitlist. Our study is the first to describe differences on how patient status changes over time and how this impacts their probability of obtaining a transplant.”
To determine if activity status changes varied among races/ethnicities and levels of sensitization, as well as if these differences were associated with transplant probability, researchers conducted a cohort study of 42,558 patients who were waitlisted for kidney transplant from the time the kidney allocation system was implemented to at least 1 year of follow-up (median age, 55; 62.4% were men; 43.3% were white; 27.8% were black; 19.5% were Hispanic). Using a semiparametric, multistate model, researchers calculated probabilities between active and inactive status and outcomes including living donor transplant, deceased donor transplant and death/other.
Researchers found that while patients in the calculated plasma reactive antibody categories of 0% or 1% to 79% did not differ in transplant probability, white patients had an advantage over black patients in the categories of 80% to 89% (HR = 1.8) and 90% or higher (HR = 2.4) and Hispanic patients had an advantage over black patients in the 90% or higher category (HR = 2.5).
In addition, researchers found that, once on the inactive list, white patients were more likely than Hispanic patients (HR = 1.2) or black patients (HR = 1.4) to resolve issues of inactivity, thus becoming active.
“Better care coordination between transplant centers and dialysis units is needed to resolve issues of inactivity and get patients ready for transplant,” Kulkarni said. “We provide a new performance metric (odds of going from inactive to active status) as a way to measure how dialysis units and transplant centers coordinate care for inactive patients.”
In a related commentary, Madison C. Cuffy, MD, MBA, and Shimul A. Shah, MD, MHCM, both of Solid Organ Transplantation, department of surgery, at the University of Cincinnati College of Medicine in Ohio, wrote: “The data presented remind us that despite having a post-kidney allocation system in place, disparities exist and need to be consistently re-examined. With kidney transplant being the optimal treatment for end-stage renal disease and the discrepancy between organ supply and demand increasing, the need for a system that still continues to address ‘equitable access and allocation’ is imperative. The data did not address the reasons for status changes and solutions to address inactivity status on the waitlist, which will need to be explored. As the authors suggest, monitoring status changes as a quality measure for transplant centers may be a metric to consider for underserved populations.” – by Melissa J. Webb
Disclosures: Kulkarni reports receiving grants from Alexion Pharmaceuticals. The other authors report no relevant financial disclosures.