Targeted interventions needed to reduce disparities in kidney transplantation
Finding that race and social determinants of health played a role in patients’ likelihood of receiving a kidney transplant, researchers contended that interventions targeting specific patients are needed.
“Non-Hispanic Black patients (Blacks) are four times more likely than non-Hispanic white patients (whites) to have kidney disease but only half as likely to undergo kidney transplantation, the optimal treatment for kidney failure,” Hannah Wesselman, BS, of the department of biological sciences at the University of Notre Dame, and colleagues wrote. “Previous studies emphasized the multifactorial nature of disparities in kidney treatment. Blacks have disproportionately lower rates of living-donor kidney transplant, which offers superior patient and allograft survival rates compared to deceased-donor kidney transplant.”
As, the researchers elaborated, “racial disparities in kidney transplant persist even after accounting for medical differences (eg, diabetes, obesity hypertension),” it is important to understand the relationship between social determinants of health (such as demographics, culturally related factors, transplant knowledge and psychosocial characteristics) and receipt of transplant.
To this end, researchers followed 1,056 patients who were referred for kidney transplant between 2010 and 2012.
After accounting for social determinants of health, Black patients had a lower likelihood of kidney transplant (subdistribution hazard ratio [SHR] = 0.74) and living-donor transplant (SHR =0.49), though they were not less likely to receive a deceased-donor transplant (SHR = 1.26).
More specifically, researchers found Black race, older age, lower income, public insurance, more comorbidities, being transplanted pre-Kidney Allocation System, greater religiosity, less social support, less transplant knowledge and fewer learning activities were associated with a lower probability of receiving any kidney transplant.
“Our data suggest a critical need for transplant centers to identify and intervene on social determinants for at-risk populations,” Larissa Myaskovsky, PhD, of the University of New Mexico Health Sciences Center, said in a related press release. “Based on our findings, developing interventions that target patients with low transplant knowledge, religious objection to living-donor transplant, or poor social support may enhance equal access to kidney transplantation because transplant teams can use these risk factors to target patients who may need more support to ensure they receive a transplant.”
In an accompanying patient voice, Monica Fox, director of outreach and government relations for the National Kidney Foundation of Illinois, wrote that for many people, having end-stage kidney disease and not being able to stop dialysis due to lack of transplant access is a “perplexing and dangerous dilemma.” As a Black woman who received a deceased donor transplant after being on hemodialysis for 3 years, Fox acknowledged that “everyone is not so lucky.”
“I am troubled and saddened by the findings,” she wrote. “I cannot help but wonder why it is that if Blacks are four times more likely than whites to have kidney disease, then why were they only 25% of the people in this study? Although Blacks were 25% of the total study participants, 25% died and 35% were censored, while only 18% were transplanted. The answer about so few transplants seems to point to the stark contrast in living donors. Of those that received living donor transplants, Blacks make up less than 10%. It is my opinion that in addition to more education about living donation there need to be some systematic changes to the process of living donation.”
Further, she added, “While this study focused on people who were in the transplant process, there are many people on dialysis who would be great transplant candidates if they had more education and support.”