Racial-Ethnic Gap in Living Donor Kidney Transplantation Widens

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New findings suggest that national strategies have failed to correct racial/ethnic disparities in live donor kidney transplantation.
New findings suggest that national strategies have failed to correct racial/ethnic disparities in live donor kidney transplantation.

From 1995 to 2014, racial and ethnic disparities in living donor kidney transplantation have increased despite national efforts to narrow the gap, according to a new study.

Of 453,162 first-time adult candidates (mean age 50.9 years; 39% women) on the Scientific Registry of Transplant Recipients (SRTR), receipt of a kidney from a living donor within 2 years on the waiting list increased from 7.0% to 11.4% among white patients and from 5.1% to 5.6% among Asian patients from 1995 to 2014. Black and Hispanic candidates were less fortunate. Receipt of a living donor kidney decreased from 3.4% to 2.9% among blacks and from 6.8% to 5.9% among Hispanics over the same period, a team led by Dorry L. Segev, MD, PhD, of Johns Hopkins Medical Institutions in Baltimore, reported in the Journal of the American Medical Association (2018;319:49-61).

During 1995–1999, black, Hispanic, and Asian patients were 55%, 17%, and 44% less likely to receive a kidney from a living donor, respectively, compared with white patients, according to Cox regression models. By 2010–2014, black, Hispanic, and Asian patients were 73%, 48%, and 58% less likely to receive living donor kidneys, respectively.

The investigators adjusted the models for age, sex, body mass index, panel reactive antibody, and ABO blood type. In separate analyses, the team also considered deaths and deceased donor kidney transplantation as competing events. From 1995 to 2014, deaths and deceased donor kidney transplantation declined proportionally across ethnic groups as the numbers of patients on the waiting list grew. Moreover, a 2003 policy change by the United Network for Organ Sharing removing the priority given to patients with HLA-B matching reduced ethnic disparities in deceased donor transplantation, the team noted.

Exploratory models revealed that health care access and socioeconomic status were more influential than transplantation center factors in reducing ethnic disparities. Socioeconomic status touches on various areas, such as education and health insurance coverage. To improve health literacy, the investigators suggested culturally specific patient education and services for living kidney donation.

“These findings suggest that national strategies for addressing disparities in receipt of live donor kidney transplantation should be revisited,” Dr Segev and his colleagues concluded. 

The race/ethnicity makeup of the study population was 48% white, 30% black, 16% Hispanic, and 6% Asian. Dr Segev's team noted that their study was limited by the variables available in the SRTR, including clinician-reported race/ethnicity and comorbidities,“which has some potential for misclassification bias.” Another limitation was the inability to further subcategorize the broad racial/ethnic categories available in the national registry “to identify unique barriers to live donor kidney transplantation in more disadvantaged racial/ethnic subgroups,” they wrote. The investigators also noted that they could not account for individual-level patient income. They stated that “the future availability of individual-level income in national registries would allow researchers to better delineate the extent to which trends in individual-level income may have contributed to changes in racial/ethnic disparities in live donor kidney transplantation.”

“Despite improvements in disparities related to access to the waiting list and deceased donor kidney transplantation rates among black and Hispanic patients, large disparities in live donor kidney transplantation rates remain,” Colleen L. Jay, MD, and Francisco G. Cigarroa, MD, of the University of Texas Health Science Center in San Antonio, stated in an accompanying editorial. “Factors related to lower socioeconomic status and current economic pressures stand strikingly at the forefront of barriers to improving these disparities. Efforts to improve financial neutrality for living donors may in fact also contribute greatly to mitigating disparities still existing according to race/ethnicity.”

References

Purnell TS, Luo X, Cooper LA, et al. Association of race and ethnicity with live donor kidney: Transplantation in the United States from 1995 to 2014. JAMA. 2018;319:49-61. doi:10.1001/jama.2017.19152

Jay CL, Cigarroa FG. Disparities in live donor kidney transplantation related to poverty, race, or ethnicity? JAMA. 2018:319:24-26. doi:10.1001/jama.2017.19617

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