Deceased-Donor Kidney Transplant Inequity Causes Vary by Ethnicity

Jim Kling

March 09, 2011

March 9, 2011 — Rates of deceased-donor kidney transplants are significantly lower among ethnic minorities than among whites, according to a study published online March 3 in the Journal of the American Society of Nephrology.

Previous studies have noted inequities in the United States in receiving deceased donor kidney transplants between racial ethnic minorities and non-Hispanic whites.

Studies have also been conducted to identify the factors that lead to low rates of wait-listing and low rates of deceased donor transplantation after wait-listing, but these have focused primarily on black Americans. No studies have looked at race-specific factors that might lead to reduced access or delayed completion of deceased donor kidney transplantation among the various racial ethnic groups in the United States.

To better understand the factors that might explain inequities, Yoshio N. Hall, MD, from the Kidney Research Institute, Department of Medicine, University of Washington, Seattle, and colleagues examined 503,090 nonelderly adults who initiated hemodialysis between 1995 and 2006, with follow-up through 2008. Time to transplant was split into time to wait-listing and time from wait-listing to transplantation to examine influence of race- or ethnicity-specific factors on each component.

American Indians/Alaskan Natives (AlANs) had the lowest annual rates of deceased donor transplantation from the time of dialysis initiation (2.4%). Blacks had a rate of 2.8%, Pacific Islanders 3.1%, and Hispanics 3.2%. Higher rates were seen in whites (5.9%) and Asians (6.4%).

When the researchers adjusted for individual-level clinical factors and individual- and Zip code–level sociodemographic factors, the relationships were attenuated in all groups except Asians. There was a wide variation in the amount that reduced rates of transplantation could be attributable to measured factors (as low as 14% in blacks and as high as 43% in AlANs).

Health insurance coverage and poverty were the biggest factors in disparity of transplant rates among blacks (17.9%; 95% confidence interval [CI], 17.0 - 18.8), Hispanics (14.3%; 95% CI, 13.4 - 15.1), and AlANs (23.2%; 95% CI, 21.3 - 25.2). Geographic variation in organ availability was an important factor among Hispanics (13.5%; 95% CI, 12.7 - 14.3) and Pacific Islanders (19.1%; 95% CI, 16.1 - 22.1), as was household linguistic isolation (Hispanics, 7.0% [95% CI, 6.0 - 8.0]; Pacific Islanders, 6.2% [95% CI, 5.3 - 7.1]). Linguistic isolation had little effect among blacks and AIANs.

AlANs and blacks had the lowest annual rates of wait-listing among patients initiating dialysis compared with Hispanics, Pacific Islanders, whites, and Asians. Health insurance coverage and poverty were important factors in reduced rate of wait-listing among blacks (21%; 95% CI, 20% - 22%) and AIANs (26%; 95% CI, 24% - 28%) compared with whites.

Compared with time to wait-list, longer time spent on the transplant wait-list seemed to be a stronger factor in the lower rates of deceased donor transplantation seen in most racial ethnic groups. Non-Hispanic whites had transplant rates more than 40% higher than any other group.

Bootstrap analyses showed that the effect on delay to transplantation attributed to measured factors ranged from 8% in blacks to 78% in Hispanics. Histocompability and sensitization had small influences on the delay in transplantation among nonwhites (blacks, 8%; Asians, 3%; Hispanics, 7%; Pacific Islanders, 2%; AIANs, 10%). Household linguistic isolation also had a small effect among wait-listed Asians (7%), Hispanics (9%), and Pacific Islanders (8%). A larger influence was seen from geographic differences in organ availability (AlANs, 24%; Hispanics, 16%; Pacific Islanders, 16%). Health insurance coverage had little effect.

Overall, the study suggests that blacks and AlANs face obstacles in accessing the transplant wait-list, primarily because of socioeconomic factors, whereas Hispanics, Asians, and Pacific Islanders are affected more by delays from the wait-list resulting from regional organ availability, linguistic isolation, and possibly cultural isolation. "Regional- and center-level efforts targeted to address local racial ethnic specific delays in transplantation may help to reduce overall disparities in kidney transplantation," the authors write.

The study was funded by the Norman S. Coplon Extramural Grant Program of Satellite Healthcare. One author receives royalties from UpToDate and grant funding from the National Institute of Aging. Two other authors receive grant funding from the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institutes of Health, respectively. The remaining authors have disclosed no relevant financial relationships.

J Am Soc Nephrol. Published online March 3, 2011.

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