Springboard Needed to Boost Access to Living Donor Kidney Transplants

Nancy A. Melville

February 05, 2021

A new study indicates numerous ways in which transplant teams can try to reduce disparities that currently mean that Black patients are far less likely than Whites to receive a kidney transplant from a living donor.

"To the best of our knowledge, ours is the first prospective examination of the influence of a comprehensive set of social determinants of health on undergoing kidney transplantation in a large population," say Hannah Wesselman, PhD candidate, University of Notre Dame, Indiana, and colleagues in their article published online in the Clinical Journal of the American Society of Nephrology.

"This body of work offers a springboard for development of new interventions that promote equitable and effective transplantation care for all patients with kidney failure," they stress.

In an accompanying "patient voice" article, Monica Fox, who is director of outreach and government relations for the National Kidney Foundation of Illinois, in Flossmoor — and herself is the recipient of a deceased donor kidney transplant after 3 years on hemodialysis — says the new study sheds light on the racial disparities and social factors surrounding transplantation.

"Education, community-based workshops, and awareness campaigns will help to increase the number of Black people who receive living and deceased donations," as well as support with "finances, transportation, psychosocial issues, and family," she urges. 

Blacks Half as Likely as Whites to Receive Organ From Living Donor

People who are non-Hispanic or Black are as much as four times more likely to have kidney disease yet only half as likely to undergo kidney transplantation — the best treatment for kidney failure — compared with White patients.

And these disparities have been observed at every stage of transplantation, including in waitlisting for a transplant, even after adjusting for medical differences and comorbidities such as diabetes and obesity, say Wesselman and colleagues, by way of background. In 2014, changes were made to the Kidney Allocation System in the United States that were designed to improve allocation of deceased donor organs.

But Black patients are also much less likely to receive kidneys from living donors, which are associated with better patient and graft survival compared with deceased donor transplantation.

To better understand the factors underlying these disparities — specifically in receiving a transplant and type of transplant — Wesselman and colleagues evaluated data on 1056 patients referred for kidney transplantation at the University of Pittsburgh Medical Center (UPMC), Pennsylvania, between 2010 and 2012 and followed through 2018.

Patients were interviewed when being evaluated for kidney transplant and were followed via their electronic medical records until they received a kidney transplant (at UPMC or another center) or they withdrew from the waitlist, their evaluation was ongoing, they were still awaiting transplant, or they died.

After multivariate adjustment that included numerous social determinants of health, Black patients were significantly less likely than White patients to undergo kidney transplantation (38% vs 24%; hazard ratio [HR], 0.74). This difference seemed to be mostly explained by the fact that Black patients were half as likely to receive a transplant from a living donor compared with Whites (HR, 0.49). No significant racial differences were observed in deceased-donor transplantation (HR, 0.92).

Black race, older age, lower income, public insurance, higher rate of comorbidities, and being transplanted before changes to the Kidney Allocation System in 2014 were all significantly associated with a lower probability of any kidney transplant. Religiosity, less social support, and less transplant knowledge were also associated with a lower probability of any transplant.  

Specific factors further associated with a lower probability of a living donor transplant included Black race, older age, lower income, public insurance, higher body mass index, dialysis prior to kidney transplant, not presenting with a potential living donor, religious objection to a living-donor transplant, and lower transplant knowledge.

Too Many Opportunities for Living Donors to Be Deterred

These new findings should help guide policies to better tackle the striking racial disparities that clearly still pervade kidney transplantation, the authors note.

"Developing interventions focused on transplant knowledge, religious objection to living-donor transplant, and social support may enhance equal access to kidney transplant because transplant teams can use these risk factors to target patients who may need more support to ensure they receive a transplant," they write.

Fox notes that the findings that only 18% of Black patients received a transplant and Black patients made up only 10% of those receiving living donor transplants requires urgent action.

"In addition to more education about living donation, there needs to be some systematic changes in the process of living donation."

For example, she describes knowing a prospective living donor who, upon submitting his information, was simply told to "lose some weight and call us back," without having been seen or given guidance on weight loss. He ultimately did not follow through.

"There are too many opportunities for living donors to be eliminated or deterred," Fox writes.

Furthermore, "although the 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," Fox asserts.

The study received funding from the National Institute of Diabetes and Digestive and Kidney Diseases, National Center for Advancing Translational Sciences, and Dialysis Clinic.

Clin J Am Soc Nephrol. Published online January 28, 2021. Full text

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