Strategies Ineffective for Addressing Racial and Ethnic Disparities in Live Donor Kidney Transplants

National strategies for reducing racial and ethnic disparities among patients waiting for kidney transplants from live donors have been ineffective, according to AHRQ-funded research findings in JAMA. Legislation over the past two decades has aimed to reduce economic barriers for potential living donors, increase knowledge to change beliefs and attitudes about the importance of living donation and improve clinical techniques. To assess the initiatives’ effectiveness, researchers analyzed the status of more than 450,000 adult first-time kidney transplant candidates between January 1995 and December 2014. They found that the likelihood of receiving a kidney within two years of getting on a transplant list increased for both whites (from 7.0 percent to 11.0 percent) and Asians (5.1 percent to 5.6 percent), but decreased for blacks (3.4 percent to 2.9 percent) and Hispanics (6.8 percent to 5.9 percent). Researchers recommended programs to overcome cultural barriers to live donor kidney transplantation in the Hispanic community, policies to standardize and increase the availability of kidney exchanges, and collaboration between researchers and patient advocates. Access the abstract.

2018 Jan 2;319(1):49-61. doi: 10.1001/jama.2017.19152.

Association of Race and Ethnicity With Live Donor Kidney Transplantation in the United States From 1995 to 2014.

Purnell TS1,2,3,4, Luo X1, Cooper LA2,3,4,5, Massie AB1,2, Kucirka LM1,2, Henderson ML1, Gordon EJ6, Crews DC4,7, Boulware LE8, Segev DL1,2.

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Abstract

IMPORTANCE:

Over the past 2 decades, there has been increased attention and effort to reduce disparities in live donor kidney transplantation (LDKT) for black, Hispanic, and Asian patients with end-stage kidney disease. The goal of this study was to investigate whether these efforts have been successful.

OBJECTIVE:

To estimate changes over time in racial/ethnic disparities in LDKT in the United States, accounting for differences in death and deceased donor kidney transplantation.

DESIGN, SETTING, AND PARTICIPANTS:

A secondary analysis of a prospectively maintained cohort study conducted in the United States of 453 162 adult first-time kidney transplantation candidates included in the Scientific Registry of Transplant Recipients between January 1, 1995, and December 31, 2014, with follow-up through December 31, 2016.

EXPOSURES:

Race/ethnicity.

MAIN OUTCOMES AND MEASURES:

The primary study outcome was time to LDKT. Multivariable Cox proportional hazards and competing risk models were constructed to assess changes in racial/ethnic disparities in LDKT among adults on the deceased donor kidney transplantation waiting list and interaction terms were used to test the statistical significance of temporal changes in racial/ethnic differences in receipt of LDKT. The adjusted subhazard ratios are estimates derived from the multivariable competing risk models. Data were categorized into 5-year increments (1995-1999, 2000-2004, 2005-2009, 2010-2014) to allow for an adequate sample size in each analytical cell.

RESULTS:

Among 453 162 adult kidney transplantation candidates (mean [SD] age, 50.9 [13.1] years; 39% were women; 48% were white; 30%, black; 16%, Hispanic; and 6%, Asian), 59 516 (13.1%) received LDKT. Overall, there were 39 509 LDKTs among white patients, 8926 among black patients, 8357 among Hispanic patients, and 2724 among Asian patients. In 1995, the cumulative incidence of LDKT at 2 years after appearing on the waiting list was 7.0% among white patients, 3.4% among black patients, 6.8% among Hispanic patients, and 5.1% among Asian patients. In 2014, the cumulative incidence of LDKT was 11.4% among white patients, 2.9% among black patients, 5.9% among Hispanic patients, and 5.6% among Asian patients. From 1995-1999 to 2010-2014, racial/ethnic disparities in the receipt of LDKT increased (P < .001 for all statistical interaction terms in adjusted models comparing white patients vs black, Hispanic, and Asian patients). In 1995-1999, compared with receipt of LDKT among white patients, the adjusted subhazard ratio was 0.45 (95% CI, 0.42-0.48) among black patients, 0.83 (95% CI, 0.77-0.88) among Hispanic patients, and 0.56 (95% CI, 0.50-0.63) among Asian patients. In 2010-2014, compared with receipt of LDKT among white patients, the adjusted subhazard ratio was 0.27 (95% CI, 0.26-0.28) among black patients, 0.52 (95% CI, 0.50-0.54) among Hispanic patients, and 0.42 (95% CI, 0.39-0.45) among Asian patients.

CONCLUSIONS AND RELEVANCE:

Among adult first-time kidney transplantation candidates in the United States who were added to the deceased donor kidney transplantation waiting list between 1995 and 2014, disparities in the receipt of live donor kidney transplantation increased from 1995-1999 to 2010-2014. These findings suggest that national strategies for addressing disparities in receipt of live donor kidney transplantation should be revisited.