U.S. NEPHROLOGISTS??? ATTITUDES TOWARDS RENAL TRANSPLANTATION: RESULTS FROM A NATIONAL SURVEY (original) (raw)
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Transplantation, 2014
We aimed to describe nephrologists' attitudes to patients' access to kidney transplantation. Studies that assessed nephrologists' perspectives toward patient referral, screening, and eligibility for kidney transplantation were synthesized. Twenty-four studies (n≥4695) were included. Patients with comorbidities, were nonadherent, of older age, ethnic minorities, or low socioeconomic status were less likely to be recommended. Six themes underpinned nephrologists' perspectives: prioritizing individual benefit and safety, maximizing efficiency, patient accountability, justifying gains, protecting unit outcomes, and reluctance to raise patients' expectations. Evidence-based guidelines may support systematic and equitable decision-making. Interventions for high-risk or disadvantaged patient populations could reduce disparities in access to transplantation.
Trends in kidney transplantation rates and disparities
Journal of the National Medical Association
To examine the likelihood of transplantation and trends over time among persons with end-stage renal disease (ESRD) in Wisconsin. We examined the influence of patient- and community-level characteristics on the rate of kidney transplantation in Wisconsin among 22,387 patients diagnosed with ESRD between January 1, 1982 and October 30, 2005. We grouped patients by the year of ESRD onset in order to model the change in transplantation rates over time. After multivariate adjustment, all other racial groups were significantly less likely to be transplanted compared with whites, and the racial disparity increased over calendar time. Older patients were less likely to be transplanted in all periods. Higher community income and education level and a greater distance from patients' residence to the nearest dialysis center significantly increased the likelihood of transplantation. Males also had a significantly higher rate of transplantation than females. These results demonstrate a grow...
Patients' views in the choice of renal transplant
Kidney International, 1996
Patients' views in the choice of renal transplant. Little is known about chronic dialysis patients' reasons for electing renal transplantation. We investigated chronic dialysis patients' reasons for choosing to be listed or not listed for renal transplantation. Chronic dialysis patients were asked to complete a questionnaire consisting of demographic information and questions related to desire for transplantation and previous transplant experience. The mean age of the dialysis population was 48 15 years (range 16 to 81 years); the population was 61% women, 39% African American, and 26% diabetic. The questionnaires of the 95 patients eligible for transplantation were analyzed. Forty-four percent of the eligible patients were active on a transplant waiting list; 56% of patients refused transplantation. Twenty-nine percent of the surveyed patients had had at least one previous transplant. Listed patients were younger (43 vs. 52 years), had fewer years of ESRD (5 vs. 9 years), and were more likely to be on home dialysis therapy (55% vs. 32%). There were no differences between listed and unlisted patients in gender, race, years of education, marital status, children, diabetes mellitus, and previous transplant experience. African American patients reporting strong religious beliefs were less likely to be listed for transplantation (76% vs. 24%); religious beliefs were not related to white patients' listing for transplantation. The most reported reason for electing transplantation was "hoping for a better quality of life" (86% of respondents). More never-transplanted patients elected transplantation "hoping it will make me live longer" (69% vs. 25% with previous transplant) and because their doctor (50% vs. 6%) or family (42% vs. 6%) thought it was a good idea. Of patients who declined transplant, 92% with previous transplant experience indicated that the experience discouraged them from seeking retransplantation; 59% of patients without transplant experience reported that seeing what happened to others with a failed transplant affected their decision not to seek transplantation. Our findings suggest that race and gender differences in electing transplant may disappear when all patients are actively solicited for transplantation. However, older patients may be less likely to elect transplant because they are more satisfied with life on dialysis or less willing to take risks. Further study of patients' reasons for electing transplantation is required before demographic variations in transplant choices can be accurately interpreted.
Non-medical factors influencing access to renal transplantation
International Urology and Nephrology, 2009
Considering the scarcity of available donor kidneys and the increasing number of patients with end-stage renal disease (ESRD) who would potentially benefit from renal transplantation, objective and equitable patient selection and equitable access to renal transplantation bear substantial importance. Inequalities in access to renal transplantation have been extensively documented over the last 2 decades with regard to age, gender, ethnicity, socioeconomic and psycho-social factors. In this paper we review a wide spectrum of social, patient and system-related factors along the transplantation process that may be associated with disparities, and we aim to describe the complex interrelationship between these factors that might influence treatment decisions by patients and health-care professionals. Understanding potentially modifiable barriers to kidney transplantation may allow designing targeted interventions in order to guarantee fair recipient selection and equal access to renal transplantation.
American Journal of Kidney Diseases, 2016
Background: Racial disparities in kidney transplantation in children have been found in the United States, but have not been studied before in Europe. Study Design: Cohort study. Setting & Participants: Data were derived from the ESPN/ERA-EDTA Registry, an international pediatric renal registry collecting data from 36 European countries. This analysis included 1,134 young patients (aged #19 years) from 8 medium-to high-income countries who initiated renal replacement therapy (RRT) in 2006 to 2012. Factor: Racial background. Outcomes & Measurements: Differences between racial groups in access to kidney transplantation, transplant survival, and overall survival on RRT were examined using Cox regression analysis while adjusting for age at RRT initiation, sex, and country of residence. Results: 868 (76.5%) patients were white; 59 (5.2%), black; 116 (10.2%), Asian; and 91 (8.0%), from other racial groups. After a median follow-up of 2.8 (range, 0.1-3.0) years, we found that black (HR, 0.49; 95% CI, 0.34-0.72) and Asian (HR, 0.54; 95% CI, 0.41-0.71) patients were less likely to receive a kidney transplant than white patients. These disparities persisted after adjustment for primary renal disease. Transplant survival rates were similar across racial groups. Asian patients had higher overall mortality risk on RRT compared with white patients (HR, 2.50; 95% CI, 1.14-5.49). Adjustment for primary kidney disease reduced the effect of Asian background, suggesting that part of the association may be explained by differences in the underlying kidney disease between racial groups. Limitations: No data for socioeconomic status, blood group, and HLA profile. Conclusions: We believe this is the first study examining racial differences in access to and outcomes of kidney transplantation in a large European population. We found important differences with less favorable outcomes for black and Asian patients. Further research is required to address the barriers to optimal treatment among racial minority groups.
Health Disparities in Kidney Transplantation for African Americans
American journal of nephrology, 2017
The persistent challenges of bridging healthcare disparities for African Americans (AAs) in need of kidney transplantation continue to be unresolved at the national level. This healthcare disparity is multifactorial: stemming from limited kidney donors suitable for AAs; inconsistent care coordination and suboptimal risk factor control; social determinants, low socioeconomic status, reduced access to care; and mistrust of clinicians and the healthcare system. There are numerous opportunities to significantly lessen the disparities in kidney transplantation for AAs through the following measures: the adoption of new care and patient engagement models that include education, enhanced practice-level cultural sensitivity, and timely referral as well as increased research on the impact of the environment on genetic risk, and implementation of new transplantation-related policies. Key Messages: This systematic review describes pretransplant concerns related to access to kidney transplantat...
JAMA Surgery
IMPORTANCE Inactive patients on the kidney transplant wait-list have a higher mortality. The implications of this status change on transplant outcomes between racial/ethnic groups are unknown. OBJECTIVES To determine if activity status changes differ among races/ethnicities and levels of sensitization, and if these differences are associated with transplant probability after implementation of the Kidney Allocation System. DESIGN, SETTING, AND PARTICIPANTS A multistate model was constructed from the Organ Procurement and Transplantation Network kidney transplant database (December 4, 2014, to September 8, 2016). The time interval followed Kidney Allocation System implementation and provided at least 1-year follow-up for all patients. The model calculated probabilities between active and inactive status and the following competing risk outcomes: living donor transplant, deceased donor transplant, and death/other. This retrospective cohort study included 42 558 patients on the Organ Procurement and Transplantation Network kidney transplant wait-list following Kidney Allocation System implementation. To rule out time-varying confounding from relisting, analysis was limited to first-time registrants. Owing to variations in listing practices, primary center listing data were used for dually listed patients. Individuals listed for another organ or pancreatic islets were excluded. Analysis began July 2017. MAIN OUTCOME AND MEASURES Probabilities were determined for transitions between active and inactive status and the following outcome states: active to living donor transplant, active to deceased donor transplant, active to death/other, inactive to living donor transplant, inactive to deceased donor transplant, and inactive to death/other. RESULTS The median (interquartile range) age at listing was 55.0 (18.0-89.0) years, and 26 535 of 42 558 (62.4%) were men. White individuals were 43.3% (n = 18 417) of wait-listed patients, while black and Hispanic individuals made up 27.8% (n = 11 837) and 19.5% (n = 8296), respectively. Patients in the calculated plasma reactive antibody categories of 0% or 1% to 79% showed no statistically significant difference in transplant probability among races/ethnicities. White individuals had an advantage in transplant probability over black individuals in calculated plasma reactive antibody categories of 80% to 89% (hazard ratio [HR], 1.8 [95% CI, 1.4-2.2]) and 90% or higher (HR, 2.4 [95% CI, 2.1-2.6]), while Hispanic individuals had an advantage over black individuals in the calculated plasma reactive antibody group of 90% or higher (HR, 2.5 [95% CI, 2.1-2.8]). Once on the inactive list, white individuals were more likely than Hispanic individuals (HR, 1.2 [95% CI, 1.17-1.3]) or black individuals (HR, 1.4 [95% CI, 1.3-1.4]) to resolve issues for inactivity resulting in activation. CONCLUSIONS AND RELEVANCE For patients who are highly sensitized, there continues to be less access to kidney transplant in the black population after the implementation of the Kidney Allocation System. Health disparities continue after listing where individuals from minority groups have greater difficulty in resolving issues of inactivity.
Differences in access to cadaveric renal transplantation in the United States
American Journal of Kidney Diseases, 2000
This national study compares waitlisting and transplantation rates by gender, race, and diabetes and evaluates physiologic factors (panel-reactive antibodies [PRA], blood type, HLA matchability) and related practices (early and multiple waitlisting) as explanatory factors. This longitudinal study of the time to transplant waitlisting among 228,552 incident end-stage renal disease (ESRD) dialysis patients and to cadaveric transplantation among 46,164 waitlist dialysis patients (n ؍ 23,275 first cadaveric transplants) used US data for 1991 to 1997. Relative rates of waitlisting (RRWL) after ESRD onset and of cadaveric transplantation (RRTx) after waitlist (Cox proportional hazards models) were adjusted for age, race, sex, ESRD cause, region, and incidence/waitlist year. We found that women have an RRWL ؍ 0.84 (P < 0.0001) and RRTx ؍ 0.86 (P < 0.0001). PRA levels can explain the difference in the transplantation rate, because accounting for PRA gives an adjusted RRTx ؍ 0.98 (NS) for women. For blacks versus whites, the RRWL ؍ 0.59 (P < 0.0001) and RRTx ؍ 0.55 (P < 0.0001). However, the transplantation rate can only partly be explained by ABO types, rare HLA types, and early and multiple waitlisting (adjusted RRTx ؍ 0.67 [P < 0.0001]). For diabetes versus glomerulonephritis, the RRWL ؍ 0.52 (P < 0.0001) and RRTx ؍ 0.98 (NS). Older patients (40 to 59 years of age) are less likely to be waitlisted and to receive a transplant after waitlisting (RRWL ؍ 0.57 [P < 0.0001], RRTx ؍ 0.88 [P < 0.0001]) versus younger patients (ages 18 to 39 years). These results indicate substantial differences by age, sex, race, and diabetes in rates of waitlisting for transplantation and by age and race for transplantation after waitlisting. These differences by race were not explained by referral practices or the physiologic factors studied here.
Racial and Socioeconomic Disparities in the Allocation of Expanded Criteria Donor Kidneys
Clinical Journal of the American Society of Nephrology, 2013
Background and objectives In carefully selected individuals, receiving expanded criteria donor (ECD) kidneys confer a survival advantage over remaining on dialysis. However, wait lists for ECD kidneys often include a significant proportion of young patients, who have no predictable survival benefit from ECD kidneys. This study hypothesized that educational and socioeconomic factors might influence a younger patient's decision to accept an ECD kidney.