Identifying when racial and ethnic disparities arise along the continuum of transplant care: a national registry study

Maya N Clark-Cutaia; Gayathri Menon; Yiting Li; Garyn T Metoyer; Mary Grace Bowring; Byoungjun Kim; Babak J Orandi; Stephen P Wall; Melissa D Hladek; Tanjala S Purnell; Dorry L Segev; Mara A McAdams-DeMarco

doi:10.1016/j.lana.2024.100895

Identifying when racial and ethnic disparities arise along the continuum of transplant care: a national registry study

Lancet Reg Health Am. 2024 Oct 3:38:100895. doi: 10.1016/j.lana.2024.100895. eCollection 2024 Oct.

Authors

Maya N Clark-Cutaia^{1

2}, Gayathri Menon³, Yiting Li³, Garyn T Metoyer³, Mary Grace Bowring⁴, Byoungjun Kim^{3

5}, Babak J Orandi^{2

3}, Stephen P Wall^{2

6}, Melissa D Hladek⁷, Tanjala S Purnell^{4

8

9

10}, Dorry L Segev^{3

5}, Mara A McAdams-DeMarco^{3

5}

Affiliations

¹ Hunter-Bellevue School of Nursing, Hunter College, City University of New York, New York, NY, USA.
² Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA.
³ Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA.
⁴ Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
⁵ Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA.
⁶ Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY, USA.
⁷ Johns Hopkins University School of Nursing, Baltimore, MD, USA.
⁸ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
⁹ Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
¹⁰ Johns Hopkins Center for Health Equity, Johns Hopkins University, Maryland Public Health, Baltimore, MD, USA.

Abstract

Background: Fewer minoritized patients with end-stage kidney disease (ESKD) receive kidney transplantation (KT); efforts to mitigate disparities have thus far failed. Pinpointing the specific stage(s) within the transplant care continuum (being informed of KT options, joining the waiting list, to receiving KT) where disparities emerge among each minoritized population is pivotal for achieving equity. We therefore quantified racial and ethnic disparities across the KT care continuum.

Methods: We conducted a retrospective cohort study (2015-2020), with follow-up through 12/10/2021. Patients with incident dialysis were identified using the US national registry data. The exposure was race and ethnicity (Asian, Black, Hispanic, and White). We used adjusted modified Poisson regression to quantify the adjusted prevalence ratio (aPR) of being informed of KT, and cause-specific hazards models to calculate adjusted hazard ratios (aHR) of listing, and transplantation after listing.

Findings: Among 637,951 adults initiating dialysis, the mean age (SD) was 63.8 (14.6), 41.8% were female, 5.4% were Asian, 26.3% were Black, 16.6% were Hispanic, and 51.7% were White (median follow-up in years [IQR]:1.92 [0.97-3.39]). Black and Hispanic patients were modestly more likely to be informed of KT (Black: aPR = 1.02, 95% confidence interval [CI]:1.01-1.02; Hispanic: aPR = 1.03, 95% CI: 1.02-1.03) relative to White patients. Asian patients were more likely to be listed (aHR = 1.18, 95% CI: 1.15-1.21) but less likely to receive KT (aHR = 0.56, 95% CI: 0.54-0.58). Both Black and Hispanic patients were less likely to be listed (Black: aHR = 0.87, 95% CI: 0.85-0.88; Hispanic: aHR = 0.85, 95% CI: 0.85-0.88) and receive KT (Black: aHR = 0.61, 95% CI: 0.60-0.63; Hispanic: aHR = 0.64, 95% CI: 0.63-0.66).

Interpretation: Improved characterization of the barriers in KT access specific to each racial and ethnic group, and the interventions to address these distinct challenges throughout the KT care continuum are needed; our findings identify specific stages most in need of mitigation.

Funding: National Institutes of Health.

Keywords: Disparities; Health equity; Kidney transplantation; Underrepresented minorities.