Dataset Information

Transplant center assessment of the inequity in the kidney transplant process and outcomes for the Indigenous American patients.

ABSTRACT:

Background

The goal is to determine the delays and reduced rates of kidney transplant (KTx) for the Indigenous Americans and variables predictive of these outcomes at a large single transplant center.

Methods

300 Indigenous Americans and 300 non-Hispanic white American patients presenting for KTx evaluation from 2012-2016 were studied.

Results

Compared to whites, the Indigenous Americans had the following: more diabetes, dialysis, physical limitation and worse socioeconomic characteristics(p<0.01); median difference of 20 day delay from referral to KTx evaluation, 17 day delay from approval to UNOS listing and 126.5 longer delay on the waitlist compared to whites(p<0.001). Of the Indigenous Americans listed, more died, were removed, or were still waiting than transplanted compared to whites (p<0.001). Variables predictive of delay from referral to transplant evaluation included: Indigenous race, distance from transplant center, coronary artery disease, and time on dialysis (p<0.05). Cumulative incidence of waitlisting and KTx was lower for Indigenous Americans (p<0.0001). Independent predictors of decreased likelihood of waitlisting included age, peripheral vascular disease, no caregiver, physical limitation, and illegal drug use history (p<0.05). Variables predictive of lower likelihood of KTx included Indigenous race, percentage of time inactive on the waitlist, no caregiver, and O blood type.

Conclusions

Among patients referred and evaluated for KTx, the Indigenous American race was independently associated with significant delays in the KTx process after accounting for co-morbid and socioeconomic factors. Cardiovascular morbidity and physical limitation were identified as important determinants of delay and decreased likelihood of waitlisting. Further quantitative and qualitative work is needed to identify and intervene on modifiable barriers to improve access to KTx for the Indigenous Americans.

SUBMITTER: Keddis MT

PROVIDER: S-EPMC6249016 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Publications

Transplant center assessment of the inequity in the kidney transplant process and outcomes for the Indigenous American patients.

Keddis Mira T MT Sharma Amit A Ilyas Muneeb M Zhang Nan N Khamash Hasan H Leischow Scott J SJ Heilman Raymond L RL

PloS one 20181121 11

<h4>Background</h4>The goal is to determine the delays and reduced rates of kidney transplant (KTx) for the Indigenous Americans and variables predictive of these outcomes at a large single transplant center.<h4>Methods</h4>300 Indigenous Americans and 300 non-Hispanic white American patients presenting for KTx evaluation from 2012-2016 were studied.<h4>Results</h4>Compared to whites, the Indigenous Americans had the following: more diabetes, dialysis, physical limitation and worse socioeconomic ...[more]

PMID: 30462724

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Project description:RATIONALE & OBJECTIVE:A robust relationship between procedure volume and clinical outcomes has been demonstrated across many surgical fields. This study assessed whether a center volume-outcome relationship exists for contemporary kidney transplantation, specifically for diabetic recipients, older recipients (aged ?65 years), and recipients of high kidney donor profile index (KDPI ? 85) kidneys. STUDY DESIGN:Retrospective cohort study. SETTING & PARTICIPANTS:Adult kidney-only transplant recipients who underwent transplantation between 2009 and 2013 (N = 79,581). EXPOSURES:The primary exposure variable was center volume, categorized into quartiles based on the total kidney transplantation volume. Quartile 1 (Q1) centers performed a mean of fewer than 66 kidney transplantations per year, whereas Q4 centers performed a mean of more than 196 kidney transplantations per year. OUTCOMES:All-cause graft failure and mortality within 3 years of transplantation. ANALYTICAL APPROACH:Multivariable Cox frailty models were used to adjust for donor characteristics, recipient characteristics, and cold ischemia time. RESULTS:Minor differences in rates of 3-year deceased donor all-cause graft failure across quartiles of center volume were observed (14.9% for Q1 vs 16.7% for Q4), including in subgroups (diabetic recipients, 18.4% for Q1 vs 19.7% for Q4; older recipients, 19.4% for Q1 vs 22.5% for Q4; recipients of high KDPI kidneys, 26.5% for Q1 vs 26.5% for Q4). Results were similar for 3-year mortality. After adjustment for donor, recipient, and graft characteristics using Cox regression, center volume was not significantly associated with all-cause graft failure or mortality within 3 years, except that diabetic recipients at Q3 centers had slightly lower mortality (compared with Q1 centers, adjusted HR of 0.85 [95% CI, 0.73-0.99]). LIMITATIONS:Potential unmeasured confounding from patient comorbid conditions and organ selection. CONCLUSIONS:These findings provide little evidence that care in higher volume centers is associated with better adjusted outcomes for kidney transplant recipients, even in populations anticipated to be at increased risk for graft failure or death.

Project description:Background:Kidney transplantation is the optimal treatment for patients with end-stage renal disease; however, long-term outcomes remain suboptimal. Objective:The objectives of our study were to examine the variation in survival rates and determine whether center volume and case mix are associated with transplant outcomes and explain the variation across kidney transplant centers in Ontario, Canada. Design:This was a population-based cohort study using health care administrative databases. Setting:A total of 5 transplant centers across Ontario, Canada. Patients:We included adults (?18 years) undergoing primary, solitary kidney transplantation between January 1, 2000 to December 31, 2013. Measurements:The co-primary outcomes were death-censored graft loss and total mortality. Methods:Multivariable Cox proportional hazards regression was used to assess potential associations and describe variation, using hazard ratios (HRs) with 95% confidence intervals (CIs) for each center relative to the average across all centers. Results:The study cohort included 5037 patients followed for a median of 5.3 years, interquartile range (2.7-8.6). In multivariable models, recipient age, body mass index, Charlson Index, time on dialysis, donor type, and age were found to be significantly associated with death-censored graft loss, and recipient age and sex, Charlson Index, time on dialysis, donor age, and time era of transplant were associated with total mortality. There was statistically significant variation across centers observed for death-censored graft loss (P = .04) with HRs ranging from 0.72 to 1.22. However, neither adjusting for case mix nor center volume meaningfully changed the HRs reflecting each center-specific effect. There was a tendency toward reduced risk of graft loss (HR, per additional 25 patients, 0.90 [95% CI, 0.78-1.04]) in centers with higher volumes. For total mortality, there was statistically significant variation across centers with HRs ranging from 0.82 to 1.13 (P = .04); however, neither adjusting for case mix or center volume meaningfully changed the HRs. Center volume was not significantly associated with total mortality (HR, per additional 25 patients, 1.04 [95% CI, 0.90-1.20]). Limitations:This study was limited by the small number of centers included. Conclusions:Outcomes differ across the 5 transplant centers in Ontario. We did not find any strong support for our hypotheses that case mix or center volume is responsible for these differences.

Dataset Information

Transplant center assessment of the inequity in the kidney transplant process and outcomes for the Indigenous American patients.

Background

Methods

Results

Conclusions

Publications

Transplant center assessment of the inequity in the kidney transplant process and outcomes for the Indigenous American patients.

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