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Evaluation of Community-Level Vulnerability and Racial Disparities in Living Donor Kidney Transplant.
JAMA Surg. 2021 12 01; 156(12):1120-1129.JS

Abstract

Importance

Living donor kidney transplant (LDKT) is the ideal treatment for end-stage kidney disease, but racial disparities in LDKT have increased over the last 2 decades. Recipient clinical and social factors do not account for LDKT racial inequities, although comprehensive measures of community-level vulnerability have not been assessed.

Objective

To determine if racial disparities persist in LDKT independent of community-level vulnerability.

Design, Setting, and Participants

This retrospective, multicenter, cross-sectional study included data from 19 287 adult kidney-only transplant recipients in the Scientific Registry of Transplant Recipients. The study included individuals who underwent transplant between January 1 and December 31, 2018.

Exposures

Recipient race and the 2018 US Centers for Disease Control and Prevention Social Vulnerability Index (SVI). Census tract-level SVI data were linked to census tracts within each recipient zip code. The median SVI measure among the census tracts within a zip code was used to describe community-level vulnerability.

Main Outcomes and Measures

Kidney transplant donor type (deceased vs living). Modified Poisson regression was used to evaluate the association between SVI and LDKT, and to estimate LDKT likelihood among races, independent of community-level vulnerability and recipient-level characteristics.

Results

Among 19 287 kidney transplant recipients, 6080 (32%) received LDKT. A total of 11 582 (60%) were male, and the median (interquartile range) age was 54 (43-63) years. There were 760 Black LDKT recipients (13%), 4865 White LDKT recipients (80%), and 455 LDKT recipients of other races (7%; American Indian, Asian, multiracial, and Pacific Islander). Recipients who lived in communities with higher SVI (ie, more vulnerable) had lower likelihood of LDKT compared with recipients who lived in communities with lower SVI (ie, less vulnerable) (adjusted relative risk [aRR], 0.97; 95% CI, 0.96-0.98; P < .001). Independent of community-level vulnerability, compared with White recipients, Black recipients had 37% lower likelihood (aRR, 0.63; 95% CI, 0.59-0.67; P < .001) and recipients of other races had 24% lower likelihood (aRR, 0.76; 95% CI, 0.70-0.82; P < .001) of LDKT. The interaction between SVI and race was significant among Black recipients, such that the disparity in LDKT between Black and White recipients increased with greater community-level vulnerability (ratio of aRRs, 0.67; 95% CI, 0.51-0.87; P = .003).

Conclusions and Relevance

Community-level vulnerability is associated with access to LDKT but only partially explains LDKT racial disparities. The adverse effects of living in more vulnerable communities were worse for Black recipients. The interaction of these constructs is worrisome and suggests evaluation of other health system factors that may contribute to LDKT racial disparities is needed.

Authors+Show Affiliations

Comprehensive Transplant Institute, University of Alabama at Birmingham.Comprehensive Transplant Institute, University of Alabama at Birmingham.Comprehensive Transplant Institute, University of Alabama at Birmingham.Comprehensive Transplant Institute, University of Alabama at Birmingham.Comprehensive Transplant Institute, University of Alabama at Birmingham.Comprehensive Transplant Institute, University of Alabama at Birmingham.Comprehensive Transplant Institute, University of Alabama at Birmingham.Comprehensive Transplant Institute, University of Alabama at Birmingham.Comprehensive Transplant Institute, University of Alabama at Birmingham.Department of Medicine, University of Pennsylvania, Philadelphia.Comprehensive Transplant Institute, University of Alabama at Birmingham.

Pub Type(s)

Evaluation Study
Journal Article
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

34524392

Citation

Killian, A Cozette, et al. "Evaluation of Community-Level Vulnerability and Racial Disparities in Living Donor Kidney Transplant." JAMA Surgery, vol. 156, no. 12, 2021, pp. 1120-1129.
Killian AC, Shelton B, MacLennan P, et al. Evaluation of Community-Level Vulnerability and Racial Disparities in Living Donor Kidney Transplant. JAMA Surg. 2021;156(12):1120-1129.
Killian, A. C., Shelton, B., MacLennan, P., McLeod, M. C., Carter, A., Reed, R., Qu, H., Orandi, B., Kumar, V., Sawinski, D., & Locke, J. E. (2021). Evaluation of Community-Level Vulnerability and Racial Disparities in Living Donor Kidney Transplant. JAMA Surgery, 156(12), 1120-1129. https://doi.org/10.1001/jamasurg.2021.4410
Killian AC, et al. Evaluation of Community-Level Vulnerability and Racial Disparities in Living Donor Kidney Transplant. JAMA Surg. 2021 12 1;156(12):1120-1129. PubMed PMID: 34524392.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Evaluation of Community-Level Vulnerability and Racial Disparities in Living Donor Kidney Transplant. AU - Killian,A Cozette, AU - Shelton,Brittany, AU - MacLennan,Paul, AU - McLeod,M Chandler, AU - Carter,Alexis, AU - Reed,Rhiannon, AU - Qu,Haiyan, AU - Orandi,Babak, AU - Kumar,Vineeta, AU - Sawinski,Deirdre, AU - Locke,Jayme E, PY - 2021/9/16/pubmed PY - 2022/1/27/medline PY - 2021/9/15/entrez SP - 1120 EP - 1129 JF - JAMA surgery JO - JAMA Surg VL - 156 IS - 12 N2 - Importance: Living donor kidney transplant (LDKT) is the ideal treatment for end-stage kidney disease, but racial disparities in LDKT have increased over the last 2 decades. Recipient clinical and social factors do not account for LDKT racial inequities, although comprehensive measures of community-level vulnerability have not been assessed. Objective: To determine if racial disparities persist in LDKT independent of community-level vulnerability. Design, Setting, and Participants: This retrospective, multicenter, cross-sectional study included data from 19 287 adult kidney-only transplant recipients in the Scientific Registry of Transplant Recipients. The study included individuals who underwent transplant between January 1 and December 31, 2018. Exposures: Recipient race and the 2018 US Centers for Disease Control and Prevention Social Vulnerability Index (SVI). Census tract-level SVI data were linked to census tracts within each recipient zip code. The median SVI measure among the census tracts within a zip code was used to describe community-level vulnerability. Main Outcomes and Measures: Kidney transplant donor type (deceased vs living). Modified Poisson regression was used to evaluate the association between SVI and LDKT, and to estimate LDKT likelihood among races, independent of community-level vulnerability and recipient-level characteristics. Results: Among 19 287 kidney transplant recipients, 6080 (32%) received LDKT. A total of 11 582 (60%) were male, and the median (interquartile range) age was 54 (43-63) years. There were 760 Black LDKT recipients (13%), 4865 White LDKT recipients (80%), and 455 LDKT recipients of other races (7%; American Indian, Asian, multiracial, and Pacific Islander). Recipients who lived in communities with higher SVI (ie, more vulnerable) had lower likelihood of LDKT compared with recipients who lived in communities with lower SVI (ie, less vulnerable) (adjusted relative risk [aRR], 0.97; 95% CI, 0.96-0.98; P < .001). Independent of community-level vulnerability, compared with White recipients, Black recipients had 37% lower likelihood (aRR, 0.63; 95% CI, 0.59-0.67; P < .001) and recipients of other races had 24% lower likelihood (aRR, 0.76; 95% CI, 0.70-0.82; P < .001) of LDKT. The interaction between SVI and race was significant among Black recipients, such that the disparity in LDKT between Black and White recipients increased with greater community-level vulnerability (ratio of aRRs, 0.67; 95% CI, 0.51-0.87; P = .003). Conclusions and Relevance: Community-level vulnerability is associated with access to LDKT but only partially explains LDKT racial disparities. The adverse effects of living in more vulnerable communities were worse for Black recipients. The interaction of these constructs is worrisome and suggests evaluation of other health system factors that may contribute to LDKT racial disparities is needed. SN - 2168-6262 UR - https://www.unboundmedicine.com/medline/citation/34524392/Evaluation_of_Community_Level_Vulnerability_and_Racial_Disparities_in_Living_Donor_Kidney_Transplant_ DB - PRIME DP - Unbound Medicine ER -