Q&A: Racial, Ethnic Disparities in Kidney Transplantation, with Maya Clark-Cutaia, RN, MSN, PhD

Maya Clark-Cutaia, RN, MSN, PhD

Credit: University of Pennsylvania Nursing

Data presented at the American Society of Nephrology Kidney Week 2023 highlighted disparities in access to kidney transplants among minoritized patients with end-stage kidney disease (ESKD), calling attention to differences in waitlisting and eventual transplantation based on race and ethnicity.

To assess disparities from ESKD diagnosis to listing and first kidney transplant, a team of investigators collected data for 2,200,356 adults diagnosed with ESKD between 1999 and 2019 from the United States Renal Data System. Using Fine and Gray sub-distribution hazards models adjusted for age, sex, race/ethnicity, comorbidities, and primary health insurance, investigators determined adjusted sub-hazards ratio (aSHR) of listing after ESKD diagnosis and transplantation after listing, using death as a competing risk. The proportional hazards assumption was tested using complementary log-log plots and Schoenfeld residuals.

Upon analysis, White candidates were more likely to be waitlisted than Black (aSHR, 0.73; 95% confidence interval [CI], 0.73-0.74), Hispanic (aSHR, 0.74; 95% CI, 0.73-0.74), and Asian (aSHR, 0.77; 95% CI, 0.76-0.78) patients. Among waitlisted candidates, investigators pointed out White patients were more likely to eventually receive a kidney transplant, especially from a living donor and preemptively, compared to other racial and ethnic groups:

• Black patients (aSHR, 0.33; 95% CI, 0.32-0.35 for living donor transplant; aSHR, 0.53; 95% CI, 0.47-0.60 for preemptive transplant)
• Hispanic patients (aSHR, 0.66; 95% CI, 0.64-0.69 for living donor transplant; aSHR, 0.65; 95% CI, 0.56-0.75 for preemptive transplant)
• Asian patients (aSHR, 0.45; 95% CI, 0.42-0.47 for living donor transplant; aSHR, 0.47; 95% CI, 0.38-0.58 for preemptive transplant)

The editorial team of HCPLive Nephrology sat down with Maya Clark-Cutaia, RN, MSN, PhD, assistant professor of nursing at New York University Rory Meyers College of Nursing, for further insight into disparities in the transplantation process, the significance of findings from the present study, and how these inequities might be addressed in clinical practice moving forward.

HCPLive Nephrology: What is the significance of kidney transplantation and why can disparities in this process be so detrimental for patients?

Clark-Cutaia: The ideal situation is that if you don't have kidney function, that we replace it with some kidney function in dialysis, whether peritoneal or hemodialysis, but neither of these are really ideal, and they don't give you the same quality of life. If there were a plethora of organs available and we had the resources, everyone would have a transplant. Unfortunately, what we have been seeing is that disparities exist all the way across the continuum, with Black and Brown patients having poor outcomes compared to their White counterparts. We were really curious as to what the kidney transplant disparities looked like, so we wanted to look across all minoritized groups and see if there was a difference in types of transplantation. What we found is, yes, the disparities persist when it comes to transplantation across all minoritized groups. Surprisingly, Asian patients have better access to kidney transplants than even White patients do, but still are not transplanted, and Black and Hispanic patients are less likely to be transplanted. In terms of the types of transplants, Black patients tend to get more deceased donor transplants, whereas there were more living donor transplants for Asian patients, even though they're still far less than what White patients usually experience. And preemptive transplantation was not good for any of the minoritized groups. So I think there's a huge disparity when it comes to planning, prevention, and a proactive approach to kidney disease and minoritized populations that we really need to pay attention to.

HCPLive Nephrology: What is your perspective on the significance of these findings?

Clark-Cutaia: Our results really showed us that we as clinicians and researchers have an understanding that the disparities exist, we just don't know where, and where the best place to intervene would be. What we're seeing from this data is that we know that all the minoritized groups are experiencing some disparity, so we need to do better there. There seems to be the biggest disparity in terms of making sure that they have the ideal situation, which is we plan in advance, we recognize they’re going to need this transplant, and they actually receive the preemptive transplant. The other thing that meant a lot to us was looking at the living donor kidney transplants. Black and Hispanic patients didn't do it as often, and so the question became ‘Why not?’ And we’re hypothesizing some of that is because minoritized patients, family members, friends, etc. may not be at the same level of health as White patients, and so they're not able to donate. And if that's the case, we have a bigger problem in terms of the health of minoritized patients when looking at other disease processes, so we’re really trying to focus on where we're using our resources in terms of education, prevention, and health promotion.

HCPLive Nephrology: How should ongoing or future efforts address these disparities?
Clark-Cutaia: To our credit, a lot of the work that has been done, especially observational trials, started several decades ago and has done a very nice job of focusing on Black and White comparisons. Some have included Hispanic patients, but they usually have very small sample sizes when it comes to Asian patients. So we have very little to go on in terms of what to do and when, especially because each of those studies also has different outcomes and different cut points. I think one of the places we need to start is with really thinking about how to do observational trials that look at minoritized populations and compare them and their outcomes across the continuum, but also thinking about the smaller spaces where we might be able to intervene. We can see from this study and from others like it that the initial conversations are important, but then each touchpoint after that is just as significant for really understanding the social determinants of health that are available to these patients to ensure that they remain active on the waitlist. Trying to figure out how best to do that and make sure that it's tailored to a specific group or specific individual is where we should really be focusing our attention.

Reference:

1. Clark-Cutaia MN, Menon G, Li Y, et al. Disparities in Access to Kidney Transplantation for Asian, Hispanic, and Black Candidates. Paper Presented at: American Society of Nephrology Kidney Week 2023. November 1-5, 2023.