Racial, Ethnic Pediatric Kidney Transplant Disparities Suggest Inequities in ESRD Care

Robyn Matloff, MD, MPH

Credit: Connecticut Children's

New research is shedding light on racial and ethnic disparities in kidney transplantation (KT) and associated clinical outcomes in pediatric patients.¹

Leveraging data from the US Scientific Registry of Transplant Recipients (SRTR) for more than 10,000 pediatric KT recipients, the study found non-Hispanic Black and Hispanic children were less likely to undergo preemptive KT and, once listed, faced longer wait times compared to non-Hispanic White children.¹

“To our knowledge, this represents the largest retrospective study examining racial and ethnic disparities in access to and outcomes from pediatric KT using a large KT database,” Robyn Matloff, MD, MPH, a pediatric nephrologist at Connecticut Children’s Medical Center, and colleagues wrote.¹

According to data from the Organ Procurement and Transplantation Network, more than 103,000 men, women, and children are on the national transplant waiting list. As of September 2024, nearly 90,000 people on the waiting list were seeking a kidney transplant. Although KT is generally considered the preferred option for end-stage renal disease due to improved quality of life and longer life expectancy than dialysis, the number of people seeking a kidney transplant far exceeds the number of available donor kidneys.^2,3

To assess the interplay of race and ethnicity on access to pediatric KT and its effects on long-term graft and patient survival, investigators retrospectively examined data from the US SRTR for all pediatric KT recipients < 18 years of age between 1999 and 2014 and compared 1- and 5-year patient survival and death-censored graft survival based on demographic factors.¹

During the 15-year period, 11,740 (6596 NHW, 2306 NHB, and 2838 Hispanic) US children received a KT. Of these pediatric patients, the majority were non-Hispanic White (56.2%), followed by Hispanic (24.2%) and non-Hispanic Black (19.6%). Investigators noted most individuals were male and were transplanted due to congenital anomalies of the kidneys and urinary tracts in all racial and ethnic groups. Additionally, they pointed out the mean age at KR was similar between groups, ranging from 10.7 years of age in the non-Hispanic White group to 11.6 years of age in the non-Hispanic Black group.¹

Results showed non-Hispanic White patients spent the least time on the waitlist (250 ± 335 days). In comparison, non-Hispanic Black patients (293 ± 348 days; P <.001) and Hispanic (322 ± 353 days; P <.001) patients spent significantly more time on the waitlist.¹

Investigators also observed significant differences in human leukocyte antigen (HLA) mismatching across the 3 cohorts, with the greatest proportion observed among non-Hispanic Black patients. Non-Hispanic White children were less likely than both non-Hispanic Black and Hispanic children to have 2 HLA mismatches across HLA A, HLA B, or HLA DR (P <.001).¹

Although 1-year patient survival was similar among the groups, at 5 years, non-Hispanic Black patient survival (93.1%) was significantly lower than non-Hispanic White (95.5%) and Hispanic (95.5%) patient survival (P = .037).¹

Investigators observed notable differences in death-censored graft survival starting at 1 year, with non-Hispanic Black children (93.7%) experiencing significantly reduced rates compared with non-Hispanic White (95.5%) and Hispanic (96.0%) children (P < 0.001). Similar disparities were observed at 5 years, with non-Hispanic Black patients continuing to experience worse outcomes (63.3% vs 80.6% and 76.3%, respectively; P <.001).¹

Multivariate analysis showed the following factors were associated with 1-year graft loss:

• Greater recipient cPRA (odds ratio [OR], 1.0; 95% CI, 1.0–1.0; P = .005)
• Greater HLA mismatch (OR, 1.1; 95% CI, 1.0–1.3; P = .008)
• Rejection (OR, 3.9; 95% CI, 2.1–7.0; P <.001)
• Secondary kidney transplantation (OR, 15.0; 95% CI, 11.5–19.4; P <.001)
• Public insurance (OR, 2.0; 95% CI, 1.5–2.6; P <.001)

Further analysis revealed factors predictive of 5-year graft loss:

• Older recipient age (OR, 1.1; 95% CI, 1.1–1.1; P <.001)
• Greater recipient cPRA (OR, 1.0; 95% CI, 1.0–1.0; P <.001)
• Greater HLA mismatch (OR, 1.1; 95% CI, 1.0–1.1; P = .002)
• Rejection (OR, 2.0; 95% CI, 1.3–3.0; P = .001)
• Secondary kidney transplantation (OR, 11.2; 95% CI, 9.6–13.0; P <.001)
• Public insurance (OR, 1.9; 95% CI, 1.7–2.2; P <.001)

Investigators outlined multiple limitations to these findings, including the retrospective study design; limited statistical analysis due to SRTR covariates that currently do not include SES status; the lack of consideration for changing patterns of treatment, organ allocation, and diagnosis; and potential inaccuracies in racial and ethnic group assignment due to self- or provider-reporting.¹

“These findings implore greater policy changes to improve access to care, financial support beyond insurance, and systemic structural changes to better support minority children with ESRD,” investigators concluded.¹ “Additional research is needed to further delineate the factors driving this disparity and enact policies and procedures to improve outcomes across all racial and ethnic groups.”

References

1. ^{Matloff R, Foster CE, Hanna J, et al. Access to Kidney Transplantation for Minority Children With End-Stage Renal Disease and Predictors of Post-Transplant Outcome: Impact of Race and Ethnicity. Pediatric Transplantation. https://doi.org/10.1111/petr.70024}
2. ^{Health Resources and Services Administration. Organ Donation Statistics. October 2024. Accessed January 9, 2025. https://www.organdonor.gov/learn/organ-donation-statistics}
3. ^{Berns JS. Patient education: Dialysis or kidney transplantation — which is right for me? (Beyond the Basics). UpToDate. November 13, 2024. Accessed January 9, 2025. https://www.uptodate.com/contents/dialysis-or-kidney-transplantation-which-is-right-for-me-beyond-the-basics/print}