Reducing racial disparities in transplant activation:Whom should we target?

doi:10.1016/S0272-6386(05)80007-1

American Journal of Kidney Diseases

Volume 37, Issue 5, May 2001, Pages 921-931

https://doi.org/10.1016/S0272-6386(05)80007-1 Get rights and content

Abstract

Several studies have documented that blacks with end-stage renal disease (ESRD) are less likely than whites tobe placed on the waiting list for a renal transplant. We examined trends in access over time to determine whether publication of these reports resulted in a reduction in disparity and identified those blacks who were most affected to focus future interventions. Three nationally representative groups of adult patients with ESRD (first dialysis in 1986 to 1987, 1990, or 1993) were followed up longitudinally to ascertain the date of first placement on the renal transplant waiting list. Cox proportional hazards models were used to characterize the magnitude of racial disparities in access to the waiting list with adjustment for clinical and sociodemographic factors. Lower rates of placement on the waiting list for blacks than whites persisted after adjustment for differences in both sociodemographic characteristics and health status (relative hazard [RH], 0.68; 95% confidence interval [Cl], 0.59 to 0.79). The gap between blacks and whites did not narrow over time (blacks versus whites: 1986 to 1967 group, RH, 0.71; 95% CI, 0.59 to 0.86;1990 group, RH, 0.69; 95% CI, 0.54 to 0.91;1993 group, RH, 0.57; 0.43 to 0.77) and was greatest for the youngest and healthiest black patients, who were 50% and 40% less likely to be listed than corresponding whites, respectively. Interventions targeted toward young and healthy blacks, who are most likely to benefit from transplantation, are urgently needed to narrow black-white differences in transplant activation.

Presented in part at the 31st Annual Meeting of theAmerican Society of Nephrology, Philadelphia, PA, October 25–28, 1998.

The data reported here have been supplied by the USRenal Data System. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy of or interpretation by the US Government.

References (40)

SoucieJ.M. et al.
Race and sex differences in the identification of candidates for renal transplantation
Am J Kidney Dis
(1992)
SehgalA.R. et al.
Prevalence, recognition, and implications of mental impairment among hemodialysis patients
Am J Kidney Dis
(1997)
LeggatJ.E. et al.
Noncompliance in hemodialysis: Predictors and survival analysis
Am J Kidney Dis
(1998)
SehgalA.R. et al.
Barriers to adequate delivery of hemodialysis
Am J Kidney Dis
(1998)
BameS.I. et al.
Variation in hemodialysis patient compliance according to demographic characteristics
Soc Sci Med
(1993)
HolleyJ.L. et al.
Patients' views in the choice of renal transplant
Kidney Int
(1996)
EggersP.W.
Effect of transplantation on the Medicare end-stage renal disease program
N Engl J Med
(1988)
EvansR. et al.
The quality of life of patients with end-stage renal disease
N Engl J Med
(1985)
PortF. et al.
Comparison of survival probabilities for dialysis patients vs cadaveric renal transplant recipients
JAMA
(1993)
HeldP.J. et al.
Access to kidney transplantation. Has the United States eliminated income and racial differences?
Arch Intern Med
(1988)

KjellstrandC.M.

Age, sex, and race inequality in renal transplantation

Arch Intern Med

(1988)

KallichJ.

Access to Cadaveric Renal Transplantation

(1993)

EggersP.W.

Racial differences in access to kidney transplantation

Health Care Financ Rev

(1995)

AlexanderG.C. et al.

Barriers to cadaveric renal transplantation among blacks, women, and the poor

JAMA

(1998)

Office of Inspector General

The Access of Dialysis Patients to Kidney Transplantation

(1987)

BlakesleeS.

Studies find unequal access to kidney transplants

New York Times

(1989)

KasiskeB.L. et al.

The effect of race on access and outcome in transplantation

N Engl J Med

(1991)

Office of Inspector General

The Distribution of Organs for Transplantation: Expectations and Practices

(1991)

RettigR. et al.

Kidney Failure and the Federal Government

(1991)

GaylinD.S. et al.

The impact of comorbid and sociodemographic factors on access to renal transplantation

JAMA

(1993)

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: Supported in part by grant no. K24DKO2643 the National Institute of Diabetes and Digestive and Kidney Diseases (N.R.P.). PPG was a Robert Wood Johnson Foundation Clinical Scholar.

View full text

Original investigationReducing racial disparities in transplant activation:Whom should we target?

Abstract

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Soc Sci Med

Kidney Int

Effect of transplantation on the Medicare end-stage renal disease program

N Engl J Med

The quality of life of patients with end-stage renal disease

N Engl J Med

Comparison of survival probabilities for dialysis patients vs cadaveric renal transplant recipients

JAMA

Access to kidney transplantation. Has the United States eliminated income and racial differences?

Arch Intern Med

Age, sex, and race inequality in renal transplantation

Arch Intern Med

Access to Cadaveric Renal Transplantation

Racial differences in access to kidney transplantation

Health Care Financ Rev

Barriers to cadaveric renal transplantation among blacks, women, and the poor

JAMA

The Access of Dialysis Patients to Kidney Transplantation

Studies find unequal access to kidney transplants

New York Times

The effect of race on access and outcome in transplantation

N Engl J Med

The Distribution of Organs for Transplantation: Expectations and Practices

Kidney Failure and the Federal Government

The impact of comorbid and sociodemographic factors on access to renal transplantation

JAMA

Original investigation
Reducing racial disparities in transplant activation:Whom should we target?