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Original Investigation
January 2, 2018

Association of Race and Ethnicity With Live Donor Kidney Transplantation in the United States From 1995 to 2014

Author Affiliations
  • 1Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
  • 2Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 3Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 4Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
  • 5Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
  • 6Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 7Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
  • 8Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
JAMA. 2018;319(1):49-61. doi:10.1001/jama.2017.19152
Key Points

Question  Have racial/ethnic disparities in the receipt of live donor kidney transplantation (LDKT) narrowed over the last 2 decades in the United States?

Findings  In this study of 453 162 adult first-time kidney transplantation candidates, the cumulative incidence of LDKT receipt at 2 years after appearing on the waiting list increased from 7.0% in 1995 to 11.4% in 2014 among white patients, decreased from 3.4% to 2.9% among black patients, decreased from 6.8% to 5.9% among Hispanic patients, and increased from 5.1% to 5.6% among Asian patients, which represent a significant increase in racial/ethnic disparities over time.

Meaning  Racial/ethnic disparities in receipt of LDKT increased from 1995-1999 to 2010-2014, suggesting that national strategies to reduce LDKT disparities have not been effective.

Abstract

Importance  Over the past 2 decades, there has been increased attention and effort to reduce disparities in live donor kidney transplantation (LDKT) for black, Hispanic, and Asian patients with end-stage kidney disease. The goal of this study was to investigate whether these efforts have been successful.

Objective  To estimate changes over time in racial/ethnic disparities in LDKT in the United States, accounting for differences in death and deceased donor kidney transplantation.

Design, Setting, and Participants  A secondary analysis of a prospectively maintained cohort study conducted in the United States of 453 162 adult first-time kidney transplantation candidates included in the Scientific Registry of Transplant Recipients between January 1, 1995, and December 31, 2014, with follow-up through December 31, 2016.

Exposures  Race/ethnicity.

Main Outcomes and Measures  The primary study outcome was time to LDKT. Multivariable Cox proportional hazards and competing risk models were constructed to assess changes in racial/ethnic disparities in LDKT among adults on the deceased donor kidney transplantation waiting list and interaction terms were used to test the statistical significance of temporal changes in racial/ethnic differences in receipt of LDKT. The adjusted subhazard ratios are estimates derived from the multivariable competing risk models. Data were categorized into 5-year increments (1995-1999, 2000-2004, 2005-2009, 2010-2014) to allow for an adequate sample size in each analytical cell.

Results  Among 453 162 adult kidney transplantation candidates (mean [SD] age, 50.9 [13.1] years; 39% were women; 48% were white; 30%, black; 16%, Hispanic; and 6%, Asian), 59 516 (13.1%) received LDKT. Overall, there were 39 509 LDKTs among white patients, 8926 among black patients, 8357 among Hispanic patients, and 2724 among Asian patients. In 1995, the cumulative incidence of LDKT at 2 years after appearing on the waiting list was 7.0% among white patients, 3.4% among black patients, 6.8% among Hispanic patients, and 5.1% among Asian patients. In 2014, the cumulative incidence of LDKT was 11.4% among white patients, 2.9% among black patients, 5.9% among Hispanic patients, and 5.6% among Asian patients. From 1995-1999 to 2010-2014, racial/ethnic disparities in the receipt of LDKT increased (P < .001 for all statistical interaction terms in adjusted models comparing white patients vs black, Hispanic, and Asian patients). In 1995-1999, compared with receipt of LDKT among white patients, the adjusted subhazard ratio was 0.45 (95% CI, 0.42-0.48) among black patients, 0.83 (95% CI, 0.77-0.88) among Hispanic patients, and 0.56 (95% CI, 0.50-0.63) among Asian patients. In 2010-2014, compared with receipt of LDKT among white patients, the adjusted subhazard ratio was 0.27 (95% CI, 0.26-0.28) among black patients, 0.52 (95% CI, 0.50-0.54) among Hispanic patients, and 0.42 (95% CI, 0.39-0.45) among Asian patients.

Conclusions and Relevance  Among adult first-time kidney transplantation candidates in the United States who were added to the deceased donor kidney transplantation waiting list between 1995 and 2014, disparities in the receipt of live donor kidney transplantation increased from 1995-1999 to 2010-2014. These findings suggest that national strategies for addressing disparities in receipt of live donor kidney transplantation should be revisited.

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