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Invited Commentary
September 15, 2021

Structural Barriers to African American Living Donor Kidney Transplant

Author Affiliations
  • 1University of Michigan Medical Center, Ann Arbor
JAMA Surg. 2021;156(12):1130. doi:10.1001/jamasurg.2021.4411

Despite the proven benefits of live donor kidney transplant (LDKT), African American individuals are less likely than their White counterparts to successfully receive a LDKT. Historically, much of the literature focused on recipient-level characteristics, such as patient interest, comorbidities, and resources.1 Over time, there was recognition that there are structural barriers out of recipients’ control that limit access to LDKT.2In this issue, Killian and colleagues3 investigate the impact of community-level vulnerability on disparities in LDKT transplant. The novel metric deployed in this study is the Centers for Disease Control and Prevention Social Vulnerability Index (SVI), designed to provide social and spatial information to aid in emergency preparedness.4 Nearly 20 000 kidney transplant recipients were included in this cross-sectional study using SVI to investigate the impact of social vulnerability on LDKT. The study demonstrated that patients who lived in communities with higher SVI scores (correlated with increased social vulnerability) had a lower likelihood of LDKT. African American individuals in high-SVI communities like the Bronx, New York, had 48% lower likelihood of LDKT when compared with their White counterparts. Of interest is the observation that SVI only partially explained the disparities between African American and White patients in LDKT. The disparity in LDKT for African American individuals persisted even in the least vulnerable communities with low SVI, such as Beverly Hills, California, where African American individuals still had a 24% lower likelihood of LDKT. These findings, along with a recent analysis by Purnell et al5 demonstrating that disparities in LDKT between African American and White patients increased from the 1995-1999 to 2000-2014 period, despite awareness of the problem, highlight the critical need to continue to focus on improving equity in LDKT.

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