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Figure.  Effect Plots for Predicted Probability of Living Donor Kidney Transplant (LDKT) Across Measures of Community-Level Vulnerability
Effect Plots for Predicted Probability of Living Donor Kidney Transplant (LDKT) Across Measures of Community-Level Vulnerability

A, Unadjusted association between US Centers for Disease Control Social Vulnerability Index (SVI) and LDKT. B, Adjusted association between SVI and LDKT with SVI and race interaction. The lines are fit for a 53-year-old man with kidney disease secondary to diabetes, a body mass index (calculated as weight in kilograms divided by height in meters squared) of 29, blood type O, and no history of any transplant or peripheral vascular disease who has been receiving dialysis for 3 years, has a high school education or less, and was not working for an income. This scenario varies only by race. The other category includes American Indian, Asian, multiracial, and Pacific Islander recipients. Solid lines demonstrate predicted probability across SVI measures and shaded areas depict 95% CIs.

Table 1.  Transplant Recipient Characteristics by Donor Typea
Transplant Recipient Characteristics by Donor Typea
Table 2.  Living Donor Kidney Transplant Recipient Characteristics by Racea
Living Donor Kidney Transplant Recipient Characteristics by Racea
Table 3.  Modified Poisson Models for Likelihood of Living Donor Kidney Transplant (vs Deceased Donor Kidney Transplant)
Modified Poisson Models for Likelihood of Living Donor Kidney Transplant (vs Deceased Donor Kidney Transplant)
Table 4.  Adjusted Modified Poisson Model for Likelihood of Living Donor Kidney Transplant (vs Deceased Donor Kidney Transplant) With Interaction Between Social Vulnerability Index (SVI) and Racea
Adjusted Modified Poisson Model for Likelihood of Living Donor Kidney Transplant (vs Deceased Donor Kidney Transplant) With Interaction Between Social Vulnerability Index (SVI) and Racea
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    Original Investigation
    September 15, 2021

    Evaluation of Community-Level Vulnerability and Racial Disparities in Living Donor Kidney Transplant

    Author Affiliations
    • 1Comprehensive Transplant Institute, University of Alabama at Birmingham
    • 2Department of Medicine, University of Pennsylvania, Philadelphia
    JAMA Surg. 2021;156(12):1120-1129. doi:10.1001/jamasurg.2021.4410
    Key Points

    Question  Are racial disparities in living donor kidney transplant (LDKT) independent of community-level vulnerability?

    Findings  In this cross-sectional study of 19 287 kidney transplant recipients, kidney recipients from racial minority groups were less likely to receive LDKT compared with White counterparts after adjusting for community-level vulnerability and recipient-level characteristics. The LDKT disparity between Black and White recipients increased with greater community-level vulnerability.

    Meaning  Community-level vulnerability only partially explained LDKT racial disparities, and the negative association between living in more vulnerable communities and access to LDKT was worse for Black kidney transplant recipients.

    Abstract

    Importance  Living donor kidney transplant (LDKT) is the ideal treatment for end-stage kidney disease, but racial disparities in LDKT have increased over the last 2 decades. Recipient clinical and social factors do not account for LDKT racial inequities, although comprehensive measures of community-level vulnerability have not been assessed.

    Objective  To determine if racial disparities persist in LDKT independent of community-level vulnerability.

    Design, Setting, and Participants  This retrospective, multicenter, cross-sectional study included data from 19 287 adult kidney-only transplant recipients in the Scientific Registry of Transplant Recipients. The study included individuals who underwent transplant between January 1 and December 31, 2018.

    Exposures  Recipient race and the 2018 US Centers for Disease Control and Prevention Social Vulnerability Index (SVI). Census tract–level SVI data were linked to census tracts within each recipient zip code. The median SVI measure among the census tracts within a zip code was used to describe community-level vulnerability.

    Main Outcomes and Measures  Kidney transplant donor type (deceased vs living). Modified Poisson regression was used to evaluate the association between SVI and LDKT, and to estimate LDKT likelihood among races, independent of community-level vulnerability and recipient-level characteristics.

    Results  Among 19 287 kidney transplant recipients, 6080 (32%) received LDKT. A total of 11 582 (60%) were male, and the median (interquartile range) age was 54 (43-63) years. There were 760 Black LDKT recipients (13%), 4865 White LDKT recipients (80%), and 455 LDKT recipients of other races (7%; American Indian, Asian, multiracial, and Pacific Islander). Recipients who lived in communities with higher SVI (ie, more vulnerable) had lower likelihood of LDKT compared with recipients who lived in communities with lower SVI (ie, less vulnerable) (adjusted relative risk [aRR], 0.97; 95% CI, 0.96-0.98; P < .001). Independent of community-level vulnerability, compared with White recipients, Black recipients had 37% lower likelihood (aRR, 0.63; 95% CI, 0.59-0.67; P < .001) and recipients of other races had 24% lower likelihood (aRR, 0.76; 95% CI, 0.70-0.82; P < .001) of LDKT. The interaction between SVI and race was significant among Black recipients, such that the disparity in LDKT between Black and White recipients increased with greater community-level vulnerability (ratio of aRRs, 0.67; 95% CI, 0.51-0.87; P = .003).

    Conclusions and Relevance  Community-level vulnerability is associated with access to LDKT but only partially explains LDKT racial disparities. The adverse effects of living in more vulnerable communities were worse for Black recipients. The interaction of these constructs is worrisome and suggests evaluation of other health system factors that may contribute to LDKT racial disparities is needed.

    Introduction

    Recent health crises have exposed systemic inequities in the US that have been documented for centuries.1-4 A national movement for advancing racial equity has urged policy reform to improve infrastructure and opportunities for education, employment, and affordable housing for racial minority populations.5 These community-level factors influence economic prosperity, disease development, and access to quality health care.6-9 Improving inequities in these social determinants of health has been deemed fundamental to the elimination of health disparities by the World Health Organization.10

    Racial disparities in kidney transplant are well recognized. Black populations are 3 times more likely to develop end-stage kidney disease (ESKD) compared with White populations, yet barriers at each step toward transplant disproportionately impact Black patients.9,11-15 Moreover, living donor kidney transplant (LDKT) is the best treatment option for ESKD; there is 85% 5-year survival following LDKT compared with 74% 5-year survival with deceased donor kidney transplant (DDKT) and 40% 5-year survival with dialysis.11,16 However, racial disparities in LDKT have increased over the last 2 decades.17

    Prior studies have accounted for recipient demographic characteristics, comorbid disease, insurance status, transplant knowledge, and cultural and psychosocial factors, yet LDKT racial disparities persist.17-19 Only limited aspects of patients’ environments, however, have been evaluated. Gore et al19 evaluated median income in recipients’ zip codes, while Purnell and colleagues20 assessed zip code–level measures for poverty and linguistic isolation. The study by Gore et al19 attributed 14% of LDKT disparities to sociodemographic factors and the study by Purnell et al20 attributed 4% to 18% of LDKT racial disparities to contextual poverty. Neighborhood-level poverty has been implicated in the increasing LDKT racial disparities, but it remains only one of the determinants known to influence health outcomes and access to care.17,21-23 Thus, more comprehensive measures of community-level social determinants of health that may better account for LDKT racial disparities are needed.

    In this study, we used the US Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI), a composite measure of community-level vulnerability based on 15 multidimensional social factors.24-26 Living in communities with greater social vulnerability has been associated with individual obesity and decreased physical activity, suggesting the SVI may serve as a powerful surrogate for community-level social determinants of health.27,28 We sought to determine the association between community-level vulnerability and LDKT, and subsequently evaluate if racial disparities persisted independent of community-level vulnerability. We hypothesized greater community-level vulnerability would be associated with lower likelihood of LDKT, and all recipients would have similar likelihood of LDKT after accounting for community-level vulnerability.

    Methods
    Data Sources

    This retrospective, cross-sectional study was performed to evaluate associations between community-level vulnerability, race, and LDKT. This study used data from the Scientific Registry of Transplant Recipients (SRTR).29 The SRTR data system includes data on all donors, wait list candidates, and transplant recipients in the US, submitted by the members of the Organ Procurement and Transplantation Network. The Health Resources and Services Administration (US Department of Health and Human Services) provides oversight to the activities of the Organ Procurement and Transplantation Network and SRTR contractors. The University of Alabama at Birmingham Institutional Review Board approved this study with a waiver of informed consent.

    This study also used data from the CDC SVI, which provides relative rankings of social vulnerability for each US county subdivision (ie, census tract) using 2014 to 2018 American Community Survey data from the US Census Bureau.24-26,30 These data comprise 15 census variables that are grouped into 4 categories, including socioeconomic status, household composition and disability, minority status and language, and housing type and transportation, and subsequently 1 measure of overall vulnerability (eTable 1 in the Supplement).24-26 Measures of SVI range from 0 to 1, with higher values indicating greater vulnerability. For example, SVI of the 90210 zip code (Beverly Hills, California) was 0.07, whereas SVI of the 10457 zip code (Bronx, New York) was 1.00. SVI was scaled by 0.1 such that relative risk (RR) estimates reflect the effect of a 10% increase in SVI. The most recent SVI data set (2018) was used.30

    Recipient characteristics were obtained from the SRTR kidney recipient file. Zip codes were obtained from the SRTR candidate zip code file. Zip codes were matched to federal information processing system codes using a 2018 zip code to census tract crosswalk.31,32 Federal information processing system codes are geographic identifiers specific to each state, county, and census tract.33 Census tract–level SVI rankings were matched to each census tract associated with each recipient zip code. The median SVI measure among the census tracts linked to each zip code was used as a measure of community-level vulnerability.30

    Study Population

    A total of 19 534 adults (18 years and older) who received a kidney-only transplant from January 1 to December 31, 2018, were identified. Exclusions from our cohort were made for permanent state of residence outside the US (n = 92), unmatched zip codes (n = 54), missing zip codes (n = 67), and multiple records (n = 34) (eFigure in the Supplement). The final cohort of 19 287 kidney transplant recipients was categorized by donor type (DDKT vs LDKT).

    Outcomes and Exposures

    Our primary outcome was receipt of LDKT (vs DDKT). Main exposures included recipient race and community-level vulnerability. Recipient race, as captured by the SRTR, was obtained from transplant candidate registration forms completed by the transplant center where a candidate was listed. Race was condensed to a 3-level categorical variable (Black, White, and other [American Indian, Asian, multiracial, and Pacific Islander]). Community-level vulnerability was defined using the SVI overall vulnerability measure as described above, hereafter referred to as SVI.24

    Statistical Analysis
    Descriptive Analyses

    Univariable analyses were performed to describe kidney transplant recipient characteristics. Frequencies and percentages were used to report categorical data, while medians and interquartile ranges (IQRs) were used to report continuous data. χ2 and Wilcoxon rank sum tests or Kruskal-Wallis tests were used for bivariate analyses using categorical and continuous variables, respectively. Bivariate analyses were used to evaluate recipients by transplant donor type and LDKT recipients by race.

    Modified Poisson Regression Models

    Modified Poisson regression was performed to evaluate the association between transplant type and SVI, and subsequently transplant type and race independent of SVI.34 Modified Poisson regression uses robust error variances to provide estimates of relative risk (RR) for binary outcomes.35 Recipient-level clinical and social characteristics were chosen for inclusion in multivariable analyses based on clinical significance. The final adjusted models included recipient age, sex, race, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), kidney disease etiology, ABO blood type, dialysis duration, history of any transplant, history of diabetes, history of peripheral vascular disease, calculated panel reactive antibodies level at listing, education level, and whether recipients were working for income (eTables 2 and 3 in the Supplement). Multiplicative interactions between SVI and recipient race were also evaluated using modified Poisson regression to determine if the association between SVI and LDKT varied by race. Effect plots were created from model data to display associations between SVI and LDKT by race.

    Sensitivity Analysis

    Descriptions of all additional analyses are included in the eMethods in the Supplement. Analyses were performed using SAS, version 9.4 (SAS Institute, Inc) and statistical tests were 2-sided with significance at P < .05.

    Results
    Cohort Characteristics

    This study included 19 287 adult, kidney-only transplant recipients, of which 6080 (32%) received an LDKT. All comparisons of LDKT and DDKT recipients were statistically significant (Table 1). LDKT recipients were younger (median [IQR] age, 52 [40-62] years vs 55 [44-64] years) and more often male (3809 [63%] vs 7773 [59%]). Transplant recipients overall were primarily White, but a larger proportion of LDKT recipients were White (4865 [80%] vs 7334 [56%]), while smaller proportions were Black (760 [13%] vs 4487 [34%]) or of other races (455 [8%] vs 1386 [11%]). A greater proportion of LDKT recipients received a preemptive (ie, prior to dialysis initiation) transplant (2022 [33%] vs 1036 [8%]) or had fewer median (IQR) years receiving dialysis compared with DDKT recipients (0.6 [0-1.9] years vs 4.0 [1.8-6.3] years). More LDKT recipients were working for income (2924 [48%] vs 3289 [25%]) and had greater than a high school education (4032 [66%] vs 6626 [50%]) compared with DDKT recipients. LDKT recipients lived in less vulnerable communities than DDKT recipients (median [IQR] SVI, 0.4 [0.2-0.6] vs 0.6 [0.4-0.8]).

    LDKT Recipient Characteristics by Race

    Of 6080 LDKT recipients, there were 760 Black LDKT recipients (13%), 4865 White LDKT recipients (80%), and 455 LDKT recipients of other races (7%). All comparisons were statistically significant (Table 2). White recipients were older (median [IQR] age 53 years vs 49 years vs 48 years) and more were male (3091 [64%]) compared with Black (438 [58%]) or other race recipients (280 [62%]). Compared with White recipients and recipients of other races, Black recipients had higher BMI (median [IQR]: Black, 29.0 [25.0-33.2]; White, 27.7 [24.1-31.7]; other races, 25.5 [22.1-29.4]) and were more likely to have a history of type 2 diabetes (Black, 222 [29%]; White, 1021 [21%]; other races, 127 [28%]). More White recipients received preemptive transplants (1756 [36%] vs 152 [20%] vs 114 [25%]) or had shorter median (IQR) years receiving dialysis (0.6 [0-1.7] vs 1.2 [0.2-2.9] vs 0.8 [0-2.0]) compared with Black recipients or recipients of other races. More recipients of other races were working for income (other race, 235 [52%]) vs White, 2371 [49%] vs Black, 318 [42%]) and had greater than a high school education (other race, 345 [76%] vs White, 3173 [65%] vs Black, 514 [68%]). Finally, White LDKT recipients lived in less vulnerable communities (median [IQR] SVI, 0.4 [0.2-0.6]) compared with Black recipients (0.6 [0.3-0.7]) or other race recipients (0.4 [0.3-0.7]).

    Associations Between SVI, Race, and LDKT

    In unadjusted analyses, higher SVI was associated with 12% lower likelihood of LDKT (RR, 0.88; 95% CI, 0.87-0.89; P < .001; Figure, A). After adjusting for recipient-level characteristics, higher SVI was associated with 3% lower likelihood of LDKT (adjusted RR [aRR], 0.97; 95% CI, 0.96-0.98; P < .001). Specifically, recipients living in communities with SVI similar to the 10457 zip code (Bronx) had 26% lower likelihood of LDKT compared with recipients in communities with SVI similar to the 90210 zip code (Beverly Hills; aRR, 0.74; 95% CI, 0.69-0.80; P < .001). In unadjusted analyses for race, Black recipients had 64% lower likelihood of LDKT (RR, 0.36; 95% CI, 0.34-0.39; P < .001) and recipients of other races had 38% lower likelihood of LDKT (RR, 0.62; 95% CI, 0.57-0.67; P < .001) compared with White counterparts. After adjusting for recipient-level characteristics and community-level vulnerability, Black recipients had 37% lower likelihood of LDKT (aRR, 0.63; 95% CI, 0.59-0.67; P < .001) and recipients of other races had 24% lower likelihood of LDKT (aRR, 0.76; 95% CI, 0.70-0.82; P < .001) compared with White recipients (Table 3).

    SVI and Race Interaction

    In a model adjusted for recipient-level characteristics and community-level vulnerability, the interaction between SVI and race was found to be significantly associated with LDKT. While Black recipients (aRR, 0.78; 95% CI, 0.67-0.90; P < .001) and recipients of other races (aRR, 0.74; 95% CI, 0.63-0.86; P < .001) demonstrated lower likelihood of LDKT compared with White counterparts (P for interaction = .01), only the interaction between SVI and Black recipients was significantly associated with LDKT (ratio of aRRs, 0.67; 95% CI, 0.51-0.87; P = .003; Table 4). Black recipients in communities with SVI similar to the 90210 zip code (Beverly Hills) had 24% lower likelihood of LDKT (aRR, 0.76; 95% CI, 0.66-0.86; P < .001), while Black recipients in communities with SVI similar to the 10457 zip code (Bronx) had 48% lower likelihood of LDKT (aRR, 0.52; 95% CI, 0.45-0.60; P < .001) compared with White counterparts in each neighborhood. The disparity in LDKT between Black and White recipients increased with greater community-level vulnerability (Figure, B).

    Sensitivity Analysis

    In all analyses, inferences were confirmed such that community-level vulnerability was significantly associated with LDKT. LDKT racial disparities persisted independent of community-level vulnerability, and there was a significant interaction between recipient race and SVI (eTables 4, 5, 6, 7, 8, and 9 in the Supplement).

    Discussion

    To our knowledge, this national study is the first to evaluate LDKT racial disparities while accounting for community-level vulnerability using the CDC SVI. Kidney transplant recipients living in more vulnerable communities had significantly lower likelihood of LDKT, while Black recipients and recipients of other races had lower likelihood of LDKT compared with White recipients, after controlling for community-level vulnerability. Black recipients living in the least vulnerable communities in the US (eg, Beverly Hills) were 24% less likely to receive LDKT. Moreover, the disparity in LDKT between Black and White recipients widened with increasing community-level vulnerability, suggesting the negative effect of living in a community with poor social determinants of health was worse for Black recipients.

    LDKT is contingent on identifying a willing, financially capable, and medically suitable donor. Donors are typically identified from a recipient’s social network, with 95% racial concordance and more than 50% median zip code income concordance between recipient-donor pairs.36,37 These data suggest recipients from vulnerable communities are likely to pursue donors from similar communities. Given that community-level vulnerability has been associated with poor health characteristics, such as obesity and physical inactivity, a medically suitable donor may be difficult to identify in areas with high SVI.27,28 This is supported by findings from Reed et al,38 who demonstrated poor population health was associated with significantly lower rates of LDKT. Lower household incomes have also been associated with lower LDKT rates as living kidney donation is not a financially neutral act—median cost to living donors is $3000.37,39 The SVI goes beyond measures of poverty or unemployment, however, and incorporates associated community-level factors, such as no-vehicle and single-parent households, that may pose additional barriers for potential donors.24 In short, shared social determinants of health between recipients and donors may contribute to the association between community-level vulnerability and LDKT.

    Inequities in community-level social determinants of health are well recognized and perpetuated by residential segregation.7,9,21 Black and racial minority populations are more likely to live in underserved areas with fewer options for healthy foods or opportunities for physical activity, employment, and education.1,7,9,40,41 Our findings are largely consistent with these disparities given that even among LDKT recipients, Black patients had significantly higher BMIs and the highest rates of type 2 diabetes, but the lowest proportion of patients working for income despite higher education levels than White LDKT recipients. Black LDKT recipients also lived in more vulnerable communities, while White patients lived in less vulnerable communities. These findings support the notion that Black recipients are disproportionately impacted by greater community-level vulnerability, and emphasize the need to address disparities in the social determinants of health as a means to mitigate racial disparities in LDKT.

    However, our findings also suggest that while improving Black recipients’ community-level social determinants of health may help narrow LDKT racial disparities, it will not eliminate them. We demonstrated that even in equivalent community settings accounting for measures of socioeconomic status and linguistic isolation as in prior work, in addition to household composition, disability, housing type, and transportation, Black recipients had lower likelihood of LDKT than White recipients.17,19,20,24-26 Thus, comprehensive measures of community-level vulnerability still only partially explained LDKT disparities. Importantly, LDKT disparities between Black and White recipients were exacerbated by greater community vulnerability.

    The possible, unmeasured explanations for this persistent disparity are complex and multifactorial. Lack of LDKT knowledge or willingness to discuss donation, concern for donor well-being, and donor lack of knowledge regarding the evaluation and approval process have been implicated as contributors to LDKT racial disparities.42-44 Importantly, mistrust of the medical system has also been shown to impact both recipients’ willingness to pursue LDKT and potential donors’ willingness to donate.45,46 This mistrust in our health care system is justifiably rooted in the historical exploitation of Black patients, and is perpetuated by ongoing health care disparities.47 As such, rebuilding trust is largely incumbent on health care professionals.47,48 The decline in Black male physicians should be reversed to build a racially concordant workforce that would improve patient-physician communication and shared decision-making, as well as build trust in the medical system.49-53 However, this endeavor will require time for realization and more immediate action within the current workforce is necessary. Specifically, the role of implicit racial biases in today’s health care disparities must be acknowledged.47,48,54

    US physicians’ biases have been shown to be similar to that of the general population; most hold implicit preferences for White compared with Black individuals.49 Evidence suggests implicit racial biases among clinicians perpetuate racial stereotypes, impact physician-patient communication, and influence clinical judgement, particularly in circumstances of clinical uncertainty.50 These findings may have implications for LDKT, particularly with respect to donor approval where data regarding long-term outcomes and lifetime risk of postdonation ESKD are lacking.55 Lower donor approval rates within the Black population have been attributed to higher prevalence of comorbid disease, but clinicians may differentially approve Black and White donors with otherwise similar risk profiles.56,57 Furthermore, our findings suggest Black donors from vulnerable communities may experience implicit racial biases compounded by poverty biases, resulting in concerns for compliance, postdonation follow-up, or development of comorbidities that increase postdonation ESKD risk.58 Clinical decisions intended to do no harm may inadvertently perpetuate LDKT racial disparities. Thus, while institutional, societal, and cultural changes are needed, acknowledgment of susceptibility to implicit biases and cultivation of bias-mitigating skills may help current health care professionals align their intentions with the care they provide as an initial step toward reestablishing trust in our health care system.53,54

    Limitations

    This study has limitations. To our knowledge, this national study is the first to use the CDC SVI in the evaluation of LDKT racial disparities. The multidimensional components of the SVI allow for a more comprehensive evaluation of community-level factors than any prior LDKT study. However, the SVI was initially developed for emergency preparedness and may not account for other neighborhood-level determinants of health that impact access to LDKT. Additionally, as zip codes were not created for geographic analyses, the boundaries of census tracts and zip codes do not overlay completely, allowing for unavoidable inaccuracies in census tract–level data aggregated to the zip code level.31 However, SVI measures among census tracts linking to the same zip code had low variation, suggesting any inaccuracies due to differing geographic boundaries would be minor and unlikely to impact study results (eTable 10 in the Supplement). Additionally, our study was retrospective, and we cannot account for residual confounding attributable to recipient-level characteristics not captured in SRTR, including recipient income which may be discordant with neighborhood-level measures of vulnerability.

    Conclusions

    In this study of kidney transplant recipients, the CDC SVI allowed for the most comprehensive evaluation of community-level vulnerability on disparate access to LDKT to date. While greater community-level vulnerability was associated with lower likelihood of LDKT, accounting for this only partially explained LDKT racial disparities. Even among recipients in the least vulnerable US communities, recipients from racial minority groups were less likely to receive LDKT. Importantly, the negative effects of living in a more vulnerable community were worse for Black patients. Thus, while policy reform is needed to improve disparate social determinants of health, evaluation of other factors that may impact access to LDKT among racial minority populations is warranted.

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    Article Information

    Accepted for Publication: July 11, 2021.

    Published Online: September 15, 2021. doi:10.1001/jamasurg.2021.4410

    Corresponding Author: Jayme E. Locke, MD, MPH, Comprehensive Transplant Institute, University of Alabama at Birmingham, 701 19th St S, LHRB 790, Birmingham, AL 35294 (jlocke@uabmc.edu).

    Author Contributions: Drs Killian and Locke had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Killian, Kumar, Sawinski, Locke.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Killian, Locke.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Killian, Shelton, MacLennan, McLeod, Qu, Locke.

    Obtained funding: Locke.

    Administrative, technical, or material support: Locke.

    Supervision: Reed, Orandi, Kumar, Sawinski, Locke.

    Conflict of Interest Disclosures: Dr Killian reported grants from the National Institute of Diabetes and Digestive and Kidney Diseases (T32DK007545) and from American College of Surgeons Resident Research Fellowship Award during the conduct of the study. Dr Orandi reported grants from National Center for Advancing Translational Sciences (1KL2TR003097) and from Career Development Award for Clinical/Outcomes/Education Research from the Society for Surgery of the Alimentary Tract during the conduct of the study. Dr Kumar reported grants from National Institutes of Health during the conduct of the study. Dr Locke reported personal fees from Sanofi Education and Novarits; other funding from Hansa; grants from United Therapeutics and National Institutes of Health and National Institute of Diabetes and Digestive and Kidney Diseases (K23DK103918 5R01DK113980-04, 5R01DK117675-03, and 1R01DK125509-01A1); consulting fees from DaVita; and has consulted for the US Food and Drug Administration outside the submitted work. No other disclosures were reported.

    Funding/Support: This work was supported by the National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases (T32DK007545, Dr Killian; R01DK113980, Dr Locke), the American College of Surgeons Resident Research Fellowship Award (Dr Killian), and the University of Alabama School of Medicine AMC 21. The data reported here have been supplied by the Hennepin Healthcare Research Institute as the contractor for the Scientific Registry of Transplant Recipients.

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy of or interpretation by the Scientific Registry of Transplant Recipients or the US government.

    Meeting Presentation: This paper was presented virtually at the Academic Surgical Congress; February 2, 2021; the Cutting Edge of Transplantation; February 25-27, 2021; and the American Transplant Congress; June 8, 2021.

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