Journal Club: Do Race and Socioeconomic Factors Still Influence Access to Kidney Transplantation?

Fact: Racial disparities continue to exist - accessing a kidney transplant is not an exception.

A new study published in the American Journal of Transplantation reveals that racial disparities exist in both the early and late steps in access to kidney transplantation.

Fig.1: Dialysis patients who were registered on a waiting list
 for transplantation, by race and ethnicity, 2000-2006
Source: U.S. Renal Data System, 2000-2006
AI/AN = American Indian or Alaska Native.

Led by Rachel E. Patzer, PhD, MPH, of the Emory Transplant Center in Atlanta, Georgia, researchers examined 2,291 adult patients referred for renal transplant evaluation at a single transplant center in the Southeastern U.S. from 2005-2007, followed through May 2010. Demographic and clinical data were assessed and Cox models were used to examine the effect of race on referral, evaluation, waitlisting, and organ receipt.

Of the 2,291 patients, 64.9% were black, the mean age was 49.4 years, and 33.6% lived in poor neighborhoods.

Racial disparities were observed in access to referral, transplant evaluation, waitlisting, and organ receipt. Socioeconomic factors, including health insurance and access to care, explained almost 1/3 of the lower rate of transplant among black vs. white patients.

However, even after adjusting for demographic, clinical, and socioeconomic factors, blacks had a 59% lower rate of transplant than whites.

The study has several limitations - single center, retrospective, and cannot exclude the possibility of residual confounding. 

The first author Rachel Patzer is quoted as saying: “Despite near-universal health care coverage for end stage renal disease (ESRD) patients through the Medicare ESRD program, black ESRD patients are at a disadvantage to receive a kidney transplantation. Socioeconomic status really accounts for about 30% of this observed racial disparity in transplant access. Further research is needed to identify what may be explaining the racial disparities that still exist in access to kidney transplantation.”

Patzer summarizes the take-home messages:

1. There are racial disparities in both the early and late steps in access to kidney transplantation. 

2. Among patients who were referred to Emory for kidney transplant evaluation, 45% never started the evaluation process. The reasons for this are unknown.

3. Patients who were referred but did not start the evaluation were more likely to be black than white.

Practical implications




1. Encourage patients who are referred to start the evaluation process.

2. Given that the rate of referral for transplant is much slower among blacks vs. whites, clinicians should place a high value on patient education. 

3. Following up with patients after an initial discussion about transplantation is also important, and if a patient expresses interest in transplant but does not pursue transplantation, the clinician must figure out why.

4. Be vigilant for physician bias as a cause for some of the racial disparity. It's possible that physician's may see a patient who is less disadvantaged or with less resources and not refer them for transplant.