Improving access to kidney care for underrepresented ESKD patients

Michael Casey is a transplant nephrologist and Derek DuBay is a transplant surgeon at the Medical University of South Carolina (Charleston, USA). They write to discuss a new intervention for making provision of kidney care in the USA more equitable.

Several studies report that African Americans are less likely to be added to the kidney transplant waitlist in the USA.^1-3 A recent study reported that African Americans were, surprisingly, referred for kidney transplantation at a higher rate than Caucasians, but were less likely to initiate kidney transplant evaluation, complete kidney transplant evaluation, and be added to the waitlist.⁴ Thus, efforts need to focus on reducing barriers to initiating and completing an evaluation once referred for transplant.  

At the Medical University of South Carolina, 65% of patients referred for kidney transplant self-identify as African American. We clearly recognised a disparity in African Americans not completing evaluations and being added to the waitlist compared to Caucasians. Therefore, our centre enacted a multilevel intervention to reduce structural barriers in transplant access in effort to close the racial disparity gap.⁵  

The first intervention was reducing physician variability in the evaluation process via the development of a formal algorithm for medical and social work evaluation which was disseminated to all persons involved in the evaluation as a laminated card and made available on our centre’s intranet. Adherence to this algorithm eliminated extraneous testing and provided a consistent message to patients, referring providers, and dialysis centres. The second intervention (reported previously⁶) involved dialysis centre-based transplant education designed to increase patients’ knowledge and self-efficacy with regards to their belief that they could complete a transplant workup. Another intervention utilised virtual evaluations to initiate kidney transplant evaluations and telehealth hubs based in metropolitan areas geographically distant from our transplant centre, allowing for improved communication and coordination with community nephrologists and dialysis centers. Finally, our centre adopted virtual social work, pharmacy, and dietary assessments to free up the in-person evaluation visit for physician assessment and key medical testing.  

We used a modified version of the Kidney Transplant Equity Index (KTEI)⁷ to measure the impact of these interventions over time. KTEI was defined as the proportion of African Americans initiating evaluation, completing evaluation and waitlisting (numerator) divided by the proportion of African Americans in South Carolina receiving dialysis (denominator). A KTEI=1 signifies equity and a KTEI<1 signifies disparity. From 2017 to 2021, KTEI trends significantly improved for initiated evaluations (KTEI 0.88 to 1.00), completed evaluations (KTEI 0.85 to 0.95), and waitlist additions (KTEI 0.83 to 0.96). 

This single-centre study suggests that the kidney transplant evaluation process is overly burdensome and reducing structural barriers during the referral and evaluation processes affords the opportunity for more African Americans to gain access to kidney transplantation. The net result of these interventions is a more streamlined evaluation process that is simpler for patients to navigate. The authors admit that there remain many opportunities to further refine the process.  

The structural barriers addressed in these interventions were not originally developed with the goal of excluding certain patient populations from kidney transplantation. In fact, the (complex) kidney transplant evaluation process was created with the best of intentions, to provide a comprehensive medical and social assessment of the end-stage kidney disease (ESKD) patient. There is a growing body of literature, however, that calls into question if some commonly-utilised medical tests used during the transplant evaluation process accurately risk stratify patients.⁸ Furthermore, there is increasing ethical scrutiny levelled against components of the social assessment.⁹  

In the USA, there are roughly 500,000 ESKD patients on dialysis and only 20% of those are represented on the kidney transplant waiting list. It is imperative that we, as a transplant community, create a more streamlined process to allow more underrepresented ESKD patients access to the waiting list and a life-saving transplant.

References: 

1. Saunders MR, Cagney KA, Ross LF, et al. Neighborhood poverty, racial composition and renal transplant Am J Transplant 2010;10:1912–1917.
2. Patzer RE, Amaral S, Wasse H, et al. Neighborhood poverty and racial disparities in kidney transplant J Am Soc Nephrol 2009;20:1333–1340.
3. Ng Y-H, Pankratz VS, Leyva Y, et al. Does racial disparity in kidney transplant wait-listing persist after accounting for social determinants of health? Transplantation 2020;104:1445–1455.
4. Patzer RE, McPherson L, Wang Z, et al. Dialysis facility referral and start of evaluation for kidney transplantation among patients treated with dialysis in the Southeastern United States. Am J Transplant 2020;20:2113–2125.
5. Taber DJ, Su Z, Gebregziabher M, et al. Multilevel Intervention to Improve Racial Equity in Access to Kidney Transplant. J Am Coll Surg 2023;236(4):721-727.
6. Morinelli TA, Taber DJ, Su Z, et al. A dialysis center educational video intervention increases patient self-efficacy and kidney transplant evaluations. Prog Transplant 2022;32:27–34.
7. Delman AM, Turner KM, Silski LS, et al. The Kidney Transplant Equity Index: improving racial and ethnic minority access to Ann Surg 2022;276:420–429.
8. Cheng XS, Van Wagner LB, Costa SP, et al. Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association: Endorsed by the American Society of Transplantation. Circulation 2022;146:e299–e324.
9. Berry KN, Daniels N, Ladin K. Should Lack of Social Support Prevent Access to Organ Transplantation? Am J Bioeth. 2019;19(11):13-24. doi:10.1080/15265161.2019.1665728