Pediatric Access to Preemptive Kidney Transplantation
Pediatric Access to Preemptive Kidney Transplantation
Preemptive kidney transplantation is the optimal treatment for pediatric end stage renal disease patients to avoid increased morbidity and mortality associated with dialysis. It is unknown how race/ethnicity and poverty influence preemptive transplant access in pediatric. We examined the incidence of living donor or deceased donor preemptive transplantation among all black, white, and Hispanic children (<18 years) in the United States Renal Data System from 2000 to 2009. Adjusted risk ratios for preemptive transplant were calculated using multivariable-adjusted models and examined across health insurance and neighborhood poverty levels. Among 8,053 patients, 1117 (13.9%) received a preemptive transplant (66.9% from LD, 33.1% from DD). In multivariable analyses, there were significant racial/ethnic disparities in access to LD preemptive transplant where blacks were 66% (RR = 0.34; 95% CI: 0.28–0.43) and Hispanics 52% (RR = 0.48; 95% CI: 0.35–0.67) less likely to receive a LD preemptive transplant versus whites. Blacks were 22% less likely to receive a DD preemptive transplant versus whites (RR = 0.78, 95% CI: 0.57–1.05), although results were not statistically significant. Future efforts to promote equity in preemptive transplant should address the critical issues of improving access to pre-ESRD nephrology care and overcoming barriers in living donation, including obstacles partially driven by poverty.
Among both deceased donor (DD) and living donor (LD) transplant recipients, the number of years on dialysis negatively correlates with patient and graft survival. Renal transplant recipients have better survival and a higher quality of life than dialysis patients. Preemptive renal transplantation, defined as transplantation prior to the initiation of dialysis, is the optimal treatment for patients with end stage renal disease (ESRD) because it avoids the increased morbidity and mortality associated with dialysis, creation of surgical dialysis access and its complications, and the costs of dialysis. Despite health care coverage for treatment of ESRD through Medicare, preemptive LD or DD kidney transplantation remains highly underutilized in the United States; only 3.2% of incident ESRD patients <70 years of age received a preemptive transplant in 2009.
In the pediatric ESRD population, where long-term outcomes take on added significance, the potential benefits of preemptive transplantation are multiplied. Pediatric patients on chronic dialysis have markedly increased rates of cardiovascular disease, bone-mineral dysregulation and impaired cognitive function versus those who are transplanted. The influence of these comorbidities is demonstrated by the 95% 5-year patient survival rate of children who receive a preemptive transplant compared to 75% for those who receive hemodialysis as their initial treatment. Preemptive transplantation requires early recognition of kidney disease progression and thus necessitates early access to pre-ESRD nephrology care. In a study of 111 children in Austria, those with at least 12 months of pre-ESRD nephrology care were more than twice as likely to receive preemptive kidney transplant versus those with less than 1 year of care. Access to pre-ESRD nephrology care may be more challenging for minority children who more often lack insurance or a medical home.
Racial disparities in preemptive transplantation have been reported in the adult ESRD population, where the odds of preemptive kidney transplantation among whites are more than twice as high than blacks and about 1.6× higher than Hispanics. Several small, single-center studies have reported racial/ethnic differences in children who present for preemptive kidney transplantation versus those who receive transplantation following dialysis, but these disparities have not been examined nationally. We previously documented racial disparities in non-preemptive transplant access among pediatric ESRD patients, where black and Hispanic children in the United States have reduced access to DD kidney transplantation even after accounting for differences in SES. Further, racial disparities in non-preemptive LD transplant exist, and following the implementation of the Share 35 allocation policy to preferentially allocate young (<35 years) donor organs to young (<18 years) recipients, the decline in non-preemptive LD transplants was more substantial among minority compared to white pediatric ESRD patients. Whether racial disparities in access to pediatric preemptive transplant vary by donor source, DD versus LD, is unknown. The goal of our study was to characterize racial/ethnic disparities in access to preemptive transplant among the national cohort of children with ESRD over the last decade (2000–2009), considering both donor source (LD vs. DD) and SES.
Abstract and Introduction
Abstract
Preemptive kidney transplantation is the optimal treatment for pediatric end stage renal disease patients to avoid increased morbidity and mortality associated with dialysis. It is unknown how race/ethnicity and poverty influence preemptive transplant access in pediatric. We examined the incidence of living donor or deceased donor preemptive transplantation among all black, white, and Hispanic children (<18 years) in the United States Renal Data System from 2000 to 2009. Adjusted risk ratios for preemptive transplant were calculated using multivariable-adjusted models and examined across health insurance and neighborhood poverty levels. Among 8,053 patients, 1117 (13.9%) received a preemptive transplant (66.9% from LD, 33.1% from DD). In multivariable analyses, there were significant racial/ethnic disparities in access to LD preemptive transplant where blacks were 66% (RR = 0.34; 95% CI: 0.28–0.43) and Hispanics 52% (RR = 0.48; 95% CI: 0.35–0.67) less likely to receive a LD preemptive transplant versus whites. Blacks were 22% less likely to receive a DD preemptive transplant versus whites (RR = 0.78, 95% CI: 0.57–1.05), although results were not statistically significant. Future efforts to promote equity in preemptive transplant should address the critical issues of improving access to pre-ESRD nephrology care and overcoming barriers in living donation, including obstacles partially driven by poverty.
Introduction
Among both deceased donor (DD) and living donor (LD) transplant recipients, the number of years on dialysis negatively correlates with patient and graft survival. Renal transplant recipients have better survival and a higher quality of life than dialysis patients. Preemptive renal transplantation, defined as transplantation prior to the initiation of dialysis, is the optimal treatment for patients with end stage renal disease (ESRD) because it avoids the increased morbidity and mortality associated with dialysis, creation of surgical dialysis access and its complications, and the costs of dialysis. Despite health care coverage for treatment of ESRD through Medicare, preemptive LD or DD kidney transplantation remains highly underutilized in the United States; only 3.2% of incident ESRD patients <70 years of age received a preemptive transplant in 2009.
In the pediatric ESRD population, where long-term outcomes take on added significance, the potential benefits of preemptive transplantation are multiplied. Pediatric patients on chronic dialysis have markedly increased rates of cardiovascular disease, bone-mineral dysregulation and impaired cognitive function versus those who are transplanted. The influence of these comorbidities is demonstrated by the 95% 5-year patient survival rate of children who receive a preemptive transplant compared to 75% for those who receive hemodialysis as their initial treatment. Preemptive transplantation requires early recognition of kidney disease progression and thus necessitates early access to pre-ESRD nephrology care. In a study of 111 children in Austria, those with at least 12 months of pre-ESRD nephrology care were more than twice as likely to receive preemptive kidney transplant versus those with less than 1 year of care. Access to pre-ESRD nephrology care may be more challenging for minority children who more often lack insurance or a medical home.
Racial disparities in preemptive transplantation have been reported in the adult ESRD population, where the odds of preemptive kidney transplantation among whites are more than twice as high than blacks and about 1.6× higher than Hispanics. Several small, single-center studies have reported racial/ethnic differences in children who present for preemptive kidney transplantation versus those who receive transplantation following dialysis, but these disparities have not been examined nationally. We previously documented racial disparities in non-preemptive transplant access among pediatric ESRD patients, where black and Hispanic children in the United States have reduced access to DD kidney transplantation even after accounting for differences in SES. Further, racial disparities in non-preemptive LD transplant exist, and following the implementation of the Share 35 allocation policy to preferentially allocate young (<35 years) donor organs to young (<18 years) recipients, the decline in non-preemptive LD transplants was more substantial among minority compared to white pediatric ESRD patients. Whether racial disparities in access to pediatric preemptive transplant vary by donor source, DD versus LD, is unknown. The goal of our study was to characterize racial/ethnic disparities in access to preemptive transplant among the national cohort of children with ESRD over the last decade (2000–2009), considering both donor source (LD vs. DD) and SES.
Source...