Miami Transplant Institute Study Explains Disparities in Kidney Transplant Waitlist

Published in the journal Transplantation, the study attributes the disparities largely to the lower socioeconomic or non-citizenship status of blacks and Hispanics, and the failure to preemptively waitlist them for transplant before starting dialysis, presumably a consequence of initiating care for their failing kidneys too late.

While a longer time on dialysis, which is associated with poorer transplant outcomes, has been well documented for African-American patients who usually lack private health insurance and are poorer than their white counterparts, there are relatively few studies specifically comparing Hispanic and white access to the kidney transplant waitlist. As a result, the study’s first author, Shivam Joshi, M.D., a 2012 graduate of the Miller School and current research fellow at the institute, senior author Gaetano Ciancio, M.D., M.B.A., the institute’s Chief Medical Officer and Chief Academic Officer, and their colleagues set out to investigate differences in waitlist access among whites, blacks, and Hispanics in South Florida. The goal was to pinpoint the risk factors that predict a longer time on dialysis before waitlisting, and to determine how to help providers improve patient care before and during the listing process.

For the study, “Disparities Among Blacks, Hispanics, and Whites in Time From Starting Dialysis to Kidney Transplant Waitlisting,” the researchers analyzed the records of 1,910 patients — 684 blacks, 452 Hispanics, and 774 whites — who were waitlisted for a kidney or kidney-pancreas transplant at the University of Miami and Jackson Memorial Hospital’s Kidney and Kidney/Pancreas Transplant Program between 2005 and 2010. They determined the time each patient spent on dialysis before being waitlisted, and their probability of being preemptively waitlisted for transplant prior to starting dialysis.

Since a longer time spent on dialysis has been associated with significantly poorer patient and graft survival after transplantation, early transplantation is the preferred treatment for end stage kidney disease. Being waitlisted before starting dialysis is considered ideal, because it maximizes the patient’s chance of both receiving and surviving a transplant.

“While we expected that whites would have greater access to the kidney transplant waitlist, we did not know to what extent and why,” Joshi said. “What we found out was surprising. Whites, of course, had the best access to a kidney transplant waitlist by having, on average, the shortest times spent on dialysis and the highest rates of preemptive waitlisting – that is, being waitlisted before starting dialysis, which maximizes the patient’s chance of avoiding dialysis and receiving a preemptive transplant. For Hispanics and blacks, we saw that their reduced access was, to a large degree, due to their having a lower socioeconomic status and non-U.S. citizenship.”

Low socioeconomic status and non-citizenship often equated with a lack of health insurance, which the researchers suggested meant that many black and Hispanic patients first presented with end stage kidney disease (ESRD) at a hospital emergency room, requiring emergency dialysis rather than early or preemptive referral to a nephrologist. As the authors noted, “A late referral to a nephrologist at the time of ESRD necessitates the immediate start of (and possibly greater requirement for) long-term dialysis, without the possibility of better pre-ESRD patient care, reduced comorbidity, preemptive waitlisting, and (preemptive) transplantation.”

The researchers concluded that a greater focus on earlier nephrology care may help erase much of the disparity.

“Earlier nephrology care, achieved through more extensive educational campaigns, improved patient monitoring both before and after referral to a transplant center, and more widespread affordability of health insurance, may allow a greater patient access to preemptive waitlisting and minimization of the patient’s time spent on dialysis, which might also help to improve long-term patient and graft survival after transplantation,” the authors wrote.

To promote earlier care, the institute has initiated a video campaign to educate South Florida’s chronic kidney disease patients about the advantages of a kidney transplant, which include reduced morbidity and mortality, increased quality of life, and potentially lower healthcare costs, over long-term dialysis.

“We want to provide the best care to all patients, especially when we know that prolonged exposure on dialysis is worse for the patient in almost every regard,” Joshi said. “As a result, we are preparing educational videos in several languages to better educate chronic kidney disease patients in South Florida about the benefits of kidney transplantation vs. staying on or receiving long-term dialysis.”

In addition to Joshi and Ciancio, others coauthors of the study were Jeffrey J. Gaynor, Ph.D., a biostatistician at the institute; Stephanie Bayers, a medical student at UM; Giselle Guerra, M.D., associate professor of medicine and Director of the Kidney Living Donor Program; Ahmed Eldefrawy, M.D., urology fellow; Zoila Chediak, clinical program coordinator; Lazara Companioni, patient access coordinator; Junichiro Sageshima, M.D., associate professor of surgery; Linda Chen, M.D., assistant professor of surgery; Warren Kupin, M.D., professor of medicine; David Roth, M.D., professor of medicine; Adela Mattiazzi, M.D., assistant professor of medicine; and George W. Burke, III, M.D., professor of surgery.

University of Miami