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Aaron M. Delman, Kevin M. Turner, Latifa S. Silski, Ralph C. Quillin, Martha Estrada, Madison Cuffy, Shimul A. Shah
Surgery, University of Cincinnati, Cincinnati, Ohio, United States

Objective: Racial and ethnic disparities for access to listing and transplant in patients with end-stage renal disease (ESRD) are well described, but metrics and variation in care among kidney transplant (KT) centers and geographic regions are unknown.

Methods: From 2013 – 2018, custom databases from the United States Renal Data System and United Network for Organ Sharing were merged to calculate the Kidney Transplant Equity Index (KTEI): the number of minority patients transplanted at a center, relative to the prevalence of minority patients on dialysis in each center’s health service area. Markers of socioeconomic status (SES), obtained from the Census Bureau, and recipient outcomes were compared between high KTEI centers and low KTEI centers.

Results: 249 transplant centers performed 111,959 KTs relative to 475,914 non-transplanted patients on dialysis. There is significant national variability in KTEIs among KT centers (FIGURE 1A/1B, p<0.001). High KTEI centers performed more KTs for Black (105.5 vs. 24, p<0.001), Hispanic (55.5 vs. 7, p<0.001), and American Indian (5.61 vs. 1.38, p<0.001) patients than low KTEI centers. In addition, high KTEI centers transplanted more patients with higher unemployment (52 vs. 44, p<0.001), worse social deprivation (53 vs. 46, p<0.001), and lower educational attainment (52 vs. 43, p<0.001). While providing increased access to transplant for minority and low SES populations, high KTEI centers had similar graft (HR: 0.94, 95% CI: 0.86-1.02) and improved patient survival (HR: 0.86, 95% CI: 0.77-0.95) on multivariable cox proportional hazards modeling. Furthermore, on subset analysis of isolated minority patients, undergoing a KT at a high KTEI center was associated with improved patient survival (HR: 0.87, 95% CI: 0.75-1.01).

Conclusions: The KTEI is the first metric to quantify minority access to KT incorporating the pre-listing ESRD prevalence individualized to transplant centers. KTEIs uncover significant national variation in transplant practices and identify highly equitable centers. This novel metric should be used to disseminate best practices for minority and low socioeconomic populations with ESRD.

FIGURE 1A: Displays the significant variability in access to transplantation for minority populations by kidney transplant index (KTEI) quintile. FIGURE 1B: Depicts the geographic distribution of equitable centers nationally. States which provide the highest access to transplant for minority populations relative to End-Stage Renal Disease (ESRD) prevalence are in orange, then in decreasing order: purple, green, red, and blue.

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