Employment status at transplant influences ethnic disparities in outcomes after deceased donor kidney transplantation

• Type of Material: Article
• Authors: Jasmin Divers, New York University; Sumit Mohan, Columbia University; W. Mark Brown, Mailman School of Public Health; Stephen Pastan, Emory University; Ajay K Israni, University of Minnesota; Robert S. Gaston, University of Alabama Birmingham; Robert Bray, Emory University; Shahidul Islam, New York University; Natalia V. Sakhovskaya, Wake Forest University; Alejandra M. Mena-Gutierrez, Wake Forest University; Amber M. Reeves-Daniel, Wake Forest University; Bruce A. Julian, University of Alabama Birmingham; Barry I. Freedman, Wake Forest University
• Language: English
• Date: 2022-01-03
• Publisher: BioMed Central
• Publication Version: Final Published Version
• Copyright Statement: © The Author(s) 2021
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1186/s12882-021-02631-4
• Title of Journal or Parent Work: BMC Nephrology
• Volume: 23
• Grant/Funding Information: This work was supported, in part, by grants from the National Institutes of Health R01 DK070941 (BIF), R01 DK084149 (BIF), R01 MD009055 (JD, BIF, BAJ), and Genomics of Transplantation U19-AI070119 (AKI, BAJ). The data reported here have been supplied by the Minneapolis Medical Research Foundation (MMRF) as the Scientific Registry of Transplant Recipients (SRTR) contractor. Interpretation and reporting of these data are the responsibilities of the authors, and in no way should be considered an official policy of, or interpretation by the SRTR or the United States Government. In addition, Dr. Mohan is supported by the National Institute of Diabetes and Digestive and Kidney Diseases (R01 DK114893 and U01116066) and the National Institute of Minority Health and Health Disparities (R01 MD014161).
• Keywords: Kidney recipient mortality; Employment status; Outcome disparity; Deceased donor kidney transplantation; Allograft failure
• Research Categories: Sociology, Ethnic and Racial Studies; Health Sciences, Medicine and Surgery; Sociology, Organizational

Abstract

Background African American (AA) recipients of deceased-donor (DD) kidney transplants (KT) have shorter allograft survival than recipients of other ethnic groups. Reasons for this disparity encompass complex interactions between donors and recipients characteristics. Methods Outcomes from 3872 AA and 19,719 European American (EA) DDs who had one kidney transplanted in an AA recipient and one in an EA recipient were analyzed. Four donor/recipient pair groups (DRP) were studied, AA/AA, AA/EA, EA/AA, and EA/EA. Survival random forests and Cox proportional hazard models were fitted to rank and evaluate modifying effects of DRP on variables associated with allograft survival. These analyses sought to identify factors contributing to the observed disparities in transplant outcomes among AA and EA DDKT recipients. Results Transplant era, discharge serum creatinine, delayed graft function, and DRP were among the top predictors of allograft survival and mortality among DDKT recipients. Interaction effects between DRP with the kidney donor risk index and transplant era showed significant improvement in allograft survival over time in EA recipients. However, AA recipients appeared to have similar or poorer outcomes for DDKT performed after 2010 versus before 2001; allograft survival hazard ratios (95% CI) were 1.15 (0.74, 1.76) and 1.07 (0.8, 1.45) for AA/AA and EA/AA, compared to 0.62 (0.54, 0.71) and 0.5 (0.41, 0.62) for EA/EA and AA/EA DRP, respectively. Recipient mortality improved over time among all DRP, except unemployed AA/AAs. Relative to DDKT performed pre-2001, employed AA/AAs had HR = 0.37 (0.2, 0.69) versus 0.59 (0.31, 1.11) for unemployed AA/AA after 2010. Conclusion Relative to DDKT performed before 2001, similar or worse overall DCAS was observed among AA/AAs, while EA/EAs experienced considerable improvement regardless of employment status, KDRI, and EPTS. AA recipients of an AA DDKT, especially if unemployed, had worse allograft survival and mortality and did not appear to benefit from advances in care over the past 20 years.