Bailey Pippa K, Caskey Fergus J, MacNeill Stephanie, Tomson Charles R V, Dor Frank J M F, Ben-Shlomo Yoav
Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom.
Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom.
Transplant Direct. 2020 Mar 13;6(4):e540. doi: 10.1097/TXD.0000000000000986. eCollection 2020 Apr.
There is evidence of socioeconomic inequity in access to living-donor kidney transplantation, but limited evidence as to why. We investigated possible mediators of the inequity.
This questionnaire-based case-control study included 14 UK hospitals. Participants were adults transplanted between April 1, 2013 and March 31, 2017. Living-donor kidney transplant (LDKT) recipients (cases) were compared with deceased-donor kidney transplant recipients (controls). We collected data on mediators identified in earlier qualitative work: perceived social support (Interpersonal Support Evaluation List shortened version-12), patient activation (Patient Activation Measure 13), and LDKT knowledge (Rotterdam Renal Replacement Knowledge Test). We performed mediation analyses to investigate what proportion of the effect of socioeconomic position (education and income) on case-control status was mediated by these variables.
One thousand two-hundred and forty questionnaires were returned (40% response). Receipt of an LDKT over a deceased-donor kidney transplant was associated with higher socioeconomic position [adjusted odds ratio (aOR) university degree versus no degree aOR = 1.48 (95% confidence interval [CI], 1.18-1.84), = 0.001 and aOR per +£1000 increase in monthly household income after tax 1.14 (95% CI, 1.11-1.17), < 0.001] higher perceived social support (aOR per +1-point Interpersonal Support Evaluation List shortened version-12 score = 1.05 (95% CI, 1.03-1.08), < 0.001), higher levels of patient activation (aOR per +1 patient activation measure level = 1.35 (95% CI, 1.24-1.48), < 0.001), and greater LDKT knowledge (aOR per + 1-point Rotterdam Renal Replacement Knowledge Test score = 1.59 (95% CI, 1.49-1.69), < 0.001). Mediation analyses revealed that perceived social support, patient activation, and LDKT knowledge together mediate 48.5% (95% CI, 12.7-84.3, = 0.008) of the association between university education and LDKT status, and 46.0% (95% CI, 28.7-63.4, < 0.001) of the association between income and LDKT status.
LDKT knowledge, perceived social support, and patient activation are associated with the socioeconomic position of people with kidney disease, and mediate approximately 50% of the association between the socioeconomic position and receipt of an LDKT. Interventions that target these factors may redress observed socioeconomic inequity.
有证据表明在活体供肾移植的可及性方面存在社会经济不平等，但关于其原因的证据有限。我们调查了这种不平等可能的中介因素。
这项基于问卷的病例对照研究纳入了英国的14家医院。参与者为2013年4月1日至2017年3月31日期间接受移植的成年人。将活体供肾移植（LDKT）受者（病例组）与尸体供肾移植受者（对照组）进行比较。我们收集了早期定性研究中确定的中介因素的数据：感知到的社会支持（人际支持评估量表简版-12）、患者激活度（患者激活量表13）和LDKT知识（鹿特丹肾脏替代知识测试）。我们进行了中介分析，以研究社会经济地位（教育和收入）对病例对照状态的影响中有多大比例是由这些变量介导的。
共返回了1240份问卷（回复率为40%）。接受LDKT而非尸体供肾移植与较高的社会经济地位相关[调整后的优势比（aOR），大学学历与无学历相比，aOR = 1.48（95%置信区间[CI]，1.18 - 1.84），P = 0.001；每月家庭税后收入每增加1000英镑，aOR为1.14（95% CI，1.11 - 1.17），P < 0.001]、更高的感知社会支持（人际支持评估量表简版-12得分每增加1分对应的aOR = 1.05（95% CI，1.03 - 1.08），P < 0.001）、更高水平的患者激活度（患者激活量表每增加1个等级对应的aOR = 1.35（95% CI，1.24 - 1.48），P < 0.001）以及更多的LDKT知识（鹿特丹肾脏替代知识测试得分每增加1分对应的aOR = 1.59（95% CI，1.49 - 1.69），P < 0.001）。中介分析显示，感知社会支持、患者激活度和LDKT知识共同介导了大学教育与LDKT状态之间关联的48.5%（95% CI，12.7 - 84.3，P = 0.008），以及收入与LDKT状态之间关联的46.0%（95% CI，28.7 - 63.4，P < 0.001）。
LDKT知识、感知社会支持和患者激活度与肾病患者的社会经济地位相关，并介导了社会经济地位与接受LDKT之间约50%的关联。针对这些因素的干预措施可能纠正观察到的社会经济不平等。
