Department of Surgery, Duke University School of Medicine, Durham, North Carolina.
Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina.
JAMA Netw Open. 2023 Dec 1;6(12):e2347826. doi: 10.1001/jamanetworkopen.2023.47826.
It is unclear whether center-level factors are associated with racial equity in living donor kidney transplant (LDKT).
To evaluate center-level factors and racial equity in LDKT during an 11-year time period.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort longitudinal study was completed in February 2023, of US transplant centers with at least 12 annual LDKTs from January 1, 2008, to December 31, 2018, identified in the Health Resources Services Administration database and linked to the US Renal Data System and the Scientific Registry of Transplant Recipients.
Observed and model-based estimated Black-White mean LDKT rate ratios (RRs), where an RR of 1 indicates racial equity and values less than 1 indicate a lower rate of LDKT of Black patients compared with White patients. Estimated yearly best-case center-specific LDKT RRs between Black and White individuals, where modifiable center characteristics were set to values that would facilitate access to LDKT.
The final cohorts of patients included 394 625 waitlisted adults, of whom 33.1% were Black and 66.9% were White, and 57 222 adult LDKT recipients, of whom 14.1% were Black and 85.9% were White. Among 89 transplant centers, estimated yearly center-level RRs between Black and White individuals accounting for center and population characteristics ranged from 0.0557 in 2008 to 0.771 in 2018. The yearly median RRs ranged from 0.216 in 2016 to 0.285 in 2010. Model-based estimations for the hypothetical best-case scenario resulted in little change in the minimum RR (from 0.0557 to 0.0549), but a greater positive shift in the maximum RR from 0.771 to 0.895. Relative to the observed 582 LDKT in Black patients and 3837 in White patients, the 2018 hypothetical model estimated an increase of 423 (a 72.7% increase) LDKTs for Black patients and of 1838 (a 47.9% increase) LDKTs for White patients.
In this cohort study of patients with kidney failure, no substantial improvement occurred over time either in the observed or the covariate-adjusted estimated RRs. Under the best-case hypothetical estimations, modifying centers' participation in the paired exchange and voucher programs and increased access to public insurance may contribute to improved racial equity in LDKT. Additional work is needed to identify center-level and program-specific strategies to improve racial equity in access to LDKT.
目前尚不清楚中心层面的因素是否与活体供肾移植（LDKT）中的种族公平有关。
在 11 年的时间内评估中心层面的因素和 LDKT 中的种族公平。
设计、设置和参与者：这是一项回顾性队列纵向研究，于 2023 年 2 月完成，研究对象为美国移植中心，这些中心至少有 12 例每年的 LDKT，数据来源于卫生资源服务管理局数据库，并与美国肾脏数据系统和移植受者科学注册处相关联。研究纳入的患者来自于 2008 年 1 月 1 日至 2018 年 12 月 31 日期间在美国进行的至少 12 例每年的 LDKT。
观察到的和基于模型的估计的黑人和白人 LDKT 率比值（RR），其中 RR 为 1 表示种族公平，并且小于 1 表示与白人患者相比，黑人患者的 LDKT 率较低。估计每年最佳情况下黑人和白人个体之间的特定中心 LDKT RR，其中可修改的中心特征被设置为有利于 LDKT 机会的数值。
最终队列包括 394625 名等待移植的成年患者，其中 33.1%为黑人，66.9%为白人，57222 名成年 LDKT 受者，其中 14.1%为黑人，85.9%为白人。在 89 家移植中心中，估计每年黑人和白人个体之间的中心层面 RR 考虑到了中心和人口特征，范围从 2008 年的 0.0557 到 2018 年的 0.771。每年的中位数 RR 范围从 2016 年的 0.216 到 2010 年的 0.285。基于模型的假设最佳情况下的估计结果导致最低 RR 几乎没有变化（从 0.0557 变为 0.0549），但最大 RR 的正偏移更大，从 0.771 变为 0.895。与观察到的 582 例黑人患者和 3837 例白人患者的 LDKT 相比，2018 年的假设模型估计黑人患者的 LDKT 增加了 423 例（增加了 72.7%），白人患者的 LDKT 增加了 1838 例（增加了 47.9%）。
在这项对肾衰竭患者的队列研究中，观察到的或协变量调整后的估计 RR 并没有随着时间的推移而得到实质性改善。在最佳假设情况下的估计中，修改中心参与配对交换和代金券计划以及增加公共保险的获取途径可能有助于改善 LDKT 中的种族公平。需要进一步努力确定中心层面和特定计划的策略，以改善活体供肾移植的获取途径中的种族公平。
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