McPherson Laura, Plantinga Laura C, Howards Penelope P, Kramer Michael, Patzer Rachel E
Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, USA.
Division of Rheumatology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
J Clin Epidemiol. 2025 Jun 24;185:111878. doi: 10.1016/j.jclinepi.2025.111878.
Socioeconomic inequities in early access to kidney transplantation among patients with end-stage kidney disease (ESKD) are well documented. It is unknown whether these inequities can be mitigated through access to nephrology care prior to starting dialysis. This study evaluated whether pre-ESKD nephrology care meaningfully explained the association between neighborhood poverty and referral for kidney transplantation among patients initiating treatment for ESKD.
In this retrospective cohort study using United States Renal Data System data (January 1, 2012 to June 30, 2021), we identified 192,318 adults with incident ESKD from dialysis facilities in Southeast, Northeast, New York, and Ohio River Valley US regions. Neighborhood poverty exposure was dichotomized based on zip code poverty rates (≥20% vs 0%-19%), and referral outcomes were assessed from 28 transplant centers. We used marginal structural Cox models with inverse probability of treatment weighting to estimate the direct effect of neighborhood poverty on referral for kidney transplantation, controlling for access to pre-ESKD nephrology care (controlled direct effect).
Findings show that 68% had pre-ESKD nephrology care, and 25% lived in high-poverty areas. Pre-ESKD nephrology care was associated with increased referral (hazard ratio (HR): 1.26, 95% CI: 1.22, 1.30). Adjusted analyses using marginal structural Cox models with inverse probability weighting revealed that pre-ESKD nephrology care did not fully explain the association between neighborhood poverty and referral for kidney transplantation (controlled direct effect HR: 0.87, 95% CI: 0.85, 0.89; total effect HR: 0.90, 95% CI: 0.88, 0.91).
These results underscore the beneficial role of pre-ESKD nephrology care in enhancing transplant referral access. However, persistent disparities linked to neighborhood poverty remain evident. The study emphasizes the continued importance of pre-ESKD nephrology care as a clinical standard for all patients with ESKD. Future research should explore interventions earlier in the kidney disease continuum to address socioeconomic disparities and improve equitable access to kidney transplantation.
For people with end-stage kidney disease (ESKD), survival depends on either regular dialysis treatments or a kidney transplant. For most people, a kidney transplant offers the best long-term survival and quality of life compared to dialysis. People living in poorer neighborhoods face significant challenges in getting referred for a kidney transplant. Our study aimed to investigate if receiving care from a kidney specialist (nephrologist) before needing dialysis (pre-ESKD nephrology care) could help overcome these income-related disparities in transplant access. We looked at records from nearly 200,000 adults across 4 US regions who started treatment for ESKD. We categorized neighborhoods as "high-poverty" (where 20% or more residents live below the poverty line) or "low-poverty" areas. Using advanced statistical methods, we analyzed how neighborhood poverty affected transplant referral, specifically assessing the role of pre-ESKD nephrology care. Our findings showed that most patients (68%) had seen a nephrologist before dialysis. Seeing a nephrologist was associated with a 26% higher chance of being referred for a transplant. However, even among those who received predialysis nephrology care, living in a high-poverty neighborhood still meant they were 13% less likely to be referred for a transplant. This study highlights that while pre-ESKD nephrology care is beneficial and increases the likelihood of transplant referral, it alone does not fully close the gap in access influenced by neighborhood poverty. To achieve equitable access to kidney transplantation for all patients, future efforts must target broader interventions that address the underlying socioeconomic factors affecting health throughout a patient's kidney disease journey.
晚期肾病（ESKD）患者在早期获得肾移植方面存在社会经济不平等，这一点已有充分记录。目前尚不清楚这些不平等是否可以通过在开始透析前获得肾脏病护理来缓解。本研究评估了ESKD前期肾脏病护理是否能有效解释社区贫困与ESKD患者肾移植转诊之间的关联。
在这项回顾性队列研究中，我们使用美国肾脏数据系统的数据（2012年1月1日至2021年6月30日），从美国东南部、东北部、纽约和俄亥俄河谷地区的透析设施中识别出192318例新发ESKD成人患者。根据邮政编码贫困率（≥20%与0%-19%）将社区贫困暴露分为两类，并从28个移植中心评估转诊结果。我们使用具有治疗权重逆概率的边际结构Cox模型来估计社区贫困对肾移植转诊的直接影响，并控制ESKD前期肾脏病护理的可及性（控制直接效应）。
研究结果显示，68%的患者接受了ESKD前期肾脏病护理，25%的患者生活在高贫困地区。ESKD前期肾脏病护理与转诊增加相关（风险比（HR）：1.26，95%置信区间：1.22，1.30）。使用具有逆概率加权的边际结构Cox模型进行的调整分析显示，ESKD前期肾脏病护理并未完全解释社区贫困与肾移植转诊之间的关联（控制直接效应HR：0.87，95%置信区间：0.85，0.89；总效应HR：0.90，95%置信区间：0.88，0.91）。
这些结果强调了ESKD前期肾脏病护理在增加移植转诊可及性方面的有益作用。然而，与社区贫困相关的持续差距仍然明显。该研究强调了ESKD前期肾脏病护理作为所有ESKD患者临床标准的持续重要性。未来的研究应探索在肾脏病连续过程中更早阶段的干预措施，以解决社会经济差距并改善肾移植的公平可及性。
对于晚期肾病（ESKD）患者来说，生存依赖于定期透析治疗或肾移植。对大多数人而言，与透析相比，肾移植能提供更好的长期生存和生活质量。生活在较贫困社区的人们在获得肾移植转诊方面面临重大挑战。我们的研究旨在调查在需要透析之前接受肾脏专科医生（肾病科医生）的护理（ESKD前期肾脏病护理）是否有助于克服这些与收入相关的移植可及性差距。我们查看了美国4个地区近20万名开始接受ESKD治疗的成年人的记录。我们将社区分为“高贫困”（20%或更多居民生活在贫困线以下）或“低贫困”地区。使用先进的统计方法，我们分析了社区贫困如何影响移植转诊，特别评估了ESKD前期肾脏病护理的作用。我们的研究结果显示，大多数患者（68%）在透析前看过肾病科医生。看肾病科医生与移植转诊的可能性高出26%相关。然而，即使在接受透析前肾病护理的患者中，生活在高贫困社区仍然意味着他们被转诊进行移植的可能性低13%。这项研究强调，虽然ESKD前期肾脏病护理有益且增加了移植转诊的可能性，但仅凭它并不能完全消除受社区贫困影响的可及性差距。为了让所有患者都能公平地获得肾移植，未来的努力必须针对更广泛的干预措施，以解决影响患者整个肾病病程健康的潜在社会经济因素。
