Association of Racial Disparities With Access to Kidney Transplant After the Implementation of the New Kidney Allocation System
Association of Racial Disparities With Access to Kidney Transplant After the Implementation of the New Kidney Allocation System
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DOI：
10.1001/jamasurg.2019.0512
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发表时间：
2019-07-01
期刊：
影响因子：
16.9
通讯作者：
Deng, Yanhong
中科院分区：
文献类型：
--
作者：
Kulkarni, Sanjay;Ladin, Keren;Deng, Yanhong
肾移植等待名单上的非活动患者死亡率较高。为了确定活动状态变化是否在种族/民族和致敏水平之间存在差异，以及这些差异是否与实施肾分配系统后的移植概率相关，设计，设置，和参与者从器官获取和移植网络肾移植数据库中构建一个多状态模型（2014年12月4日至2016年9月8日）。时间间隔遵循肾脏分配系统的实施，并为所有患者提供至少1年的随访。该模型计算了活动和非活动状态之间的概率以及以下竞争风险结果：活体供体移植，已故供体移植和死亡/其他。这项回顾性队列研究纳入了42558例在肾脏分配系统实施后在器官获取和移植网络肾移植等待名单上的患者。为了排除重新上市的时变混杂因素，分析仅限于首次注册者。由于列表实践的差异，双重收载患者使用主要中心列表数据。排除其他器官或胰岛列出的个体。分析开始于2017年7月。主要结局和指标确定了活动状态和非活动状态之间转换的概率以及以下结局状态：对活体供体移植有效，对已故供体移植有效，对死亡/其他有效，对活体供体移植无效，对已故供体移植无效，结果：入组时的中位年龄（四分位距）为55.0（18.0-89.0）岁，42558人中有26535人（62.4%）为男性。白色个体占等待患者的43.3%（n = 18417），而黑人和西班牙裔个体分别占27.8%（n = 11837）和19.5%（n = 8296）。计算的血浆反应性抗体类别为0%或1%至79%的患者显示，不同人种/种族之间的移植概率无统计学显著差异。白色个体在计算的血浆反应性抗体类别中的移植概率比黑人个体具有80%至89%的优势（风险比[HR]，1.8 [95% CI，1.4-2.2]）和90%或更高（HR，2.4 [95% CI，2.1-2.6]），而西班牙裔个体在90%或更高的计算血浆反应性抗体组中比黑人个体具有优势（HR，2.5 [95% CI，2.1-2.8]）。一旦进入非活跃名单，白色个体比西班牙裔个体更有可能（HR，1.2 [95% CI，1.17-1.3]）或黑人个体（HR，1.4 [95%CI，1.3-1.4]）来解决不活动导致激活的问题。在实施肾脏分配系统后，黑人获得肾脏移植的机会继续减少。列入名单后，健康方面的差异继续存在，少数群体的个人更难以解决不活动的问题。
IMPORTANCE Inactive patients on the kidney transplant wait-list have a higher mortality. The implications of this status change on transplant outcomes between racial/ethnic groups are unknown.OBJECTIVES To determine if activity status changes differ among races/ethnicities and levels of sensitization, and if these differences are associated with transplant probability after implementation of the Kidney Allocation System.DESIGN, SETTING, AND PARTICIPANTS A multistate model was constructed from the Organ Procurement and Transplantation Network kidney transplant database (December 4, 2014, to September 8, 2016). The time interval followed Kidney Allocation System implementation and provided at least 1-year follow-up for all patients. The model calculated probabilities between active and inactive status and the following competing risk outcomes: living donor transplant, deceased donor transplant, and death/other. This retrospective cohort study included 42558 patients on the Organ Procurement and Transplantation Network kidney transplant wait-list following Kidney Allocation System implementation. To rule out time-varying confounding from relisting, analysis was limited to first-time registrants. Owing to variations in listing practices, primary center listing data were used for dually listed patients. Individuals listed for another organ or pancreatic islets were excluded. Analysis began July 2017.MAIN OUTCOME AND MEASURES Probabilities were determined for transitions between active and inactive status and the following outcome states: active to living donor transplant, active to deceased donor transplant, active to death/other, inactive to living donor transplant, inactive to deceased donor transplant, and inactive to death/other.RESULTS The median (interquartile range) age at listing was 55.0 (18.0-89.0) years, and 26535 of 42558 (62.4%) were men. White individuals were 43.3% (n = 18 417) of wait-listed patients, while black and Hispanic individuals made up 27.8% (n = 11837) and 19.5% (n = 8296), respectively. Patients in the calculated plasma reactive antibody categories of 0% or 1% to 79% showed no statistically significant difference in transplant probability among races/ethnicities. White individuals had an advantage in transplant probability over black individuals in calculated plasma reactive antibody categories of 80% to 89% (hazard ratio [HR], 1.8 [95% CI, 1.4-2.2]) and 90% or higher (HR, 2.4 [95% CI, 2.1-2.6]), while Hispanic individuals had an advantage over black individuals in the calculated plasma reactive antibody group of 90% or higher (HR, 2.5 [95% CI, 2.1-2.8]). Once on the inactive list, white individuals were more likely than Hispanic individuals (HR, 1.2 [95% CI, 1.17-1.3]) or black individuals (HR, 1.4 [95% CI, 1.3-1.4]) to resolve issues for inactivity resulting in activation.CONCLUSIONS AND RELEVANCE For patients who are highly sensitized, there continues to be less access to kidney transplant in the black population after the implementation of the Kidney Allocation System. Health disparities continue after listing where individuals from minority groups have greater difficulty in resolving issues of inactivity.