Reaching Equity for Adults and CHildren in Transplant (REACH-TRANSPLANT)

项目摘要 二十多年来，黑人和西班牙裔接受肾移植的可能性一直低于非 西班牙裔白人(NHW)，尤其是来自活着的捐赠者(LD)。许多研究都集中在与接受者相关的研究上 可能导致这些差异的障碍，但对这些差异如何可能引起的关注较少 在接受者和LD评估、LD选择和LD随访期间出现。例如，我们目前的系统 对移植候选的评估建议，当受者的 估计的肾小球滤过率(EGFR)为30毫升/分钟/1.73平方米，并允许在以下情况下等待登记 EGFR为20ml/min/1.73m2。然而，众所周知，肾脏疾病在黑人中进展更快， 拉美裔(vs.nhw)，因此黑人或西班牙裔(vs.nhw)接受者的捐赠者可能没有更少的时间完成 受者在需要透析之前进行检查。黑人捐赠者也被注意到有 与白人献血者相比，献血后发生终末期肾病(ESRD)的风险更高。 在以前的黑色LD中对较高的ESRD风险的更高认识可能倾向于降低接受度 即使是健康的活着的黑人捐赠者候选人(其中大多数捐赠者是黑人受赠者)，因此 减少了LD的数量。最后，缺乏对先前LDS的一致医疗随访可能会减少机会 及早预防和干预，减少慢性肾脏病的危险因素，特别是在黑人中 或者西班牙裔身份证。关于捐献后的健康监测是否存在以下差异，可以获得的数据很少 种族/民族，以及慢性肾脏疾病(CKD)的风险因素是否可以更好地管理 降低以前的黑人/西班牙裔LD患ESRD的较高风险。如果黑人或西班牙裔的结果 捐助者可以得到改善，黑人和西班牙裔受助人获得法律援助服务的机会也可以得到改善。在这 提案中，我们的目标是检查1)使用基于风险的阈值(与绝对EGFR阈值相比)是否 当我们推荐患者进行移植候选(和捐赠者)评估时，指南可能会改善 按种族/族裔分列的移植准备时间(目标1)；2)区别接受黑人或 西班牙裔(vs.nhw)捐赠者候选人总体上以及提供者或移植中心的情况仍在发生，尽管 提供捐赠者终末期营养不良风险的客观衡量标准(目标2)；3)捐献后健康监测和风险因素 在黑人和西班牙裔(vs.nhw)LDS(目标3)中，修改是不够的。为了实现我们的目标，我们将 使用前瞻性和回溯性地从全国各地的移植中心收集的电子健康记录数据 美国(AIMS 1-2)，并预期为AIM 3招募LD。来自本提案的数据将为多 改善移植结果差异的水平干预措施，包括1)更好地认识到 在计划移植转诊时机时CKD进展率的变化；2)增加使用 捐赠者评估期间ESRD风险的客观指标；以及3)提高对捐献后健康的遵从性 监测的目的是提供早期风险因素修正，以改善捐赠者的结果。

PROJECT ABSTRACT For over two decades, blacks and Hispanics have been less likely to receive kidney transplantation than non- Hispanic whites (NHWs), especially from a living donor (LD). Many studies have focused on recipient-related barriers that may contribute to these disparities, but less attention has been paid to how these disparities may arise during recipient and LD evaluation, LD selection, and LD follow-up. For instance, our current system for the evaluation of transplant candidacy recommends referral to transplant centers when the recipient's estimated glomerular filtration rate (eGFR) is < 30mL/min/1.73 m2, and allows for waitlist registration when the eGFR is <20mL/min/1.73 m2. However, kidney disease is known to progress more rapidly among blacks and Hispanics (vs. NHWs), so donors to a black or Hispanic (vs. NHW) recipient may have less time to complete their workup before the need for dialysis arises in the recipient. Black donors have also been noted to have higher risk of developing end-stage renal disease (ESRD) compared to white donors after donation. Heightened awareness of the higher ESRD risk among prior black LDs may predispose to reduced acceptance of even healthy black living donor candidates (the majority of whom donate to black recipients), thereby diminishing the pool of LDs. Finally, lack of consistent medical follow-up of prior LDs may reduce opportunities for early prevention and intervention to reduce risk factors for the development of CKD, especially among black or Hispanic LDs. Sparse data are available regarding whether post-donation health monitoring differs by race/ethnicity, and whether risk factors for chronic kidney disease (CKD) could be more optimally managed to mitigate the higher risk of ESRD among prior black/Hispanic LDs. If outcomes among black or Hispanic donors could be improved, access of black and Hispanic recipients to LDs could also improve. In this proposal, our goal is to examine whether 1) use of a risk-based threshold (vs. an absolute eGFR threshold) to guide when we refer patients for transplant candidacy (and donor) evaluation may improve inequities in the time available for transplant preparation by race/ethnicity (Aim 1); 2) differential acceptance of black or Hispanic (vs. NHW) donor candidates overall, and by provider or transplant center, are occurring despite the availability of objective metrics of donor ESRD risk (Aim 2); 3) post-donation health monitoring and risk factor modification is inadequate among black and Hispanic (vs. NHW) LDs (Aim 3). To accomplish our aims, we will use electronic health record data collected prospectively and retrospectively from transplant centers across the US (Aims 1-2) and prospectively recruit LDs for Aim 3. Data from this proposal will inform the design of multi- level interventions to improve disparities in transplant outcomes, including 1) better acknowledgement of variations in the rate of CKD progression when planning the timing of transplant referral; 2) increased use of objective metrics of ESRD risk during donor evaluation; and 3) enhanced compliance with post-donation health monitoring with the goal of providing early risk factor modification to improve donor outcomes.