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

项目摘要 二十多年来，黑人和西班牙裔人接受肾移植的可能性比非黑人和西班牙裔人低。 西班牙裔白人（NHWs），特别是来自活体捐赠者（LD）。许多研究都集中在与肥胖相关的 可能导致这些差异的障碍，但很少注意这些差异如何可能 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 移植候选人的评估建议转诊到移植中心时， 估计肾小球滤过率（eGFR）<30 mL/min/1.73 m2，并允许等待登记时， eGFR <20 mL/min/1.73 m2。然而，众所周知，肾脏疾病在黑人中进展得更快， 西班牙裔（vs. NHW），因此黑人或西班牙裔（vs. NHW）接受者的捐赠者完成捐赠的时间可能更短 在接受者需要透析之前对其进行检查。黑人捐赠者也被注意到 与白色捐献者相比，捐献后发生终末期肾病（ESRD）的风险更高。 在既往黑人LD患者中，对ESRD风险较高的认识提高可能导致接受度降低 即使是健康的黑人活体捐赠候选人（其中大多数捐赠给黑人受体）， 减少LD池。最后，缺乏对既往LD的一致医学随访可能会减少 早期预防和干预，以减少CKD发展的风险因素，特别是黑人 或者西班牙裔身份证关于献血后健康监测是否因以下因素而不同， 种族/民族，以及慢性肾脏病（CKD）的风险因素是否可以更好地管理， 缓解既往黑人/西班牙裔LD中较高的ESRD风险。如果黑人或西班牙裔的结果 尽管可以改善捐赠者，黑人和西班牙裔接受者获得LD的机会也可以改善。在这 我们的目标是检查1）是否使用基于风险的阈值（与绝对eGFR阈值相比）， 当我们推荐患者进行移植候选人（和供体）评估时，指南可能会改善 按人种/种族划分的移植准备可用时间（目标1）; 2）黑人或 西班牙裔（与NHW）供体候选人总体上，并由供应商或移植中心，发生尽管 供体ESRD风险客观指标的可用性（目标2）; 3）捐献后健康监测和风险因素 在黑人和西班牙裔（相对于NHW）LD中，修改是不够的（目标3）。为了实现我们的目标，我们将 使用从移植中心前瞻性和回顾性收集的电子健康记录数据， 美国（目标1-2）和前瞻性招募LD用于目标3。本提案中的数据将为设计多- 水平干预，以改善移植结果的差异，包括1）更好地认识 计划移植转诊时间时CKD进展率的变化; 2）增加使用 供体评估期间ESRD风险的客观指标;以及3）增强对捐献后健康的依从性 监测的目标是提供早期风险因素的修改，以改善捐助者的成果。

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.