Reaching Equity in ACess to Home Dialysis And Re-Transplantation (REACH-DART)

项目摘要 肾移植和家庭透析是终末期肾病的首选治疗方式 与中心血液透析相比，ESKD具有更好的生活质量和更低的成本。 然而，在移植失败的患者中，第二次肾移植的优先再登记率和 腹膜透析（PD）是次优的，尤其是在黑人和西班牙裔肾移植受者（KTR）中。 虽然在移植初治患者中获得移植或PD的障碍被归因于缺乏 患者对其肾脏疾病的认识，亚专科护理的延迟转诊以及教育不足，这些 这些因素不应适用于已经接受肾移植的人群， 第一次移植前的透析，以及可以获得肾脏护理的人。令人沮丧的是，只有一半的 肾移植前接受PD治疗的KTR在移植失败后选择返回这种模式， 只有15%的移植失败的患者被重新考虑进行第二次肾移植。PD率 在移植失败的黑人和西班牙裔KTR中，使用和重新登记的比例特别低。确定可能 旨在改善前KTR获得家庭透析和重复移植的机会， 改善移植失败患者的结局，但也让我们了解了 即使在获得保健不太可能成为解释因素的情况下也存在。在目标1中，我们建议对 在移植物功能障碍的晚期阶段花费的时间，并确定是否存在种族或民族 在这段时间里，这对患者为疾病的下一阶段做好准备至关重要。我们 然后将确定在移植物功能障碍的晚期阶段花费的时间是否与获得 腹膜透析或重新登记在第二次肾移植的等待名单上。在目标2中，我们将执行半结构化 与患者、透析提供者和移植提供者进行访谈，了解他们对 阻碍了PD和抢先重新上市然后，我们将使用从这些定性访谈中获得的数据， 制定一项将在全国范围内进行的调查，以确认这些障碍的重要性，并确定 可以用来克服这些障碍的战略。在目标3中，我们将研究系统级因素， 可能会导致在国家候补名单和PD访问中的抢先重新列名的差异，包括变化 在候选人资格评估期间使用客观的虚弱评估和随访频率 KTR与移植中心移植物周围衰竭之间的接触。为了实现我们的目标，我们将 来自美国肾脏数据系统的数据，将与Medicare、Medicaid和Optum索赔相关联 数据在一部分患者中，我们将从电子健康记录系统中收集更细粒度的本地数据， 丰富这些行政数据。本提案中的数据将为干预措施、最佳做法和 促进重复移植和腹膜透析的政策。

PROJECT ABSTRACT Kidney transplantation and home dialysis are the preferred treatment modalities for end-stage kidney disease (ESKD) given the better quality of life and lower cost of these modalities compared with in-center hemodialysis. However, in patients with graft failure, rates of preemptive re-listing for a second kidney transplant and use of peritoneal dialysis (PD) are suboptimal, especially in Black and Hispanic kidney transplant recipients (KTRs). While barriers in access to transplantation or PD in transplant-naïve patients have been attributed to lack of patient awareness of their kidney disease, late referral for subspecialty care, and inadequate education, these factors should not apply to a population that already received a kidney transplant, were likely exposed to dialysis before their first transplant, and who have access to nephrology care. Disappointingly, only half of KTRs treated with PD before their kidney transplant choose to return to this modality following graft failure, and only 15% of patients with graft failure are relisted preemptively for a second kidney transplant. The rate of PD use and relisting is particularly low in Black and Hispanic KTRs with graft failure. Identifying barriers that can be addressed to improve access of former KTRs to home dialysis and repeat transplantation will not only improve the outcomes of patients with graft failure, but also inform our understanding of the roadblocks that are present even when access to care is unlikely to be the explanatory factor. In Aim 1, we propose to model the time spent in the advanced stages of graft dysfunction and determine whether there are racial or ethnic disparities in this time, which is critical for the preparation of patients for the next phase of their disease. We will then determine if the time spent in the advanced stages of graft dysfunction is associated with access to PD or re-registration on the waitlist for a second kidney transplant. In Aim 2, we will perform semi-structured interviews with patients, dialysis providers, and transplant providers to understand their perceptions of the barriers to PD and preemptive relisting. We will then use the data derived from these qualitative interviews to develop a survey that will be administered nationally to confirm the importance of these barriers and identify strategies that can be used to surmount these barriers. In Aim 3, we will examine system-level factors that may contribute to disparities in preemptive relisting on the national waitlist and PD access, including variations in the use of objective assessments of frailty during candidacy evaluations and the frequency of follow-up contact between KTRs and their transplant center peri-graft failure. To accomplish our aims, we will leverage data from the United States Renal Data System that will be linked to Medicare, Medicaid, and Optum claims data. In a subset of patients, we will collect more granular local data from electronic health record systems to enrich these administrative data. The data from this proposal will inform the interventions, best practices, and policies that are needed to promote access to repeat transplantation and PD.