Renal transplant Equity through Partnership And Structural Transformation (REPAST)

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Abstract Kidney transplantation (KTx) is considered the preferred treatment for patients with end-stage kidney disease. Despite recent changes to the kidney allocation Black and Hispanic individuals are less likely to receive KTx, a multi-step process requiring patient referral, patient medical/surgical/psychosocial evaluation, and patient waitlisting. As there are no standardized acceptable metrics for psychosocial evaluations, each of steps is impacted by provider and patient bias and thwarted by social determinants often overlooked and structural racism continues to drive of racial and ethnic disparities in KTx. We have identified barriers and facilitators to evaluation and waitlisting for KTx, including provider bias, high unmet social determinants of health and symptom burden in patients on hemodialysis. To address the impact of structure racism on KTx, we now propose a multi-level intervention in full partnership with an Executive Stakeholder Board and Workgroups comprised of patients, clinicians, caregivers, advocates, and system leaders for dialysis organizations and transplant centers. This work will be built on 2 decades of community-engaged research and trials to improve health in diverse populations. We will work with the Board to develop an intervention based on past work by our team and others, supplemented by formative interview with patients, caregivers, and clinicians. To increase rates of patients receiving KTx evaluation, patient navigators who have chronic kidney disease and waitlisted for kidney transplant or are transplant recipients themselves will guide patients through the transplant evaluation process. This will include conducting a social needs screen and addressing barriers uncovered, including facilitating appointments to address unmet needs such as food insecurity and transportation, control of symptoms and mental health challenges. To increase rates of waitlisting among those evaluated, we will identify stigmatizing language from KTx providers; notes and provide an anti-bias initiative including structural changes to evaluation and education for KTx nephrologists. We will evaluate the impact of this multifactorial intervention in a clinical trial among 320 adults with an eGFR <20ml/min/1.73m2 or on in-center hemodialysis with a primary outcome of transplant waitlisting. Together, we will also develop a blueprint of how to conduct this work, so that it can be used nationally to reduce inequities and inform policies, systems and practices. Our Board will serve as a durable resource for future kidney equity work.