Health Care Utilization and Race: Live Kidney Donor Risks and Outcomes

 描述(申请人提供)：在美国，每年有超过6000名健康的人接受活体供肾切除，以造福于患有终末期肾病的亲人，甚至是陌生人。由于已故捐赠者池停滞不前，活体捐赠是解决日益增长的等待名单的关键组成部分，目前约占肾脏移植的40%。活体肾脏捐赠者不期望从肾脏捐赠中获得任何医疗利益；然而，他们确实希望医学界了解肾脏捐赠的风险。虽然捐赠者面临的直接风险很低，而且大家都很清楚，但长期风险仍然令人担忧和难以捉摸。对于非裔美国人(AA)捐赠者来说尤其如此，他们患高血压(HTN)、慢性肾脏疾病(CKD)、终末期肾病(ESRD)和死亡的风险最高。例如，我们已经表明，再生障碍性贫血捐赠者的ESRD风险是高加索捐赠者的3.3倍，匹配的健康再生障碍性贫血非捐赠者的3.1倍(JAMA 2014)，再生障碍性贫血捐赠者的死亡风险是高加索捐赠者的2.9倍(JAMA 2010)。然而，造成这些差异的根本原因仍不清楚。医疗保健利用是普通民众健康结果的主要驱动因素。肾脏捐赠者是一个独特的人群，他们本来健康，但健康状况不佳的风险增加。没有定期利用初级保健资源，包括对初级保健提供者和肾病学家进行例行访问的捐助者可能会错过重要的筛查和预防措施。未能识别和或治疗疾病的早期症状，如HTN和CKD，可能会导致疾病进一步发展。为了更好地了解在活体捐赠者中HTN和肾脏疾病的发展与种族之间的关系，我们将利用一项正在进行的、由R01资助的大型多中心研究来解决以下目标：(1)确定活体捐赠后的医疗利用与HTN和CKD的发展之间的关系；以及(2)调查基于种族的影响修正在卫生保健利用和捐赠后后遗症之间的关系。考虑到父母研究的丰富的一次数据收集和二次数据联系，这些目标是高度可行的。我们假设，不太频繁就诊的捐赠者，特别是非裔美国捐赠者，捐献后HTN和CKD的比率会更高。了解医疗保健利用和捐献后遗症之间的关系将改善捐赠者的选择、知情同意和管理。我们的发现对于制定稳健和循证的捐献后临床指南至关重要。活体肾脏捐赠者冒着生命危险帮助他人克服严重疾病，他们应该更好地了解风险评估和捐献后护理。我们的发现将对美国活体肾脏捐赠的实践产生重大、直接的影响，最终目标是影响活体肾脏捐赠者的政策和医疗保健获取系统，以确保最佳的健康结果。

 DESCRIPTION (provided by applicant): Every year, over 6000 healthy individuals undergo live donor nephrectomy in the United States to benefit a loved one, or even a stranger, with ESRD. With a stagnant deceased donor pool, live donation is a critical component of addressing the growing waiting list, and currently comprises about 40% of kidney transplants. Live kidney donors do not expect to gain any medical benefit from kidney donation; however, they do expect the medical community to understand the risks of kidney donation. Although the immediate risks to the donor are low and well-understood, long-term risks remain concerning and elusive. This is particularly true for African American (AA) donors, in whom risks of hypertension (HTN), chronic kidney disease (CKD), end-stage renal disease (ESRD), and death are highest. For example, we have shown that risk of ESRD in AA donors is 3.3x Caucasian donors and 3.1x matched healthy AA non-donors (JAMA 2014), and that risk of death in AA donors is 2.9x Caucasian donors (JAMA 2010). However, the underlying reasons for these differences remain unclear. Healthcare utilization is a major driver of health outcomes of the general population. Kidney donors are a unique population of otherwise healthy individuals who are at increased risk of poor health outcomes. Donors that do not regularly utilize primary healthcare resources including routine visits to primary care providers and nephrologists may be missing important screening and preventive measures. Failure to identify and or treat early signs of diseases, such as HTN and CKD, is likely to allow further disease progression. To better understand the relationship between healthcare utilization and race with the development of HTN and kidney disease in live donors, we will leverage a major, ongoing, R01-funded, multicenter study to address the following aims: (1) to determine the relationship between healthcare utilization following live donation and development of HTN and CKD; and (2) to investigate race-based effect modification in the relationships between health care utilization and post-donation sequelae. These aims are highly feasible given the rich primary data collection and secondary data linkage of the parent study. We hypothesize that donors with less frequent healthcare visits, particularly African American donors, will have elevated rates of post-donation HTN and CKD. Understanding the relationship between healthcare utilization and post-donation sequelae will improve donor selection, informed consent, and management. Our findings are critical to the development of robust and evidence-based post-donation clinical guidelines. Live kidney donors, who risk their safety to help others to overcome serious illness, deserve a better understanding of risk assessment and post-donation care. Our findings will have a major, direct impact on the practice of live kidney donation in the US, with a goal of ultimately influencing policy and healthcare access systems for live kidney donors to ensure optimal health outcomes.