Early Access to Kidney Transplantation among Patients with Lupus Nephritis

项目总结 系统性红斑狼疮(SLE)是一种慢性、多系统自身免疫性疾病，可导致严重的 肾脏表现称为狼疮性肾炎(LN)，并最终导致LN相关的终末期肾病 (Ln-ESKD)。LN-ESKD在SLE患者中的发展尤其令人关注，因为其风险很高。 过早死亡及其对年轻患者和少数族裔及以下人群的不成比例影响 社会经济地位。LN-ESKD患者只有两种治疗选择，研究表明 与长期透析相比，肾移植提供了更大的生存益处。尽管如此， 大多数LN-ESKD患者在透析时开始，很大程度上还不清楚进展到 肾移植过程已经启动，以及社会经济和卫生系统可能存在哪些障碍 阻碍了这一人群的治疗过渡。肾移植的过程对患者来说是复杂的 需要在多个提供者和卫生系统之间进行协调沟通，包括初级保健 提供者、肾病学家、透析设备和移植中心。这项研究的首要目标是 建议描述成年(≥，18岁)LN患者早期接受肾移植的特征。 ESKD在美国通过评估社会经济和卫生系统进程对#年第一步的影响 肾脏移植过程，转诊到移植中心进行评估。这项研究将利用 来自美国肾脏数据系统(USRDS)的ESKD患者国家监测数据与 来自早期移植访问注册中心的未在国家或地区收集的新患者转介信息 区域监测系统检查这一进入移植手术的关键和必要的第一步。目标1 将评估1)从ESKD转诊肾移植的时间开始比较LN-ESKD患者和 使用COX比例风险模型分析与LN无关的ESKD患者。目标2将评估 LN-ESKD患者的社区贫困与转诊肾移植的关系 ESKD开始前去看肾脏专家的潜在中介作用。目标3将使用交叉分类 Logistic多水平模型用于确定卫生系统因素的影响(包括透析设施和 移植中心特征)对ESKD患者进行肾移植的转诊。由此产生的结果是 拟议的研究项目将深入了解LN-LN肾移植转诊的流行病学。 ESKD患者。此外，它还将为临床医生治疗LN-ESKD患者提供参考 强调及时转诊肾移植以减少患者透析时间的重要性 以及在等待名单上因其他原因死亡。这些结果也将为制定有针对性的 在进展为ESKD之前改善肾脏科医生的可获得性和加强患者护理的干预措施 在透析设施和移植中心之间的医疗保健系统之间进行协调。

PROJECT SUMMARY Systemic lupus erythematosus (SLE) is a chronic, multisystem autoimmune disease that can result in a serious renal manifestation known as lupus nephritis (LN) and eventually, LN-associated end-stage kidney disease (LN-ESKD). The development of LN-ESKD among patients with SLE is of particular concern due to its high risk of premature death and its disproportionate impact on younger patients and patients of minority race and lower socioeconomic status. There are only two treatment options for patients with LN-ESKD, and research suggests that kidney transplantation provides a greater survival benefit compared to long-term dialysis. Despite this, the majority of LN-ESKD patients are initiated on dialysis and it is largely unknown how soon after progression to ESKD that the kidney transplant process is initiated and what socioeconomic and health system barriers may hinder this treatment transition in this population. The kidney transplant process is complex for patients and requires coordinated communication across multiple providers and health systems, including primary care providers, nephrologists, dialysis facilities, and transplant centers. The overarching goal of this research proposal is to characterize early access to kidney transplantation among adult (≥18 years) patients with LN- ESKD in the U.S. by evaluating the impact of socioeconomic and health systems processes on the first step in the kidney transplant process, referral for an evaluation at a transplant center. This research will leverage national surveillance data of ESKD patients from the United States Renal Data System (USRDS) linked with novel patient referral information from the Early Transplant Access Registry that is not collected in national or regional surveillance systems to examine this critical and necessary first step to accessing a transplant. Aim 1 will estimate the timing of 1) kidney transplant referral from ESKD start comparing LN-ESKD patients to patients with ESKD unrelated to LN, using Cox proportional hazards models. Aim 2 will evaluate the association between neighborhood poverty and referral for kidney transplant in patients with LN-ESKD and the potential mediating effect of visiting a kidney specialist prior to ESKD start. Aim 3 will use cross-classified logistic multilevel models to determine the influence of health system factors (including dialysis facility and transplant center characteristics) on referral for kidney transplant in patients with ESKD. The results from this proposed research project will provide insight into the epidemiology of referral for kidney transplant in LN- ESKD patients. Furthermore, it will inform clinical practice among clinicians treating patients with LN-ESKD by emphasizing the importance of timely referral for kidney transplant to reduce patients’ time spent on dialysis and death from other causes while on the waitlist. These results will also inform development of targeted interventions to improve access to a nephrologist prior to progressing into ESKD and to enhance patient care coordination across healthcare systems between dialysis facilities and transplant centers.