Early access to kidney transplantation among patients with lupus nephritis Open Access

Abstract

Kidney transplantation is preferred over dialysis for most patients with lupus nephritis-associated end-stage kidney disease (LN-ESKD), although there is little information regarding access to early steps in the kidney transplant process for this patient population. The overarching goal of this dissertation was to characterize early access to kidney transplantation among adult patients with LN-ESKD in select U.S. regions by evaluating the impact of socioeconomic indicators and health systems processes on the first two steps in the kidney transplant process, referral for kidney transplant and starting an evaluation at a transplant center.

 

In Aim 1, we used population-based registries of patients starting dialysis to examine how referral for kidney transplant and start of an evaluation at a transplant center among patients with LN-ESKD compared to patients with ESKD unrelated to LN (other-ESKD). Among patients with ESKD, having a primary diagnosis of LN-ESKD versus other-ESKD was associated with higher rates of early transplant access outcomes.

 

In Aim 2, we performed a mediation analysis to assess whether a hypothetical intervention providing all patients with nephrology care prior to starting dialysis would impact the effect of neighborhood poverty on referral for kidney transplantation among patients with ESKD and a subset of patients with LN-ESKD. Pre-ESKD nephrology care was associated with improved access to kidney transplant referral among patients with ESKD. However, access to pre-ESKD nephrology care did not explain the association been higher neighborhood poverty and lower referral rates.

 

In Aim 3, we leveraged cross-classified multilevel models to simultaneously examine the contextual effects of dialysis facilities and transplant centers on variation in evaluation start at a transplant center among patients starting dialysis. When taking both dialysis facilities and transplant centers into account, variation in evaluation start was observed at both the dialysis facility and transplant center-level but variation was greater among transplant centers.

 

Together, the results of this dissertation can inform the development of targeted interventions to encourage timely referral for kidney transplantation and equitable transplant center practices and policies. Further research is needed to explore other domains which could better alleviate the burden of persistent socioeconomic disparities in early access to kidney transplantation. 

Table of Contents

List of Tables. 1

List of Figures. 3

Chapter 1: Background and Literature Review.. 4

Systemic lupus erythematosus, lupus nephritis, and end-stage kidney disease. 4

Epidemiology of Systemic Lupus Erythematosus. 5

Epidemiology of Lupus Nephritis. 7

Epidemiology of End-Stage Kidney Disease. 8

Epidemiology of Lupus Nephritis-Associated End-Stage Kidney Disease. 8

Lupus Nephritis. 8

Treatment for Lupus Nephritis. 9

Outcomes of Lupus Nephritis. 9

Inequities in the Prevalence of Lupus Nephritis. 10

Treatment for ESKD.. 11

Dialysis. 11

Epidemiology of Dialysis. 11

Kidney Transplantation. 12

The Kidney Transplantation Process. 13

Epidemiology of Kidney Transplantation. 14

Treatment for LN-ESKD.. 15

Barriers and Inequities in Early Access to Kidney Transplantation. 16

Referral for Kidney Transplantation. 17

Evaluation for Kidney Transplantation. 18

Pre-ESKD Nephrology Care. 19

Healthcare System Impact on Early Access to Kidney Transplantation. 20

Summary of Critical Literature Review.. 21

Chapter 2: Significance and Specific Aims. 23

Study Motivation. 23

Potential Application of the Results to Lupus Nephritis. 23

Potential Application of Results Outside Lupus Nephritis. 24

Specific Aims. 25

Chapter 3: Data Sources. 27

Chapter 4: Aim 1. 30

Abstract 31

Introduction. 33

Methods. 34

Results. 38

Discussion. 42

Tables and Figures. 47

Chapter 5: Aim 2. 63

Abstract 64

Introduction. 66

Methods. 67

Results. 71

Discussion. 74

Tables and Figures. 80

Chapter 6: Aim 3. 92

Abstract 93

Introduction. 95

Methods. 97

Results. 103

Discussion. 105

Tables and Figures. 112

Chapter 7: Public Health Implications and Future Directions. 123

Summary of Findings. 123

Strengths and Limitations. 126

Future Directions. 129

References. 131

About this Dissertation

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School	Laney Graduate School
Department	Epidemiology
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Health Sciences, Epidemiology
Keyword	lupus nephritis kidney transplantation healthcare access
Committee Chair / Thesis Advisor	Rachel E. Patzer, Indiana University
Committee Members	Penelope P. Howards, Emory University Laura Plantinga, University of California, San Francisco Michael Kramer, Emory University

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