Community Deprivation and Age as Effect Modifiers of the Association Between Race and Referral for Kidney Transplantation in the Southeastern US 公开

Abstract

Introduction: Variations in racial differences in access to kidney transplantation have been well documented, but the potential modifying role of social determinants of health in this process are largely unexplored. This study investigated the modifying role of community deprivation and age on the association between race and referral for kidney transplant.

Methods: The study population consisted of 59,088 adult patients with end stage kidney disease (ESKD) incidence between January 1, 2012, and December 31, 2018, in Georgia, North Carolina, or South Carolina. Patient data were retrospectively collected from the United States Renal Data System and Early Steps to Transplant Access Registry. Multivariable-adjusted log-binomial modeling assessed the association between race and referral for kidney transplantation within one year of ESKD start and the modifying role of community deprivation and age.

Results: Among the study population, 32.1% were referred for kidney transplant within one year of their ESKD start. After full adjustment, the incidence of referral remained higher among Black patients than White patients, with an adjusted relative incidence of 1.16 (95% CI: 1.13-1.19). Among the study population, 50.8% overall lived in areas of high community deprivation, but a higher proportion of Black patients (58.9%) lived in these areas compared to White patients (41.0%). After full adjustment, it was found that living in areas of high deprivation was associated with 10% less incidence of referral for transplant within one year of dialysis start than the incidence among ESKD patients living in areas of low deprivation (RR: 0.90, CI: 0.89-0.93). There was significant interaction of race with community deprivation and age. Living in areas of high deprivation or older age was associated with lower incidence of referral for all patients, but Black patients had higher incidence of referral at all levels.

Conclusions: This study highlights the importance of community deprivation as a modifiable factor to reduce racial variations in referral for kidney transplant. Efforts to increase equitable access to the earliest steps of kidney transplantation should focus on socioeconomically deprived regions to help reduce downstream transplantation disparities.

Table of Contents

Table of Contents

Introduction……………………………………………………………………………………...1

Methods……………………………………………………………………………………………3

   Study Design and Population……………………………………………………………....3

Data Sources…………………………………………………………………………….........…4

Study Variables……………………………………………………………………..….…………4

Statistical Analyses……………………………...……………………………….…..…......…6

Results…………………….………………………………………………………………….….…7

Study Population...……………………………………………………………….……….........7

Figure 1. Study Cohort Inclusion and Exclusion Criteria Flow Chart………………….9

Patient Characteristics………………...………………………………………………….......10

Table 1. Baseline Characteristics of Incident U.S. Adult ESKD Patients within ESRD Network 6 by Race, 2012-2018…………………………...……………………………....11

Referral Characteristics………………………...……………………………………........….13

Table 2. Baseline Characteristics of Incident U.S. Adult ESKD Patients within ESRD Network 6 by Referral Status , 2012-2018…………………………………...…….……14

Multivariable-adjusted Analyses………………………………………………....……..…..16

Table 3. Multivariable Sequential Log-Binomial Regression Modeling for the Effect of Race on Referral for Kidney Transplant Within 1 Year of ESKD Start…………….……17

Table 4. Evaluation of the Interaction Effect of Race with Community Deprivation Index on Referral for Kidney Transplant within 1 Year of ESKD Start for ESKD patients initiating dialysis in GA, NC, and SC between 2012-2018…………………………..….18

Table 5. Evaluation of the Interaction Effect of Race with Categorized Age on Referral for Kidney Transplant within 1 Year of ESKD Start for ESKD patients initiating dialysis in GA, NC, and SC between 2012-2018………………………………………………....20

Discussion……………………..…………………………………………………………………21

Conclusions……………………………………………………………………………………....25

Acknowledgements………………………………………………………………………………27

References………………………………………………………………………………………..28

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Epidemiology - MPH & MSPH
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Surgery Health Sciences, Public Health Health Sciences, Epidemiology
关键词	Age Epidemiology Social Determinants of Health Community Deprivation End Stage Kidney Disease Patient Referral Health Services and Outcomes Research Kidney Transplantation Race
Committee Chair / Thesis Advisor	Rachel Patzer, Emory University

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