The Role of Racial Residential Segregation in Access to Early Kidney Transplant Steps Open Access

Abstract

Background: Substantial racial inequities exist throughout the kidney transplant process, though

few studies have examined the impact of institutionalized racism. Prior studies suggest that racial

residential segregation is associated with access to multiple aspects of care in the end-stage

kidney disease (ESKD) population. We examined the association of racial residential segregation

with referral for kidney transplant and start of the kidney transplant evaluation.

Methods: The study cohort included adult incident ESKD patients initiating dialysis in ESRD

Network 6 facilities (GA, NC, SC) between January 2012 and August 2016, with outcomes

followed through February 2018. Patient-level data were linked to the 2017 United States Renal

Data System and to the 2012-2016 American Community Survey. We employed the racial Index

of Concentration at the Extremes (ICE) as a measure of racial segregation at the ZIP code

tabulation area (ZCTA) level, and classified into tertiles where lower values indicate a higher

concentration of Black residents and higher values indicate a higher concentration of White

residents. To examine the association between segregation and kidney transplant referrals and

evaluations, we utilized Cox models with robust sandwich variance estimators.

Results: Among 33,043 non-Hispanic Black and White ESKD patients initiating dialysis in

ESRD Network 6, there were 14,146 patients (42.8%) who were referred and 7404 (52.4%)

patients who started the transplant evaluation. In adjusted multivariable analyses, White patients

in the lowest ICE tertile had a 15% higher (95% CI: 1.03-1.28) hazard of referral compared to

White patients in the highest tertile, although White patients across all ICE tertiles had similar

hazards of evaluation. Black patients in the lowest ICE tertile had a 16% (95% CI: 1.06-1.27)

higher hazard of referral, compared to Black patients in the highest ICE tertile. In addition, Black

patients in the lowest ICE tertile were 23% (95% CI: 1.09-1.40) more likely to be evaluated

compared to Black patients in highest ICE tertile.

Conclusions: Our results suggest that residence in highly segregated White neighborhoods is

associated with lower kidney transplant referral and evaluation start. Contextual factors, like

racial residential segregation, should be considered in formulating interventions addressing

barriers to transplant among marginalized ESKD populations.

Table of Contents

Table of Contents

Chapter 1: Background ................................................................................................................ 1

End-stage kidney disease and treatment ................................................................................. 1

Racial disparities in kidney transplant ................................................................................... 2

Racial residential segregation in the United States ................................................................ 5

Racial residential segregation in ESKD .................................................................................. 8

Chapter II: Manuscript .............................................................................................................. 10

Abstract .................................................................................................................................... 10

Introduction ............................................................................................................................. 11

Methods .................................................................................................................................... 13

Study population and data sources ........................................................................................ 13

Study variables ...................................................................................................................... 14

Statistical analyses ................................................................................................................. 16

Results ...................................................................................................................................... 16

Study population .................................................................................................................... 16

Patient and neighborhood characteristics .............................................................................. 17

Referral and evaluation start .................................................................................................. 18

Multivariable adjusted analyses ............................................................................................. 18

Sensitivity analyses ................................................................................................................ 19

Discussion ................................................................................................................................. 19

Study strengths and limitations .............................................................................................. 23

Conclusions ........................................................................................................................... 24

References .................................................................................................................................... 25

Tables and Figures ...................................................................................................................... 29

Appendix ...................................................................................................................................... 36

About this Master's Thesis

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• Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.

School	Rollins School of Public Health
Department	Epidemiology
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Medicine and Surgery
Keyword	health disparities kidney transplant segregation
Committee Chair / Thesis Advisor	Rachel E. Patzer, Emory University

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