Waiting-List and early posttransplant prognosis among ethnoracial groups: Data from the organ procurement and transplantation network

Abstract

Background: Racial/ethnic disparity in waiting-list mortality among candidates listed for kidney transplantation (KT) in the United States remains unclear. We aimed to assess racial/ethnic disparity in waiting-list prognosis among patients listed for KT in the United States in the current era.

Methods: We compared waiting-list and early posttransplant in-hospital mortality or primary nonfunction (PNF) among adult (age ≥18 years) white, black, Hispanic, and Asian patients listed for only KT in the United States between July 1, 2004 and March 31, 2020.

Results: Of the 516,451 participants, 45.6%, 29.8%, 17.5%, and 7.1% were white, black, Hispanic, and Asian, respectively. Mortality on the 3-year waiting list (including patients who were removed for deterioration) was 23.2%, 16.6%, 16.2%, and 13.8% in white, black, Hispanic, and Asian patients, respectively. The cumulative incidence of posttransplant in-hospital death or PNF after KT was 3.3%, 2.5%, 2.4%, and 2.2% in black, white, Hispanic, and Asian patients,respectively. White candidates had the highest mortality risk on the waiting list or of becoming too sick for a transplant, while black (adjusted hazard ratio, [95% confidence interval, CI], 0.67 [0.66-0.68]), Hispanic (0.59 [0.58-0.60]), and Asian (0.54 [0.52-0.55]) candidates had a lower risk. Black KT recipients (odds ratio, [95% CI] 1.29 [1.21-1.38]) had a higher risk of PNF or death before discharge than white patients. After controlling confounders, black recipients (0.99 [0.92-1.07]) had a similar higher risk of posttransplant in-hospital mortality or PNF as white patients than Hispanic and Asian counterparts.

Conclusions: Despite having a better socioeconomic status and being allocated better kidneys, white patients had the worst prognosis during the waiting periods. Black recipients and white recipients have higher posttransplant in-hospital mortality or PNF.

Keywords: early posttransplant in-hospital mortality; kidney allocation system; kidney transplantation; primary nonfunction; racial/ethnic disparities; waiting-list mortality.

Figure 1

Flow diagram of the study participants. KT: kidney transplant; PNF: Primary nonfunction. Note: 1. GTIME, a variable derived from UNOS, indicates graft lifespan-kidney-days from transplant to failure/death/last follow-up; 2. Of the 853 deaths, 836 were simultaneously diagnosed with PNF.

Figure 2

The proportion of outcomes for white (A), black (B), Hispanic (C), and Asian (D) patients listed for a kidney transplant in the United States.

Figure 3

The cumulative percentage of those who died or became too sick for a transplant in the four groups. These two endpoints are simply referred to as Wait-List mortality*.

Figure 4

Multivariate predictors of waiting-list death or removal from the list owing to clinical deterioration. KAS, Kidney Allocation System BMI, body mass index (calculated as weight in kilograms divided by height in metres squared); CPRA, calculated panel reactive antibody; ESRD, end-stage renal disease; DM, diabetes mellitus.

Figure 5

The cumulative percentage of recipients who died or suffered from PNF before discharge in the 4 groups. These two endpoints are simply referred to as PNF^#.

Figure 6

Multivariate predictors of posttransplant in-hospital death or PNF. KAS, Kidney Allocation System BMI, body mass index (calculated as weight in kilograms divided by height in metres squared); CPRA, calculated panel reactive antibody; ESRD, end-stage renal disease; DM, diabetes mellitus; PNF, primary nonfunction.

Figure 7

(A) illustrates the number of patients who died on the waiting list, and (B) depict its trend. (C) illustrates the number of recipients with PNF or who died posttransplant, and (D) depict its trend. *Includes patients who were removed from the list due to deterioration. #Includes patients who died posttransplant. The vertical line in the figure indicates the start time of KAS.