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. 2024 Dec 13;20(2):256-266.
doi: 10.2215/CJN.0000000586. Online ahead of print.

Reducing Disparities in Access to Kidney Transplantation Regional Study: A Randomized Trial in the Southeastern United States

Rachel E Patzer  1   2 , Jade Buford  2 , Megan Urbanski  3 , Laura McPherson  4 , Sudeshna Paul  5 , Mengyu Di  2 , Jessica L Harding  6 , Goni Katz-Greenberg  7 , Ana Rossi  8 , Prince Mohan Anand  9 , Amber Reeves-Daniel  10 , Heather Jones  11 , Laura Mulloy  12 , Stephen O Pastan  3 ; Southeastern Kidney Transplant Coalition
Collaborators, Affiliations

Reducing Disparities in Access to Kidney Transplantation Regional Study: A Randomized Trial in the Southeastern United States

Rachel E Patzer et al. Clin J Am Soc Nephrol. .

Abstract

Key Points:

  1. Declines in referral mirror national trends; however, declines were less for some groups receiving the intervention, warranting long-term follow-up.

  2. The findings provide important context for future modification and scale-up of multilevel, multicomponent interventions in dialysis settings.

Background: The Southeastern United States has among the lowest rates of kidney transplantation nationally and has documented racial and socioeconomic disparities in transplant access. We assessed the effectiveness and implementation of a multicomponent intervention aimed at increasing access and reducing disparities in access to early transplant steps in Georgia, North Carolina, and South Carolina.

Methods: The Reducing Disparities in Access to Kidney Transplantation Regional Study randomized 440 dialysis facilities in Georgia, North Carolina, and South Carolina to receive the Reducing Disparities in Access to Kidney Transplantation Regional educational and quality intervention or standard of care in 2018. The primary outcome was a change in dialysis facility–level transplant referral within 1 year of dialysis start after intervention, with secondary outcomes examining changes in evaluation start within 6 months of referral and waitlisting within 1 year of evaluation start. A process evaluation included a postimplementation survey (N=220) and semistructured interviews of staff (N=4). Generalized linear mixed-effects models assessed intervention effectiveness overall and in race subgroups.

Results: Among the 25,586 patients with ESKD treated in 440 dialysis facilities, referral rates decreased across both intervention arms 1 year after intervention; however, a greater decrease in referrals was observed among control (11.2% to 9.2%) versus intervention (11.2% to 10.5%) facilities. We observed no significant difference in the likelihood of referral among Black patients in intervention versus control facilities after intervention (adjusted odds ratio, 1.12; 95% confidence interval, 0.94 to 1.33); however, a significant increase in referral was observed among White patients in intervention facilities after intervention (odds ratio, 1.24; 95% confidence interval, 1.02 to 1.51). Interviews highlighted the importance of tailored interventions, federal mandates, and implementation challenges for large pragmatic trials.

Conclusions: Postintervention declines in referral mirror national trends; however, these declines were less for some groups receiving the intervention, warranting long-term follow-up. These findings provide important context for future modification and scale-up of multilevel, multicomponent interventions in dialysis settings.

Clinical Trial registry name and registration number:: The study protocol is available on ClinicalTrials.gov (identifier: NCT02389387).

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Conflict of interest statement

Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/CJN/C122.

References

    1. United States Renal Data System. 2022 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2022.
    1. Tonelli M Wiebe N Knoll G, et al. . Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes. Am J Transplant. 2011;11(10):2093–2109. doi:10.1111/j.1600-6143.2011.03686.x - DOI - PubMed
    1. Patzer RE Paul S Plantinga L, et al. . A randomized trial to reduce disparities in referral for transplant evaluation. J Am Soc Nephrol. 2017;28(3):935–942. doi:10.1681/ASN.2016030320 - DOI - PMC - PubMed
    1. Patzer RE McPherson L Wang Z, et al. . Dialysis facility referral and start of evaluation for kidney transplantation among patients treated with dialysis in the Southeastern United States. Am J Transplant. 2020;20(8):2113–2125. doi:10.1111/ajt.15791 - DOI - PMC - PubMed
    1. Waterman AD, Rodrigue JR, Purnell TS, Ladin K, Boulware LE. Addressing racial and ethnic disparities in live donor kidney transplantation: priorities for research and intervention. Semin Nephrol. 2010;30(1):90–98. doi:10.1016/j.semnephrol.2009.10.010 - DOI - PMC - PubMed

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