Exploring inequity in access to renal transplantation

Abstract

Transplantation is the most cost effective treatment for end stage renal disease (ESRD), but demand outstrips supply. In the UK, retrospective analyses of Registry data show there is variation in access to transplantation between renal centres, and that despite ethnic minority populations and those from lower socioeconomic groups having a higher incidence of ESRD, they have reduced access to transplantation. As part of the NIHR funded ATTOM (Access to Transplantation and Transplant Outcome Measures) study, a mixed methods approach explored the impact of both the compositional properties of a centre and modifiable centre factors relating to organisation and processes of care, on access to transplant listing. The inter-personal relationships between living kidney donors and their recipients were also examined.

Thematic analysis of 45 semi-structured qualitative interviews with key stakeholders conducted across 9 renal centres in the UK informed the development of an online survey, which was, distributed to the Clinical Directors of all 71 UK renal centres. Major themes identified were pathways of care relating to transplant recipient assessment and chronic kidney disease management as well as cardiac assessment and decision-making. The subsequent national survey achieved a 100% response rate and demonstrated significant variation in the assessment criteria of patients, delivery of care, role of multi-disciplinary teams and level of transplant surgical involvement prior to listing. A prospective cohort of incident renal replacement therapy (RRT) patients in ATTOM with 18 month follow up were subsequently analysed to assess listing for transplantation. A multi-level hierarchical logistic regression model was used to assess factors associated with listing. The majority of observed inter-centre variation was accounted for by patient factors including independently age, ethnicity, socioeconomic status and several co-morbidities. Centre factors included the use of a written protocol to wait-list, whether the centre was a transplanting centre, and the universal discussion of transplantation with all patients. The study on living donor-recipient relationships demonstrated that living-kidney donation is subject to significant unexplained relationship differences amongst ethnic-minorities. Spousal donation is significantly lower in the Black population and gender disparity greatest in the Asian spousal population.

Further research is need to understand these observed differences to tackle inequity in access to transplantation for socially deprived patients and ethnic minorities as well as to to increase donation rates in ethnic minorities. There is also need for consensus on recipient work up and between centre harmonisation, as well as research to examine cardiovascular screening utility in potential transplant recipients.

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Identifiers

ORCID for Paul Roderick: orcid.org/0000-0001-9475-6850

ORCID for Geraldine Leydon: orcid.org/0000-0001-5986-3300

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