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Individual- and Community-Level Socioeconomic Status and Deceased Donor Renal Transplant Outcomes

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Abstract

Background

This study examined the relationship between socioeconomic status (SES), race, and ethnicity and clinical outcomes following deceased donor kidney transplant (DDKT) at a high-volume transplant center.

Methods

This retrospective cohort study used regression models and survival analyses to examine the relationship between individual- and community-level SES, race, and ethnicity and DDKT outcomes (i.e., delayed graft function, graft failure, mortality) adjusting for potential confounders.

Results

The analytic sample included 3366 patients; 40.7% (n = 1370) were female, the mean age was 54.7 (SD = 13.3) years, 49.3% were non-Hispanic White, and the median follow-up time was 39.5 months (IQR = 24.2–68.1). Patients living in the most disadvantaged communities (using the US Census data) had a higher likelihood of delayed graft function (adjusted relative risk [RR] = 1.12, p = 0.042) and a higher hazard of mortality (adjusted hazard ratio [HR] = 1.32, p = 0.025) compared to patients living in the least disadvantaged communities. Patients without a high school diploma had a higher risk of delayed graft function compared to patients with an associate degree or more (RR = 1.37, p < 0.001). Patients with public insurance coverage had a higher risk of delayed graft function (RR = 1.24, p < 0.001) and a higher hazard of mortality (HR = 1.37, p < 0.001) and graft failure (HR = 1.71, p < 0.001) compared to patients without public insurance. There were no differences in graft failure or mortality by race and ethnicity.

Conclusions

SES was not consistently associated with outcomes following DDKT; however, many of the predictors were associated with delayed graft function. With a large and diverse sample size, these findings further the heterogeneity of the present renal transplant research suggesting the need for further investigation to guide implementation of innovative strategies and interventions.

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Data availability

Not available as it contains personal health information.

Code availability

Available upon request.

Abbreviations

HR:

Hazard ratio

ANOVA:

Analysis of variance

RR:

Relative risk

CDI:

Community disadvantage index

CPT:

Current procedural terminology

DDKT:

Deceased donor kidney transplantation

ICD-10:

International Statistical Classification of Disease, Tenth Revision

ICD-9:

International Classification of Disease, Ninth Revision

SES:

Socioeconomic status

References

  1. National data - OPTN [Internet]. Retrieved August 17, 2023 from https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/

  2. Augustine J. Kidney transplant: new opportunities and challenges. Cleve Clin J Med. 2018;85:138–44.

    Article  PubMed  Google Scholar 

  3. Stevens MA, Beebe TJ, Wi C-I, Taler SJ, St. Sauver JL, Juhn YJ. HOUSES index as an innovative socioeconomic measure predicts graft failure among kidney transplant recipients. Transplantation. 2020;104:2383–92.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Tumin D, Horan J, Shrider EA, Smith SA, Tobias JD, Hayes D, et al. County socioeconomic characteristics and heart transplant outcomes in the United States. Am Heart J. 2017;190:104.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Cron DC, Husain SA, Adler JT. The New Distance-Based Kidney Allocation System: implications for patients, transplant centers, and organ procurement organizations. Curr Transplant Rep. 2022;9:302–7.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Kidney disease statistics for the United States. National Institute of Diabetes and Digestive and Kidney Diseases. 2023. Retrieved August 17, 2023 from https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease

  7. Chronic kidney Disease (CKD) in the United States - Race/Ethnicity. (n.d.). Retrieved August 17, 2023 from https://nccd.cdc.gov/ckd/FactorsOfInterest.aspxtype=Race/Ethnicity#:~:text=Chronic%20Kidney%20Disease%20,Most%20Recent%20Year%20Data%20Source

  8. Gordon EJ, Ladner DP, Caicedo JC, Franklin J. Disparities in kidney transplant outcomes: a review. Semin Nephrol. 2010;30:81–9.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Gugushvili A, Bulczak G, Zelinska O, Koltai J. Socioeconomic position, social mobility, and health selection effects on allostatic load in the United States. PLoS One. 2021;16:e0254414.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Warnecke RB, Oh A, Breen N, Gehlert S, Paskett E, Tucker KL, et al. Approaching health disparities from a population perspective: the National Institutes of Health Centers for Population Health and Health Disparities. Am J Public Health. 2008;98:1608–15.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Axelrod DA, Dzebisashvili N, Schnitzler MA, Salvalaggio PR, Segev DL, Gentry SE, et al. The interplay of socioeconomic status, distance to center, and interdonor service area travel on kidney transplant access and outcomes. Clin J Am Soc Nephrol. 2010;5:2276–88.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Naylor KL, Knoll GA, Shariff SZ, McArthur E, Garg AX, Van Walraven C, et al. Socioeconomic status and kidney transplant outcomes in a universal healthcare system: a population-based cohort study. Transplantation. 2019;103:1024–35.

    Article  PubMed  Google Scholar 

  13. Wong YHS, Wong G, Johnson DW, McDonald S, Clayton P, Boudville N, et al. Socio-economic disparity, access to care and patient-relevant outcomes after kidney allograft failure. Transpl Int. 2021;34:2329–40.

    Article  PubMed  Google Scholar 

  14. Oakes JM, Rossi PH. The measurement of SES in health research: current practice and steps toward a new approach. Soc Sci Med. 2003;56:769–84.

    Article  PubMed  Google Scholar 

  15. Geronimus AT. Invited commentary: using area-based socioeconomic measures--think conceptually, act cautiously. Am J Epidemiol. 2006;164:835–40. discussion 841-843

    Article  PubMed  Google Scholar 

  16. Suliman ST, Carlson J, Smotherman C, Gautam S, Heilig CW, Munroe C, et al. Effect of race and ethnicity on renal transplant referral. Clin Nephrol. 2019;92:221–5.

    Article  PubMed  Google Scholar 

  17. Saunders MR, Lee H, Maene C, Schuble T, Cagney KA. Proximity does not equal access: racial disparities in access to high quality dialysis facilities. J Racial Ethn Health Disparities. 2014;1:291–9.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Wesselman H, Ford CG, Leyva Y, Li X, Chang C-CH, Dew MA, et al. Social determinants of health and race disparities in kidney transplant. Clin J Am Soc Nephrol. 2021;16:262–74.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Patzer RE, McClellan WM. Influence of race, ethnicity and socioeconomic status on kidney disease. Nat Rev Nephrol. 2012;8:533–41.

    Article  PubMed  PubMed Central  Google Scholar 

  20. U.S. Census Bureau QuickFacts: Maricopa County, Arizona [Internet]. Retrieved March 29, 2023 from https://www.census.gov/quickfacts/maricopacountyarizona

  21. US2010 [Internet]. Retrieved March 29, 2023 from https://s4.ad.brown.edu/projects/diversity/segregation2010/city.aspx?cityid=455000

  22. Prener CG, Fox B. Creating open source composite geocoders: pitfalls and opportunities. Trans GIS. 2021;25:1868–87.

    Article  Google Scholar 

  23. Danos DM, Ferguson TF, Simonsen NR, Leonardi C, Yu Q, Wu X-C, et al. Neighborhood disadvantage and racial disparities in colorectal cancer incidence: a population-based study in Louisiana. Ann Epidemiol. 2018;28:316-321.e2.

  24. Coulon SJ, Velasco-Gonzalez C, Scribner R, Park CL, Gomez R, Vargas A, et al. Racial differences in neighborhood disadvantage, inflammation and metabolic control in Black and White pediatric type 1 diabetes patients. Pediatr Diabetes. 2017;18:120–7.

    Article  CAS  PubMed  Google Scholar 

  25. Danos D, Leonardi C, Gilliland A, Shankar S, Srivastava RK, Simonsen N, et al. Increased risk of hepatocellular carcinoma associated with neighborhood concentrated disadvantage. Front Oncol. 2018;8:375.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Scaria E, Powell WR, Birstler J, Alagoz O, Shirley D, Kind AJH, et al. Neighborhood disadvantage and 30-day readmission risk following Clostridioides difficile infection hospitalization. BMC Infect Dis. 2020;20:762.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Cahill LM, Fisher KA, Robinson WT, Beiter KJ, Zabaleta J, Tseng TS, et al. Asthma status moderates the relationship between neighbourhood disadvantage and obesity in African American adolescent females. Obes Sci Pract. 2019;5:564–9.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Ross CE, Mirowsky J. Neighborhood disadvantage, disorder, and health. J Health Soc Behav. 2001;42:258–76.

    Article  CAS  PubMed  Google Scholar 

  29. Kwan JM, Hajjiri Z, Chen YF, Metwally A, Perkins DL, Finn PW. Donor and recipient ethnicity impacts renal graft adverse outcomes. J Racial Ethn Health Disparities. 2018;5:1003–13.

    Article  PubMed  Google Scholar 

  30. Zou G. A modified Poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159:702–6.

    Article  PubMed  Google Scholar 

  31. Arvelakis A, Lerner S, Wadhera V, Delaney V, Ames S, Benvenisty A, et al. Different outcomes after kidney transplantation between African Americans and Whites: a matter of income? A single-center study. Clin Transpl. 2019;33:e13725.

    Article  Google Scholar 

  32. Crenshaw K. On intersectionality: essential writings. Faculty Books [Internet]. 2017. Retrieved March 29, 2023 from https://scholarship.law.columbia.edu/books/255

  33. Furr-Holden C, Campbell K, Milam A, Smart M, Ialongo N, Leaf P. Metric properties of the Neighborhood Inventory for Environmental Typology (NIfETy): an environmental assessment tool for measuring indicators of violence, alcohol, tobacco and other drug exposures. Eval Rev. 2010;34:159–84.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Allen H, Gordon SH, Lee D, Bhanja A, Sommers BD. Comparison of utilization, costs, and quality of Medicaid vs subsidized private health insurance for low-income adults. JAMA Netw Open. 2021;4:e2032669.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Brown CS, Montgomery JR, Neiman PU, Wakam GK, Tsai TC, Dimick JB, et al. Assessment of potentially preventable hospital readmissions after major surgery and association with public vs private health insurance and comorbidities. JAMA Netw Open. 2021;4:e215503.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Hart A, Gustafson SK, Wey A, Salkowski N, Snyder JJ, Kasiske BL, et al. The association between loss of Medicare, immunosuppressive medication use, and kidney transplant outcomes. Am J Transplant. 2019;19:1964–71.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Gill JS, Tonelli M. Penny wise, pound foolish? Coverage limits on immunosuppression after kidney transplantation. N Engl J Med. 2012;366:586–9.

    Article  CAS  PubMed  Google Scholar 

  38. End-Stage Renal Disease (ESRD) | CMS [Internet]. Retrieved March 29, 2023 from https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/End-Stage-Renal-Disease-ESRD/ESRD

  39. Gepty AA, Lambert SF, Milam AJ, Ialongo NS. Residential mobility, neighborhood cohesion, and depressive symptoms among urban-dwelling African American adolescents. J Commun Psychol. 2022;50:3280–99.

    Article  Google Scholar 

  40. Dong M, Anda RF, Felitti VJ, Williamson DF, Dube SR, Brown DW, et al. Childhood residential mobility and multiple health risks during adolescence and adulthood: the hidden role of adverse childhood experiences. Arch Pediatr Adolesc Med. 2005;159:1104–10.

    Article  PubMed  Google Scholar 

  41. Simsek M, Costa R, de Valk HAG. Childhood residential mobility and health outcomes: a meta-analysis. Health Place. 2021;71:102650.

    Article  PubMed  Google Scholar 

  42. Malek SK, Keys BJ, Kumar S, Milford E, Tullius SG. Racial and ethnic disparities in kidney transplantation. Transpl Int. 2011;24:419–24.

    Article  PubMed  Google Scholar 

  43. Young CJ, Gaston RS. African Americans and renal transplantation: disproportionate need, limited access, and impaired outcomes. Am J Med Sci. 2002;323:94–9.

    Article  PubMed  Google Scholar 

  44. Fan P-Y, Ashby VB, Fuller DS, Boulware LE, Kao A, Norman SP, et al. Access and outcomes among minority transplant patients, 1999-2008, with a focus on determinants of kidney graft survival. Am J Transplant. 2010;10:1090–107.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Epstein AM, Ayanian JZ, Keogh JH, Noonan SJ, Armistead N, Cleary PD, et al. Racial disparities in access to renal transplantation--clinically appropriate or due to underuse or overuse? N Engl J Med. 2000;343:1537–44, 2 p preceding 1537.

  46. Eckhoff DE, Young CJ, Gaston RS, Fineman SW, Deierhoi MH, Foushee MT, et al. Racial disparities in renal allograft survival: a public health issue? J Am Coll Surg. 2007;204:894–902. discussion 902-903

    Article  PubMed  Google Scholar 

  47. Hutchings A, Purcell WM, Benfield MR. Increased costimulatory responses in African-American kidney allograft recipients. Transplantation. 2001;71:692–5.

    Article  CAS  PubMed  Google Scholar 

  48. Ng Y-H, Pankratz VS, Leyva Y, Ford CG, Pleis JR, Kendall K, et al. Does racial disparity in kidney transplant wait-listing persist after accounting for social determinants of health? Transplantation. 2020;104:1445–55.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Resende L, Guerra J, Santana A, Mil-Homens C, Abreu F, da Costa AG. Influence of dialysis duration and modality on kidney transplant outcomes. Transplant Proc. 2009;41:837–9.

    Article  CAS  PubMed  Google Scholar 

  50. Kadatz M, Lan JH, Brar S, Vaishnav S, Chang DT, Gill J, et al. Transplantation of patients with long dialysis vintage in the current deceased donor kidney allocation system (KAS). Am J Kidney Dis. 2022;80:319-329.e1.

  51. Jo D. The interpretation bias and trap of multicenter clinical research. Korean J Pain. 2020;33:199–200.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Skelton SL, Waterman AD, Davis LA, Peipert JD, Fish AF. Applying best practices to designing patient education for patients with end-stage renal disease pursuing kidney transplant. Prog Transplant. 2015;25:77–84.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Strauss AT, Sidoti CN, Purnell TS, Sung HC, Jackson JW, Levin S, et al. Multicenter study of racial and ethnic inequities in liver transplantation evaluation: understanding mechanisms and identifying solutions. Liver Transpl. 2022;12:1841–56.

    Article  Google Scholar 

  54. Chang CF, Winsett RP, Osama Gaber A, Hathaway DK. Cost-effectiveness of post-transplantation quality of life intervention among kidney recipients. Clin Transpl. 2004;18:407–14.

    Article  Google Scholar 

  55. Boulware LE, Sudan DL, Strigo TS, Ephraim PL, Davenport CA, Pendergast JF, Pounds I, Riley JA, Falkovic M, Alkon A, Hill-Briggs F, Cabacungan AN, Barrett TM, Mohottige D, McElroy L, Diamantidis CJ, Ellis MJ. Transplant social worker and donor financial assistance to increase living donor kidney transplants among African Americans: the TALKS Study, a randomized comparative effectiveness trial. Am J Transplant Off J Am Soc Transplant Am Soc Transplant Surg. 2021;21(6):2175–87.

    Article  Google Scholar 

  56. Tinland A, Loubière S, Boucekine M, Boyer L, Fond G, Girard V, Auquier P. Effectiveness of a housing support team intervention with a recovery-oriented approach on hospital and emergency department use by homeless people with severe mental illness: a randomised controlled trial. Epidemiology and Psychiatric Sciences. 2020;29:e169.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Author information

Authors and Affiliations

  1. Mayo Clinic Alix School of Medicine, Scottsdale, AZ, 85259, USA

    Shyam Patel

  2. Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA

    Chelsea Alfafara, Molly B. Kraus, Mohanad R. Youssef, Karl A. Poterack & Adam J. Milam

  3. Department of Clinical Trials and Biostatistics, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA

    Skye Buckner-Petty

  4. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA

    Timethia Bonner

  5. Division of Nephrology, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA

    Girish Mour

  6. Division of Transplant Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA

    Amit K. Mathur

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Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed SB-P. The first draft of the manuscript was written by SP and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

SP, BS: This author helped conceive and design the study, interpret the data, write, and critically revise the manuscript, and approve the final version of the manuscript, and agrees to be accountable for all aspects of this work.

CA, MD: This author helped conceive and design the study, interpret the data, write and critically revise the manuscript, and approve the final version of the manuscript, and agrees to be accountable for all aspects of this work.

MBK, MD: This author helped conceive and design the study, interpret the data, write and critically revise the manuscript, and approve the final version of the manuscript, and agrees to be accountable for all aspects of this work.

SB-P, MPH: This author helped conceive and design the study, analyze and interpret the data, write and critically revise the manuscript, and approve the final version of the manuscript, and agrees to be accountable for all aspects of this work.

TB, DPM, PhD: This author helped write and critically revise the manuscript, and approve the final version of the manuscript, and agrees to be accountable for all aspects of this work.

MRY, MD: This author helped write and critically revise the manuscript, and approve the final version of the manuscript, and agrees to be accountable for all aspects of this work.

KP, MD: This author helped conceive and design the study, write and critically revise the manuscript, and approve the final version of the manuscript, and agrees to be accountable for all aspects of this work.

GM, MD, MBBS: This author helped write and critically revise the manuscript, and approve the final version of the manuscript, and agrees to be accountable for all aspects of this work.

AKM, MD MS: This author helped write and critically revise the manuscript, and approve the final version of the manuscript, and agrees to be accountable for all aspects of this work.

AJM, MD, PhD: This author helped conceive and design the study, interpret the data, write and critically revise the manuscript, and approve the final version of the manuscript, and agrees to be accountable for all aspects of this work.

Corresponding author

Correspondence to Adam J. Milam.

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Appendix

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Table 3 Race, ethnicity, SES, and dialysis duration
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Patel, S., Alfafara, C., Kraus, M.B. et al. Individual- and Community-Level Socioeconomic Status and Deceased Donor Renal Transplant Outcomes. J. Racial and Ethnic Health Disparities (2023). https://doi.org/10.1007/s40615-023-01851-8

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