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Unexpected Race and Ethnicity Differences in the US National Veterans Affairs Kidney Transplant Program

Myaskovsky, Larissa PhD1; Kendall, Kellee MPH2; Li, Xingyuan MS3; Chang, Chung-Chou H. PhD2; Pleis, John R. PhD, MS4; Croswell, Emilee BA2; Ford, C. Graham MS1; Switzer, Galen E. PhD2,5; Langone, Anthony MD6,7; Mittal-Henkle, Anuja MD, MPH8; Saha, Somnath MD, MPH9,10; Thomas, Christie P. MBBS11,12; Adams Flohr, Jareen RN13; Ramkumar, Mohan MBBS2,13; Dew, Mary Amanda PhD14

doi: 10.1097/TP.0000000000002905
Original Clinical Science—General

Background. Racial/ethnic minorities have lower rates of deceased kidney transplantation (DDKT) and living donor kidney transplantation (LDKT) in the United States. We examined whether social determinants of health (eg, demographics, cultural, psychosocial, knowledge factors) could account for differences in the Veterans Affairs (VA) Kidney Transplantation (KT) Program.

Methods. We conducted a multicenter longitudinal cohort study of 611 Veterans undergoing evaluation for KT at all National VA KT Centers (2010–2012) using an interview after KT evaluation and tracking participants via medical records through 2017.

Results. Hispanics were more likely to get any KT (subdistribution hazard ratios [SHR] [95% confidence interval (CI)]: 1.8 [1.2-2.8]) or DDKT (SHR [95% CI]: 2.0 [1.3-3.2]) than non-Hispanic white in univariable analysis. Social determinants of health, including marital status (SHR [95% CI]: 0.6 [0.4-0.9]), religious objection to LDKT (SHR [95% CI]: 0.6 [0.4-1.0]), and donor preference (SHR [95% CI]: 2.5 [1.2-5.1]), accounted for some racial differences, and changes to Kidney Allocation System policy (SHR [95% CI]: 0.3 [0.2-0.5]) mitigated race differences in DDKT in multivariable analysis. For LDKT, non-Hispanic African American Veterans were less likely to receive an LDKT than non-Hispanic white (SHR [95% CI]: 0.2 [0.0-0.7]), but accounting for age (SHR [95% CI]: 1.0 [0.9-1.0]), insurance (SHR [95% CI]: 5.9 [1.1-33.7]), presenting with a living donor (SHR [95% CI]: 4.1 [1.4-12.3]), dialysis duration (SHR [95% CI]: 0.3 [0.2-0.6]), network of potential donors (SHR [95% CI]: 1.0 [1.0-1.1]), self-esteem (SHR [95% CI]: 0.4 [0.2-0.8]), transplant knowledge (SHR [95% CI]: 1.3 [1.0-1.7]), and changes to Kidney Allocation System policy (SHR [95% CI]: 10.3 [2.5-42.1]) in multivariable analysis eliminated those disparities.

Conclusions. The VA KT Program does not exhibit the same pattern of disparities in KT receipt as non-VA centers. Transplant centers can use identified risk factors to target patients who may need more support to ensure they receive a transplant.

1 The Center for Healthcare Equity in Kidney Disease (CHEK-D) and the Department of Internal Medicine, University of New Mexico, School of Medicine, Albuquerque, NM.

2 Department of Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, PA.

3 Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA.

4 Division of Research and Methodology, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD.

5 Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.

6 Renal Section, Tennessee Valley VA Healthcare System, Nashville, TN.

7 Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN.

8 Kaiser Permanente, Northwest, Portland, OR.

9 Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR.

10 Department of Medicine, Oregon Health and Science University, Portland, OR.

11 Renal Section, Iowa City VA Healthcare System, Iowa City, IA.

12 Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.

13 Renal Section, VA Pittsburgh Healthcare System, Pittsburgh, PA.

14 Department of Psychiatry, Psychology, and Epidemiology University of Pittsburgh, Pittsburgh, PA.

Received 15 February 2019. Revision received 25 June 2019.

Accepted 18 July 2019.

L.M., M.A.D., and G.E.S. designed the study; L.M., K.K., E.C., A.L., A.M.H., S.S., M.R., J.A.F., and C.P.T. carried out the project; X.L., C.C.H.C., and J.R.P. prepared and analyzed the data; X.L., C.G.F., and C.C.H.C. made the tables and figures; L.M., K.K., X.L., C.G.F., and C.C.H.C. drafted and revised the article; all authors edited and approved the final version of the article.

The authors declare no conflicts of interest.

This material is based upon work supported (or supported in part) by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, and Health Services Research and Development. Work on this project was funded in part by a grant from the VA Health Services Research and Development Department (IIR 06-220), a grant from the National Institute of Diabetes Digestive and Kidney Diseases (R01DK081325), and a grant from Dialysis Clinic, Inc, a nonprofit corporation.

The contents do not represent the views of the Department of Veterans Affairs or the United States Government.

The data that support the findings of this study are available on request from the first author. The data are not publicly available due to privacy or ethical restrictions.

Correspondence: Larissa Myaskovsky, PhD, 1 University of New Mexico, MSC10 5550,Albuquerque, NM 87131. (

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.