How Long Can We Afford to Wait for Equity in the Renal Transplant Waiting List?
Authors: Keith C. Norris, Lawrence Y. Agodoa
Journal: Journal of the American Society of Nephrology (2009)

“I used to think I was poor. Then they told me I wasn’t poor. I was needy. Then they told me it was self-defeating to think of myself as needy. I was deprived. Then they told me underprivileged was overused. I was disadvantaged. I still don’t have a dime. But I have a great vocabulary” —Jules Feiffer, 1965. Although “a rose by any other name would smell as sweet,” poverty and its magnified impact on health outcomes in the absence of universal health care, by any other name, remains a souring indictment of the moral compass of the wealthiest nation on earth. Nephrology is one of the first subspecialties to recognize disparities in the prevalence of one of its key areas of care, ESRD.1 More recently, nephrology has witnessed an awakening to understanding many of the underlying factors that contribute to ESRD,2–5 as well as addressing the quality of care for patients afflicted with chronic kidney disease (CKD) or ESRD, especially across racial and ethnic, gender, and income demographics.6,7 As Powe2 notes in his urge for us to take disparities seriously, when it comes to kidney transplants, white patients in 2004 were 30% more likely to receive a transplant within 2 yr than black patients and 20% more likely than Hispanic patients. So then, why is it that more than 35 yr after Congress resolved the issue of reimbursement for dialysis and kidney transplantation by enacting the Social Security Amendments of 1972, black patients with ESRD remain less likely to be placed on waiting lists for kidney transplantation? In 2000, Furth et al.8 reported racial differences in access to the kidney transplant waiting lists for children and adolescents, and Wolfe et al.9 reported similar findings among adults. Keith et al.10 observed between January 2001 and December 2004 access to waiting lists for patients who had CKD and wanting cadaveric donor renal transplantation was markedly worse for patients with Medicare, racial and ethnic minorities, and those with low levels of educational attainment. In adjusted subgroup analyses for patients who are older than 64 yr, Medicare is no longer a risk for low access to waiting lists, likely because this is the cutoff point when Medicare eligibility restrictions are lifted; however, the large disparity in access to waiting lists for racial and ethnic minorities and those with low levels of educational attainment persists, suggesting that even for dialysis patients who benefit from a form of universal coverage, equity exists for many but not all services or conditions. Geographic variations in placement on waiting lists and kidney transplantation rates among patients with ESRD contribute to these racial disparities, with rural black individuals being less likely to be placed on the waiting list and undergoing transplantation than those who reside in urban areas in some studies11 but not all.12 Additional barriers to transplantation include but are not limited to distance from residence to a transplant center, religious beliefs, lower quality matches as a result of the limited availability of organs for transplantation, less access to care, increased number and/or severity of comorbid conditions, lack of family or social support, fear of specialized procedures at complex medical centers, lower likelihood to be rated as appropriate candidates for transplantation, lower chances of referral for evaluation, greater likelihood of incomplete evaluations, and facility-level effects.5,13,14 In this issue of JASN, Patzer et al.15 look beyond the traditional boundaries of clinical and social determinants of health that compose most traditional medical analyses to explore the role of neighborhood socioeconomic factors on health, specifically the likelihood of being placed on the waiting list for a kidney transplant. Using data for a cohort of 35,000 incident, adult patients with ESRD in ESRD Network 6 (Georgia, North Carolina, and South Carolina) and linking it to data from the United Network for Organ Sharing transplant registry through 2005 they find, in contrast to others, that the distance from patient residence to the nearest transplant center does not predict placement on the transplant waiting list. In fact, they found race, neighborhood poverty, gender, age, diabetes, hypertension, body mass index, albumin, and the use of erythropoietin on initiation of dialysis are more associated with placement on the waiting list. As neighborhood poverty increases, the likelihood of placement on the waiting list decreases for black compared with white patients in each poverty category, with black patients being more than 50% less likely to be placed on the waiting list than white patients in the poorest neighborhoods. Their findings reinforce those of Hall et al.,16 who reported reduced rates of kidney transplantation associated with neighborhood poverty among Asians and Pacific Islanders with ESRD in the United States. Steven Schroeder,17 former president of the Robert Wood Johnson Foundation, stated more broadly that “since all of the actionable determinants of health—personal behavior, social factors, health care, and the environment—disproportionately affect the poor, strategies to improve national health rankings must focus on this population.” The recognition of neighborhood poverty, an emerging social determinant of health,18 as an important contributor to reduced placement on the waiting list for black patients provides an opportunity to design potential interventions; however, whereas Patzer et al. seems to eliminate distance between residence and the transplant center as an independent factor, their analysis was limited by not being able to assess the method of transportation and travel time to a transplant center. In the setting of higher neighborhood poverty, there may be an interaction with limited bus routes or routes for other forms of mass transportation, access to a car, cost of gas, and related aspects that may link neighborhood poverty and “effective distance” to a transplant center or other health facilities as important factors. This brings us back to our original question of why black patients with ESRD remain less likely to be placed on waiting lists for kidney transplantation. Although the answer remains incomplete, Patzer et al. bring us a step closer to defining better some modifiable and nonmodifiable issues. Building on the recommendations of Garg et al.,19 who suggested narrow black–white differences in transplant activation should target young and healthy black patients, who are most likely to benefit from transplantation, yet another challenge has been issued to the nephrology community: How to engage more effectively low-resource communities to achieve improved rates of renal transplantation. The increasing recognition of neighborhood-level influences on CKD provides a unique opportunity to advance our understanding of how biologic mediators and environmental, psychosocial, and cultural factors intersect ultimately to influence clinical outcomes.2–5 The findings of Patzer et al.15 and Hall et al.16 suggesting the need to address community-level factors to increase access to renal transplantation present a compelling case for concentrating or focusing health care efforts on the less fortunate, a strategy that if fully embraced should attenuate health disparities. For many physicians, the role of social determinants on health outcomes may seem like a distant footnote, relegated to social scientists; however, the future of medicine may soon include an electronic report that includes a variable on patient neighborhood, including community assets and deficits, providing modified strategies to promote lifestyle recommendations based on community-level data, possibly suggesting a social worker consult, and perhaps even providing a new Current Procedural Terminology code. The unique interplay among care, research, and policy has left nephrology at the doorstep of opportunity in a transforming society in the midst of health care reform.20 As much as it takes a village to raise a child, we now realize it takes a more comprehensive understanding of that village for us, as providers, to address optimally the health of its members for whom we care. DISCLOSURES None. K.C.N. is supported in part by the National Center for Research Resources, Research Centers in Minority Institutions (G12-RR03026 and U54 RR019234), and the DREW/UCLA Project EXPORT, National Institutes of Health, National Center on Minority Health and Health Disparities (P20-MD00182).