004 - Do inequities in social determinants of health explain the racial disparities in access to pediatric preemptive kidney transplants?

Publication Number: 4.4095

Judith S. VanSickle, Children's Mercy Hospitals and Clinics, Kansas City, MO, United States; Darcy K.. Weidemann, Children's Mercy Hospital, Kansas City, MO, United States; Bradley A. Warady, Children's Mercy, Kansas City, MO, United States

Background: Preemptive Kidney Transplantation (PKT) is the preferred modality of treatment for children with end-stage kidney disease (ESKD) due to improved patient and graft survival. Unfortunately, mounting evidence demonstrates substantial racial inequities in access to PKT. The relationship between race (R), socioeconomic status (SES), and access to PKT has been inadequately studied in the pediatric ESKD population.

Objective: To determine whether the observed racial disparities in access to PKT are due to SES-related factors among pediatric ESKD patients.

Design/Methods: Single-center, retrospective analysis of children who received ESKD care between 2010-2020. Charts were reviewed for pertinent demographic, clinical, and socioeconomic factors. Glomerular filtration rate (eGFR) at first visit and at the time of KT referral was assessed by bedside Schwartz formula. Family social support (FSS) was assessed during each pre-transplant evaluation. SES was assessed by the Child Opportunity Index (COI). Descriptive statistics with independent-T test, and univariate analysis by ꭕ-squared were used to compare patients with PKT and with Non-PKT (dialysis only+dialysis followed by KT). Multivariate logistic regression modeling was performed to determine the best predictors for receiving PKT adjusted for clinical and demographic variables.

Results: Of the 177 children, 165 received KT. Demographic data and main characteristics are presented by KT group (Table 1). Children with PKT were more likely White (W), (p=0.01), had shorter wait time to transplant referral ( < 0.03), and had higher eGFR at time of referral for KT (p < 0.001). Univariate analysis (Table 2) identified a significant correlation between receipt of PKT and LD as donor type (( < 0.001), ESKD diagnosis (p=0.03) and R (p=0.01), but no correlation with COI status (p=0.13). Adequate FSS also correlated with receipt of PKT (p < 0.001) and with LD-KT ( < 0.001). W families were more likely to report adequate FSS (p=0.019). In our final multivariant logistic analysis using several predictive models for receiving PKT (Table 3), model 3 (FSS and Donor type) was the best fit and significantly predicted PKT if donor type was LD versus DD (p < 0.001).

Conclusion(s): The observed racial differences in access to PKT are related to differences in the availability of LD transplants, number of CGs, and adequate FSS, but not to SES as characterized by COI. Greater attention should be directed to strategies targeted to overcome social and fiscal obstacles to LD to enhance equity in pediatric PKT.

Table 1. Demographic data and characteristics of 177 children with ESKD cared by our center between 2010-2020
Table 1. Demographic description of ESKD patients per modality. PKT: pre-emptive kidney transplant. Non-PKT: dialysis only + dialysis followed by kidney transplant. Independent test
and Χ-square test.
GFR: glomerular filtration rate, calculated by bedside Schwartz formula.
W: white. NW: non-white. GN: glomerulonephritis. CAKUT: congenital anomaly of the kidney and urogenital system


Table 2. Univariate analysis of the ESKD patients per modality groups followed by our center between 2010-2020
Univariate statistical analysis of potential predictor of PKT by Chi-square test., p< 0.05.
PKT: pre-emptive kidney transplant. Non-PKT: dialysis +dialysis followed by kidney transplant
DD: deceased donor. LD: living donor.
PKT: pre-emptive kidney transplant.
FSS: family social support to help with coping
COI: Neighborhood Child Opportunity Index


Table 3. Modeling with multinominal logistic regression analysis for predicting Pre-emptive kidney transplant in our cohort

Three models of multinominal logistic regression to evaluate predictive value of CG, Race, COI 1-5, FSS and Donor type for PKT.
Model 3 shows the best fit, with LD being a significant predictor of PKT. Multinominal regression analysis, p< 0.005).
PKT: pre-emptive kidney transplant. Non-PKT: Dialysis + Dialysis followed by kidney transplant. CG: number of care giver in the home. W: white, NW: non-white. FSS: family social support. DD: deceased donor. LD: living related donor


Table 1. Demographic data and characteristics of 177 children with ESKD cared by our center between 2010-2020
Table 1. Demographic description of ESKD patients per modality. PKT: pre-emptive kidney transplant. Non-PKT: dialysis only + dialysis followed by kidney transplant. Independent test
and Χ-square test.
GFR: glomerular filtration rate, calculated by bedside Schwartz formula.
W: white. NW: non-white. GN: glomerulonephritis. CAKUT: congenital anomaly of the kidney and urogenital system


Table 2. Univariate analysis of the ESKD patients per modality groups followed by our center between 2010-2020
Univariate statistical analysis of potential predictor of PKT by Chi-square test., p< 0.05.
PKT: pre-emptive kidney transplant. Non-PKT: dialysis +dialysis followed by kidney transplant
DD: deceased donor. LD: living donor.
PKT: pre-emptive kidney transplant.
FSS: family social support to help with coping
COI: Neighborhood Child Opportunity Index


Table 3. Modeling with multinominal logistic regression analysis for predicting Pre-emptive kidney transplant in our cohort

Three models of multinominal logistic regression to evaluate predictive value of CG, Race, COI 1-5, FSS and Donor type for PKT.
Model 3 shows the best fit, with LD being a significant predictor of PKT. Multinominal regression analysis, p< 0.005).
PKT: pre-emptive kidney transplant. Non-PKT: Dialysis + Dialysis followed by kidney transplant. CG: number of care giver in the home. W: white, NW: non-white. FSS: family social support. DD: deceased donor. LD: living related donor