003 - Citizenship and Pediatric Kidney Transplantation Outcomes from UNOS 2000-2023

Publication Number: 3.4127

Kristal Wong, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Westbury, NY, United States; Carol L. Shen, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, United States; Abby Basalely, Cohen Childrens Medical Center Northwell Health, New Hyde park, NY, United States; Laura Castellanos Reyes, Cohen Children's Medical Center, New Hyde Park, NY, United States; Christine Sethna, Cohen Childrens Medical Center, Northwell, New Hyde Park, NY, United States; Pamela Singer, Cohen Children's Medical Center, New Hyde Park, NY, United States

Background: Kidney transplantation (KTx) is the most cost-effective and efficacious form of kidney replacement therapy. US citizenship status may be associated with differences in transplant access and outcomes, however, there has been little research to assess this association.

Objective: To explore and compare kidney transplantation outcomes among children in the US who hold US citizenship and those who do not hold US citizenship.

Design/Methods: Data from the United Network for Organ Sharing (UNOS) database from 2000-2023 was used to analyze the association between US citizenship status and pediatric KTx outcomes in the US. Citizenship was dichotomized into US citizen and non-US citizen, the latter of which included anyone not characterized as US citizen in the UNOS database. Children undergoing KTx after 2000 and under the age of 18 were included. Demographic variables such as age, gender, race/ethnicity, insurance, BMI, KDPI, and time on wait list were analyzed using chi squared and t-test to assess bivariate associations and assess potential covariates. Adjusted logistic and Cox regression models were created using a backwards stepwise elimination method to analyze KTx outcomes including rejection at 6 months, rejection at 1 year, graft failure, death-censored graft failure (DCGF). Statistical analyses were performed using STATA.

Results: Study sample included 17,712 pediatric participants. 16,543 (93.34%) had US citizenship and 1,169 (6.66%) did not have US citizenship. The mean age was 13 years (IQR 7, 16) and included 10,426 (58.86%) males. Amongst US citizens, the majority identified as white (7,823 [47.29%]), and most non-US citizens identified as Hispanic (781 [66.87%]) (p < 0.001). Pre-transplant dialysis and dialysis vintage were significantly greater in the non-citizen population. Non-citizens were more likely to receive a deceased rather than living donor transplant. In adjusted models, US citizens had a greater risk of acute rejection at 6 months (OR 2.03, IQR 1.28-3.23, p=0.003) and at 1 year (OR 1.57, CI 1.25-1.97, p< 0.001) when compared to non-US citizens. Transplant recipients with US citizenship also had a greater risk of graft failure (HR 1.22, CI 1.02-1.43, p=0.012) and DCGF (HR 1.18, CI 1.01-1.40, p=0.038). US citizens also had a 2.5 higher risk of mortality when compared to non-US citizens (HR 2.53, CI 1.63, 3.80, p< 0.001).

Conclusion(s): Children without US citizenship experienced better KTx outcomes than US citizens undergoing KTx. Further research on pediatric KTx and US citizenship status is necessary to promote equity in KTx.

Table 1: Clinical and Demographic Variables
Table1.pdf

Table 2: Adjusted Analysis of Kidney Transplantation Outcomes
Figure2.pdf

Table 1: Clinical and Demographic Variables
Table1.pdf

Table 2: Adjusted Analysis of Kidney Transplantation Outcomes
Figure2.pdf