Year: 2024
Type: article
Abstract: To the Editor, The UK Renal Registry (UKRR) plays a crucial role in reporting and assessing the quality of care and outcomes for all patients eligible for dialysis and kidney transplantation [1]. A recent UKRR report, Inequity of Access to the UK Kidney Transplant Waiting List, highlighted important disparities in access to the transplant waiting list [2]. The report examines important aspects of access to transplant listing based on patient characteristics that could contribute to inequities in kidney transplantation waitlisting outcomes. Disappointingly disparities remain, and reporting is essential due to clinical significance and considerable public interest. The central premise of the report is the crucial role of early transplant wait-listing in increasing the likelihood of receiving a kidney transplant from a deceased donor; the current national kidney allocation scheme [3], prioritizes potential recipients with a longer duration on the waiting list. Consequently, kidney centres that achieve early transplant wait-listing offer their patients a valuable clinical advantage, but there are consistent variations among kidney centres, and the potential for inequalities based on patient characteristics. This report includes UK transplant listing data from 1 March 2017 to 28 February 2020 and includes patients aged 18–75 years who started dialysis or received a transplant during this period. Patients were followed up for 2 years after starting kidney replacement therapy (KRT). UKRR data include the KRT start date, and patient characteristics age group, sex, ethnicity, primary renal disease (PRD) diabetic nephropathy and socioeconomic status. The proportion of all incident KRT patients listed for transplantation within 2 years of starting KRT was calculated unadjusted/adjusted. Indirect standardization was used to calculate the listing rate adjusting for patient characteristics. Interactions were explored between patient characteristics; while some interactions were statistically significant, they were not included in the final model for parsimony and interpretability (see Supplementary data for details). The impact of patient characteristics on the odds of being listed for transplant within 2 years after KRT start were assessed using logistic regression models. The odds compared patients treated at non-transplant centres and those at transplant centres, adjusted for patient characteristics. Funnel plots visually compared the proportion of patients listed within 2 years, based on logistic regression model results. Demographic and centre-specific factors contributed to variations in access to transplantation in the UK. Notably, patients of Asian ethnicity exhibit a higher likelihood of being listed, while patients of Black ethnicity demonstrate a lower likelihood compared with White patients (Fig. 1). These disparities persist after accounting for other patient characteristics. Kidney centres providing in-house transplantation services (transplant centres) have higher listing rates within 2 years from start of KRT than centres referring patients to other centres for transplantation (non-transplant centres). In absolute terms, 45% of patients from transplant centres were waitlisted within 2 years, compared with 30% from non-transplant centres. Among ethnic groups, 40% of Asian patients were listed and only 20% of Black patients compared with 35% of White patients. Odds ratio of listing within 2 years of starting KRT adjusted by age, sex, ethnicity, PRD (diabetic nephropathy) and socioeconomic status. As expected, age-related disparities are evident and younger patients have a higher likelihood of being listed. Patients aged 18–29 years exhibit a 3.9-fold higher odds of listing compared with those aged 50–59 years, while patients aged 70–75 years have an 81% lower odds of listing. In absolute terms, 60% of patients aged 18–29 years were listed, compared with only 10% of aged 70–75 years. No significant gender-based differences in listing odds were observed in this analysis. Socioeconomic status plays a crucial role, with patients in more affluent areas having 47% higher odds of being listed compared with those in the middle socioeconomic quintile. Patients in the most deprived quintile experience a 44% lower odds of being listed. Overall, 40% of patients in the most affluent quintile were listed, compared with 20% in the most deprived quintile. To address previous findings suggesting lower listing rates for females [4–,6], we conducted an additional analysis of historical data from 2008 to 2019 (Appendix A3 in the main report). This analysis, separate from our main study period of 2017–22, examined trends in the proportion of female patients listed for kidney transplantation. We found no significant increasing or decreasing trend in female listing rates over this period. This historical context complements our current finding of no significant sex-based differences in listing odds. This report reveals significant disparities in kidney transplant listing rates across UK centres and substantial variations associated with ethnicity, age and socioeconomic status, while showing no significant differences based on sex, highlighting the need for a closer examination of centre-specific practices (Fig. 2). We speculate that there is potential for lower listing centres to learn from the higher listing centres. Centre listing rate with 95% confidence interval, adjusted by age, sex, ethnicity, PRD (diabetic nephropathy) and socioeconomic status. Over the past 15 years, several publications explored the topic of access to the kidney transplant waiting list. Following the publication in 2010 by Udayaraj et al. [7], the UKRR featured a chapter on this topic in the UKRR Annual Report every 2 years between 2011 and 2019 [4, 5, 8–10]. The Access to Transplantation and Transplant Outcome Measures (ATTOM) study also reported on inequity in access to transplantation in the UK in 2020 [6]. Comparing the main findings of our current report with these earlier studies, the results consistently show transplant centres typically have higher listing rates compared with non-transplant centres after case-mixed adjustments, mirroring the findings in our current report. While the overall trend shows higher listing rates in transplant centres, approximately half of non-transplant centres perform similar to transplant centres (Fig. 2). Listing rates between transplant and non-transplant centres likely reflect logistic barriers for listing in non-transplanting centres, however details can only be assessed by scrutiny of local pathways which vary across the country. As anticipated, the studies showed similar results for age and PRD. The ATTOM study analysed the pre-emptive listing population separately from patients receiving dialysis; they found females have a lower likelihood of listing in the dialysis population, which aligns with some of the UKRR reports [4, 5]. In this analysis, we combined pre-emptive transplants/listings and dialysis patients to evaluate all patients who received/were eligible for a transplant, and found no sex difference. This may reflect ongoing improvements in sex equity in transplant listing practices, possibly due to increased awareness and efforts to address disparities in recent years; however, it is important to continue monitoring this trend and to investigate other aspects of the transplant journey where sex-based disparities might still exist. The reasons for the nuanced disparities in listing rates across ethnic groups are complex and not fully understood, warranting further investigation. Research should investigate which targeted interventions are needed to address specific barriers faced by different ethnic groups, to ultimately achieve a more equitable listing process. Regular reporting and active challenging of disparities should be ongoing to justify the need for such research. It is notable that our analyses spanned 2 years during which the healthcare landscape experienced significant disruption due to the COVID-19 pandemic. While it is impossible to rule out the impact of the pandemic on our findings, we did observe that patients who initiated KRT from March 2019 to February 2020 had lower odds of being listed. Limitations include the impact of COVID-19 pandemic on listing practices and healthcare delivery during the follow-up period. We were unable to account for all confounding factors, such as patient comorbidities and preferences. Additionally, variations in uncollected factors, such as variation in assessment practices for kidney transplantation and patient treatment choices across different centres, may have introduced biases. Previously, kidney centres did not report if a patient has been formally assessed as ‘unsuitable for kidney transplantation’, nor when any transplant suitability assessment was started, which introduces a degree of inaccuracy in our results. These data are now routinely expected from kidney centres, allowing us to understand patient and centre differences in much greater detail in the future [11]. We also acknowledge limitations in available data that may mask more subtle disparities. In conclusion, this report highlights persistent inequities in UK kidney transplant listing rates, influenced by ethnicity, age and socioeconomic factors. These findings underscore the importance of understanding centre-specific practices and considering targeted interventions. While progress has been observed in some areas, continued monitoring and research remain important to address remaining disparities and evaluate the impact of systemic changes. Regular reporting and analysis of these issues can contribute to efforts towards improving equity in the transplant system for all patients. The authors wish to thank NHSBT, Dr Rommel Ravanan, Members of the UK Association Patient Council, Dr Barnaby Hole, Dr Anna Casula and Dr Shalini Santhakumaran. The UK Kidney Association (UKKA) is a trading name of the Renal Association, registered charity number 800733. E.W.—conceptualization, methodology, formal analysis, writing—original draft, writing—review & editing. R.S.—methodology, formal analysis, writing—review & editing. D.N.—methodology, formal analysis, writing—review & editing. J.F.M.—conceptualization, methodology, writing—original draft, writing—review & editing. The data underlying this study were obtained from the UK Renal Registry. Access to these data is restricted and can be requested through the UK Renal Registry's data application process. Further details about the application process and access conditions can be found at [https://www.ukkidney.org/audit-research/how-access-data/ukrr-data]. Researchers interested in accessing these data should submit a formal application, which will be reviewed following the UK Renal Registry's governance and ethical approval policies. The authors of this letter have no conflict of interest to declare. Supplementary Material for Analysis of Ethnicity and Transplant Listing Rates is available from: https://ukkidney.org/sites/renal.org/files/Access%20to%20Transplant%20Waiting%20List%20-%20patient%20infographic.pdf
DOI: 10.1093/ndt/gfae284
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
Award: G7840145249
OpenAlex ID: W4405230428