Equity in Access to Kidney Transplantation: Policy Change Is Necessary But Not Enough

Innovation has been the hallmark of transplantation, making it one of the most exciting frontiers of modern medicine. Over the past 40 y, immunosuppression has become more precise, organs have been revitalized by machine perfusion strategies, and genetically modified xenografts have even been transplanted into human recipients. Despite this tremendous innovation, however, Madusoodanan et al1 reminded us that inequities in access to transplantation remain persistent with little evidence of improvement over decades. Their findings highlight the urgent need for attention in an area of transplantation that continues to remain stagnant. Black Americans are almost 4 times more likely to develop end-stage kidney disease (ESKD) but are less likely to be referred for transplant evaluation, less likely to be waitlisted, wait longer for an organ on average, and have poorer outcomes if eventually transplanted.2 It has also been documented that Hispanic/LatinX individuals have decreased rates of transplant evaluation completion and preemptive transplants. Unfortunately, these statements have been unchanged for decades. Although the reasons are multifactorial, it is largely a reflection of the complexity of this problem. Although equity has emerged as a priority in the field,3 achieving it will require multidimensional action across the entire transplant ecosystem. This is well visualized by applying the socioecological health model to transplantation. The model allows for the conceptualization of interventions as acting on the individual, interpersonal, institutional, community, or policy level (Figure 1).4FIGURE 1.: Socioecological model of health applies to kidney transplantation.Madusoodanan et al focused specifically on assessing the efficacy of policy-level interventions. In 2014, several significant changes were made to the kidney allocation system including (1) removing the HLA-B priority, (2) adding dialysis time as a factor (rather than simply time on the waiting list), and (3) allowing deceased donors with A2 blood type to donate to patients with blood type B. At a time when only 18.5% of patients with ESKD were being referred for transplantation, the stated goal of these allocation changes was to improve access to transplantation for minority communities and those who were highly sensitized.5 In this study by Madusoodanan et al, the authors investigated whether these 2014 changes increased access to kidney transplantation for minority communities by studying data from the Scientific Registry of Transplant Recipients from January 2015 to June 2023. After adjustment for patient-level and regional characteristics, Black and Hispanic/LatinX patients continued to have inequitable access to deceased donor kidney transplantation despite having more cumulative dialysis time than non-Hispanic White patients. Their findings also suggest that disparities in access to deceased donor kidney transplantation for Hispanic/LatinX patients are largely region-dependent, whereas disparities for Black Americans are ubiquitous. These findings demonstrate that changes in the kidney allocation policy were not enough to eliminate racial and ethnic inequities in transplant access. Although policy change is an important lever of change, it addresses the most upstream dimension of the transplant ecosystem (Figure 1). Change at this level has the most potential for deep impact but does not guarantee additional change downstream. Moving downstream, interventions at the community level, such as educational programming in dialysis centers or local media campaigns to increase awareness of transplantation, could engage minority communities and increase knowledge of the transplantation process.6 Given the documented uncertainty about transplantation among Black patients, community-level interventions have the potential to increase the number of minority patients on the waitlist who stand to benefit from the 2014 policy changes. Moving further downstream, healthcare institutions can promote equity by investing in data monitoring or culturally specific access programs. In the current system, centers are able to act as passive participants in the work to achieve equity, often unaware of center-level disparities and rarely held responsible if disparities are uncovered. As Madusoodanan et al suggested, centers can take a more active role in this work by monitoring their own data, adjusting for waiting time and patient-level factors, and identifying center-specific opportunities for improvement. Some centers have created culturally specific transplant access programs.7-9 These programs work to decrease modifiable institutional and structural barriers that often exist for patients from minoritized communities, and they have been shown to increase access to transplantation for these patients. Center-level changes could and should also be used to address challenges faced by other structurally vulnerable populations, such as patients with lower incomes, lower levels of education, and those who live in rural areas with limited access to a transplant center. At the most downstream levels, subconscious individual biases of clinicians may contribute to waitlist decisions such as listing inactive instead of active, turning away a patient based on body habitus, the choice to offer a patient an out-of-sequence offer, or the many other decisions that can impact a patient’s ability to receive an organ. A single intervention may be limited in impact, but pairing community-wide, institutional, or interpersonal interventions with equity-promoting policy change could greatly benefit minority patients who seek to access kidney transplantation. Although addressing disparities in transplant access for Black and Hispanic/LatinX patients is paramount and the focus of the authors’ work, we would be remiss not to discuss disparities seen in other minoritized populations lest we contribute to their erasure. Disparities in ESKD development and transplant access have been found among American Indians or Alaska Natives10 and are rarely explored among Native Hawaiian or other Pacific Islanders and Middle Eastern and North African patients. Equity in access to transplantation must include all vulnerable patient populations, especially those whose experiences are rarely centered in these discussions. However, it is also critical to acknowledge the unique challenges experienced by each racial and ethnic group and to recognize that there is no universal solution to access challenges. As emphasized in the public health literature, inequities in any system are best addressed through multilevel and multidisciplinary interventions that dismantle socioeconomic, environmental, and institutional barriers.11 This same approach is critical to creating and implementing the interventions needed to ensure equitable access to transplantation for patients of all backgrounds. As Madusoodanan et al demonstrated, the kidney allocation policy changes, although well intentioned, did not succeed in eliminating or significantly reducing disparities in access for Black and Hispanic/LatinX communities. We know that innovation is—and will continue to be—the bedrock of transplantation. Leveraging this spirit of innovation to create multidimensional interventions along the socioecological spectrum is key to ensuring lasting and meaningful progress toward achieving equity in kidney transplantation.