letter to the editor
Race, ethnicity, and pediatric transplantation: unanswered question To the Editor: I read with great interest the findings reported by Patzer et al.1 This study again identifies that less Hispanic and black patients are receiving living-donor transplants, less likely to be preemptively transplanted,2 and are spending longer duration on dialysis when compared with whites.1,3 Allograft outcome disparities were seen persistently among those with both higher and lower socioeconomic status, in children who identified with the black race, however, not of Hispanic ethnicity, compared with whites. Further race and detailed ethnicity data of the kidney transplant recipients are not available for review from this study, but raise the following questions: are other minority groups likely to have worse outcomes similar to those included in the black race or better graft outcomes like the Hispanic group in this study. The more detailed data would also help in ensuring avoidance of misclassification, which could lead to inappropriate conclusions, as previous studies addressing pediatric kidney transplants have focused on disparities between white and black children only.4–6 In addition, we would point out the astonishing differences in graft survival between black deceased-donor recipients compared with Hispanic or white counterparts, particularly at 5 years from transplantation. These findings provide the aim to address additional questions to be further studied, with focus on healthcare cost burden, appointment adherence, and medication adherence, as well as assessing their potential contribution to disparities at both shortand long-term follow-up from transplantation. Identification of these factors would drive specific strategies aimed to eliminate such disparities throughout the transplantation process. 1. 2.
3.
4.
Patzer RE, Mohan S, Kutner N et al. Racial and ethnic disparities in pediatric renal allograft survival in the United States. Kidney Int 2015; 87: 584–592. Grams ME, Chen BP, Coresh J et al. Preemptive deceased donor kidney transplantation: considerations of equity and utility. Clin J Am Soc Nephrol 2013; 8: 575–582. Freeman MA, Myaskovsky L. An overview of disparities and interventions in pediatric kidney transplantation worldwide. Pediatr Nephrol 2014 (e-pub ahead of print 15 October 2014). Furth SL, Garg PP, Neu AM et al. Racial differences in access to the kidney transplant waiting list for children and adolescents with end-stage renal disease. Pediatrics 2000; 106: 756–761. Shatat IF, Taber DJ, Shrivastava S et al. Graft outcomes in pediatric kidney transplantation: focus on the role of race. Saudi J Kidney DisTranspl 2012; 23: 684–692. Omoloja A, Stolfi A, Mitsnefes M. Racial differences in pediatric renal transplantation-24-year single center experience. J Natl Med Assoc 2006; 98: 154–157.
The Author Replies: We thank Dr Beam for the important comments1 regarding our study of racial and ethnic disparities in pediatric renal allograft survival in the United States.2 We agree that more research is needed to examine whether transplant outcomes vary among other race/ ethnicities. We excluded a total of 659 patients (9.6% of our cohort) with reported race/ethnicity other than white, Hispanic, or black due to small sample size. Those excluded were Asian (64.5%), ‘other/multi-racial’ (17.8%), American Indian/Alaskan Native (17%), or unknown (o1%). Although numbers are too small to conduct multivariable analyses, in crude Cox models, Asian children had a similar rate of graft failure (hazard ratio (HR): 1.08; 95% confidence interval (CI): 0.80–1.46) and American Indian/Alaskan Native children had a non-significantly higher rate of graft failure (HR: 1.53; 95% CI: 0.97–2.43) versus whites. Patients with ‘other/multi-racial’ or unknown race/ethnicity had a lower rate of graft failure versus whites (HR: 0.53; 95% CI: 0.28–0.99). As pointed out by Beam, assessments of the burdens of treatment adherence are strikingly absent from current national pediatric kidney transplant data. Further, the complex interactions between biological and socioenvironmental factors must be better disentangled to direct the targeted interventions in disparity reduction across racial and ethnic sub-groups.3 Beam’s comments highlight the importance of collaboration across kidney transplant programs to provide meaningful, granular data on race/ethnicity, socioeconomic indicators, and adherence measures that can inform better treatment and policy strategies that optimize quality and access to care for all ESRD patients, regardless of racial or ethnic background. 1. 2. 3.
Beam E. Race, ethnicity and pediatric transplantation, unanswered questions. Kidney Int 2015; 87: 858. Patzer RE, Mohan S, Kutner N et al. Racial and ethnic disparities in pediatric renal allograft survival in the United States. Kidney Int 2015; 87: 584–592. Amaral S, Patzer R. Disparities, race/ethnicity and access to pediatric kidney transplantation. Curr Opin Nephrol Hypertens 2013; 22: 336–343.
Rachel E. Patzer1,2, Sumit Mohan3, Nancy Kutner4, William M. McClellan2,5 and Sandra Amaral6,7
1 Department of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA Correspondence: Elena Beam, Department of Infectious Diseases, Mayo Clinic, 200 1st SW, Rochester, Minnesota 55905, USA. E-mail: [email protected]
1 Division of Transplantation, Department of Surgery, Emory University, Atlanta, Georgia, USA; 2Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; 3Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York, USA; 4Department of Rehabilitation Medicine, Emory University, Atlanta, Georgia, USA; 5Division of Nephrology, Emory University, Atlanta, Georgia, USA; 6Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA and 7Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA Correspondence: Rachel E. Patzer, Emory University School of Medicine, Emory Transplant Center, 101 Woodruff Circle, 5125 Woodruff Memorial Research Building, Atlanta, Georgia 30322, USA. E-mail: [email protected]
Kidney International (2015) 87, 858; doi:10.1038/ki.2015.35
Kidney International (2015) 87, 858; doi:10.1038/ki.2015.37
5.
6.
Elena Beam1
858
Kidney International (2015) 87, 857–864
Race, ethnicity, and pediatric transplantation: unanswered question To the Editor: I read with great interest the findings reported by Patzer et al.1 This study again identifies that less Hispanic and black patients are receiving living-donor transplants, less likely to be preemptively transplanted,2 and are spending longer duration on dialysis when compared with whites.1,3 Allograft outcome disparities were seen persistently among those with both higher and lower socioeconomic status, in children who identified with the black race, however, not of Hispanic ethnicity, compared with whites. Further race and detailed ethnicity data of the kidney transplant recipients are not available for review from this study, but raise the following questions: are other minority groups likely to have worse outcomes similar to those included in the black race or better graft outcomes like the Hispanic group in this study. The more detailed data would also help in ensuring avoidance of misclassification, which could lead to inappropriate conclusions, as previous studies addressing pediatric kidney transplants have focused on disparities between white and black children only.4–6 In addition, we would point out the astonishing differences in graft survival between black deceased-donor recipients compared with Hispanic or white counterparts, particularly at 5 years from transplantation. These findings provide the aim to address additional questions to be further studied, with focus on healthcare cost burden, appointment adherence, and medication adherence, as well as assessing their potential contribution to disparities at both shortand long-term follow-up from transplantation. Identification of these factors would drive specific strategies aimed to eliminate such disparities throughout the transplantation process. 1. 2.
3.
4.
Patzer RE, Mohan S, Kutner N et al. Racial and ethnic disparities in pediatric renal allograft survival in the United States. Kidney Int 2015; 87: 584–592. Grams ME, Chen BP, Coresh J et al. Preemptive deceased donor kidney transplantation: considerations of equity and utility. Clin J Am Soc Nephrol 2013; 8: 575–582. Freeman MA, Myaskovsky L. An overview of disparities and interventions in pediatric kidney transplantation worldwide. Pediatr Nephrol 2014 (e-pub ahead of print 15 October 2014). Furth SL, Garg PP, Neu AM et al. Racial differences in access to the kidney transplant waiting list for children and adolescents with end-stage renal disease. Pediatrics 2000; 106: 756–761. Shatat IF, Taber DJ, Shrivastava S et al. Graft outcomes in pediatric kidney transplantation: focus on the role of race. Saudi J Kidney DisTranspl 2012; 23: 684–692. Omoloja A, Stolfi A, Mitsnefes M. Racial differences in pediatric renal transplantation-24-year single center experience. J Natl Med Assoc 2006; 98: 154–157.
The Author Replies: We thank Dr Beam for the important comments1 regarding our study of racial and ethnic disparities in pediatric renal allograft survival in the United States.2 We agree that more research is needed to examine whether transplant outcomes vary among other race/ ethnicities. We excluded a total of 659 patients (9.6% of our cohort) with reported race/ethnicity other than white, Hispanic, or black due to small sample size. Those excluded were Asian (64.5%), ‘other/multi-racial’ (17.8%), American Indian/Alaskan Native (17%), or unknown (o1%). Although numbers are too small to conduct multivariable analyses, in crude Cox models, Asian children had a similar rate of graft failure (hazard ratio (HR): 1.08; 95% confidence interval (CI): 0.80–1.46) and American Indian/Alaskan Native children had a non-significantly higher rate of graft failure (HR: 1.53; 95% CI: 0.97–2.43) versus whites. Patients with ‘other/multi-racial’ or unknown race/ethnicity had a lower rate of graft failure versus whites (HR: 0.53; 95% CI: 0.28–0.99). As pointed out by Beam, assessments of the burdens of treatment adherence are strikingly absent from current national pediatric kidney transplant data. Further, the complex interactions between biological and socioenvironmental factors must be better disentangled to direct the targeted interventions in disparity reduction across racial and ethnic sub-groups.3 Beam’s comments highlight the importance of collaboration across kidney transplant programs to provide meaningful, granular data on race/ethnicity, socioeconomic indicators, and adherence measures that can inform better treatment and policy strategies that optimize quality and access to care for all ESRD patients, regardless of racial or ethnic background. 1. 2. 3.
Beam E. Race, ethnicity and pediatric transplantation, unanswered questions. Kidney Int 2015; 87: 858. Patzer RE, Mohan S, Kutner N et al. Racial and ethnic disparities in pediatric renal allograft survival in the United States. Kidney Int 2015; 87: 584–592. Amaral S, Patzer R. Disparities, race/ethnicity and access to pediatric kidney transplantation. Curr Opin Nephrol Hypertens 2013; 22: 336–343.
Rachel E. Patzer1,2, Sumit Mohan3, Nancy Kutner4, William M. McClellan2,5 and Sandra Amaral6,7
1 Department of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA Correspondence: Elena Beam, Department of Infectious Diseases, Mayo Clinic, 200 1st SW, Rochester, Minnesota 55905, USA. E-mail: [email protected]
1 Division of Transplantation, Department of Surgery, Emory University, Atlanta, Georgia, USA; 2Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; 3Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York, USA; 4Department of Rehabilitation Medicine, Emory University, Atlanta, Georgia, USA; 5Division of Nephrology, Emory University, Atlanta, Georgia, USA; 6Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA and 7Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA Correspondence: Rachel E. Patzer, Emory University School of Medicine, Emory Transplant Center, 101 Woodruff Circle, 5125 Woodruff Memorial Research Building, Atlanta, Georgia 30322, USA. E-mail: [email protected]
Kidney International (2015) 87, 858; doi:10.1038/ki.2015.35
Kidney International (2015) 87, 858; doi:10.1038/ki.2015.37
5.
6.
Elena Beam1
858
Kidney International (2015) 87, 857–864
