Unexpected Race and Ethnicity Differences in the US National Veterans Affairs Kidney Transplant Program

BACKGROUND: Racial/ethnic minorities have lower rates of deceased kidney transplantation (DDKT) and living donor kidney transplantation (LDKT) in the United States. We examined whether social determinants of health (eg, demographics, cultural, psychosocial, knowledge factors) could account for differences in the Veterans Affairs (VA) Kidney Transplantation (KT) Program. METHODS: We conducted a multicenter longitudinal cohort study of 611 Veterans undergoing evaluation for KT at all National VA KT Centers (2010-2012) using an interview after KT evaluation and tracking participants via medical records through 2017. RESULTS: Hispanics were more likely to get any KT (subdistribution hazard ratios SHR 95% confidence interval (CI): 1.8 1.2-2.8) or DDKT (SHR 95% CI: 2.0 1.3-3.2) than non-Hispanic white in univariable analysis. Social determinants of health, including marital status (SHR 95% CI: 0.6 0.4-0.9), religious objection to LDKT (SHR 95% CI: 0.6 0.4-1.0), and donor preference (SHR 95% CI: 2.5 1.2-5.1), accounted for some racial differences, and changes to Kidney Allocation System policy (SHR 95% CI: 0.3 0.2-0.5) mitigated race differences in DDKT in multivariable analysis. For LDKT, non-Hispanic African American Veterans were less likely to receive an LDKT than non-Hispanic white (SHR 95% CI: 0.2 0.0-0.7), but accounting for age (SHR 95% CI: 1.0 0.9-1.0), insurance (SHR 95% CI: 5.9 1.1-33.7), presenting with a living donor (SHR 95% CI: 4.1 1.4-12.3), dialysis duration (SHR 95% CI: 0.3 0.2-0.6), network of potential donors (SHR 95% CI: 1.0 1.0-1.1), self-esteem (SHR 95% CI: 0.4 0.2-0.8), transplant knowledge (SHR 95% CI: 1.3 1.0-1.7), and changes to Kidney Allocation System policy (SHR 95% CI: 10.3 2.5-42.1) in multivariable analysis eliminated those disparities. CONCLUSIONS: The VA KT Program does not exhibit the same pattern of disparities in KT receipt as non-VA centers. Transplant centers can use identified risk factors to target patients who may need more support to ensure they receive a transplant.