Reaching Equity for Adults and CHildren in Transplant (REACH-TRANSPLANT)

实现成人和儿童移植平等（REACH-TRANSPLANT）

• 批准号: 10016295
• 负责人: Sandra Amaral
• 金额: $ 70.23万
• 依托单位: UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-09-11 至 2024-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10016295
• 关键词: Address; Adopted; Adult; Age; Attention; Awareness; Blood Pressure; Child; Childhood; Chronic Kidney Failure; Data; Data Collection; Detection; Development; Dialysis procedure; Disease Progression; Donor Selection; Donor person; Electronic Health Record; Eligibility Determination; End stage renal failure; Ensure; Equation; Ethnic Origin; Ethnic group; Evaluation; Glomerular Filtration Rate; Goals; Health; Hispanics; Hypertension; Impaired health; Improve Access; Individual; Infrastructure; Intervention; Kidney; Kidney Diseases; Kidney Failure; Kidney Transplantation; Lead; Living Donors; Longterm Follow-up; Medical; Modeling; Modification; Monitor; Multicenter Studies; National Children' s Study; Not Hispanic or Latino; Outcome; Patient Self-Report; Pattern; Phase; Policies; Preparation; Preventive Intervention; Process; Provider; Race; Research; Risk; Risk Estimate; Risk Factors; Safety; Standardization; System; Time; Transplant Recipients; Transplantation; United Network for Organ Sharing; Variant; Wait Time; Waiting Lists; adverse outcome; base; design; disorder risk; electronic data; ethnic difference; experience; follow-up; health literacy; high risk; improved; parity; prospective; racial and ethnic; racial and ethnic disparities; recruit; screening; success; system-level barriers; tool; transplant centers

PROJECT ABSTRACT For over two decades, blacks and Hispanics have been less likely to receive kidney transplantation than non- Hispanic whites (NHWs), especially from a living donor (LD). Many studies have focused on recipient-related barriers that may contribute to these disparities, but less attention has been paid to how these disparities may arise during recipient and LD evaluation, LD selection, and LD follow-up. For instance, our current system for the evaluation of transplant candidacy recommends referral to transplant centers when the recipient's estimated glomerular filtration rate (eGFR) is < 30mL/min/1.73 m2, and allows for waitlist registration when the eGFR is <20mL/min/1.73 m2. However, kidney disease is known to progress more rapidly among blacks and Hispanics (vs. NHWs), so donors to a black or Hispanic (vs. NHW) recipient may have less time to complete their workup before the need for dialysis arises in the recipient. Black donors have also been noted to have higher risk of developing end-stage renal disease (ESRD) compared to white donors after donation. Heightened awareness of the higher ESRD risk among prior black LDs may predispose to reduced acceptance of even healthy black living donor candidates (the majority of whom donate to black recipients), thereby diminishing the pool of LDs. Finally, lack of consistent medical follow-up of prior LDs may reduce opportunities for early prevention and intervention to reduce risk factors for the development of CKD, especially among black or Hispanic LDs. Sparse data are available regarding whether post-donation health monitoring differs by race/ethnicity, and whether risk factors for chronic kidney disease (CKD) could be more optimally managed to mitigate the higher risk of ESRD among prior black/Hispanic LDs. If outcomes among black or Hispanic donors could be improved, access of black and Hispanic recipients to LDs could also improve. In this proposal, our goal is to examine whether 1) use of a risk-based threshold (vs. an absolute eGFR threshold) to guide when we refer patients for transplant candidacy (and donor) evaluation may improve inequities in the time available for transplant preparation by race/ethnicity (Aim 1); 2) differential acceptance of black or Hispanic (vs. NHW) donor candidates overall, and by provider or transplant center, are occurring despite the availability of objective metrics of donor ESRD risk (Aim 2); 3) post-donation health monitoring and risk factor modification is inadequate among black and Hispanic (vs. NHW) LDs (Aim 3). To accomplish our aims, we will use electronic health record data collected prospectively and retrospectively from transplant centers across the US (Aims 1-2) and prospectively recruit LDs for Aim 3. Data from this proposal will inform the design of multi- level interventions to improve disparities in transplant outcomes, including 1) better acknowledgement of variations in the rate of CKD progression when planning the timing of transplant referral; 2) increased use of objective metrics of ESRD risk during donor evaluation; and 3) enhanced compliance with post-donation health monitoring with the goal of providing early risk factor modification to improve donor outcomes.

项目摘要 二十多年来，黑人和西班牙裔接受肾移植的可能性低于非黑人和西班牙裔。 西班牙裔白人 (NHW)，尤其是活体捐赠者 (LD)。许多研究都集中在与接受者相关的 可能导致这些差异的障碍，但很少有人关注这些差异如何影响 在接受者和 LD 评估、LD 选择和 LD 随访期间出现。例如，我们当前的系统 当受者的病情恶化时，对移植候选资格的评估建议转介至移植中心 估计肾小球滤过率 (eGFR) < 30mL/min/1.73 m2，并允许在以下情况下进行候补登记： eGFR 小于 20mL/min/1.73 m2。然而，众所周知，肾脏疾病在黑人和白人中进展得更快。 西班牙裔（相对于 NHW），因此黑人或西班牙裔（相对于 NHW）接受者的捐赠者可能需要更少的时间来完成 在接受者出现透析需要之前对其进行检查。黑人捐助者也被注意到 与白人捐赠者相比，捐赠后患终末期肾病（ESRD）的风险更高。 先前的黑人 LD 中对较高 ESRD 风险的认识提高可能会导致接受度降低 甚至是健康的黑人活体捐赠者候选者（其中大多数捐赠给黑人接受者），从而 减少 LD 池。最后，对先前的 LD 缺乏一致的医疗随访可能会减少机会 早期预防和干预，以减少 CKD 发展的危险因素，尤其是黑人 或西班牙裔 LD。关于捐赠后健康监测是否存在差异的数据很少 种族/民族，以及慢性肾脏病 (CKD) 的危险因素是否可以得到更优化的管理 降低既往黑人/西班牙裔 LD 中 ESRD 的较高风险。如果结果是黑人或西班牙裔 捐助者的数量可以得到改善，黑人和西班牙裔接受者获得 LD 的机会也可以得到改善。在这个 提案中，我们的目标是检查是否 1) 使用基于风险的阈值（相对于绝对 eGFR 阈值） 当我们转介患者进行移植候选（和捐赠者）评估时的指南可能会改善移植候选者（和捐赠者）评估中的不平等 按种族/民族划分的移植准备时间（目标 1）； 2）对黑色或黑色的接受程度不同 尽管存在 提供供者 ESRD 风险的客观指标（目标 2）； 3）捐献后健康监测和危险因素 在黑人和西班牙裔（相对于 NHW）LD 中，修改不充分（目标 3）。为了实现我们的目标，我们将 使用从整个移植中心前瞻性和回顾性收集的电子健康记录数据 美国（目标 1-2）并为目标 3 前瞻性地招募 LD。该提案中的数据将为多重设计提供信息 改善移植结果差异的干预措施，包括 1) 更好地认识 规划移植转诊时间时 CKD 进展率的变化； 2）增加使用 捐助者评估期间 ESRD 风险的客观指标； 3) 加强对捐献后健康的遵守 监测的目的是提供早期风险因素修正以改善捐赠者的结果。