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 二十年来，黑人和西班牙裔人接受肾脏移植的可能性较小，而不是非非 - 西班牙裔白人（NHWS），尤其是来自活的捐助者（LD）。许多研究集中于接收者相关的 可能导致这些差异的障碍，但对这些差异的关注减少了 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 移植候选资格的评估建议在接收者的情况下转介到移植中心 估计的肾小球滤过率（EGFR）<30ml/min/1.73 m2，允许在候补名单上进行注册。 EGFR <20ml/min/1.73 m2。然而，众所周知，肾脏疾病在黑人和 西班牙裔（vs. NHWS），因此对黑人或西班牙裔（NHW）接收者的捐助者可能有更少的时间完成 他们在需要透析之前的工作在接受者中出现。黑人捐助者也被认为有 与捐赠后的白人供体相比，与白人捐助者相比，出现终末期肾脏疾病（ESRD）的风险更高。 先前黑色LD的ESRD风险较高的意识提高了可能会降低接受度 即使是健康的黑人活着的捐助者候选人（大多数向黑人接收者捐款） 减少LDS池。最后，缺乏对先前LDS的医学随访可能会减少机会 为了早期预防和干预以减少CKD发展的危险因素，尤其是在黑人中 或西班牙裔LD。关于奉献后健康监测是否有所不同，可用的数据稀疏 种族/种族，以及是否可以更优化的慢性肾脏病风险因素（CKD） 在先前的黑色/西班牙裔LD中减轻ESRD的较高风险。如果黑人或西班牙裔中的结果 可以改善捐助者，黑色和西班牙裔接受者进入LD的捐助者也可以改善。在这个 提案，我们的目标是检查1）是否使用基于风险的阈值（与绝对EGFR阈值） 指南当我们转介患者进行移植候选（和捐助者）评估时，可能会改善不平等的不平等 可以通过种族/民族进行移植准备的时间（AIM 1）； 2）差异接受黑色或 尽管有一个 供体ESRD风险的客观指标的可用性（AIM 2）； 3）奉献后健康监测和危险因素 在黑人和西班牙裔（与NHW）LDS（AIM 3）中，修改不足。为了实现我们的目标，我们将 使用前瞻性和追溯从整个移植中心收集的电子健康记录数据 美国（AIMS 1-2），并前瞻性地招募LDS到AIM 3。该提案的数据将为多种多样的设计提供信息 改善移植结果差异的水平干预措施，包括1）更好地确认 计划移植转介的时间时，CKD进展速率的变化； 2）增加使用 捐助者评估期间ESRD风险的客观指标； 3）增强了对奉献后健康的遵守 监视的目的是提供早期的风险因素修改以改善捐助者的结果。