Racial differences in determinants of live donor kidney transplantation in the United States.

Few studies have compared determinants of live donor kidney transplantation (LDKT) across all major US racial-ethnic groups. We compared determinants of racial-ethnic differences in LDKT among 208 736 patients who initiated treatment for end-stage kidney disease during 2005-2008. We performed proportional hazards and bootstrap analyses to estimate differences in LDKT attributable to sociodemographic and clinical factors. Mean LDKT rates were lowest among blacks (1.19 per 100 person-years [95% CI: 1.12-1.26]), American Indians/Alaska Natives-AI/ANs (1.40 [1.06-1.84]) and Pacific Islanders (1.10 [0.78-1.84]), intermediate among Hispanics (2.53 [2.39-2.67]) and Asians (3.89 [3.51-4.32]), and highest among whites (6.46 [6.31-6.61]). Compared with whites, the largest proportion of the disparity among blacks (20%) and AI/ANs (29%) was attributed to measures of predialysis care, while the largest proportion among Hispanics (14%) was attributed to health insurance coverage. Contextual poverty accounted for 16%, 4%, 18%, and 6% of the disparity among blacks, Hispanics, AI/ANs and Pacific Islanders but none of the disparity among Asians. In the United States, significant disparities in rates of LDKT persist, but determinants of these disparities vary by race-ethnicity. Efforts to expand preESKD insurance coverage, to improve access to high-quality predialysis care and to overcome socioeconomic barriers are important targets for addressing disparities in LDKT.

Racial and ethnic differences in pediatric access to preemptive kidney transplantation in the United States.

Preemptive kidney transplantation is the optimal treatment for pediatric end stage renal disease patients to avoid increased morbidity and mortality associated with dialysis. It is unknown how race/ethnicity and poverty influence preemptive transplant access in pediatric. We examined the incidence of living donor or deceased donor preemptive transplantation among all black, white, and Hispanic children (<18 years) in the United States Renal Data System from 2000 to 2009. Adjusted risk ratios for preemptive transplant were calculated using multivariable-adjusted models and examined across health insurance and neighborhood poverty levels. Among 8,053 patients, 1117 (13.9%) received a preemptive transplant (66.9% from LD, 33.1% from DD). In multivariable analyses, there were significant racial/ethnic disparities in access to LD preemptive transplant where blacks were 66% (RR = 0.34; 95% CI: 0.28-0.43) and Hispanics 52% (RR = 0.48; 95% CI: 0.35-0.67) less likely to receive a LD preemptive transplant versus whites. Blacks were 22% less likely to receive a DD preemptive transplant versus whites (RR = 0.78, 95% CI: 0.57-1.05), although results were not statistically significant. Future efforts to promote equity in preemptive transplant should address the critical issues of improving access to pre-ESRD nephrology care and overcoming barriers in living donation, including obstacles partially driven by poverty.

Racial variation in medical outcomes among living kidney donors.

BACKGROUND: Data regarding health outcomes among living kidney donors are lacking, especially among nonwhite persons. METHODS: We linked identifiers from the Organ Procurement and Transplantation Network (OPTN) with administrative data of a private U.S. health insurer and performed a retrospective study of 4650 persons who had been living kidney donors from October 1987 through July 2007 and who had post-donation nephrectomy benefits with this insurer at some point from 2000 through 2007. We ascertained post-nephrectomy medical diagnoses and conditions requiring medical treatment from billing claims. Cox regression analyses with left and right censoring to account for observed periods of insurance benefits were used to estimate absolute prevalence and prevalence ratios for diagnoses after nephrectomy. We then compared prevalence patterns with those in the 2005-2006 National Health and Nutrition Examination Survey (NHANES) for the general population. RESULTS: Among the donors, 76.3% were white, 13.1% black, 8.2% Hispanic, and 2.4% another race or ethnic group. The median time from donation to the end of insurance benefits was 7.7 years. After kidney donation, black donors, as compared with white donors, had an increased risk of hypertension (adjusted hazard ratio, 1.52; 95% confidence interval [CI], 1.23 to 1.88), diabetes mellitus requiring drug therapy (adjusted hazard ratio, 2.31; 95% CI, 1.33 to 3.98), and chronic kidney disease (adjusted hazard ratio, 2.32; 95% CI, 1.48 to 3.62); findings were similar for Hispanic donors. The absolute prevalence of diabetes among all donors did not exceed that in the general population, but the prevalence of hypertension exceeded NHANES estimates in some subgroups. End-stage renal disease was identified in less than 1% of donors but was more common among black donors than among white donors. CONCLUSIONS: As in the general U.S. population, racial disparities in medical conditions occur among living kidney donors. Increased attention to health outcomes among demographically diverse kidney donors is needed. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others.)

Pediatric kidney transplant practice patterns and outcome benchmarks, 1987-2010: a report of the North American Pediatric Renal Trials and Collaborative Studies.

The NAPRTCS transplant registry has collected clinical information on children undergoing kidney transplantation since 1987 and now includes information on 11 603 kidney transplants in 10 632 patients. Since the first data analysis in 1989, NAPRTCS reports have documented marked improvements in outcome after kidney transplantation in addition to identifying factors associated with both favorable and poor outcomes. Patient demographics have changed over the course of the registry with a decrease in the percentage of white recipients from a high of 72% in 1987 to less than 43% in 2007. The percentage of living donors decreased to its lowest point in 2007 at 37%. Acute rejection rates continue to decline with improvements in short- and long-term graft survival. Recently, NAPRTCS data have been used as a source of benchmark data for pediatric kidney transplant centers.

Young aboriginals are less likely to receive a renal transplant: a Canadian national study.

BACKGROUND: Previous studies have demonstrated Aboriginals are less likely to receive a renal transplant in comparison to Caucasians however whether this applies to the entire population or specific subsets remains unclear. We examined the effect of age on renal transplantation in Aboriginals. METHODS: Data on 30,688 dialysis (Aboriginal 2,361, Caucasian 28, 327) patients obtained between Jan. 2000 and Dec. 2009 were included in the final analysis. Racial status was self-reported. Cox proportional hazards, the Fine and Grey sub-distribution method and Poisson regression were used to determine the association between race, age and transplantation. RESULTS: In comparison to Caucasians, Aboriginals were less likely to receive a renal transplant (Adjusted HR 0.66 95% CI 0.57-0.77, P < 0.0001) however after stratification by age and treating death as a competing outcome, the effect was more predominant in younger Aboriginals (Age 18-40: 20.6% aboriginals vs. 48.3% Caucasians transplanted; aHR 0.50(0.39-0.61), p < 0.0001, Age 41-50: 10.2% aboriginals vs. 33.9% Caucasians transplanted; aHR 0.46(0.32-0.64), p = 0.005, Age 51-60: 8.2% aboriginals vs. 19.5% Caucasians transplanted; aHR0.65(0.49-0.88), p = 0.01, Age >60: 2.7% aboriginals vs. 2.6% Caucasians transplanted; aHR 1.21(0.76-1.91), P = 0.4, Age X race interaction p < 0.0001). Both living and deceased donor transplants were lower in Aboriginals under the age of 60 compared to Caucasians. CONCLUSION: Younger Aboriginals are less likely to receive a renal transplant compared to their Caucasian counterparts, even after adjustment for comorbidity. Determination of the reasons behind these discrepancies and interventions specifically targeting the Aboriginal population are warranted.

The impact of diabetes on ethnic disparities seen in kidney transplantation.

Graft failure rates following kidney transplant is disproportionately higher in African American (AA) renal transplant recipients. The aim of our study was to measure the impact of diabetes and other known confounding risk factors on this disparity. This was a long-term cohort study of adult kidney transplant recipients between 2000 and 2008 comparing AA transplant recipients to White recipients. 987 patients were included and patients were followed for up to 12 years post-transplant. Univariate analysis demonstrated AA recipients were more likely to have diabetes (35% vs 23%, P<.001), hypertension (97% vs 94%, P=.029), human leukocyte antigen mismatches (4 vs 3, P<.001), and receiving dialysis for a longer period prior to transplant (3.9 vs 2.0 yrs, P<.001). AA patients were also less likely to receive a living donor transplant (7% vs 31%, P<.001). Multivariable modeling established both AA ethnicity (HR 1.32 [95% CI 1.04-1.68]) and pre-existing diabetes (1.58 [95% CI 1.25-2.00]) as important predictors of graft failure. Diabetes was a significant modifier on the influence of AA ethnicity as a risk factor for graft loss (19% HR reduction); tight glycemic control, which was less common in AA recipients (35% vs 51%, P=.013), additionally attenuated the ethnic disparities seen in graft loss (28% risk reduction). In the final fully adjusted model, which included sociodemographic, immunologic, and cardiovascular risk factor as variables, the influence of AA ethnicity on graft failure was essentially nullified (HR 1.09 [.81-1.48]). In conclusion, AA ethnicity continues to be an important risk factor for graft loss, which can be significantly attenuated by controlling for pre-existing diabetes, glycemic control, and other transplant and cardiovascular variables.

Racial disparities in access to pediatric kidney transplantation since share 35.

Share 35 was enacted in 2005 to shorten transplant wait times and provide high-quality donors to children with ESRD. To investigate the possible effect of this policy on racial disparities in access to pediatric transplantation, we analyzed data from the US Renal Data System before and after Share 35. Among 4766 pediatric patients with incident ESRD, the probability of receiving a deceased-donor kidney transplant increased 46% after Share 35, with Hispanics experiencing the greatest improvements (increases of 81% for Hispanics, 45% for blacks, and 37% for whites). On average, patients received a deceased-donor kidney transplant earlier after Share 35, but this finding varied by race: 63 days earlier for whites, 90 days earlier for blacks, and 201 days earlier for Hispanics. Furthermore, a shift from living- to deceased-donor sources occurred with Share 35 for all races, with a 25% reduction in living donors for whites compared with 48% and 46% reductions for Hispanics and blacks, respectively. In summary, Share 35 seems to have attenuated racial disparities in the time to and probability of children receiving a deceased-donor kidney transplant. These changes coincided with changes in the rates of living-donor sources, which vary by race. Future studies should explore how these changes may impact racial differences in long-term graft outcomes.

A lack of living donor renal transplantation for Asian children represents an opportunity to improve pediatric healthcare.

INTRODUCTION: The relationship between pediatric primary care practitioners and families provides an early opportunity to address ethnic/racial pediatric subspecialty health care disparities. Living donor pediatric renal transplantation is safe and more effective than deceased donor renal transplantation. The purpose of this study is to identify groups of children who may be less likely to receive living donor renal transplantation, as the first step in assisting pediatric clinicians to increase living donor renal transplantation. METHOD: We employed a retrospective cohort design. We analyzed data from the medical records of 80 children receiving renal transplantation over 20 years in a large pediatric medical center. RESULTS: The proportions of children receiving a living donor renal allograft differed by ethnicity/race (P = .04). Specifically, children of Asian ethnicity/ race were significantly less likely than children of White ethnicity/race to receive a living donor renal allograft (P = .01). There were no significant differences in age at transplantation or wait time for deceased donor transplantation. DISCUSSION: We discuss the possible reasons for the discrepancy and potential directions for family-centered pediatric practice, policy, and research to address this potential pediatric healthcare disparity.

Racial disparities in pediatric access to kidney transplantation: does socioeconomic status play a role?

Racial disparities persist in access to renal transplantation in the United States, but the degree to which patient and neighborhood socioeconomic status (SES) impacts racial disparities in deceased donor renal transplantation access has not been examined in the pediatric and adolescent end-stage renal disease (ESRD) population. We examined the interplay of race and SES in a population-based cohort of all incident pediatric ESRD patients <21 years from the United States Renal Data System from 2000 to 2008, followed through September 2009. Of 8452 patients included, 30.8% were black, 27.6% white-Hispanic, 44.3% female and 28.0% lived in poor neighborhoods. A total of 63.4% of the study population was placed on the waiting list and 32.5% received a deceased donor transplant. Racial disparities persisted in transplant even after adjustment for SES, where minorities were less likely to receive a transplant compared to whites, and this disparity was more pronounced among patients 18-20 years. Disparities in access to the waiting list were mitigated in Hispanic patients with private health insurance. Our study suggests that racial disparities in transplant access worsen as pediatric patients transition into young adulthood, and that SES does not explain all of the racial differences in access to kidney transplantation.

The role of race and poverty on steps to kidney transplantation in the Southeastern United States.

Racial disparities in access to renal transplantation exist, but the effects of race and socioeconomic status (SES) on early steps of renal transplantation have not been well explored. Adult patients referred for renal transplant evaluation at a single transplant center in the Southeastern United States from 2005 to 2007, followed through May 2010, were examined. Demographic and clinical data were obtained from patient's medical records and then linked with United States Renal Data System and American Community Survey Census data. Cox models examined the effect of race on referral, evaluation, waitlisting and organ receipt. Of 2291 patients, 64.9% were black, the mean age was 49.4 years and 33.6% lived in poor neighborhoods. Racial disparities were observed in access to referral, transplant evaluation, waitlisting and organ receipt. SES explained almost one-third of the lower rate of transplant among black versus white patients, but even after adjustment for demographic, clinical and SES factors, blacks had a 59% lower rate of transplant than whites (hazard ratio = 0.41; 95% confidence interval: 0.28-0.58). Results suggest that improving access to healthcare may reduce some, but not all, of the racial disparities in access to kidney transplantation.

Center-level factors and racial disparities in living donor kidney transplantation.

BACKGROUND: On average, African Americans attain living donor kidney transplantation (LDKT) at decreased rates compared with their non-African American counterparts. However, center-level variations in this disparity or the role of center-level factors is unknown. STUDY DESIGN: Observational cohort study. SETTING & PARTICIPANTS: 247,707 adults registered for first-time kidney transplants from 1995-2007 as reported by the Scientific Registry of Transplant Recipients. PREDICTORS: Patient-level factors (age, sex, body mass index, insurance status, education, blood type, and panel-reactive antibody level) were adjusted for in all models. The association of center-level characteristics (number of candidates, transplant volume, LDKT volume, median time to transplant, percentage of African American candidates, percentage of prelisted candidates, and percentage of LDKT) and degree of racial disparity in LDKT was quantified. OUTCOMES: Hierarchical multivariate logistic regression models were used to derive center-specific estimates of LDKT attainment in African American versus non-African American candidates. RESULTS: Racial parity was not seen at any of the 275 transplant centers in the United States. At centers with the least racial disparity, African Americans had 35% lower odds of receiving LDKT; at centers with the most disparity, African Americans had 76% lower odds. Higher percentages of African American candidates (interaction term, 0.86; P = 0.03) and prelisted candidates (interaction term, 0.80; P = 0.001) at a given center were associated with increased racial disparity at that center. Higher rates of LDKT (interaction term, 1.25; P < 0.001) were associated with less racial disparity. LIMITATIONS: Some patient-level factors are not captured, including a given patient's pool of potential donors. Geographic disparities in deceased donor availability might affect LDKT rates. Center-level policies and practices are not captured. CONCLUSIONS: Racial disparity in attainment of LDKT exists at every transplant center in the country. Centers with higher rates of LDKT attainment for all races had less disparity; these high-performing centers might provide insights into policies that might help address this disparity.

Impact of race on predialysis discussions and kidney transplant preemptive wait-listing.

BACKGROUND/AIMS: US registry data have consistently shown that blacks are less likely than whites to be wait-listed before beginning dialysis. METHODS: The Comprehensive Dialysis Study (CDS) was a special study conducted by the US Renal Data System (USRDS) in which a national cohort of patients who began maintenance dialysis therapy in 2005-2007 were asked whether kidney transplantation (KT) had been discussed with them before they started dialysis. Using responses from black and white CDS participants and information from the USRDS, we investigated preemptive wait-listing as a function of patient-reported predialysis KT discussion. RESULTS: Among those reporting early KT discussion, 31.0% of patients preemptively wait-listed were black, compared to 27.5% of those not preemptively wait-listed. Two thirds of preemptively wait-listed patients had received nephrology care more than 12 months before starting dialysis and reported that KT was discussed with them 12 months or more before dialysis. Early KT discussion and higher serum albumin and hemoglobin levels remained significant predictors of preemptive wait-listing in an adjusted logistic regression analysis. Among those preemptively wait-listed, 33% of blacks and 60% of whites had received a transplant by September 30, 2009 (study end date). CONCLUSION: Early KT discussion appeared to reduce barriers to black patients' waiting list placement before the start of dialysis, which in turn may facilitate earlier access to a deceased donor organ transplant.

Review of ethnic disparities in access to renal transplantation.

Renal transplantation is the gold standard treatment for patients with end-stage renal disease and is associated with several advantages over dialysis, including increased quality of life, reduced morbidity and mortality, and lower healthcare costs. Barring the constraints of a limited organ supply, the goals of the patient care should focus on attaining renal transplantation while minimizing, or even eliminating, time spent on dialysis. Disparities in access to renal transplantation between African Americans and Caucasians have been extensively documented, with African Americans having significantly poorer access. There is a growing corpus of literature examining the determinants of reduced access among other racial ethnic minority groups, including Hispanics. These determinants include patient and physician preference, socioeconomic status, insurance type, patient education, and immunologic factors. We review these determinants in access to renal transplantation in the United States among all races and ethnicities.

Impact of posttransplantation glomerulonephritis on long-term outcome of kidney transplants: single-center 20-year experience.

BACKGROUND: Successful renal transplantation has been performed in patients with end-stage renal disease and has been routine in patients with end-stage renal failure for more than two decades. Despite advances in the use of immunosuppressants, there has been only modest improvement in long-term allograft survival. Accumulating data have demonstrated that chronic rejection and recurrent glomerulonephritis are major causes of long-term allograft loss. However, data regarding the long-term impact of posttransplantation glomerulonephritis (PTGN) on ethnic Chinese populations are still unavailable. METHODS: From 1984 to 2010, a total of 268 patients who underwent renal allograft biopsies were reviewed retrospectively. Renal outcomes were compared by Kaplan-Meier analysis, and risk factors for renal survival and all-cause mortality were analyzed using the Cox proportional hazards model. RESULTS: In all, 85 patients (31.7%) had PTGN, and the mean time of disease onset was 5.32±5.18 years after transplantation. Among the 85 PTGN cases, 33 (39%) were immunoglobulin A (IgA) nephropathy, 24 (28%) were focal segmental glomerulosclerosis, and 8 (9.4%) were membranous GN. Significant risk was associated with posttransplant IgA GN in hepatitis B virus carriers (odds ratio 5.371, 95% confidence interval 1.68, 17.19; p=0.0064). A total of 45 PTGN patients had allograft loss, of whom 49% had IgA nephropathy. Patients with PTGN had inferior allograft survival rates compared to those with other pathologic findings (p<0.0003). CONCLUSIONS: Taken together, our results indicate that PTGN had a strong negative impact on long-term kidney graft survival. Posttransplant IgA nephropathy is a leading cause of allograft loss in Chinese kidney transplant patients with PTGN.

Body mass index and postoperative complications in kidney transplant recipients.

BACKGROUND: There is a growing number of overweight and obese patients receiving kidney transplants, despite elevated body mass index (BMI) being associated with postoperative complications. Understanding associations between BMI and complications would allow more objectivity when recommending patients for transplantation or otherwise. METHODS: We analysed a retrospective cohort of 508 adult patients who received primary kidney grafts at a single centre in South Australia, 2002-2009, using hospital records and Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) data. Complications within 1 year of transplantation were classified into: surgical, wound, urological, delayed graft function, early nephrectomy and admission to intensive care unit (ICU). RESULTS: Overall, 62% of transplant recipients had a BMI above 25 kg/m(2) at transplant. Higher BMI was associated with an increased risk of wound complications (P < 0.001), early nephrectomy (P = 0.002) and delayed graft function (P = 0.03), but not associated with surgical or urological complications, or ICU admission. These associations were stronger for Indigenous Australians than other patients, especially for surgical complications. There was no BMI value above which risks of complications increase substantially. CONCLUSION: Delayed graft function is an important determinant of patient outcomes. Wound complications can be serious, and are more common in patients with higher BMI. This may justify the use of elevated BMI as a contraindication for transplantation, although no obvious cut-off value exists. Investigations into other measures of body fat composition and distribution are warranted.

Multisystemic engagement and nephrology based educational intervention: a randomized controlled trial protocol on the KidneyTteam At Home study.

BACKGROUND: Living donor kidney transplantation (LDKT) is the most successful form of renal replacement therapy in terms of wait time and survival rates. However, we observed a significant inequality in the number of LDKT performed between the Dutch and the non-Dutch patients. The objective of this study is to adapt, implement and test an educational home-based intervention to contribute to the reduction of this inequality. Our aim is to establish this through guided communication together with the social network of the patients in an attempt that well-informed decisions regarding renal replacement therapy can be made: Multisystemic Engagement & Nephrology. This manuscript is a detailed description of the Kidney Team At Home-study protocol. METHODS AND DESIGN: All patients (>18 yrs) that are referred to the pre-transplantation outpatient clinic are eligible to participate in the study. Patients will be randomly assigned to either an experimental or a control group. The control group will continue to receive standard care. The experimental group will receive standard care plus a home-based educational intervention. The intervention consists of two sessions at the patient's home, an initial session with the patient and a second session for which individuals from their social network are invited to take part. Based on the literature and behavioural change theories we hypothesize that reducing hurdles in knowledge, risk perception, subjective norm, self-efficacy, and communication contribute to well-informed decision making and reducing inequality in accessing LDKT programs. A change in these factors is consequently our primary outcome-measure. Based on power calculations, we aim to include 160 patients over a period of two years. DISCUSSION: If we are able to show that this home-based group educational intervention contributes to 1) achieving well-informed decision regarding treatment and 2) reducing the inequality in LDKT, the quality of life of patients will be improved while healthcare costs are reduced. As the intervention is investigated in a random heterogeneous patient group in daily practice, the transfer to clinical practice in other kidney transplant centers should be relatively easy. TRIAL REGISTRATION: Netherlands Trial Register, NTR2730.

Racial ethnic differences in rates and determinants of deceased donor kidney transplantation.

Contemporary studies have not comprehensively compared waiting times and determinants of deceased donor kidney transplantation across all major racial ethnic groups in the Unites States. Here, we compared relative rates and determinants of waitlisting and deceased donor kidney transplantation among 503,090 nonelderly adults of different racial ethnic groups who initiated hemodialysis between1995 and 2006 with follow-up through 2008. Annual rates of deceased donor transplantation from the time of dialysis initiation were lowest in American Indians/Alaska Natives (2.4%) and blacks (2.8%), intermediate in Pacific Islanders (3.1%) and Hispanics (3.2%), and highest in whites (5.9%) and Asians (6.4%). Lower rates of deceased donor transplantation among most racial ethnic minority groups appeared primarily to reflect differences in time from waitlisting to transplantation, but this was not the result of higher rates of waitlist inactivity or removal from the waitlist. The fraction of the reduced transplant rates attributable to measured factors (e.g., demographic, clinical, socioeconomic, linguistic, and geographic factors) varied from 14% in blacks to 43% in American Indians/Alaska Natives compared with whites. In conclusion, adjusted rates of deceased donor kidney transplantation remain significantly lower among racial ethnic minorities compared with whites; generally, differences in time to waitlisting were not as pronounced as differences in time between waitlisting and transplantation. Determinants of delays in time to transplantation differed substantially by racial ethnic group. Area-based efforts targeted to address racial- and ethnic-specific delays in transplantation may help to reduce overall disparities in deceased donor kidney transplantation in the United States.

Interleukin-2 receptor antagonist does not decrease biopsy-proven acute rejection among adult Chinese kidney transplant recipients.

Induction therapy with interleukin-2 receptor antagonist (IL2RA) is widely used for renal transplant recipients and this study aimed to examine the impact of IL2RA among Chinese renal transplant recipients. Two hundred and thirty-eight Chinese renal transplant recipients aged 18-65 years at the Taichung Veterans General Hospital from January 2004 to July 2009 were retrospectively studied to assess the influence of IL2RA on biopsy-proven acute rejection (BPAR) within 1 year. Secondary outcomes included acute rejection rate in the first 3 months, delayed graft function, post-transplant diabetes mellitus, and malignancy. Cox proportional hazard analysis was used for multivariate analysis. Of all the patients, 116 received IL2RA (basiliximab, n = 44; daclizumab, n = 72) and 122 had no induction therapy. The mean follow-up duration was 43.3 months (range, 1-79 months). Overall, 227 (95.4%) patients completed the 12-month follow-up period with a functioning graft. No difference of BPAR was observed between the two groups and the secondary outcomes were also similar. After adjusting potential covariates with Cox regression, IL2RA use still provided no benefit on BPAR. In conclusion, there is no benefit of IL2RA in decreasing BPAR was observed in our study. Routine use of IL2RA for adult Chinese kidney transplant recipients may not be as effective as we thought before. More research is still needed to elucidate the effect of IL2RA among Chinese kidney transplant recipients.

Weighing potential candidates for kidney transplant: the ethics of exclusion for elevated body mass index.

With more than 80 000 patients in the United States on waiting lists for a kidney-and more than 100 000 patients beginning treatment for end-stage renal disease each year-transplant programs must evaluate potential recipients in a fair and efficient manner. To this end, certain "absolute exclusion criteria" have been proposed to screen out candidates who will not sufficiently benefit from transplant. Some programs use elevated body mass index as such an exclusion criterion, given that some studies have reported an association with increased risk of delayed graft function and acute rejection, longer hospitalization, and decreased overall graft survival. Upon further examination, however, elevated body mass index turns out to be a poor evaluative criterion for transplant candidates, as it is only variably associated with negative transplant outcomes. Moreover, use of a body mass index cutoff is potentially discriminatory and may mask underlying prejudice against persons of size.

Evaluation of living kidney donors: variables that affect donation.

Approximately 10000 deceased donor organs are available yearly for 85 000 US patients awaiting kidney transplant. Living kidney donation is essential to close this gap and offers better survival rates. However, nationally, 80% of potential donors evaluated fail to donate. Nurse coordinators who perform predonation screening and education need additional insight into the large number of potential donors who fail to complete the donation process. Reasons for nondonation in donor candidates undergoing medical evaluation, and variables affecting nondonation at Vanderbilt University Medical Center between 2004 and 2009 are examined. Multivariable logistic regression models are used to test the effects of age and race on donation status and reasons for nondonation. Summary data are frequencies, percentages, and means (SD). The sample included 706 candidates (63% female, 80% white; mean age, 40 [SD, 12] years). Almost half (46%) received clearance to donate. Undiagnosed hypertension (14%), abnormal glucose tolerance (10%), and protein-urea (9%) were the most prevalent medical reasons for nondonation. About 13% of candidates changed their minds during evaluation. Analyses demonstrated an increased likelihood of older candidates (P < .001) and a decreased likelihood of white candidates (P = .007) being excluded from donation. Within the nondonation group, increased age was associated with undiagnosed hypertension and abnormal glucose tolerance (both race-adjusted, P = .01). Younger candidates (race-adjusted, P = .003) and African Americans (age-adjusted, P = .04) were more likely to decide against donation. The most prevalent medical reasons for nondonation could be identified through enhanced prescreening, and improved preevaluation education could decrease nondonation rates.