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      Socioeconomic Inequalities in the Kidney Transplantation Process: A Registry-Based Study in Sweden

      research-article
      , MSc 1 , , PhD 1 , 2 , 3 , , MD 4 , 5 , 6 , , PhD 1
      Transplantation Direct
      Lippincott Williams & Wilkins

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          Abstract

          Supplemental digital content is available in the text.

          Abstract

          Background

          Few studies have examined the association between individual-level socioeconomic status and access to kidney transplantation. This study aims to investigate the association between predialysis income and education, and access to (i) the kidney waitlist (first listing), and (ii) kidney transplantation conditional on waitlist placement. Adjustment will be made for a number of medical and nonmedical factors.

          Methods

          The Swedish Renal Register was linked to national registers for adult patients in Sweden who started dialysis during 1995 to 2013. We employed Cox proportional hazards models.

          Results

          Nineteen per cent of patients were placed on the waitlist. Once on the waitlist, 80% received kidney transplantation. After adjusting for covariates, patients in the highest income quintile were found to have higher access to both the waitlist (hazard ratio [HR], 1.73; 95% confidence interval [CI], 1.53-1.96) and kidney transplantation (HR, 1.33; 95% CI, 1.16-1.53) compared with patients in the lowest income quintile. Patients with higher education also had better access to the waitlist and kidney transplantation (HR, 2.16; 95% CI, 1.94-2.40; and HR, 1.16; 95% CI, 1.03-1.30, respectively) compared with patients with mandatory education.

          Conclusions

          Socioeconomic status-related inequalities exist with regard to both access to the waitlist, and kidney transplantation conditional on listing. However, the former inequality is substantially larger and is therefore expected to contribute more to societal inequalities. Further studies are needed to explore the potential mechanisms and strategies to reduce these inequalities.

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          Most cited references17

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          Barriers to evaluation and wait listing for kidney transplantation.

          Many factors have been shown to be associated with ESRD patient placement on the waiting list and receipt of kidney transplantation. Our study aim was to evaluate factors and assess the interplay of patient characteristics associated with progression to transplantation in a large cohort of referred patients from a single institution. We examined 3029 consecutive adult patients referred for transplantation from 2003 to 2008. Uni- and multivariable logistic models were used to assess factors associated with progress to transplantation including receipt of evaluations, waiting list placement, and receipt of a transplant. A total of 56%, 27%, and 17% of referred patients were evaluated, were placed on the waiting list, and received a transplant over the study period, respectively. Older age, lower median income, and noncommercial insurance were associated with decreased likelihood to ascend steps to receive a transplant. There was no difference in the proportion of evaluations between African Americans (57%) and Caucasians (56%). Age-adjusted differences in waiting list placement by race were attenuated with further adjustment for income and insurance. There was no difference in the likelihood of waiting list placement between African Americans and Caucasians with commercial insurance. Race/ethnicity, age, insurance status, and income are predominant factors associated with patient progress to transplantation. Disparities by race/ethnicity may be largely explained by insurance status and income, potentially suggesting that variable insurance coverage exacerbates disparities in access to transplantation in the ESRD population, despite Medicare entitlement.
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            Equity of access to renal transplant waiting list and renal transplantation in Scotland: cohort study.

            To examine the access to the renal transplant waiting list and renal transplantation in Scotland. Cohort study. Renal and transplant units in Scotland. 4523 adults starting renal replacement therapy in Scotland between 1 January 1989 and 31 December 1999. Impact of age, sex, social deprivation, primary renal disease, renal or transplant unit, and geography on access to the waiting list and renal transplantation. 1736 of 4523 (38.4%) patients were placed on the waiting list for renal transplantation and 1095 (24.2%) underwent transplantation up to 31 December 2000, the end of the study period. Patients were less likely to be placed on the list if they were female, older, had diabetes, were in a high deprivation category, and were treated in a renal unit in a hospital with no transplant unit. Patients living furthest away from the transplant centre were listed more quickly. The only factors governing access to transplantation once on the list were age, primary renal disease, and year of listing. A significant centre effect was found in access to the waiting list and renal transplantation. A major disparity exists in access to the renal transplant waiting list and renal transplantation in Scotland. Comorbidity may be an important factor.
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              Quality of life in adult transplant recipients more than 15 years after kidney transplantation.

              With continuously rising survival rates following renal transplantation, health-related quality of life (HQOL) of long-term transplant survivors becomes increasingly important. Recipients more than 15 years after successful renal transplantation were studied retrospectively. HQOL in 139 long-term transplant recipients was assessed using the SF-36 and the disease-specific kidney transplant questionnaire (KTQ-25). Long-term transplant recipients revealed satisfactory HQOL that was comparable to the healthy population in four of eight SF-36 categories (role physical, social functioning, role emotional and mental health). Other SF-36 categories such as physical functioning, physical pain, general health, and vitality were reduced. Among the study population, disease-specific HQOL was comparable or even improved to that of patients awaiting transplantation. In contrast to retired or unemployed patients, employed recipients revealed a highly significant improved HQOL in numerous SF-36 categories such as physical functioning (P 0.001), uncertainty/fear (P<0.01), and emotions (P<0.05). Other factors positively correlating with improved HQOL in certain dimensions were living situation, systolic blood pressure, and recipient age. More than 15 years after renal transplantation, recipients present satisfactory HQOL comparable to the general healthy population or at least to pretransplant patients. Vocational rehabilitation following renal transplantation is of highest importance among long-term survivors and is associated with improved HQOL.
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                Author and article information

                Journal
                Transplant Direct
                Transplant Direct
                TXD
                Transplantation Direct
                Lippincott Williams & Wilkins
                2373-8731
                February 2018
                02 February 2018
                : 4
                : 2
                : e346
                Affiliations
                [1] 1 Health Economics Unit, Department of Clinical Sciences, Lund University, Lund, Sweden.
                [2] 2 Department of Economics, Lund University, Lund, Sweden.
                [3] 3 Centre for Economic Demography, Lund University, Lund, Sweden.
                [4] 4 Department of Nephrology Skåne University Hospital, Lund University, Lund, Sweden.
                [5] 5 Institution of Clinical Sciences, Lund University, Lund, Sweden.
                [6] 6 Swedish Renal Registry, Jönköping, Sweden.
                Author notes
                Correspondence: Ye Zhang, MSc, Department of Clinical Sciences, Lund University, Lund, Sweden. ( ye.zhang@ 123456med.lu.se ).
                Article
                TXD50241 00002
                10.1097/TXD.0000000000000764
                5811275
                29464207
                58ca7770-f727-4e36-affb-9aa046a905fc
                Copyright © 2018 The Author(s). Transplantation Direct. Published by Wolters Kluwer Health, Inc.

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

                History
                : 24 October 2017
                : 13 November 2017
                : 16 November 2017
                Page count
                Pages: 0
                Categories
                016
                Kidney Transplantation
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