Karen Yeates|Alan Cass|Thomas D. Sequist|S. McDonald|Meg Jardine|Lilyanna Trpeski|John Z. Ayanian
Indigenous people in Australia, Canada, New Zealand and the United States are less likely to receive renal transplantation
Queen's University|The George Institute for Global Health|University of Sydney|Harvard University|Harvard Vanguard Medical Associates|Brigham and Women's Hospital|Australia and New Zealand Dialysis and Transplant Registry|The George Institute for Global Health|Canadian Institute for Health Information|Harvard University|Brigham and Women's Hospital
australia canada new zealand united states indigenous people high rates chronic kidney disease poor access effective therapies fully define issues compared demographics renal transplantation indigenous patients 4 countries data encompassing 312507 indigenous white patients 1864 years age initiated dialysis within 11year period ending 2005 obtained countrys endstage kidney disease registry studys end 88173 patients received renal transplant 130261 died without receiving compared white patients adjusted likelihood receiving transplant indigenous patients significantly lower australia hazard ratio hr 023 canada hr 034 new zealand hr 023 united states hr 044 four countries indigenous patients significantly longer overall median waiting times compared white patients study shows despite marked differences health care delivery systems indigenous patients less likely white patients receive renal transplant countries understanding addressing barriers renal transplantation indigenous patients remains important concern australia canada new zealand united states indigenous people high rates chronic kidney disease poor access effective therapies fully define issues compared demographics renal transplantation indigenous patients 4 countries data encompassing 312507 indigenous white patients 1864 years age initiated dialysis within 11year period ending 2005 obtained countrys endstage kidney disease registry studys end 88173 patients received renal transplant 130261 died without receiving compared white patients adjusted likelihood receiving transplant indigenous patients significantly lower australia hazard ratio hr 023 canada hr 034 new zealand hr 023 united states hr 044 four countries indigenous patients significantly longer overall median waiting times compared white patients study shows despite marked differences health care delivery systems indigenous patients less likely white patients receive renal transplant countries understanding addressing barriers renal transplantation indigenous patients remains important concern australia canada new zealand united states indigenous people experience substantially worse health outcomes nonindigenous people1bramley hebert p jackson r et alindigenous disparities diseasespecific mortality crosscountry comparisonnz med j 2004 117 u1215pubmed google scholar last two decades prevalence chronic disease among indigenous people risen dramatically well documented excess burden diabetes heart disease kidney disease1bramley hebert p jackson r et alindigenous disparities diseasespecific mortality crosscountry comparisonnz med j 2004 117 u1215pubmed google scholar 2mcdonald sp russ gr burden endstage renal disease among indigenous peoples australia new zealandkidney int suppl 2003 83 s123s127abstract full text full text pdf pubmed scopus 78 google scholar 3dyck rf mechanisms renal disease indigenous populations influences work canadas indigenous peoplenephrology 2001 6 37crossref scopus 28 google scholar 4narva spectrum kidney disease american indianskidney int suppl 2003 83 s3s7abstract full text full text pdf pubmed scopus 50 google scholar 5canadian institute health information cihi canadian organ replacement register 2001 report volume 1 dialysis renal transplantation includes data 19811999 cihi ottawa2001google scholar australia new zealand canada indigenous people experience twice prevalence endstage kidney disease eskd whites similarly united states american indians alaskan natives 25 percent higher prevalence eskd compared white americans1bramley hebert p jackson r et alindigenous disparities diseasespecific mortality crosscountry comparisonnz med j 2004 117 u1215pubmed google scholar 2mcdonald sp russ gr burden endstage renal disease among indigenous peoples australia new zealandkidney int suppl 2003 83 s123s127abstract full text full text pdf pubmed scopus 78 google scholar 3dyck rf mechanisms renal disease indigenous populations influences work canadas indigenous peoplenephrology 2001 6 37crossref scopus 28 google scholar 4narva spectrum kidney disease american indianskidney int suppl 2003 83 s3s7abstract full text full text pdf pubmed scopus 50 google scholar 5canadian institute health information cihi canadian organ replacement register 2001 report volume 1 dialysis renal transplantation includes data 19811999 cihi ottawa2001google scholar 6scavini stidley ca paine ss et althe burden chronic kidney disease among zuni indians zuni kidney projectclin j soc neph 2007 2 509516crossref pubmed scopus 21 google scholar 7dyck rf mechanisms renal disease indigenous populations influences work canadian indigenous peoplesnephrology 2001 6 37crossref scopus 36 google scholar 8mcdonald sp russ gr current incidence treatment patterns outcome endstage renal disease among indigenous groups australia new zealandnephrology 2003 8 4248crossref pubmed scopus 78 google scholar systematic differences rates utilization primary care preventive services contribute poorer outcomes9shah br gunraj n hux jg markers access quality primary care aboriginal people ontario canadaam j public health 2003 93 798801crossref pubmed scopus 91 google scholar indigenous patients also unequal access diagnostic therapeutic procedures used treat chronic diseases angiography percutaneous coronary interventions coronary artery bypass grafting coronary artery disease compared nonindigenous patients10coorey md walsh wf rates percutaneous coronary interventions bypass surgery acute myocardial infarction indigenous patientsmed j aust 2005 182 507512pubmed google scholar 11cunningham j diagnostic therapeutic procedures among australian hospital patients identified indigenousmed j aust 2002 176 5862pubmed google scholar 12sequist td zaslavsky galloway jm et alcardiac procedure use following acute myocardial infarction among american indiansam heart j 2006 151 909914abstract full text full text pdf pubmed scopus 13 google scholar kidney transplantation considered optimal treatment nonelderly patients eskd conferring significant survival advantage improvement quality life dialysis therapy13wolfe ra ashby vb milford el et alcomparison mortality patients dialysis patients dialysis awaiting transplantation recipients first cadaveric transplantn engl j med 1999 341 17251730crossref pubmed scopus 3576 google scholar14laupacis keown p pus n et ala study quality life costutility renal transplantationkidney int 1996 50 235242abstract full text pdf pubmed scopus 837 google scholar however analyses individual countries regional scope others limited adjustment confounding factors shown indigenous patients low rates kidney transplantation15sequist td narva stiles sk et alaccess renal transplantation among american indians hispanicsam j kidney dis 2004 44 344352abstract full text full text pdf pubmed scopus 100 google scholar 16yeates ke schaubel de cass et alaccess renal transplantation minority patients esrd canadaam j kidney dis 2004 44 10831089abstract full text full text pdf pubmed scopus 47 google scholar 17cass cunningham j snelling p et alrenal transplantation indigenous australians identifying barriers equitable accessethn health 2003 8 111119crossref pubmed scopus 46 google scholar 18tonelli hemmelgarn b manns bj et aldeath renal transplantation among aboriginal people undergoing dialysiscmaj 2004 17 577582crossref scopus 65 google scholar study compared renal transplant utilization indigenous patients across four countries australia canada new zealand united states distinctly different health care systems study two primary objectives 1 assess transplantation rates overall deceased living donors among indigenous white patients controlling comparable demographic clinical variables across four countries 2 compare median transplant waiting times donor type among indigenous white patients country cohort consisted 312507 patients ages 18 64 years including 9837 australia 17986 canada 2771 new zealand 281913 united states 31 december 2006 28 cohort 88173 patients received renal transplant 416 130261 died without receiving transplant characteristics indigenous white patients beginning maintenance dialysis country depicted table 1 indigenous patients represented 18 study cohort australia 9 canada 56 new zealand 3 united states exception new zealand significantly fewer men women indigenous cohorts compared nonindigenous cohorts four countries indigenous patients significantly likely body mass index bmi greater 30 kgm2 diabetes whites significantly higher rates ischemic heart disease among indigenous patients australia new zealand higher rates peripheral vascular disease among indigenous patients four countries rates chronic lung disease smoking significantly lower indigenous patients united states higher australia new zealand indigenous patients significantly likely smoke australia canada new zealand less likely smoke united statestable 1demographic clinical characteristics indigenous white patients australia canada new zealand united statescountryaustraliacanadanew zealandunited stateswhiteindigenouswhiteindigenouswhiteindigenouswhiteindigenousn 8058 8191779 18116336 9081650 921216 4391555 561274125 9727788 28age n 1829 years819 106114 64p0011109 68151 92p001119 98108 69p00116870 61404 52p001 3044 years1987 247522 293p0013817 234346 209p001319 262282 181p00157454 2101584 203p001 4565 years5252 6471143 627p00111410 6981153 699778 6391165 749p001199801 7295800 745p001gender n male4919 610824 463p00110136 621806 489p001740 598873 552p005157828 5763846 494p001 female3139 389955 537p0016200 379844 511p001476 391682 438p005116295 4243942 506p001body mass index n 185 mgm2317 3992 52p001538 3730 21p00137 3013 08p00112904 52266 37p001 185249 mgm23276 409599 339p0015548 384405 277p001536 444269 175p00185028 3412101 290p001 25299 mgm22555 319520 295p0014309 299511 350p001394 326493 320p00169372 2792247 311p001 30 mgm21849 231522 313p0014038 279514 352p001240 199763 496p00181698 3282616 362p001diabetes n 2255 2791293 727p0015840 3581011 613p001278 2291072 689p001122823 4485122 658p001 cerebrovascular disease n 509 63147 83p0051272 86147 9574 61117 7516541 60481 62 ischemic heart disease n 1514 189429 241p0012586 157256 155190 156329 212p00154134 1971414 182p001 peripheral vascular disease n 1081 134315 177p0012819 173397 241p001144 118288 185p00132240 1181235 159p001 chronic lung disease n 866 107253 142p0011225 75106 64103 85276 178p00113345 49217 28p001 current smoker n 1272 158472 265p0012993 183368 223p001197 162384 247p00120139 73450 58p001 p005 p001 open table new tab four countries indigenous patients significantly lower crude transplant rates per 100 personyears white patients table 2 unadjusted transplant rates indigenous recipients different among countries p001 disparities access transplantation observed living deceased donor sources proportion transplants living donors lower among indigenous among white transplant recipients australia 219 vs 392 new zealand 342 vs 421 united states 368 vs 442 contrast proportion transplants living donors slightly higher indigenous white recipients canada 395 vs 377 table 2table 2crude transplant ratesarates calculated per 100 patientyears indigenous white patients australia canada new zealand united statescountryethnicityall transplantsdeceased donorliving donorliving donor sourceunadjusted rates 95 ciunadjusted rates 95 ciunadjusted rates 95 ci totalaustraliaindigenous33 283826 223007 0509219white148 14315389 869458 5460392canadaindigenous38 334323 182615 1218395white118 11512172 697446 4448377new zealandindigenous28 243218 152209 0712342white195 178210113 10112482 7194421united statesindigenous41 384326 242814 1316368white104 10310458 575845 4446442ci confidence intervala rates calculated per 100 patientyears open table new tab ci confidence interval table 3 displays unadjusted adjusted hazard ratios hrs renal transplantation overall donor type indigenous patients relative white patients unadjusted hrs renal transplantation overall 023 ci 019028 australia 033 ci 026036 canada 015 ci 013019 new zealand 042 ci 036042 united states age sex comorbid conditions explained small portion disparities adjustment variables changed respective hr country minimally country disparities access similar deceased living donor transplants table 3table 3unadjusted adjusted hazard ratios indigenous patients relative white patients australia canada new zealand united statescountryall transplantsdeceased donorliving donorunadjusted hr 95 ciadjustedaadjusted age sex primary cause endstage kidney disease year diagnosis comorbidities diabetes cerebrovascular disease ischemic heart disease peripheral vascular disease chronic lung disease current smoking region hr 95 ciunadjusted hr 95 ciadjustedaadjusted age sex primary cause endstage kidney disease year diagnosis comorbidities diabetes cerebrovascular disease ischemic heart disease peripheral vascular disease chronic lung disease current smoking region hr 95 ciunadjusted hr 95 ciadjustedaadjusted age sex primary cause endstage kidney disease year diagnosis comorbidities diabetes cerebrovascular disease ischemic heart disease peripheral vascular disease chronic lung disease current smoking region hr 95 ciaustralia023 020026023 019027029 024033032 027037015 010019018 013025canada033 028037034 029040031 026037031 026037035 028043039 030049new zealand015 012018023 019028015 013018022 017028014 010018026 018037united states042 040045044 042047046 043049049 045053037 033041040 036044ci confidence interval hr hazard ratioa adjusted age sex primary cause endstage kidney disease year diagnosis comorbidities diabetes cerebrovascular disease ischemic heart disease peripheral vascular disease chronic lung disease current smoking region open table new tab ci confidence interval hr hazard ratio table 4 presents median waiting times overall donor type indigenous compared white patients four countries indigenous patients significantly longer overall median waiting times p001 compared white patients indigenous recipients waited longest deceased donor transplants united states 3 years shortest canada 25 years waiting times living donor transplants significantly longer indigenous compared white patients australia 27 vs 07 years p001 canada 16 vs 08 years p001 new zealand 12 vs 06 years p001 united states 12 vs 06 years p001table 4median renal transplant wait times years country among transplant recipientscountryethnicityall transplantsdeceased donorliving donormedian yearsinterquartile rangemedian yearsinterquartile rangemedian yearsinterquartile rangeaustraliawhite150629211135070117indigenous241339261536271843canadawhite150627191033080216indigenous211235251539160926new zealandwhite120424170929060016indigenous221236271942120322united stateswhite110324180832060013indigenous211138301644120520 open table new tab cumulative incidence curves time first renal transplant years indigenous white patients country displayed figure 1 indigenous patients four countries similar curves showing lower cumulative incidence renal transplantation compared whites white patients united states lowest cumulative incidence first renal transplants overall followed canada australia new zealand respectively knowledge study first multinational evaluation indigenous access renal transplantation using similar methods adjust comparable variables national renal registries identical periods despite indigenous populations country bearing significantly heavier burden eskd whites indigenous people dialysis undergoing renal transplantation less half rate white patients respective countries notwithstanding substantial differences health care systems renal transplant programs indigenous models health care delivery country disparities renal transplant rates indigenous people strikingly similar magnitude across four countries study provides several important insights regarding access renal transplantation four countries studied first disparity access transplantation indigenous patients four countries significant deceased living donor kidneys second access first renal transplant whites poorest united states followed canada australia new zealand respectively particularly deceased donor kidneys result magnitude disparity observed indigenous patients relative white patients countries largely driven differences white access renal transplantation within country hence united states utilization renal transplants looks relatively better native americans comparison countries studied low overall renal transplant rates among white americans comparison australia canada new zealand third access living donor kidneys relatively better indigenous patients canada united states australia new zealand disparities living donor transplantation concerning option increasingly important determinant transplant access context global shortage deceased donor kidneys within indigenous communities awareness living donor transplants treatment option medical suitability relatives community members donation key issues addressed number potential mediators may contribute low indigenous transplant rates including language barriers patient preferences health practitioners attitudes19cass cunningham j anderson k et aldecisionmaking suitability kidney transplantation results national survey australian nephrologistsnephrology carlton 2007 12 299304crossref pubmed scopus 20 google scholar lack culturally appropriate patient education programs however evidence regarding relative importance factors remains scant knowledge culturally appropriate educational materials regarding kidney transplantation specifically targeted preferred ways communicating levels health literacy indigenous patients developed implemented geographical remoteness also suggested factor associated lower transplantation rates evidence point mixed20axelrod da guidinger mk finlayson et alrates solidorgan waitlisting transplantation survival among residents rural urban areasjama 2008 299 202207crossref pubmed scopus 151 google scholar21tonelli klarenbach manns b alberta kidney disease network et alresidence location likelihood kidney transplantationcmaj 2006 175 478482crossref pubmed scopus 55 google scholar potential barriers indigenous patients include delayed referral transplant evaluation22cass cunningham j snelling p et allate referral nephrologist reduces access renal transplantationam j kidney dis 2003 42 10431049abstract full text full text pdf pubmed scopus 99 google scholar23winkelmayer wc glynn rj levin r et allate nephrologist referral access renal transplantationtransplantation 2002 3 19181923crossref scopus 57 google scholar delays initial referral waitlisting15sequist td narva stiles sk et alaccess renal transplantation among american indians hispanicsam j kidney dis 2004 44 344352abstract full text full text pdf pubmed scopus 100 google scholar 17cass cunningham j snelling p et alrenal transplantation indigenous australians identifying barriers equitable accessethn health 2003 8 111119crossref pubmed scopus 46 google scholar 24tonelli hemmelgarn b gill js alberta kidney disease network et alwaitlisting kidney transplantation among aboriginal hemodialysis patientsam j kidney dis 2005 46 11171123abstract full text full text pdf pubmed scopus 29 google scholar reflected near absence preemptive transplants among indigenous patients study countries studied particular renal transplant organ allocation systems general however organ allocation among systems prioritized similarly patient waiting time immune matching carrying relatively less weight patients successfully waitlisted transplant allocation algorithms favor higher levels hlamatching waiting time reduce access patients ethnic minorities deceased donors kidneys predominantly drawn majority white population25delmonico fl milford el goguen j et ala novel united network organ sharing region kidney allocation plan improves transplant access minority candidatestransplantation 1999 68 18751879crossref pubmed scopus 14 google scholar26leffell ms zachary aa national impact 1995 changes unos renal allocation system united network organ sharingclin j transplant 1999 13 287295crossref pubmed scopus 24 google scholar addition institutional bias racism may impede indigenous patients access renal transplantation people complex chronic diseases kidney disease must negotiate often fragmented health care systems access necessary care27ayanian jz determinants racial ethnic disparities surgical careworld j surg 2008 32 509515crossref pubmed scopus 32 google scholar among four countries studied indian health service united states provides comprehensive indigenous health care system also funds substantial component services managed indian tribes nonetheless presence indian health service tribal health councils united states associated substantially better access renal transplantation american indians alaskan natives probably organizations mainly focused primary secondary care often face restricted access tertiary services renal transplantation major cardiac procedures12sequist td zaslavsky galloway jm et alcardiac procedure use following acute myocardial infarction among american indiansam heart j 2006 151 909914abstract full text full text pdf pubmed scopus 13 google scholar15sequist td narva stiles sk et alaccess renal transplantation among american indians hispanicsam j kidney dis 2004 44 344352abstract full text full text pdf pubmed scopus 100 google scholar australia canada new zealand federally managed indigenous health agencies countries developed communitycontrolled health services improve access indigenous patients united states however renal transplantation highly specialized procedure provided tertiary centers focused indigenous patients therefore communication across indigenous nonindigenous health services crucial support indigenous patients access renal transplantation study several strengths limitations strengths study include large inclusive cohorts patients consistent adjustment relevant clinical variables across four countries however able verify accuracy indigenous designations determine precisely much time indigenous patients spent transplant waiting lists active inactive status categories addition access accurate information regarding residence location study patients registry data sets would allowed us address possibility relationship exists rural residence location racial identity indigenous impacts renal transplant utilization study groups would considerably strengthened study lastly unable obtain data regarding clinical characteristics hla matching registries would provide useful information analyses relating organ allocation algorithms substantial disparities access renal transplantation persist indigenous people eskd across diverse health care systems australia canada new zealand united states findings suggest reduced access may strongly influenced social determinants operating beyond confines respective health systems poverty lower levels educational attainment shown reduce engagement health care disproportionately affect indigenous populations without knowledge barriers within beyond health systems success improving access renal transplantation effective medical surgical services indigenous people remain elusive analyzed data respective national eskd registries including australia new zealand dialysis transplant registry anzdata28macdonald anzdata registry 2003 australia new zealand dialysis transplant registry adelaide2003google scholar canadian organ replacement register corr5canadian institute health information cihi canadian organ replacement register 2001 report volume 1 dialysis renal transplantation includes data 19811999 cihi ottawa2001google scholar canadian institute health information united states renal data system usrds29us renal data system 2005 annual data report atlas endstage renal disease united states national institutes health bethesda2005google scholar anzdata corr voluntary registries seek participation renal units providing dialysis transplant services anzdata includes essentially patients eskd australia new zealand whereas corr includes 80 patients canada usrds included patients eskd united states since may 1995 medicare endstage renal disease program requires medicare evidence form submitted patients regardless insurance eligibility status complete deidentified dataset requested variables acquired respective renal registries analyzed canadian institute health information toronto canada study protocol approved research ethics board queens university human studies committee harvard medical school ethics committee sydney south western area health service sydney australia examined data indigenous patients australia canada new zealand united states initiated maintenance dialysis eskd 1 january 1995 31 december 2005 indigenous people identified aboriginal australians torres strait islanders australia maori samoans tongans pacific people cook islanders new zealand aboriginal people including first nations mtis inuit canada american indians alaska natives united states majority population termed white current analysis designated white caucasian caucasoid individual registries approximately 10 patients country missing raceethnicity data therefore excluded patients racial groups restricted analysis adult patients aged 1864 years initiation dialysis older patients less likely clinically appropriate renal transplantation variables extracted national renal registry included patients age sex primary renal diagnosis comorbid conditions height weight smoking status region initial dialysis treatment race reported registry participating clinical facilities basis information recorded patients medical records bmi kgm2 categorized according world health organization criteria underweight bmi 185 kgm2 normal weight bmi 185249 kgm2 overweight bmi 250299 kgm2 obese bmi 300 kgm230wwwcdcgovnccdphpdnpabmiindexhtm last accessed 29 october 2008google scholar comorbid conditions recorded registry onset eskd included diabetes mellitus ischemic heart disease myocardial infarction angina peripheral vascular disease cerebrovascular disease chronic obstructive pulmonary disease current smoking demographic clinical characteristics indigenous white patients compared within country using pearsons 2test unadjusted transplant rates per 100 patientyears treatment calculated indigenous white patients country