BACKGROUND/RATIONALE:
Living donor kidney transplantation (LDKT) is the optimal and most cost-effective treatment for patients with end-stage renal disease (ESRD). A recent study found that ESRD patients with VA coverage were 35% less likely to get a kidney transplant than privately insured patients. Moreover, minority patients within the VA were less likely to get a transplant than whites (WH). While the incidence of ESRD in African Americans (AA) is four times higher than in whites in the US, AAs are less than half as likely to be referred for or to undergo LDKT.

OBJECTIVE(S):
The goal of this study is to identify racial differences in patients' decisions about LDKT, and determine how a variety of culturally-related factors known to play a significant role in AA's other health behaviors, might influence those decisions and subsequent differences in rates of LDKT. Specifically, the study is designed to: (a) compare AA and WH transplant candidates along four domains (culturally-related factors, transplant-related beliefs, psychosocial characteristics, and demographics/health factors); (b) examine the association of race and the four domains with transplant decision-making/preference at baseline interview; and, (c) examine the mechanisms that underlie the relationships between race, culturally-related factors, transplant decisions at follow-up interview, and type of scheduled transplant.

METHODS:
The study will assess transplant candidates at all 4 VA Kidney Transplant centers after they have been approved for transplant by the VA National Transplant Office (VANTO), at two critical time points leading to transplantation. Baseline data (Time 1) will come from a telephone interview that occurs shortly after their initial clinic visit. Time 2 data will be collected from all patients who participated at baseline either after they have been assigned to the deceased donor wait list, are scheduled for a LDKT, or have been rejected from transplant.

FINDINGS/RESULTS:
The table below indicates the demographic characteristics, as well as some of the key cultural predictor variables, of our sample from our final data pull:
Characteristics of Kidney Transplant Candidates Across all 4 VA Kidney Transplant Centers (n=602)
CharacteristicWhite
(n=271)African American
(n=199)Othera
(n=132)p-value
Age - M(SD)61.4(8.4)57.4(9.6)59.2(9.1)<0.001
Gender - (% male)97.894.597.7NS
Educational level - % High School35.830.226.5NS
Family Income - % < $50,00071.972.177.5NS
Marital Status - % not married 35.144.745.5<0.050
Experience of discrimination - % any19.959.637.4<0.001
Medical mistrust - M(SD)2.4(0.5)2.6(0.5)2.5(0.5)<0.001
Perceived Racism - M(SD)2.2(0.7)2.6(0.7)2.4(0.8)<0.001
Transplant knowledge - M(SD)22.2(2.2)21.4(2.7)21.1(2.6)<0.001
Note: aOther includes Hispanic adults and all non-Hispanic adults reporting more than one race, as well as non-Hispanic adults whose only reported race was neither white nor African American.

IMPACT:
The study is designed to determine the extent to which culturally-related factors influence patients' preferences and decision-making in the key steps leading to transplantation, and has the potential to help explain the disparities in LDKT among veterans. This step will enable us to target interventions at patients when they first arrive to the transplant center and have the greatest opportunity and time to identify potential donors.

Our results can be used to better tailor the educational material provided to patients when they first learn about transplantation to include issues related to our findings regarding culturally-related factors and transplant-related beliefs; or, they may be used in "peer counselor" programs (i.e., previous transplant recipients and donors), designed to enhance discussions about transplant options with potential transplant recipients and donors. Intervention also can be developed for physicians who care for ESRD patients to make them aware of the unique culturally-related factors and transplant-related beliefs that play a role in patients' decision-making about transplant.

As a result of the extensive connections made between our research team and the operational partners at each of the transplant center sites, we will embark upon another multi-site project to be submitted for HSR&D Merit Review. The proposal, which is encouraged and supported by our transplant center operational partners, will focus on an intervention and tracking system for living kidney donors. Because living kidney donors have given an amazing "gift of life" to Veterans in need of a kidney transplant, and because such donors become patients of the VA Healthcare System, it is imperative that we design a system to ensure their long-term safety and health. We must also determine long-term psychosocial, behavioral, financial and quality of life outcomes to these donors in order to ensure that they do not suffer undue harm as a result of their donation.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Freeman MA, Pleis JR, Bornemann KR, Croswell E, Dew MA, Chang CH, Switzer GE, Langone A, Mittal-Henkle A, Saha S, Ramkumar M, Adams Flohr J, Thomas CP, Myaskovsky L. Has the Department of Veterans Affairs Found a Way to Avoid Racial Disparities in the Evaluation Process for Kidney Transplantation? Transplantation. 2017 Jun 1; 101(6):1191-1199. [view]
2. Myaskovsky L, Almario Doebler D, Posluszny DM, Dew MA, Unruh M, Fried LF, Switzer GE, Kim S, Chang CC, Ramkumar M, Shapiro R. Perceived discrimination predicts longer time to be accepted for kidney transplant. Transplantation. 2012 Feb 27; 93(4):423-9. [view]
3. Myaskovsky L, Kendall K, Li X, Chang CH, Pleis JR, Croswell E, Ford CG, Switzer GE, Langone A, Mittal-Henkle A, Saha S, Thomas CP, Adams Flohr J, Ramkumar M, Dew MA. Unexpected Race and Ethnicity Differences in the US National Veterans Affairs Kidney Transplant Program. Transplantation. 2019 Dec 1; 103(12):2701-2714. [view]

Journal Other

1. Myaskovsky L, Pleis J, Ramkumar M, Langone A, Saha S, Thomas C. Fewer race disparities in the National VA Kidney Transplant Program. [Abstract]. American Journal of Transplantation. 2014 Jun 1; 14(S3):827. [view]

Newspaper Articles

1. Conte A, Myaskovsky L. Organ transplant program 'mistrust' studied. Pittsburgh Tribune-Review. 2010 May 2. [view]

Conference Presentations

1. Myaskovsky L, Pleis J, Ramkumar M, Langone A, Saha S, Thomas C. Fewer race disparities in the National VA Kidney Transplant Program. Poster session presented at: World Transplant Congress; 2014 Jul 29; San Francisco, CA. [view]
2. Myaskovsky L, Pleis J, Ramkumar M, Mittalhenkle A, Langone A, Thomas C. Has the VA found a way to reduce racial disparities in kidney transplant evaluation? Preliminary results from the National VA Kidney Transplant Study. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 23; Baltimore, MD. [view]
3. Myaskovsky L, Pleis J, Ramkumar M, Mittalhenkle A, Langone A, Thomas C. Has the VA found a way to reduce racial disparities in kidney transplant evaluation? Preliminary results from the National VA Kidney Transplant Study. Poster session presented at: American Society of Transplant Surgeons / American Society of Transplantation Annual American Transplant Congress; 2013 May 20; Seattle, WA. [view]
4. Myaskovsky L, Switzer GE, Dew MA, Crowley-Matoka M, Unruh M, DeVito Dabbs A, Shapiro R, Tan H. Is donating a kidney associated with changes in health habits? Paper presented at: European Society for Organ Transplantation Annual Meeting; 2010 Apr 18; Rotterdam, Netherlands. [view]
5. Myaskovsky L, Switzer GE, Dew MA, Crowley-Matoka M, Unruh M, DeVito Dabbs A, Shapiro R, Tan H. Is donating a kidney associated with changes in health habits? Poster session presented at: American Society of Transplant Surgeons / American Society of Transplantation Annual American Transplant Congress; 2010 May 4; San Diego, CA. [view]
6. Myaskovsky L, McNulty M, Kormos R, Dew MA. Predictors of quality of life in caregivers to cardiothoracic transplant recipients. Paper presented at: European Society for Organ Transplantation Annual Meeting; 2010 Apr 19; Rotterdam, Netherlands. [view]
7. Myaskovsky L, McNulty M, Dew MA, Kormos R. Predictors of quality of life in caregivers to cardiothoracic transplant recipients. Paper presented at: American Society of Transplant Surgeons / American Society of Transplantation Annual American Transplant Congress; 2010 May 5; San Diego, CA. [view]
8. Myaskovsky L, Almario D, Dew MA, Switzer GE, Unruh M, Ramkumar M, Shapiro R. Racial disparities in kidney transplant: beyond medical factors. Paper presented at: European Society for Organ Transplantation Annual Meeting; 2010 Apr 19; Rotterdam, Netherlands. [view]
9. Myaskovsky L, Doebler DA, Chang CH, Dew MA, Switzer GE, Ramkumar M, Shapiro R. Racial disparities in kidney transplant: beyond medical factors. Paper presented at: VA HSR&D Field-Based Equity Conference; 2010 Sep 13; Boston, MA. [view]
10. Myaskovsky L, Almario D, Dew MA, Switzer GE, Unruh M, Ramkumar M, Shapiro R. Racial disparities in kidney transplant: beyond medical factors. Poster session presented at: American Society of Transplant Surgeons / American Society of Transplantation Annual American Transplant Congress; 2010 May 1; San Diego, CA. [view]
11. Myaskovsky L. Understanding disparities in kidney transplantation. Paper presented at: Center for Organ Recovery and Education / Minority Organ Tissue Transplant Education Program Annual Kountz/Callender Rappaport Transplant Symposium; 2011 Sep 15; Pittsburgh, PA. [view]

DRA: Health Systems Science, Kidney Disorders
DRE: Etiology, Treatment - Observational
Keywords: Care Management, Ethnic/cultural, Patient preferences
MeSH Terms: none