Gurprataap S. Sandhu

Association between initial type of hemodialysis access used in the elderly and mortality

We hypothesized that certain subpopulations (elderly and those with greater comorbidity) may not have significant benefit from “fistula first” initiative. A cohort of incident hemodialysis patients from 2005 to 2007, who were ≥70 years old, was derived from the United States Renal Data System. Primary variable of interest was type of vascular access used at first outpatient hemodialysis (i.e., fistula, graft, or central catheter), with primary outcome of all‐cause mortality (time to death measured from the first outpatient hemodialysis). A cohort of 82,202 patients was stratified by age (70 to ≤80, 81 to ≤90, and >90). Each group demonstrated a survival benefit with the use of an arterio‐venous fistula compared with catheter (hazard ratio [HR] 0.56 [P < 0.001], HR 0.55 [P < 0.001], and HR 0.69 [P = 0.007], respectively). Comparing graft to with a catheter, both groups, 70 to ≤80 and 81 to ≤90, had significant benefit compared with catheter (HR 0.73, P < 0.001 and HR 0.74, P < 0.001, respectively). However, significance was lost in those ≥90 (HR 0.83, P = 0.354). When substratified by comorbidity, those 81 to ≤90 years old with a history of malignancy or peripheral vascular disease also did not reach significant benefit compared with a catheter (HR 0.88, P = 0.423 and HR 0.85, P = 0.221, respectively). While specific subgroups in the hemodialysis population exist where use of fistulas and grafts at time of dialysis initiation is not of proven statistical benefit to survival, elderly hemodialysis patients with comorbidities still appear to benefit from the use of fistulas and grafts.

Effect of education on racial disparities in access to kidney transplantation

Goldfarb‐Rumyantzev AS, Sandhu GS, Baird B, Barenbaum A, Yoon JH, Dimitri N, Koford JK, Shihab F. Effect of education on racial disparities in access to kidney transplantation. 
Clin Transplant 2012: 26: 74–81. 
© 2010 John Wiley & Sons A/S.

Social adaptability index predicts kidney transplant outcome: a single-center retrospective analysis

BACKGROUND Social adaptability index (SAI) is the composite index of socioeconomic status based upon employment status, education level, marital status, substance abuse and income. It has been used in the past to define populations at higher risk for inferior clinical outcomes. The objective of this retrospective study was to evaluate the association of the SAI with renal transplant outcome. METHODS We used data from the clinical database at the Beth Israel Deaconess Medical Center Transplant Institute, supplemented with data from United Network for Organ Sharing for the years 2001-09. The association between SAI and graft loss and recipient mortality in renal transplant recipients was studied using Cox model in the entire study population as well as in the subgroups based on age, race, sex and diabetes status. RESULTS We analyzed 533 end-stage renal disease patients (mean age at transplant 50.8 ± 11.8 years, 52.2% diabetics, 58.9% males, 71.1% White). Higher SAI on a continuous scale was associated with decreased risk of graft loss [hazard ratio (HR) 0.89, P < 0.05, per 1 point increment in the SAI] and decreased risk of recipient mortality (HR 0.84, P < 0.01, per 1 point increment in the SAI). Higher SAI was also significantly associated with decreased risk for graft loss/recipient mortality in some study subgroups (age 41-65 years, males, non-diabetics). CONCLUSIONS SAI has an association with graft and recipient survival in renal transplant recipients. It can be helpful in identifying patients at higher risk for inferior transplant outcome as a target population for potential intervention.

Social adaptability index predicts access to kidney transplantation

Goldfarb‐Rumyantzev AS, Sandhu GS, Baird BC, Khattak M, Barenbaum A, Hanto DW. Social adaptability index predicts access to kidney transplantation. 
Clin Transplant 2011: 25: 834–842.

Social Adaptability Index: application and outcomes in a dialysis population

BACKGROUND Patient groups associated with disparities in health care are usually defined on the basis of race, gender or geographic location. Social Adaptability Index (SAI), calculated based on education, marital status, income, employment and substance abuse, has been strongly associated with clinical outcome in other patient populations and may be used to identify individuals at risk. We used data from the United States Renal Data System to evaluate the role of SAI in survival of patients on dialysis. METHODS We used Cox model analyses to study the association between SAI and patient survival in patients with ESRD on dialysis, as well as in the subgroups based on age, race, sex, comorbidites and diabetic status. RESULTS We analyzed 3396 patients (age of ESRD onset 56.9 ± 16.1 years, 54.2% males, 64.2% white, 30.3% African-American). Mean SAI of the entire population was 7.1 ± 2.5 (range 0-12 points). SAI was higher in whites (7.4 ± 2.4) than in African-Americans (6.5 ± 2.5) (analysis of variance, P <0.001) and greater in men (7.4 ± 2.4) than in women (6.7 ± 2.5) (t-test, P <0.001). In a Cox model adjusted for potential confounders, SAI was associated with decreased mortality [hazards ratio of 0.97 (95% confidence interval 0.95-0.99), P = 0.006]. Subgroup analysis demonstrated an association of SAI with survival in most of the subgroups. Potential limitations of the study include reverse causality, possible misclassification and retrospective design. CONCLUSION We demonstrated that SAI is significantly associated with mortality in dialysis patients. SAI could be used to identify individuals at risk for inferior clinical outcomes.

Factors Associated with Nonadherence to Medication in Kidney Transplant Recipients

Nonadherence in kidney transplant recipients was evaluated in this report using a questionnaire with five binary questions and one question on a continuous scale. Study participants at the University of Utah Transplant Program (n = 199) were 43.0 ± 14.2 years old; 67% were males, and 81% were White. Two questions that produced heterogeneous outcome were analyzed: ‘Do you ever forget to take your medication?’ (79% no, 21% yes) and ‘Have you ever taken your medications late?’ (67% no, 33% yes). Responses to these questions correlated (χ2 65.2, p < 0.001; correlation coefficient 0.57, p < 0.001). We performed a logistic regression analysis to identify factors associated with the combined outcome of forgetting/not taking medications altogether or taking medications off schedule. Higher comorbidity index [odds ratio (OR) 2.19, p < 0.001], living (compared to deceased) donor (OR 2.81, p = 0.005) and full-time employment were associated with forgetting medications or taking them late (OR 3.12, p = 0.01). Recipient age tended to be associated with lower risk of nonadherence, but did not reach statistical significance (OR 0.98 per year of age, p = 0.13). Education level, smoking status, recipient race, dialysis modality, number of medications and the time since first kidney transplantation were not associated with the outcome. In conclusion, renal transplant recipients with greater comorbidity, receiving kidney from a living donor and with full-time employment reported lower levels of medication adherence.

Association Of Marital Status With Access To Renal Transplantation

In this report we evaluated the association of marital status with access to renal transplantation. We analyzed data from the USRDS. In patients with ESRD aged ≥27 (mean age of first marriage in the US), we analyzed the association of marital status with two outcomes: (1) likelihood of being placed on the waiting list for renal transplantation or first transplant, (2) likelihood of receiving kidney transplant in patients already listed. We analyzed marital status as a categorical variable: (1) not married (including never been married and widowed); (2) divorced or separated; and (3) currently married. Subgroups based on age, race, sex, donor type and diabetic status were also analyzed. After adjustments for the included independent variables and compared to individuals never married or widowed, those who were divorced/separated (HR 1.55, p < 0.001) and currently married (HR 1.54, p < 0.001) had a higher likelihood of being placed on the transplant waiting list. Once listed, married individuals had higher chances of getting transplanted as well (HR 1.28, p = 0.033). This trend was consistent in most of the subgroups studied. We demonstrated that being married is associated with better access to renal transplantation compared to those who were never married/widowed.

Impact of substance abuse on access to renal transplantation.

Background. With an ever-increasing demand for kidneys and limited supply pool, it is essential to understand the balance between utility and equity in transplant access. The goal of this project was to evaluate the association between recipients substance abuse and renal transplant access in patients with end-stage renal disease (ESRD). Methods. We used data from the United States Renal Data System. The primary variables of interest were abuse of alcohol, tobacco, or illicit drugs based on information from Centers for Medicare & Medicaid Services form 2728. We analyzed three outcomes in Cox model: (1) being placed on the waiting list for renal transplantation or transplanted (whichever occurred first); (2) first transplant in patients who were placed on the waiting list; and (3) graft loss or mortality after transplant. In addition, we performed subgroup analysis based on age, race, sex, diabetic status, and donor type. Results. We analyzed 1,077,699 patients (age of ESRD onset 62.9±15.5 years, 54.1% males, 64.2% white, and 29.7% African American). When compared with those with no substance abuse, abusing all three substances was associated with reduced transplant access (hazard ratio 0.39, P<0.001 for wait listing/transplant; hazard ratio 0.67, P=0.019 for transplant). This trend was similar in most subgroups studied. Conclusion. We demonstrated that patients with ESRD abusing or dependent on tobacco, alcohol, or illicit drugs are less likely to be placed on the waiting list for kidney transplant; and once on the list are less likely to be transplanted. The possible utility justifications for such disparity and potential interventions are discussed.

Education is associated with reduction in racial disparities in kidney transplant outcome.

In this study, we hypothesized that higher level of education might be associated with reduced racial disparities in renal transplantation outcomes.

Recipient's unemployment restricts access to renal transplantation

Equitable distribution of a scarce resource such as kidneys for transplantation can be a challenging task for transplant centers. In this study, we evaluated the association between recipients employment status and access to renal transplantation in patients with end‐stage renal disease (ESRD). We used data from the United States Renal Data System (USRDS). The primary variable of interest was employment status at ESRD onset. Two outcomes were analyzed in Cox model: (i) being placed on the waiting list for renal transplantation or being transplanted (whichever occurred first); and (ii) first transplant in patients who were placed on the waiting list. We analyzed 429 409 patients (age of ESRD onset 64.2 ± 15.2 yr, 55.0% males, 65.1% White). Compared with patients who were unemployed, patients working full time were more likely to be placed on the waiting list/transplanted (HR 2.24, p < 0.001) and to receive a transplant once on the waiting list (HR 1.65, p < 0.001). Results indicate that recipients employment status is strongly associated with access to renal transplantation, with unemployed and partially employed patients at a disadvantage. Adding insurance status to the model reduces the effect size, but the association still remains significant, indicating additional contribution from other factors.