Impact of Social Vulnerability on Access to Educational Programming Designed to Enhance Living Donation

Introduction Transplant candidate participation in the Living Donor Navigator Program is associated with an increased likelihood of achieving living donor kidney transplantation; yet not every transplant candidate participates in navigator programming. Research Question We sought to assess interest and ability to participate in the Living Donor Navigator Program by the degree of social vulnerability. Design Eighty-two adult kidney-only candidates initiating evaluation at our center provided Likert-scaled responses to survey questions on interest and ability to participate in the Living Donor Navigator Program. Surveys were linked at the participant-level to the Centers for Disease Control and Prevention Social Vulnerability Index and county health rankings and overall social vulnerability and subthemes, individual barriers, telehealth capabilities/ knowledge, interest, and ability to participate were assessed utilizing nonparametric Wilcoxon ranks sums tests, chi-square, and Fisher's exact tests. Results Participants indicating distance as a barrier to participation in navigator programming lived approximately 82 miles farther from our center. Disinterested participants lived in areas with the highest social vulnerability, higher physical inactivity rates, lower college education rates, and higher uninsurance (lack of insurance) and unemployment rates. Similarly, participants without a computer, who never heard of telehealth, and who were not encouraged to participate in telehealth resided in areas of highest social vulnerability. Conclusion These data suggest geography combined with being from under-resourced areas with high social vulnerability was negatively associated with health care engagement. Geography and poverty may be surrogates for lower health literacy and fewer health care interactions.

Development of an intervention to improve access to living-donor kidney transplantation (the ASK study)

A living-donor kidney transplant (LDKT) is one of the best treatments for kidney failure. The UK’s LDKT activity falls behind that of many other countries, and there is evidence of socioeconomic inequity in access. We aimed to develop a UK-specific multicomponent intervention to support eligible individuals to access a LDKT. The intervention was designed to support those who are socioeconomically-deprived and currently disadvantaged, by targeting mediators of inequity identified in earlier work. We identified three existing interventions in the literature which target these mediators: a) the Norway model (healthcare practitioners contact patients’ family with information about kidney donation), b) a home education model, and c) a Transplant candidate advocate model. We undertook intervention development using the Person-Based Approach (PBA). We performed in-depth qualitative interviews with people with advanced kidney disease (n = 13), their family members (n = 4), and renal and transplant healthcare practitioners (n = 15), analysed using thematic analysis. We investigated participant views on each proposed intervention component. We drafted intervention resources and revised these in light of comments from qualitative ‘think-aloud’ interviews. Four general themes were identified: i) Perceived cultural and societal norms; ii) Influence of family on decision-making; iii) Resource limitation, and iv) Evidence of effectiveness. For each intervention discussed, we identified three themes: for the Norway model: i) Overcoming communication barriers and assumptions; ii) Request from an official third party, and iii) Risk of coercion; for the home education model: i) Intragroup dynamics; ii) Avoidance of hospital, and iii) Burdens on participants; and for the transplant candidate advocates model: i) Vested interest of advocates; ii) Time commitment, and iii) Risk of misinformation. We used these results to develop a multicomponent intervention which comprises components from existing interventions that have been adapted to increase acceptability and engagement in a UK population. This will be evaluated in a future randomised controlled trial.

FC 119SURVIVAL BENEFIT OF KIDNEY TRANSPLANTATION COMPARED TO REMAINING ON WAITLIST ACROSS DIFFERENT AGES OF TRANSPLANT CANDIDATES: A RETROSPECTIVE COHORT STUDY USING TARGET TRIAL EMULATION

Background and Aims Kidney transplantation is considered to be the optimal treatment strategy for eligible end stage renal disease patients. However, the body of evidence to underpin the anticipated survival advantage for kidney transplant recipients is weak, as random treatment allocation to either kidney transplantation or remaining on dialysis is not feasible and previously reported results obtained from observational studies did not allow for causal interpretation. The aim of this study is to investigate survival differences of kidney transplantation compared to remaining waitlisted on dialysis across different transplant candidate ages applying causal inference methodology. Method We conducted a retrospective cohort study using the Austrian Dialysis and Transplant Registry. We included all maintenance dialysis patients who were waitlisted for their first kidney transplant between January 2000 and December 2018 and utilized repeated updates on waitlisting status and relevant covariates. To estimate the causal effect of kidney transplantation compared to remaining waitlisted on all-cause survival we applied a sequential Cox approach mimicking a series of target trials, where each trial started at the time of a transplantation. In each of these emulated trials transplanted patients were classified as treated and patients with current active waitlisting status as controls, and the groups were balanced for covariates by inverse probability weighting. Controls who were transplanted at later times were censored but assigned to the treated group in a later target trial of the series. All trials were combined into a single data set and analyzed by a Cox proportional hazards model using inverse probability weighting also to adjust for artificial censoring. Additionally, we evaluated potential effect modifications by age at trial initiation (continuous) and stratified our analyses by time on waitlist before trial initiation (up to 1 year, between 1 and 2 years, and more than 2 years). Results are reported as hazard ratios (HRs), 5-year survival probabilities and restricted mean survival time together with respective bootstrap confidence intervals (CIs). Results The study cohort consisted of 4206 patients, of whom one third were women and the mean age was 52 years. In total, 3399 patients (81%) received a transplant and 1256 patients died. The median time from waitlisting to transplantation was 1.8 years. Overall, patients who received a kidney transplant had a significant survival benefit compared to patients who remained waitlisted (HR 0.36, 95% CI 0.29 to 0.43). Assessing survival across different ages showed a significant benefit for kidney transplantation for patients between 32 and 77 years of age at time of transplantation (e.g. HR at age of 70: 0.43, 95% CI 0.33 to 0.54). For older and younger patients our analysis did not provide definitive conclusions due to limited sample sizes. Transplanted patients had higher predicted survival and longer restricted mean survival time compared to patients remaining waitlisted. For example, within 5 years after engraftment, a transplanted patient 70 years of age at trial initiation had a 0.28 higher survival probability (95% CI 0.20-0.37) and was expected to gain 0.75 years of survival time. Our stratified analyses showed a survival benefit for kidney transplantation regardless of time on waitlist before trial initiation across all ages. Conclusion Our study provides robust evidence based on state-of-the-art causal inference methodology for increased survival after kidney transplantation across different transplant candidate ages and irrespective of time on waiting list.