Reaching Equity in ACess to Home Dialysis And Re-Transplantation (REACH-DART)

PROJECT ABSTRACT Kidney transplantation and home dialysis are the preferred treatment modalities for end-stage kidney disease (ESKD) given the better quality of life and lower cost of these modalities compared with in-center hemodialysis. However, in patients with graft failure, rates of preemptive re-listing for a second kidney transplant and use of peritoneal dialysis (PD) are suboptimal, especially in Black and Hispanic kidney transplant recipients (KTRs). While barriers in access to transplantation or PD in transplant-naïve patients have been attributed to lack of patient awareness of their kidney disease, late referral for subspecialty care, and inadequate education, these factors should not apply to a population that already received a kidney transplant, were likely exposed to dialysis before their first transplant, and who have access to nephrology care. Disappointingly, only half of KTRs treated with PD before their kidney transplant choose to return to this modality following graft failure, and only 15% of patients with graft failure are relisted preemptively for a second kidney transplant. The rate of PD use and relisting is particularly low in Black and Hispanic KTRs with graft failure. Identifying barriers that can be addressed to improve access of former KTRs to home dialysis and repeat transplantation will not only improve the outcomes of patients with graft failure, but also inform our understanding of the roadblocks that are present even when access to care is unlikely to be the explanatory factor. In Aim 1, we propose to model the time spent in the advanced stages of graft dysfunction and determine whether there are racial or ethnic disparities in this time, which is critical for the preparation of patients for the next phase of their disease. We will then determine if the time spent in the advanced stages of graft dysfunction is associated with access to PD or re-registration on the waitlist for a second kidney transplant. In Aim 2, we will perform semi-structured interviews with patients, dialysis providers, and transplant providers to understand their perceptions of the barriers to PD and preemptive relisting. We will then use the data derived from these qualitative interviews to develop a survey that will be administered nationally to confirm the importance of these barriers and identify strategies that can be used to surmount these barriers. In Aim 3, we will examine system-level factors that may contribute to disparities in preemptive relisting on the national waitlist and PD access, including variations in the use of objective assessments of frailty during candidacy evaluations and the frequency of follow-up contact between KTRs and their transplant center peri-graft failure. To accomplish our aims, we will leverage data from the United States Renal Data System that will be linked to Medicare, Medicaid, and Optum claims data. In a subset of patients, we will collect more granular local data from electronic health record systems to enrich these administrative data. The data from this proposal will inform the interventions, best practices, and policies that are needed to promote access to repeat transplantation and PD.