Inequities in Pediatric Kidney Transplantation

All children with CKD should have access to timely and high-quality kidney care that enables them to live long and full lives. In the case of kidney failure, gold-standard care typically involves kidney transplantation, ideally preemptive transplantation from a living donor, to maximize graft and patient survival, quality of life, and avoid the burdens of dialysis on school, social life, and caregiver work and income. The stark reality is that this is not the case—globally, children experiencing socioeconomic disadvantage, from minoritized racial and ethnic groups, and in lower resource settings are less likely to receive the care that they need to thrive.1,2 This issue of Kidney360 highlights these inequities with an important paper from Fairless et al.3 reporting on their retrospective observational study of racial and ethnic and socioeconomic inequities in access to preemptive and living kidney transplantation among 343 pediatric kidney transplant recipients at Texas Children's Hospital from 2000 to 2022. Among other social factors, the authors examined access to transplantation across race and ethnicity and area-level socioeconomic deprivation using the multidimensional Area Deprivation Index (ADI), which comprises 17 items related to neighborhood disadvantage, including housing, income, employment, and education. Using logistic regression, the authors identified lower odds of preemptive living donor kidney transplantation for Black children (compared with White children) and children living in more socioeconomically disadvantaged neighborhoods (compared with neighborhoods with more advantaged ADI scores). Black children (compared with White children) and children in more disadvantaged neighborhoods (compared with more advantaged) were also more likely to receive a deceased donor kidney transplant (compared with living donor), although the ADI finding was NS in the adjusted model. For Hispanic children, inequities were present in unadjusted but not adjusted models—potentially because adjusted models included neighborhood disadvantage, which may be an explanatory factor for these inequities. Although time to waitlisting/transplantation was also examined, it did not differ across race and ethnicity or ADI. The study's sobering findings are powerfully illustrated by the descriptive statistics for preemptive transplantation—received by 34% of non-Hispanic White children in socioeconomically advantaged areas compared with 9% of White children in disadvantaged areas, 23%/18% of Hispanic children in advantaged/disadvantaged areas, respectively, 6% of Black children in advantaged areas, and 0% of Black children in disadvantaged areas. These findings mirror those seen time and time again globally for children with CKD experiencing socioeconomic disadvantage or who are minoritized in relation to their race, ethnicity, or other social factors such as Indigeneity or migratory status.1,2 This includes lower rates of preemptive transplantation for children living in more socioeconomically disadvantaged areas or of Black or Asian ethnicity in the United Kingdom4 and reduced access to preemptive transplantation among Indigenous children and young people in Australia, Canada, and New Zealand.5 Many children also face inequities related to their migratory status—for undocumented children in the United States, lack of federal funding for transplantation and post-transplant care often poses insurmountable financial barriers.6 At the global level, many children in lower resource settings do not have access to kidney transplantation at all, with a recent global survey of low-and middle-income countries finding that only one third of centers can provide pediatric transplantation.7 Where transplantation is available, it may require a long wait, be inaccessible because of catastrophic out-of-pocket costs, or families may discontinue treatment entirely because of geographic or financial barriers.1 These social inequities in access to kidney care, like many other health and health care inequities around the world, are avoidable and unjust—simply put, it should not be this way and it does not have to be. Inequities in the distribution of power, money, and resources contribute to differences in the conditions in which children are born, grow, live, learn, and play.8 These social determinants of health play a key role in shaping health outcomes and opportunities throughout life.8 At the most upstream level, this involves structural factors across political, economic, social, and environmental domains. Globally, this includes inequities in economic power, social status, health care resources/infrastructure and workforce, knowledge production, and sharing between higher and lower resource countries.1 Global social, economic, and political forces (e.g., economic and political instability, war and conflicts, popularity of political ideologies such as populism and authoritarianism) are also fundamental upstream drivers that flow on to within-country drivers of inequities in access to care and health outcomes for children with CKD, including who is in power across levels of government and the policies they implement across sectors. This includes migration (e.g., availability of health insurance for undocumented children), housing, education (which influences families' health literacy and economic opportunities), welfare/employment (e.g., sufficiency of income payments to prevent child poverty, availability of leave and income support for donors), transport (e.g., public transport to enable travel to care), and health (e.g., costs of primary/preventative care, which facilitates early detection of CKD to enable preemptive transplantation). All of these factors then flow on to families' socioeconomic and material circumstances (e.g., educational attainment, employment, income, and housing), which in turn determine psychosocial stress; health literacy; access to nutritious foods; social support; and ability to reach, pay for, and engage in care at the more downstream level (including families' knowledge, confidence, and activation in transplant processes) as well as their health through multiple pathways.1,2 Racism operates across multiple levels, shaping societal structures and individual experiences.9 At a broader level, structural racism can contribute to inequities through discriminatory societal systems and policies, which result in disparate opportunities for minoritized individuals, while institutional racism may be reflected in health care institutions through policies and practices that pose barriers to equitable care.9 Racism can also operate at an interpersonal level through interpersonal discrimination.9 Racism compromises health and access to care for minoritized children, including transplantation. This includes structural factors leading to socioeconomic disadvantage for minoritized families, experiences of bias and discrimination in health care interactions, policies that inadvertently create barriers to transplantation, limited availability of culturally responsive services, and experiences of historical injustices and colonization that compromise trust in the health care system.1 Time and time again, we see that children with less access to power, money, and resources have reduced access to kidney care and poorer kidney health outcomes. The challenges of treating inequities often overwhelm the resources of the health system and leave little capacity for looking upstream, leading to a focus on downstream factors that feel more within our grasp, such as engagement in care. However, if we do not find a way to address the upstream drivers, we are destined for an inequitable future for the next generation. This is illustrated by the well-known story of the river10:“There I am standing by the shore of a swiftly flowing river and I hear the cry of a drowning man. So I jump into the river, put my arms around him, pull him to shore and apply artificial respiration. Just when he begins to breathe, there is another cry for help. So I jump into the river, reach him, pull him to shore, apply artificial respiration, and then just as he begins to breathe, another cry for help. So back in the river again, reaching, pulling, applying, breathing and then another yell. Again and again, without end, goes the sequence. You know, I am so busy jumping in, pulling them to shore, applying artificial respiration, that I have no time to see who the hell is upstream pushing them all in.” There is a critical need to use our voices as a kidney community to agitate for lasting upstream structural change on social, political, economic, and environmental factors that drive inequities in children's kidney care and health, working in partnership with patients, families, and communities.1,4 This includes increasing representation of minoritized communities in positions of political and health leadership; advocating for universal health care and government action on social and economic factors such as poverty, housing, and education; holding governments to account for structural racism; tackling institutional racism in the health system; and at the global level sharing resources and power.1,4 As a research community, we also need to direct our gaze upstream and drive action on inequities—prioritizing research on neglected areas, such as structural and institutional racism, developing equitable and sustained partnerships with patients and families from affected communities to coproduce research that addresses community priorities, and shifting the balance of health equity research toward solution-oriented work to identify what works, for whom, and in which contexts. This will require cross-disciplinary partnerships with areas such as economics, politics, and sociology and adoption of diverse methods including natural experiments, causal inference methods, and policy studies to examine effects of social, economic, and political factors on kidney care and health as well as implementation science and mixed-methods approaches to examine interventions at the health system level. Health professionals can also take action within the clinic—screening for social determinants of health and referring to services for unmet social needs, training mentees to understand health inequities and provide culturally safe and culturally sensitive care, and supporting efforts to tackle institutional racism.1 Inequities in kidney care and health are a complex and challenging problem, one without a single solution. Creating lasting change requires us to act in solidarity as a global nephrology community to work toward a fairer world for all children with CKD. To address the inequities highlighted in this important work by Fairless et al.,3 we must all take action locally in our clinical and research work and advocate for upstream change nationally and globally on social, economic, political, and environmental factors.

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