Racial and Income-Based Disparities in Access to Kidney Transplantation in the Context of a Nationally-Financed Health System in Brazil

A. Saha¹, G. Ferreira², Y. Yu¹, M. Waldram¹, V. Colares², J. Bastos², M. Henderson¹, D. Segev¹, A. Massie¹

¹Surgery, Johns Hopkins School of Medicine, Baltimore, MD, ²Santa Casa de Misericordia de Juiz de Fora, Juiz de Fora, Brazil

Meeting: 2019 American Transplant Congress

Abstract number: 618

Keywords: Economics, Kidney transplantation, Waiting lists

Session Information

Session Name: Concurrent Session: Non-Organ Specific: Disparities and Access to Healthcare II

Session Type: Concurrent Session

Date: Tuesday, June 4, 2019

Session Time: 4:30pm-6:00pm

Presentation Time: 5:30pm-5:42pm

Location: Room 208

*Purpose: Changes in economic and social factors in low- and middle-income countries have led to rising burden of chronic disease. Brazil, a middle-income country with the second-largest volume of transplants in the world, has a nationally-financed healthcare system. We studied whether demographic and socioeconomic factors influence access to kidney transplantation in a Brazilian transplant center.

*Methods: We analyzed time to DDKT and LDKT among 827 KT registrants from 2012-2018 at a large transplant center in Brazil, using multivariable Cox regression adjusting for age, sex, race (White/Asian, Black, or pardo (mixed-race)), and income quartile (Q₁ (lowest)-Q₄ (highest)). We studied LDKT with DDKT as a competing risk and vice versa and performed a mediation analysis for race, income, and access to transplantation.

*Results: Compared to White/Asian patients, Black (aHR: _0.390.59_0.93, p=0.02) and pardo (aHR: _0.340.55_0.88, p=0.01) patients had lower access to LDKT (Table 1). These associations were partially mediated by differences in income for pardo patients (including income, aHR(pardo)=0.86). Older patients were less likely to receive LDKT (aHR: _0.630.73_0.85, p=<0.01). Patients in income Q₃ (aHR: _1.262.48_4.86, p<0.01) and Q₄ (aHR: _1.082.25_4.70, p=0.03) had substantially higher access to LDKT than those in Q₁.

*Conclusions: Despite having a nationally-financed transplantation system, lower-income, black, and pardo patients face substantially lower access to LDKT than higher-income, white and Asian patients. Access to kidney transplants is largely, but not completely, mediated by income. Even in the context of public financing, disparities in access to healthcare persist in this setting.

Table 1. Association of Clinical and Demographic Characteristics and Access to Transplantation
	DDKT		LDKT
	aHR	p-value	aHR	p-value
White/Asian	REF		REF
Black	_0.801.08_1.45	0.62	_0.370.59_0.93	0.02
Pardo	_1.111.51_2.04	0.01	_0.340.55_0.88	0.01
Male	REF		REF
Female	_0.480.63_0.81	<0.01	_0.801.15_1.64	0.46
Age at listing (per10 years)	_1.011.12_1.25	0.04	_0.630.73_0.85	<0.01

Table 2. Association of Income and Access to Transplantation
	DDKT		LDKT
Income Quartile	aHR	p-value	aHR	p-value
Q₁	REF		REF
Q₂	_1.171.84_2.87	0.01	_0.501.07_2.26	0.87
Q₃	_0.560.95_1.61	0.85	_1.262.48_4.86	0.01
Q₄	_0.791.30_2.15	0.30	_1.082.25_4.70	0.03
*Adjusted for age, race, and sex.

To cite this abstract in AMA style:

Saha A, Ferreira G, Yu Y, Waldram M, Colares V, Bastos J, Henderson M, Segev D, Massie A. Racial and Income-Based Disparities in Access to Kidney Transplantation in the Context of a Nationally-Financed Health System in Brazil [abstract]. Am J Transplant. 2019; 19 (suppl 3). https://atcmeetingabstracts.com/abstract/racial-and-income-based-disparities-in-access-to-kidney-transplantation-in-the-context-of-a-nationally-financed-health-system-in-brazil/. Accessed May 18, 2025.

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