title: Overall Graft Loss Versus Death-Censored Graft Loss: Unmasking the Magnitude of Racial Disparities in Outcomes Among US Kidney Transplant Recipients.
abstract: BACKGROUND
  Black kidney transplant recipients experience disproportionately high rates of graft loss. This disparity has persisted for 40 years, and improvements may be impeded based on the current public reporting of overall graft loss by US regulatory organizations for transplantation.
  
  
  METHODS
  Longitudinal cohort study of kidney transplant recipients using a data set created by linking Veterans Affairs and US Renal Data System information, including 4918 veterans transplanted between January 2001 and December 2007, with follow-up through December 2010. Multivariable analysis was conducted using 2-stage joint modeling of random and fixed effects of longitudinal data (linear mixed model) with time to event outcomes (Cox regression).
  
  
  RESULTS
  Three thousand three hundred six non-Hispanic whites (67%) were compared with 1612 non-Hispanic black (33%) recipients with 6.0 ± 2.2 years of follow-up. In the unadjusted analysis, black recipients were significantly more likely to have overall graft loss (hazard ratio [HR], 1.19; 95% confidence interval [95% CI], 1.07-1.33), death-censored graft loss (HR, 1.67; 95% CI, 1.45-1.92), and lower mortality (HR, 0.83; 95% CI, 0.72-0.96). In fully adjusted models, only death-censored graft loss remained significant (HR, 1.38; 95% CI, 1.12-1.71; overall graft loss [HR, 1.08; 95% CI, 0.91-1.28]; mortality [HR, 0.84; 95% CI, 0.67-1.06]). A composite definition of graft loss reduced the magnitude of disparities in blacks by 22%.
  
  
  CONCLUSIONS
  Non-Hispanic black kidney transplant recipients experience a substantial disparity in graft loss, but not mortality. This study of US data provides evidence to suggest that researchers should focus on using death-censored graft loss as the primary outcome of interest to facilitate a better understanding of racial disparities in kidney transplantation.
authors.affiliation: 1 Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC. 2 Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC. 3 Division of Transplant Nephrology, College of Medicine, Medical University of South Carolina, Charleston, SC. 4 Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H Johnson VAMC, Charleston, SC.
authors.forename: David J
authors.initials: DJ
authors.lastname: Taber
authors.forename: Mulugeta
authors.initials: M
authors.lastname: Gebregziabher
authors.forename: Elizabeth H
authors.initials: EH
authors.lastname: Payne
authors.forename: Titte
authors.initials: T
authors.lastname: Srinivas
authors.forename: Prabhakar K
authors.initials: PK
authors.lastname: Baliga
authors.forename: Leonard E
authors.initials: LE
authors.lastname: Egede
mesh_terms: D000328:Adult; D001741:Black or African American; D000368:Aged; D016009:Chi-Square Distribution; D016208:Databases, Factual; D005260:Female; D006085:Graft Survival; D054624:Health Status Disparities; D054625:Healthcare Disparities / Q000208:ethnology*; D006801:Humans; D053208:Kaplan-Meier Estimate; D016030:Kidney Transplantation / Q000009:adverse effects* / Q000401:mortality; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D017064:Process Assessment, Health Care; D016016:Proportional Hazards Models; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs; D044465:White People