Q&A with Hopewell Health Advisor Dr. Jim Rodrigue

March 19, 2024

Q&A with Hopewell Health Advisor Dr. Jim Rodrigue

March 19, 2024

In this two-part Q&A series with Hopewell Health’s esteemed advisor Dr. Jim Rodrigue, we delve into the profound insights and innovative strategies aimed at addressing the pressing challenges and opportunities in kidney transplantation today. From dissecting the roots of inequity to pioneering transformative solutions, Rodrigue’s vision illuminates pathways toward a more equitable transplant landscape.

Stay tuned as we unravel Rodrigue’s insights and embark on a journey toward a more equitable future in kidney health.

From your extensive experience, what do you see as the most significant challenges and opportunities in kidney transplantation and/or living donor kidney transplantation today? How have these evolved over your career?

There are several challenges facing the field of kidney transplantation today. Fortunately, these challenges represent great opportunities for the transplant community. 

Most important among these challenges, in my view, is the critical shortage of donated kidneys compared to the growing number of patients on the transplant waiting list. On a very positive note, in the last 5 years, the number of deceased donor kidney transplants increased by 27%. In fact, there were more than 21,000 kidney transplants in 2023, the first time that’s ever happened. That’s a real testament to outstanding and complex work being done by Organ Procurement Organizations.

The flip side of this positive news about the rising number of kidney transplants performed is that there are two worrisome trends.

First, in these last 5 years, there’s been a 92% increase in the number of kidneys recovered by OPOs that have not been used by transplant programs – more than 8,000 kidneys in 2023. Reversing this trend is of paramount importance for all stakeholders, including donors, donor families, patients waiting for a transplant.

Second, the number of kidney transplants from living donors has dropped in the last 5 years. A living donor kidney transplant has many advantages, an important one being that the transplant kidney is likely to last longer. So, it’s critically important that we understand the reasons for this decline and do whatever we can to remove any disincentives to living kidney donation.

The other major challenge is the persistent racial and economic inequity in kidney transplantation access. Over the course of my career, there have been important advances in policy and clinical practice that have improved access to transplantation. But it remains the case that only a fraction of patients with end-stage kidney disease ever makes it to a transplant center for evaluation and is placed on the list for the best treatment available to them (transplantation). This is particularly true for Black patients, who are already disproportionately overrepresented among those with end-stage kidney disease. The National Academies issued a number of recommendations in 2022 to increase equity in the transplant system, and it’s incumbent upon us to most urgently heed this call for action.

In your research and professional observations, what are the primary sources of inequity in kidney transplantation, and how do they manifest in patient outcomes? Could you elaborate on the roles of socioeconomic status, race, and geography in these inequities?

For many patients with end-stage kidney disease, transplantation – particularly a living donor transplant – is the treatment with the best outcomes. But access to transplant programs, and therefore the waiting list, is more limited for certain racial and ethnic minorities, those who live at or below the poverty line, and patients living in rural areas where distance to a transplant program is a major barrier.

Further upstream, Black patients have a disproportionately high prevalence of kidney disease relative to the Black population, they are often diagnosed with kidney disease much later in the disease process, and they are less likely to be referred for transplantation in general. When they are referred for transplant evaluation, they are more likely to have been on dialysis longer, which increases their risk of death while waiting and leads to less-than-optimal outcomes after transplantation. Moreover, if a Black patient makes it onto the waiting list, they are substantially less likely to receive a living donor kidney transplant, compared to patients of all other races or ethnicity.

Another inequity is that patients of lower socioeconomic status have less access to transplantation. Patients with limited financial resources are more likely to have unstable housing, barriers to reliable transportation, difficulty affording medications, limited social support, and other complex psychosocial needs, which are all relative contraindications to transplantation. Thus, they are referred for transplant evaluation less often and, when referred, are less likely to be added to the waiting list. If on the waiting list, their access to living donor transplantation is very limited because of the out-of-pocket expenses and missed work time members of their social network are likely to face as potential living donors. The United States is one of the few countries that does not compensate all living kidney donors for out-of-pocket expenses and lost wages associated with living kidney donation. While there is a national program to offset some of the expenses associated with living donation, living donors and patients must meet certain financial thresholds, which significantly limits its reach.

There have been national policy changes in recent years designed to increase equity in kidney transplantation, there remains much to be done to overcome decades of discrimination in healthcare generally, and in kidney transplantation specifically.

Based on your studies and initiatives, what innovative strategies would you recommend for increasing living kidney donations while ensuring the safety and well-being of donors and recipients?

Living kidney donation declined during the COVID pandemic and have not yet returned to pre-pandemic levels. Additionally, the growth in living donation lags behind the growth in deceased donation, making this an important priority area for ensuring that those who are healthy and motivated are able to donate a kidney.

Several innovative strategies have been developed to increase the number of living donors in the United States. All of these programs are designed to help patients find potential living donors and some also disseminate information to the patient’s family.

More than 20 years ago now, we developed Transplant House Calls (THC), an innovative transplant educational program designed to: (a) educate patients and their social network members about ESKD, transplantation (including LDKT), and living donation, (b) facilitate discussions between the patient and their social network about LDKT and living donation, and (c) reduce feelings of distrust and bias about the transplant process. Trained THC Educators deliver transplant-related educational content to the patient and members of their social network in the patient’s home or using a virtual platform.

The THC approach has several advantages over education delivered in transplant centers, including: engaging family members, friends, and other social network members who otherwise cannot attend transplant clinic appointments; directly providing potential living donors in the patient’s social network with information that is most relevant to their decision-making; convenience for transplant patients who may have multiple comorbidities; and secondary benefits of educating others about kidney disease and its treatment options. For racial and ethnic minorities, THCs provide an opportunity to talk openly about racial inequities and structural racism in healthcare generally, and racial disparities in transplantation specifically.

The THC program has been shown to increase the number of people in the patient’s social network who inquire with the transplant program about living donation, who undergo evaluation as a potential living donor, and who actually donate a kidney.

Stay tuned next week for Part 2!

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