Forging a path toward kidney transplant equity through multilevel interventions

Abstract

Purpose of review

Persistent disparities in access to kidney transplantation, particularly living donor transplant and preemptive transplant, have gained increasing national attention including efforts to describe their multifactorial root causes. Multilevel structural impediments occurring at the recipient, donor, clinician, and health system level contribute to these disparities. This review overviews these key barriers, as well as recent successful interventions designed to address longstanding disparities.

Recent findings

Several systems-level interventions including the Systems Intervention to Achieve Early and Equitable Transplants (STEPS) study (NCT05014256) may offer effective solutions to address critical roadblocks that lead to living donor kidney transplantation (LDKT) disparities by leveraging health system capabilities, coupled with individually-tailored support. Novel approaches leveraging community-based organizations, tele-health programs that overcome physical and transport related barriers, transplant navigators, and other individuals trained to meet patients’ specific needs as they navigate complex transplant journeys, also offer promise. In addition, programs that fast-track complex evaluation requirements through tailored coordination offer promise to reduce racial and ethnic disparities in transplant receipt.

Summary

The success and sustainability of future interventions designed to eliminate longstanding transplant disparities will require concerted investments in multilevel interventions and access-enhancing policies that address the cascade of barriers impacting patients, donors, clinicians, and health systems.

INTRODUCTION

Decades-long, persistent racial, ethnic, and place-based disparities in access to and receipt of kidney transplantation, especially living donor and preemptive transplantation, require systems-level change and structural interventions [1–5,7–10]. Despite multiple intervention efforts, living donor kidney transplantation (LDKT), which confers superior outcomes for graft survival and morbidity when compared to deceased donor transplant and other dialysis modalities, demonstrated worsening racial disparities with Black individuals being at least 70% less likely to receive living donor kidney transplants compared to White individuals [4,11].

Little progress has been made to close preemptive transplant disparities despite progress in reducing deceased donor kidney transplant racial disparities resulting from numerous efforts, including revisions to the 2014 kidney allocation system [1–4]. Evidence suggests stark and persistent disparities in preemptive and LDKT are deeply rooted in structural impediments emanating at recipient, donor, clinician, and health system levels. Few interventions have addressed contributors to disparities at these often-intersecting levels. In this review, we review a range of contributors to transplant equity and describe potential novel structural interventions that are currently being studied across diverse settings. We also summarize key evidence to inform future interventions designed to enhance transplant equity.

STRUCTURAL IMPEDIMENTS TO LIVING DONOR OR PRE-EMPTIVE KIDNEY TRANSPLANTS

Recipient level impediments

Cascading structural impediments disproportionately impact disadvantaged individuals with kidney disease and contribute to well described disparities in receipt of LDKT and preemptive kidney transplant [1,2,12]. Potential recipient low transplant knowledge, inadequate education reciept about transplant [8], poor health literacy, suboptimal social support [62], and barriers to sustained motivation (including complexity, lack of transparency in the transplant process), have been identified as areas requiring intervention [5,6,39,63–65]. A landmark study found that significant number of patients initiating dialysis had not received transplant specific education and that patients with older age, public or no insurance, and for profit dialysis units were less likely to be assessed for transplant when compared to their counterparts [7]. In the Talking About Live Kidney Donation study of individuals with advanced chronic kidney disease, Black individuals, women, and individuals with lower income less than $20 000 were less likely to have discussed transplant (vs. dialysis) when compared to White individuals, men, and those with higher [8] income.

Financial barriers also uniquely impact LDKT and other transplant disparities. Individuals with limited finances are less likely to receive LDKT [9] and or preemptive transplants [10]. Quantitative studies demonstrate that transplant recipients have higher income and fewer concerns regarding transplant costs vs. non recipients [11]. Qualitative studies have corroborated these findings. For instance, a focus-group based study of African–American and non-African–American pretransplant patients highlighted many concerns regarding costs of transplant and donor evaluation, as well as post transplantation financial fears (cost of immune suppression, loss of insurance) and living donor experiences [12]. In other studies, financial concerns outweighed fears about transplantation, specifically concerns about transportation, scheduling, the operation, and medications and their coverage posttransplant [9,10,13].

Donor-level impediments

One contributor to disparities in LDKT or preemptive kidney transplants is a lesser availability of living donors. Several interrelated factors have been hypothesized to contribute to lower rates of donation among minoritized groups for whom trust of the medical institution, and socio-structural barriers related to historic, present-day and vicarious bias and harm are critical considerations [14]. For instance, several studies have documented potential bias in kidney clinicians’ consideration of donor characteristics including perceptions of lower clinical suitability [15], race-related concerns regarding genetic risk such as having one to two high-risk APOL1 alleles (which among Black Americans impact 11–14% of the population) [16–19], and inaccurate presumptions that specific racial groups have smaller social networks [20]. Social-network focused analyses have demonstrated that Black candidates report similar access to living donor networks when compared to White counterparts [21], thereby refuting harmful stereotypes.

Clinician level impediments

Healthcare provider biases, inaccurate assumptions regarding candidacy, and inappropriate referral patterns may contribute substantially to inequities in access to LDKT or preemptive transplants. Several studies have demonstrated that Black Americans are significantly less likely to be referred for preemptive transplantation when compared to their White counterparts [22]. In one study, adult patients referred for kidney transplant in the Southeastern US, Black individuals had a 59% lower rate of transplant than White individuals even after adjusting for demographic, clinical and SES factors [32▪▪]. In a separate study, Black individuals had 22% higher rates of referral but had lower evaluation starts when compared with White non-Hispanic individuals [32▪▪]. In a Georgia study, the odds of Black individuals being preemptively referred for transplant evaluation were 37% lower than for white individuals from 2005 to 2012 data [22].

Clinicians’ inadequate understanding of racial inequities or misperceptions of “disinterest” among Black and other patients may further exacerbate the long-described inadequate attention to eliminating disparities in referral [23]. In a qualitative study of 250 nephrologists, those with two or fewer transplant centers within 50 miles were more likely to report inadequate social support or patient age greater than 65 years as reasons to exclude patients from referral [24]. Finally, fragmented kidney care for people with ESKD and advanced CKD, including poor communication and lack of interoperable referral systems between patients, caregivers, clinicians, and transplant centers, also exacerbates disparities and requires urgent solutions [25].

Residential, place-based and policy-level impediments

Several structural factors that impact patients’ journeys are context and place-specific such as those occurring at the neighborhood and residential level, as well as those influenced by broader, state, and national policies (e.g., Medicaid expansion). In Table 1, we highlight evidence and summarize key points from studies examining the association between residential and neighborhood contexts, policy change, and transplantation.

Table 1.

Exemplar studies describing domains of transplant access and equity

Domain of investigation	Exemplar studies	Summary points and considerations
Rurality and transplant access	A retrospective study of a 5-year US cohort between 1999 and 2004, found that residents in areas classified as rural or small town were significantly less likely to be waitlisted for kidney transplant (RR = 0.92; 95% CI, 0.90–0.95; P < 0.001) or to have a completed receipt of a kidney transplant (covariate-adjusted RR = 0.90; 95% CI, 0.88–0.93; P < 0.001) [61]. This disparity was postulated to reflect heightened difficulty in completing the complex referral and evaluation process when living at a farther distance from a transplant center exacerbated by rural workforce shortages. A cross-sectional study of 552,279 patients who initiated dialysis between January 1, 1995, and December 31, 2002, found that the association of rural residence with survival and time to transplant differed by racial-ethnic group. Importantly, Black adults living in rural areas were less likely to be transplanted than their urban counterparts [62]. In a cohort of 699,751 adult patients with kidney failure who initiated kidney replacement therapy between 1995 and 2007, time to transplantation was not significantly lower among individuals who were more remotely located than for those living closer for any of the subgroups (race, sex, and insurance status) that significantly modified the relationship of distance from the transplant center and the likelihood of transplantation [63]. After adjusting for distance from the closest transplant center, those living in rural areas had a small but statistically significant increase in the adjusted likelihood of transplantation compared with their urban residing counterparts. Additional, no significant differences were identified in waitlist times between rural and urban areas. In a Southeastern study of adults with ESKD from GA, NA, and SC facilities evaluated from 2012 to 2015, there was no significant association between distance to a transplant center and likelihood of transplant referral or evaluation initiation [64]. A pediatric study of 18530 children examined between 2000 and 2019 found better LDKT access among individuals living in rural and micropolitan areas compared to individuals living in metropolitan areas [65]	• Discussions regarding transplant equity have long considered the role of physical access to transplant centers and resources required to complete transplant workups in individuals’ ability to successfully complete the complex process of evaluation and waitlisting. • Quantitative studies evaluating differences in waitlisting times and transplant receipt in patients from rural communities compared to urban have yielded largely mixed results. • Compounding or intersecting barriers uniquely burden rurally-located, minoritized populations. These factors such as poverty, must be considered within the context of other intersecting factors, including race-ethnicity specific experiences of rurality [66].
Neighborhood resources and residential contexts	Black (63.8%) and Hispanic (66.7%) individuals living with kidney failure were twice as likely than White (27.4%) individuals to live in resource-deprived [measured by the social deprivation index (SDI) and other indices] neighborhoods [67]. Among these individuals, those living in neighborhoods with greatest resource deprivation had lower rates of LDKT receipt [67]. In a USRDS-based analysis from 2023, Black individuals living in the least deprived neighborhoods had lower rates of LDKT receipt vs. White individuals living in the most deprived neighborhoods, suggesting multifactorial contributors to racial gaps beyond the level of the neighborhood [67]. Living in neighborhoods with greater poverty was associated with decreased likelihood of waitlisting for Black and White individuals in all poverty categories, suggesting that neighborhood factors influence transplant waitlisting across SES and racial groups [68]. Living in neighborhoods with greater poverty was associated with decreased likelihood of waitlisting for Black and White individuals in all poverty categories, suggesting that neighborhood factors influence transplant waitlisting across SES and racial groups [68]. In a multicenter cross sectional study of 19287 transplant recipients who underwent transplant in 2018, only 13% (760) of LDKT recipients were Black vs. 80% (4865) who were White [69]. Racial disparities persisted in LDKT receipt even after adjusting for community-level vulnerability and recipient-level characteristics, such that Black recipients had 37% lower likelihood of LDKT (aRR, 0.63; 95% CI, 0.59–0.67; P<0.001) and recipients of other races had 24% lower likelihood of LDKT (aRR, 0.76; 95% CI, 0.70–0.82; P<0.001) compared with White recipients [69]. A study of 162587 candidates for kidney transplant examined between 1995 and 2021 wherein first time LDKT receipt was a primary outcome, structural racism-related factors were hypothesized to be a fundamental driver of hypothesized disparities. The authors’ findings that living in a high-segregation neighborhood was associated with 10% (adjusted hazard ratio [AHR], 0.90 [95% CI, 0.84–0.97]) lower access to LDKT relative to residence in low-segregation neighborhoods among Black (but not White candidates) suggest that for Black individuals, the compounding effects of interpersonal racism and community-level disinvestment due to structural and systemic racism require multilevel intervention [70▪▪] Most notably, in this study, being listed in transplant centers in high segregation neighborhoods was demonstrated to be related to lower LDKT access relative to individuals listed at centers within low-segregation neighborhoods. This finding suggests transplant center resources and infrastructure may influence key outcomes [70▪▪].	• A large body of work demonstrates the impact of neighborhood and residential factors (e.g., resource availability, neighborhood poverty) on transplant access • Neighborhood or area-level poverty and resource deprivation appears to have associations with receipt of transplant across multiple racial and ethnic groups, and may be a potent target for policy interventions. • Given the compounding burden of resource deprivation and other forms of bias/discrimination for specific subgroups, intersectional analyses which consider the compounding effects of neighborhood-level resource deprivation on minoritized individuals are essential. • Center-level resources and community investments may be needed to mitigate the adverse contributions of resource deprivation on transplant access
Policy changes (e.g., Medicaid) and transplant access	Medicaid expansion contributed to larger increases in Medicaid coverage among racial and ethnic minority preemptive KT listings than White KT listings post-KAS [71]. Black individuals had a lower odds OR 0.41 (CI: 0.37–0.45) of receiving a preemptive deceased donor kidney transplant vs. White counterparts since 2015 (vs. OR 0.48 before KAS implementation) [72]. This same analysis demonstrated reduced access among individuals with Medicare vs. private insurers [72]. In an analysis designed to explore whether race and primary-payer together contribute to racial disparities, cumulative incidence of LDKT was lowest for Black candidates regardless of payer. More specifically, among 9639 candidates who received an LDKT between 2015 and 2016, only 13% were African American and when compared to African–American/Non-Medicaid candidates, the adjusted likelihood of LDKT was higher for both Non-African–American/Medicaid (HR 1.60, 95% CI 1.43–1.78) and Non-African–American/Non-Medicaid candidates (HR 2.66, 95% CI 2.50–2.83) [73]. A study examining racial equity in Black White LDKT rate ratios demonstrated no substantial improvement in equity occurred across US transplant centers between 2008 and 2018, even after accounting for modifiable center-level characteristics [57]. In this study, several characteristics were associated with improved LDKT rates for Black individuals which included higher patient educational levels, state-level Medicaid expansion, as well as center level LDKT volume as a ratio of total KT [57].	• Several studies suggest that interventions exclusively focused on addressing individual SES and access to healthcare may be insufficient to close wide disparities in transplantation. • Specific structural barriers impacting patients (e.g., insurance status) should be coupled with center and state-policy level to achieve equitable outcomes.

INTERVENTIONS TO ADDRESS LIVING DONOR OR PRE-EMPTIVE KIDNEY TRANSPLANT DISPARITIES

Recipient and donor-level interventions

Coordinated patient-centered support is essential to aid patients and their loved ones to overcome barriers to completion of the complex steps toward preemptive transplant and specifically LDKT [26,27]. However, many interventions to date have focused on patient-facing education, social support, and resources, including financial assistance. Many of these have inadequately addressed the multilevel structural barriers to transplant, and few have engaged navigators [23,62–66]. This is a critical gap because a leading cause of inactive status among new transplant listings includes incomplete candidate workups [2,28], which often relate to navigating complex referral and evaluation steps. In one study, Black patients were less likely to have completed pretransplant evaluation requirements vs. White counterparts and Black race was associated with time to completion of the transplantation [28]. These incomplete workups may not simply reflect personal fears, knowledge or beliefs, but rather a complex set of socio-contextual barriers that occur at an interpersonal (e.g., prior discrimination increasing a sense of low trust in the system) or financial strain [12].

Despite substantial intervention efforts to increase patient-level knowledge, decision-support, and other instrumental support around transplantation discussions, many of these individual-level education-focused interventions alone have not effectively reduced racial disparities or increased waitlisting, though studies have shed light on ideal educational strategies [66–69,70▪▪]. In the TALKS study, a social worker transplant intervention alone or paired with living donor financial assistance did not significantly increase LDKT activation events or receipt among African American candidates [29]. In a separate study comparing culturally tailored home vs. clinic-based LDKT education, patients receiving clinic and home-based education regarding LDKT had significantly more LDKT receipt, evaluation, and LDKT inquires vs. clinic-based education alone [30]. Individually tailored education delivered continuously over time demonstrated modest effects on LDKT readiness. For instance, among 802 patients enrolled into standard of care vs. an individually tailored coaching and education program for transplant delivered at 4 points in time, intervention group participants had significantly increased LDKT readiness and transplant knowledge and pursuit vs. standard of care [31]. Finally, a multicomponent cluster randomized trial in Canda which enrolled 20, 375 patients from CKD programs to receive administrative support, transplant education, living transplant donor story sharing, and program performance report review by transplant administration [32▪▪] showed promise. Although this robust, stakeholder informed pragmatic trial had high intervention uptake even during the COVID-19 pandemic, significant differences in completion of transplant steps were not detected. Null findings from this trial and others suggest that future interventions may target systems-level and structural investment (e.g., addressing key resource barriers) in patient-level interventions [33]. Additionally, analyses including the APOLLO study will yield important insights about the role of genetic risk on long term donor outcomes, potentially mitigating effects of imprecise decision-making related to race [34].

Clinician-level interventions

Several recent studies have tested interventions to improve equitable referral for transplant. In a single-site quality improvement study from 2017, implementation of EHR-based guidance for nephrologist to refer patients with an eGFR of less than 20 ml/min/1.73 m² coupled with annual referral-focused educational sessions for nephrologists significantly improved referral [35]. Similar studies have built off this theme including a dialysis facility–based, randomized trial among 134 dialysis facilities treating over 9000 patients with kidney failure, which demonstrated that dialysis facility receipt of a multicomponent educational and outreach intervention resulted in a 75% increased adjusted odds of referral for kidney transplant evaluation over a 1-year evaluation time period [36]. More notably, this study intervention resulted in the intervention group having a higher proportion of patients referred for transplant who were Black [adjusted mean difference, 6.4%; 95% confidence interval (95% CI), 4.3–8.6%] vs. White (adjusted mean difference, 3.7%; 95% CI, 1.6–5.9; P < 0.05). Notably, Patzer et al.[36–38] also describe results from the ASCENT study, a cluster-randomized, pragmatic, multilevel, effectiveness-implementation trial including 655 US dialysis facilities with low waitlisting, randomized to receive either the ASCENT intervention (a performance feedback report, a webinar, and staff and patient educational videos about the 2014 KAS policy) or an educational brochure [37–39]. This intervention which enrolled 56, 332 prevalent and 23, 623 incident dialysis patients demonstrated a positive effect in referral; yet, the study did not yield significant overall increases in waitlisting rates [38]. Notably, the impact of intervention differed by race whereby Black-White disparities in waitlisting were attenuated, which may be a consideration for future systems-level interventions.

These results, not withstanding, referral alone does not suffice as individuals seeking transplant are required to navigate a complex and multistep process to initiate and complete transplant evaluation, which include psychological assessments, and completion of numerous test which require coordination. Furthermore, even after referral for transplantation, Black individuals have been shown to be less likely to initiate or complete evaluations vs. White counterparts (44 vs. 50%) [40]. The underlying factors driving these disparities which may include experiences of discrimination in healthcare and lower trust [40–42], require system-level coordinated interventions that rectify such barriers.

System-level integrated interventions

An increasing number of transplant focused studies have focused on addressing the mechanisms through which patient-level interventions are bolstered by system-changes, to enhance equity in transplant. These interventions have included navigation of potential recipients through the transplant evaluation and waitlisting processes [43,44]. Key principles of navigation include person-centered healthcare delivery, identification and elimination of barriers faced by patients throughout the care journey, team integration that optimizes patient outcomes above and beyond standard clinical care, determination of “who navigates” based on the skills needed for a specific phase of navigation, and careful coordination and bridging of needs and cross-talk across fragmented systems [45].

Interventions deploying navigators have demonstrated promising but mixed results [67–69]. For instance, Sullivan et al.[46] describe an intervention which deployed patient navigators to aid participants during the first visit to a transplant center, and key steps associated with active waitlisting. In this study, navigators informed patients about contraindications to transplant, provided education regarding each step of the transplant journey, provided encouragement regarding communication with their transplant center, and provided guidance regarding critical items to ask of the transplant team. Navigators also monitored completion of workup elements, communicated with the transplant team about outstanding tests, and encouraged timely completion of incomplete steps, while providing education about LDKT and specific actionable steps needed to achieve these gaps. Although intervention participants completed more than twice as many steps as control participants (3.5 vs. 1.6 steps; difference, 1.9 steps; 95% CI, 1.3–2.5 steps), intervention effects were similar across race and sex subgroups [46] and overall, participants did not have significantly increased transplant rates. In a separate intervention, investigatorsr studied the effects of a transplant intervention focused on socioeconomically disadvantaged individuals wherein navigators assisted with scheduling, appointment reminders, financial aid, transportation, and interpretative services for non-native English speakers. Navigators also provided social support including referrals to support groups and community resources; and served as a liaison between patients and a multidisciplinary care team including the transplant center and dialysis facility [47]. In this single-center RCT of 401 referred patients randomized to usual care vs. trained navigation, waitlisting was not significantly different between intervention (32%) vs. control (26%) patients and time from referral to waitlisting was longer for intervention patients, possibly reflecting the complexity of barriers to transplant in this study population [48]. However, intervention patients had more living donor inquiries (18 vs. 10%) and also were more likely to be waitlisted after 500 days (65 vs. 25%). This intervention embedded several promising characteristics, including integration of navigators into decision-making processes (e.g., navigators attended a multidisciplinary selection conference, where waitlist decision are made) [49]. In sum, existing navigator-led interventions manage individual patient-level barriers, missing opportunities to intervene on provider and system-level contributors to transplant inequity. Interventions to date may often be low touch (i.e., monthly meetings), though significantly more time may be needed to meet patient and caregivers’ informational and structural needs (e.g., financial resources, transportation resources, motivational elements).

A third promising intervention deployed in South Carolina aimed to increase transplant access deployed between 2017 and 2021 included a standardized algorithm for transplant evaluation and testing needs, virtual social worker delivered diet and pharmacy evaluation which reduced additional visits for evaluation requirement, and an effective comprehensive educational program delivered by transplant staff to dialysis unit staff [50]. In this study which included 11 487 people with ESKD (64.7% African–American) referred between January 2017 and September 2021, 1229 underwent transplantation (55.3% African–American) and the kidney transplant equity index for initiated evaluations improved to 1.00 in 2021 (P = 0.0045) from 0.89 in 2017 [51▪]. Similar studies are also investigating the role of navigated, intensive fast track evaluation processes for transplant including the Kidney Transplant Fast Track (KTFT)-TALK study in which offerings to bypass common structural barriers to evaluation (e.g., offering same day completion of Echocardiography and other tests) are complemented by significant nurse coordinator efforts post evaluation to ensure completion [52].In addition, robust programs such as the African American Transplant Access Program (AATAP), are being evaluated in a multicenter trial. AATAP uniquely focuses on ensuing culturally-congruent tailored support to increase transplant access among Black Americans [53,54]. Notably, results from the KTFT study demonstrated that after adjusting for demographic and clinical factors, individuals receiving an intervention which deployed streamlined, coordinated care processes which center addressing patients’ needs and barriers had a higher likelihood of being placed on the active KT waitlist (hazard ratio = 1.40; 95% CI: 1.24–1.59). AmongBlack patients, those receiving the intervention were more likely than those in the historic control to undergo kidney transplant (sHR 1.52, 95% CI 1.06–2.16), though no significant differences were found from patients from other racial/ethnic groups [55▪▪].

The ongoing System Interventions to Achieve Early and Equitable Transplants (STEPS) study (NCT05014256) [56▪▪] aims to address critical roadblocks that lead to LDKT disparities by leveraging health system capabilities and the chronic care model to simultaneously address several previously described cascading barriers (Fig. 1). To mitigate complex and longstanding disparities in preemptive transplant, authors have proposed several potential solutions to address key structural gaps, including targeting educational efforts toward primary care clinicians and other nephrologists re: early referral for TXP before eGFR less than 20, expanded CME training regarding racial disparities in preemptive transplant, integrated EMR support related to education and referral, coordinated EMR-based referral directly to transplant centers, and electronic medical record reminders [1]. STEPS is one example of a promising multisite intervention designed to effectively identify and refer all potential transplant candidates to a multilevel program through which social workers and transplant coordinators help patients navigate the complex referral and evaluation journey. This comprehensive intervention which seeks to break down silos and fragmentation and place the patient journey at the center of the transplant journey, also integrates health-systems level solutions.

FIGURE 1.

Wagner’s chronic care model applied to kidney transplant equity [60].

Place-based interventions

Successful novel community-based programs such as Kidney Care Partners in Michigan https://www.kidneycompanions.org/ may be models for larger-scale interventions addressing specific transplant barriers (e.g., social support, transportation) impacting rurally-located and other disadvantaged populations. By building volunteer teams to serve as “companion” navigators for patients on their transplant journey, such community-engaged models require further study, investment, and cross-sector partnership to expand their reach and ensure effective implementation. As policy makers and health systems strive to address longstanding inequity, further interventions are needed to examine and support center-specific characteristics and resources that can overcome disparities at the level of candidates’ neighborhoods, or individual SES [57]. Additional work will also be needed to expand upon policy-levers (e.g., Medicaid expansion) which broadly impact multilevel barriers to transplant, including financial barriers to donation [58].

CONCLUSION

As we continue to identify the impediments to LDKT and preemptive kidney transplantation, interventions impacting multiple levels of influence will be needed. The field is evolving to develop multidimensional interventions that address these impediments using a population health approach to enhance intervention development and data collection [59]. As evidence emerges on the effectiveness of these interventions, efforts to equitably implement and scale them across the US are urgently needed. To ensure success, support for center-level and federal policies that ensure sustainability of these interventions will be paramount. Through decades of careful investigation, we have uncovered several modifiable barriers to the transplant equity crisis. The success of future efforts and our path forward will depend on our sustained commitment to multilevel interventions that support patients, donors, clinicians, and health systems to tackle the most salient barriers in the complex journey to transplant.

KEY POINTS.

• Eliminating longstanding U.S. disparities in LDKT and preemptive transplantation requires multilevel, structural interventions.

• Effective strategies must combine patient-level support that is adaptive to specific contextual needs (e.g. unique social barriers) to transplant, with health system-wide strategies, clinician education, and community-engaged strategies that leverage existing resource navigation opportunities.

• Sustained, equity-focused policies and implementation of proven models are essential to achieving transplant equity.