I noticed a troublesome trend during my three weeks working in the pediatric dialysis unit and the post-kidney transplant unit. The whiter and younger pediatric patients were resting comfortably in the post-transplant unit with their new surgically placed kidneys being meticulously taken care of. The darker and older pediatric patients spent countless, mindless hours attached to a dialysis machine with little hope for a new kidney after years of being on the waitlist.

At first, I attributed this difference to be purely coincidental. I convinced myself that there was a greater medical urgency for transplant for the white child or maybe that the black child didn’t have insurance and was unable to afford the transplant surgery. Yet, after reviewing the difference in clinical courses and socioeconomic information of our own pre- and post-kidney pediatric transplant patients, I found out that I was wrong.

So, I delved into the research and found tons of evidence supporting the simple fact that being a minority child with the same kidney disease, same socioeconomic status (SES), and same insurance as a white child lowers your chances of receiving a kidney transplant even though a black child is twice as likely to develop end-stage renal disease (ESRD) in the first place. This is an injustice to our minority children that has not been appropriately challenged, and we need to start taking action now.

Racial disparities exist even with equal SES and clinical factors.

With 10,000 children living with ESRD and only 800 pediatric kidney transplants done yearly, 1 out of 100 ESRD children will receive a kidney transplant. But imagine lowering those chances only because a child is not white. Considering similar clinical factors and SES between a black and white child, the black child would be 12 percent less likely to get a kidney, 40 percent less likely to get a deceased donor transplant and 69 percent less likely to receive a living donor transplant.

Unsurprisingly, living donor kidneys lead to superior health outcomes in ESRD patients compared to the deceased donor transplant. These differences are not only seen from being placed on the waitlist to getting a kidney, but occurs through all steps of the kidney transplant process: referral, evaluation completion, and waitlisting. When correcting for clinical, demographic, and SES factors, nephrologists were more likely to refer a white child rather than a Black child for transplantation, even with similar parental nonadherence behaviors. Additionally, black children are less likely to complete their pre-transplant evaluation and are 8 percent less likely to be placed on the waitlist.

There are evidence-based interventions to reduce the racial disparity.

Interestingly, targeting social determinants of health, specifically education, has been shown to ameliorate these racial disparities in kidney transplantation. In adult nephrology, studies found that implementing initiatives that promote health literacy for the patient and family showed a 40 percent increase in pre-transplantation evaluation completion. These initiatives consist of formal, in-center patient education curriculums that increased access to renal transplantation for poor and minority patients and, luckily, was more cost-effective than its alternative.

Although these interventions have been implemented in adult nephrology teams, these methods and, ideally, the results could be replicated in pediatric nephrology teams. I mention this intervention as an example of how programs are targeting and reducing racial disparities and to underline the importance that this can be done in a pragmatic, impactful, and cost-effective way.

There are numerous non-clinical reasons for the racial disparities.

But why do these disparities exist? Well, the causes of racial disparities in pediatric renal transplant access are multifactorial and hard to assess. If controlling for clinical and SES factors, studies consistently identify physician bias, systemic racism, and historical distrust of the transplant process as the main contributors. To be sure, there are many individualistic and systemic reasons why certain patients get kidney transplants at different rates than others that are not all explained by racism and distrust.

However, the point of this article is to show that racial disparities independent of clinical and SES factors exist in access to pediatric kidney transplants and that preventable and targetable causes need to be addressed to practice equitable and effective health care.

Lien Morcate is a medical student.