"Disparities in Kidney Transplantation in the Immigrant Patient Population in Italy: Towards an Intervention to Improve Equity "

In Italy, many adult patients with end-stage kidney disease (ESKD) are of non-European Union (EU) origin. Kidney transplant (KT) is the gold standard for treatment of ESKD. Italy guarantees universal access to KT and post-transplant regimens for all clinically eligible migrants registered in the National Health System under the same conditions as nationals. Yet, immigration is an important social determinant of health, with the potential for disparities in accessibility, quality, and outcomes of care. Prior research has shown that non-EUborn individuals in Italy are more likely to experience unequal access to and quality of care because of potential barriers associated with immigration. While disparities in KT for ethnic minority patients are well-known, studies on disparities associated with immigration background remain scarce and none have ever been performed in Italy. This study pursues three main objectives: (1) to assess whether disparities exist in KT outcomes in the immigrant patient population in Italy, (2) to discuss the ethical dimensions with the potential for disparities in this vulnerable group of patients, and (3) to explore the causal mechanisms linking immigration with disparities in KT and identify areas for intervention. Three research phases were outlined to pursue these objectives: (1) A study to assess disparities in KT outcomes in the immigrant patient population was retrospectively performed based on national-level data of the Italian National Transplantation Center. (2) Three clinical cases describing the challenges that might account for disparities in KT in this group of patients were analyzed by the Stanford Integrated Psychosocial Assessment for Transplantation and by the Four-Boxes Method for ethical decisions in clinical medicine. (3) A conceptual model of the causal mechanisms of disparities was developed and the potential for intervention to reduce them was discussed. Study 1 revealed that non-European immigration background is associated with long-term kidney graft function decline. Study 2 found that the Four-Boxes Method is a useful tool to gain a more comprehensive picture of the ethical dimensions of single clinical cases and to fulfill the ethical obligation to provide whole-person care. Study 3 suggests that multiple modifiable factors may explain disparities in KT. While it would be necessary to act directly upon the structural causes of disparities, it is more realistic to foster action on modifiable risk factors by development of targeted interventions with the potential to enable the prevention/mitigation/elimination of disparities in KT in this vulnerable group of patients. Prospective studies are needed to further elucidate the causal mechanisms linking immigration with disparities in KT more rigorously. Further, research is necessary to develop interventions and to assess their effectiveness in immigrant patients pursuing KT.