Project Summary/Abstract The broad, long-term objectives of this proposal are two-fold: 1) to provide high-quality mentoring to contribute to the career development of trainees from diverse backgrounds and 2) to advance the quality, rigor and breadth of health equity research in transplantation and pediatric nephrology. For decades, it has been recognized that Blacks and Hispanics are less likely to receive kidney transplantation compared with non-Hispanic whites (NHWs), especially from a living donor. Most published disparities studies have used race/ethnicity as a social construct and attributed differences in transplant access and outcomes to social determinants of health (SDOH). Yet, assessments of SDOH are often limited to race/ethnicity, health insurance status and neighborhood poverty level, and most studies are descriptive with few providing actionable findings to mitigate inequities. Further, proposed interventions are often targeted at the individual patient rather than the healthcare systems that perpetuate systemic racial bias. Another challenge in achieving equity in transplant access lies in the limits of national data. Currently, national surveillance registries capture patients when they begin renal replacement therapy (United States Renal Data System) and when they are waitlisted or transplanted (Scientific Registry of Transplant Recipients), but not what happens during the time in between when patients must undergo transplant referral and evaluation to be deemed transplant eligible. Given this context, the transplant community has asserted a call to action to achieve equity in transplantation by improving rigor, quality and transparency in transplant-related health equity research. Dr. Amaral’s research proposal seeks to move from describing disparities to achieving equity in transplant access and outcomes through research that leverages diverse study designs and varied data sources to identify potentially modifiable healthcare system barriers to transplant access. Two current projects will support this award. The REACH-TRANSPLANT study (R01 DK120886) examines racial/ethnic inequities that arise during recipient and living donor (LD) evaluation, LD selection, and LD follow-up. The study has three aims and applies both primary and secondary data collection, large electronic health records, research cohort data and survey data. The second project, The House Calls Project, focuses on identifying and addressing adverse social determinants of health (SDOH) that interfere with pediatric kidney transplant evaluation completion. This study will use interview and survey data. These studies provide robust training opportunities in health equity research for Dr. Amaral as a mentor and for mentees across many levels and background, making this proposal ideally aligned with the overarching goals of the K26 award mechanism.

PROJECT NARRATIVE Kidney transplantation has clear benefits to quality and duration of life over dialysis, yet many patients with end-stage kidney disease face difficulties getting through the transplant referral and evaluation process. The proposed studies will help improve understanding of healthcare system level practices that contribute to inequity in transplant candidate referrals, living donor evaluations and follow-up, and we will identify modifiable social determinants of health that contribute to delays in pediatric kidney transplant evaluation completion. This proposal also provides scientific training for the mentor applicant and her mentees.