Disparities in Kidney Transplant Waitlisting Among Young Patients Without Medical Comorbidities

Disparities in Access to Timely Waitlisting Among Pediatric Kidney Transplant Candidates

BACKGROUND AND OBJECTIVES

Kidney transplantation with minimal or no dialysis exposure provides optimal outcomes for children with end-stage kidney disease. We sought to understand disparities in timely access to transplant waitlisting.

METHODS

We conducted a retrospective, registry-based cohort study of candidates ages 3 to 17 added to the US kidney transplant waitlist 2015 to 2019. We defined "preemptive waitlisting" as waitlist addition before receiving dialysis and compared demographics of candidates based on preemptive status. We used competing risk regression to determine the association between preemptive waitlisting and transplantation. We then identified waitlist additions age >18 who initiated dialysis as children, thereby missing pediatric allocation prioritization, and evaluated the association between waitlisting with pediatric prioritization and transplantation.

RESULTS

Among 4506 pediatric candidates, 48% were waitlisted preemptively. Female sex, Hispanic ethnicity, Black race, and public insurance were associated with lower adjusted relative risk of preemptive waitlisting. Preemptive listing was not associated with time from waitlist activation to transplantation (adjusted hazard ratio 0.94, 95% confidence interval 0.87-1.02). Among transplant recipients waitlisted preemptively, 68% had no pretransplant dialysis, whereas recipients listed nonpreemptively had median 1.6 years of dialysis at transplant. Among 415 candidates initiating dialysis as children but waitlisted as adults, transplant rate was lower versus nonpreemptive pediatric candidates after waitlist activation (adjusted hazard ratio 0.54, 95% confidence interval 0.44-0.66).

CONCLUSIONS

Disparities in timely waitlisting are associated with differences in pretransplant dialysis exposure despite no difference in time to transplant after waitlist activation. Young adults who experience delays may miss pediatric prioritization, highlighting an area for policy intervention.

Highly Sensitized Kidney Transplant Outcomes After the 2014 Kidney Allocation System Change

Introduction: Kidney Allocation System (KAS) was implemented by United Network for Organ Sharing in 2014 to reduce allocation disparities. Research Questions: Outcomes of highly sensitized patients (calculated panel reactive antibody (cPRA) ≥ 97%) before and after KAS were compared to low-risk recipients (cPRA <10%) in the post-KAS era were examined. The impact on racial disparities was determined. Design: This was a retrospective study of national registry data. Two cohorts of adult candidates waitlisted for deceased donor transplantation during 3-year periods before and after KAS were identified. Results: Highly sensitized patients (N = 1238 and 4687) received a deceased donor kidney transplant between January 1, 2011 and December 31, 2013 and between January 1, 2015 and December, 31, 2017. Racial disparity for highly sensitized patients improved, yet remained significant (P < 0.001), with Black patients comprising 40% and 41% of the highly sensitized candidates and 28% and 34% of the recipients pre- and post-KAS. While posttransplant death-censored graft failure for highly sensitized recipients was similar overall, post-KAS was associated with improved graft survival in the first year after transplant (HR 0.56, 95% CI 0.40-0.78). When compared to contemporaneous lowrisk recipients, both death-censored and all-cause graft failure were similar for highly sensitized recipients and was associated with increased risk for death-censored graft failure beyond the first year (HR 1.39, 95% CI 1.11-1.73). Conclusion: The allocation system led to an increase in transplantation in highly sensitized candidates without compromising outcomes. Although KAS has led to more balanced transplant rates between highly sensitized Black and White patients, racial inequalities persist.

A Transplant-Inclusive Value-Based Kidney Care Payment Model

In the United States, kidney care payment models are migrating toward value-based care (VBC) models incentivizing quality of care at lower cost. Current kidney VBC models will continue through 2026. We propose a future transplant-inclusive VBC (TIVBC) model designed to supplement current models focusing on patients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD). The proposed TIVBC is structured as an episode-of-care model with risk-based reimbursement for "referral/evaluation/waitlisting" (REW, referencing kidney transplantation), "primary hospitalization to 180 days posttransplant," and "long-term graft survival." Challenges around organ acquisition costs, adjustments to quality metrics, and potential criticisms of the proposed model are discussed. We propose next steps in risk-adjustment and cost-prediction to develop as an end-to-end, TIVBC model.

Racial disparities across multiple stages of the deceased organ donation process

Pervasive structural violence causes higher organ failure rates among Black Americans and excess Black potential deceased organ donors. Underuse of Black donors would exacerbate organ shortages that disproportionately harm Black transplant candidates. This study investigates racial differences in transit between distinct donation steps among 132 968 potential donors across 557 hospitals and 6 Organ Procurement Organizations (OPOs) from 2015 through 2021. Multilevel multistate modeling with patient covariates and OPO random effects shows adjusted likelihoods (95% confidence interval [CI]) of non-Black versus Black patients transitioning from OPO referral to approach: odds ratio (OR) 1.23 (95% CI 1.18, 1.27), approach to authorization: OR 1.64 (95% CI 1.56, 1.72), authorization to procurement: OR 1.08 (95% CI 1.02, 1.14), and procurement to transplant: OR 0.99 (95% CI 0.93, 1.04). Overall organ utilization rates for Black, Latino, White, and other OPO referrals were 5.88%, 8.17%, 6.78%, and 5.24%, respectively. Adjusting for patient covariates and hospital and OPO random effects, multilevel logistic models estimated that compared with Black patients, Latino, White, and other patients had ORs of organ utilization of 1.82 (95% CI 1.61, 2.04), 3.19 (95% CI 2.91, 3.50), and 1.25 (95% CI 1.06, 1.47), respectively. Nationwide in 2022, donor conversion disparities likely lost more than 1800 donors-70% of whom would have been Black. Achieving racial equity for transplant candidates will require reducing racial disparities in organ donation.