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Cutrone AM, Rega SA, Feurer ID, Karp SJ. Effects of the March 2021 Allocation Policy Change on Key Deceased-donor Kidney Transplant Metrics. Transplantation 2024:00007890-990000000-00779. [PMID: 38831485 DOI: 10.1097/tp.0000000000005044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND A major change to deceased-donor kidney allocation in the United States, Kidney Allocation System 250 (KAS250), was implemented on March 15, 2021. Evaluating the consequences of this policy on critical system performance metrics is critical to determining its success. METHODS We performed a retrospective analysis of critical performance measures of the kidney transplant system by reviewing all organs procured during a 4-y period in the United States. To mitigate against possible effects of the COVID-19 pandemic, Scientific Registry of Transplant Recipients records were stratified into 2 pre- and 2 post-KAS250 eras: (1) 2019; (2) January 1, 2020-March14, 2021; (3) March 15, 2021-December 31, 2021; and (4) 2022. Between-era differences in rates of key metrics were analyzed using chi-square tests with pairwise z-tests. Multivariable logistic regression and analysis of variations methods were used to evaluate the effects of the policy on rural and urban centers. RESULTS Over the period examined, among kidneys recovered for transplant, nonuse increased from 19.7% to 26.4% (all between-era P < 0.05) and among all Kidney Donor Profile Index strata. Cold ischemia times increased (P < 0.001); however, the distance between donor and recipient hospitals decreased (P < 0.05). Kidneys from small-metropolitan or nonmetropolitan hospitals were more likely to not be used over all times (P < 0.05). CONCLUSIONS Implementation of KAS250 was associated with increased nonuse rates across all Kidney Donor Profile Index strata, increased cold ischemic times, and shorter distance traveled.
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Affiliation(s)
- Alissa M Cutrone
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA
| | - Scott A Rega
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN
| | - Irene D Feurer
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Seth J Karp
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
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2
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Reed RD, Locke JE. Mitigating Health Disparities in Transplantation Requires Equity, Not Equality. Transplantation 2024; 108:100-114. [PMID: 38098158 PMCID: PMC10796154 DOI: 10.1097/tp.0000000000004630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Despite decades of research and evidence-based mitigation strategies, disparities in access to transplantation persist for all organ types and in all stages of the transplant process. Although some strategies have shown promise for alleviating disparities, others have fallen short of the equity goal by providing the same tools and resources to all rather than tailoring the tools and resources to one's circumstances. Innovative solutions that engage all stakeholders are needed to achieve equity regardless of race, sex, age, socioeconomic status, or geography. Mitigation of disparities is paramount to ensure fair and equitable access for those with end-stage disease and to preserve the trust of the public, upon whom we rely for their willingness to donate organs. In this overview, we present a summary of recent literature demonstrating persistent disparities by stage in the transplant process, along with policies and interventions that have been implemented to combat these disparities and hypotheses for why some strategies have been more effective than others. We conclude with future directions that have been proposed by experts in the field and how these suggested strategies may help us finally arrive at equity in transplantation.
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Affiliation(s)
- Rhiannon D. Reed
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E. Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
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3
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McPherson LJ, Di M, Adams AA, Plantinga L, Pastan SO, Patzer RE. Geographic Differences in Racial Disparities in Access to Kidney Transplantation. Kidney Int Rep 2023; 8:2474-2477. [PMID: 38025234 PMCID: PMC10658202 DOI: 10.1016/j.ekir.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 06/17/2023] [Accepted: 08/02/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Laura J. McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Mengyu Di
- Regenstrief Institute, Indianapolis, Indiana, USA
| | - Ayrenne A. Adams
- Department of Medicine, Division of General Internal Medicine and Innovation, New York University Grossman School of Medicine, New York, New York, USA
| | - Laura Plantinga
- Divisions of Rheumatology and Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Stephen O. Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rachel E. Patzer
- Regenstrief Institute, Indianapolis, Indiana, USA
- Department of Surgery, Division of Transplantation, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Biabani F, Rahmani A, MahmudiRad G, Hassankhani H, Azadi A. Reasons for kidney transplant refusal among patients receiving peritoneal dialysis: A qualitative study. Perit Dial Int 2023; 43:395-401. [PMID: 36601692 DOI: 10.1177/08968608221146865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Even though kidney transplantation has better outcomes compared to dialysis therapies, some patients undergoing peritoneal dialysis (PD) refuse to consider kidney transplantation. Identification of the underlying reason for patient refusal may improve patients' acceptance of kidney transplantation. AIM The aim of this study was to describe the reasons given by Iranian PD patients for refusing kidney transplantation. METHOD Eighteen patients undergoing PD participated. Data were collected using semi-structured interviews and were analysed using conventional qualitative content analysis. RESULTS The analysis leads to the emergence of two categories and six subcategories: negative outcomes of kidney transplantation (financial burden, psychosocial problems and physical complications) and doubtful factors for kidney transplantation (negative attitudes towards kidney transplantation, long waiting time for kidney transplantation and compatibility of PD with daily life). The financial burden and long waiting time for kidney transplantation were the most important factors in the reluctance of kidney transplantation by PD patients. IMPLICATION FOR PRACTICE Patients undergoing PD declined kidney transplantation for several reasons, such as financial burden, fear of post-transplantation side effects, long waiting time for kidney transplantation. Reducing the time of kidney transplantation and insurance coverage of transplant costs can change the attitude of PD patients towards transplant.
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Affiliation(s)
- Fateme Biabani
- Nursing and Midwifery Faculty, Birjand University of Medical Sciences, Iran
| | - Azad Rahmani
- Medical-Surgical Department, Nursing and Midwifery Faculty, Tabriz University of Medical Sciences, Iran
| | | | - Hadi Hassankhani
- Medical-Surgical Department, Nursing and Midwifery Faculty, Tabriz University of Medical Sciences, Iran
| | - Arman Azadi
- Nursing Department, Faculty of Nursing and Midwifery, Ilam University of Medical Sciences, Iran
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5
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Watters TK, Glass BD, Mallett AJ. Identifying the barriers to kidney transplantation for patients in rural and remote areas: a scoping review. J Nephrol 2023:10.1007/s40620-023-01755-0. [PMID: 37656389 DOI: 10.1007/s40620-023-01755-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 07/31/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Populations in rural and remote areas have higher rates of chronic kidney disease and kidney failure than those in urban or metropolitan areas, and mortality rates for chronic kidney disease are almost twice as high in remote areas compared to major cities. Despite this, patients residing in regional, rural, or remote areas are less likely to be wait-listed for or receive a kidney transplant. The objective of this scoping review is to identify specific barriers to kidney transplantation for adult patients residing in rural and remote areas from the perspectives of health professionals and patients/carers. METHODS Studies were identified through database (MEDLINE, CINAHL, Emcare, Scopus) searches and assessed against inclusion criteria to determine eligibility. A descriptive content analysis was undertaken to identify and describe barriers as key themes. RESULTS The 24 selected studies included both quantitative (n = 5) and qualitative (n = 19) methodologies. In studies conducted in health professional populations (n = 10) the most prevalent themes identified were perceived social and cultural issues (80%), burden of travel and distance from treatment (60%), and system-level factors as barriers (60%). In patient/carer populations (n = 14), the most prevalent themes were limited understanding of illness and treatment options (71%), dislocation from family and support network (71%), and physical and psychosocial effects of treatment (71%). CONCLUSIONS Patients in regional, rural, and remote areas face many additional barriers to kidney transplantation, which are predominantly associated with the need to travel or relocate to access required medical testing and transplantation facilities.
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Affiliation(s)
- Tara K Watters
- College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia.
- Department of Renal Medicine, Cairns Hospital, PO Box 902, Cairns, QLD, 4870, Australia.
| | - Beverley D Glass
- College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
| | - Andrew J Mallett
- College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Department of Renal Medicine, Townsville University Hospital, Townsville, QLD, Australia
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia
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6
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Cron DC, Husain SA, King KL, Mohan S, Adler JT. Increased volume of organ offers and decreased efficiency of kidney placement under circle-based kidney allocation. Am J Transplant 2023; 23:1209-1220. [PMID: 37196709 PMCID: PMC10527286 DOI: 10.1016/j.ajt.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/19/2023] [Accepted: 05/07/2023] [Indexed: 05/19/2023]
Abstract
The newest kidney allocation policy kidney allocation system 250 (KAS250) broadened geographic distribution while increasing allocation system complexity. We studied the volume of kidney offers received by transplant centers and the efficiency of kidney placement since KAS250. We identified deceased-donor kidney offers (N = 907,848; N = 36,226 donors) to 185 US transplant centers from January 1, 2019, to December 31, 2021 (policy implemented March 15, 2021). Each unique donor offered to a center was considered a single offer. We compared the monthly volume of offers received by centers and the number of centers offered before the first acceptance using an interrupted time series approach (pre-/post-KAS250). Post-KAS250, transplant centers received more kidney offers (level change: 32.5 offers/center/mo, P < .001; slope change: 3.9 offers/center/mo, P = .003). The median monthly offer volume post-/pre-KAS250 was 195 (interquartile range 137-253) vs. 115 (76-151). There was no significant increase in deceased-donor transplant volume at the center level after KAS250, and center-specific changes in offer volume did not correlate with changes in transplant volume (r = -0.001). Post-KAS250, the number of centers to whom a kidney was offered before acceptance increased significantly (level change: 1.7 centers/donor, P < .001; slope change: 0.1 centers/donor/mo, P = .014). These findings demonstrate the logistical burden of broader organ sharing, and future allocation policy changes will need to balance equity in transplant access with the operational efficiency of the allocation system.
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Affiliation(s)
- David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Syed A Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Kristen L King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Joel T Adler
- Division of Transplantation, Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA.
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7
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Rea KE, West KB, Dorste A, Christofferson ES, Lefkowitz D, Mudd E, Schneider L, Smith C, Triplett KN, McKenna K. A systematic review of social determinants of health in pediatric organ transplant outcomes. Pediatr Transplant 2023; 27:e14418. [PMID: 36321186 DOI: 10.1111/petr.14418] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/27/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Equitable access to pediatric organ transplantation is critical, although risk factors negatively impacting pre- and post-transplant outcomes remain. No synthesis of the literature on SDoH within the pediatric organ transplant population has been conducted; thus, the current systematic review summarizes findings to date assessing SDoH in the evaluation, listing, and post-transplant periods. METHODS Literature searches were conducted in Web of Science, Embase, PubMed, and Cumulative Index to Nursing and Allied Health Literature databases. RESULTS Ninety-three studies were included based on pre-established criteria and were reviewed for main findings and study quality. Findings consistently demonstrated disparities in key transplant outcomes based on racial or ethnic identity, including timing and likelihood of transplant, and rates of rejection, graft failure, and mortality. Although less frequently assessed, variations in outcomes based on geography were also noted, while findings related to insurance or SES were inconsistent. CONCLUSION This review underscores the persistence of SDoH and disparity in equitable transplant outcomes and discusses the importance of individual and systems-level change to reduce such disparities.
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Affiliation(s)
- Kelly E Rea
- Department of Psychology, University of Georgia, Athens, Georgia, USA
| | - Kara B West
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anna Dorste
- Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Debra Lefkowitz
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily Mudd
- Cleveland Clinic Children's, Center for Pediatric Behavioral Health, Wilmington, North Carolina, USA
| | - Lauren Schneider
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Courtney Smith
- Norton Children's, University of Louisville, Louisville, Kentucky, USA
| | - Kelli N Triplett
- Children's Health, Children's Medical Center Dallas, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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8
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Stewart D, Mupfudze T, Klassen D. Does anybody really know what (the kidney median waiting) time is? Am J Transplant 2023; 23:223-231. [PMID: 36695688 DOI: 10.1016/j.ajt.2022.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/10/2022] [Accepted: 12/05/2022] [Indexed: 01/13/2023]
Abstract
The median waiting time (MWT) to deceased donor kidney transplant is of interest to patients, clinicians, and the media but remains elusive due to both methodological and philosophical challenges. We used Organ Procurement and Transplantation Network data from January 2003 to March 2022 to estimate MWTs using various methods and timescales, applied overall, by era, and by candidate demographics. After rising for a decade, the overall MWT fell to 5.19 years between 2015 and 2018 and declined again to 4.05 years (April 2021 to March 2022), based on the Kaplan-Meier method applied to period-prevalent cohorts. MWTs differed markedly by blood type, donor service area, and pediatric vs adult status, but to a lesser degree by race/ethnicity. Choice of methodology affected the magnitude of these differences. Instead of waiting years for an answer, reliable kidney MWT estimates can be obtained shortly after a policy is implemented using the period-prevalent Kaplan-Meier approach, a theoretical but useful construct for which we found no evidence of bias compared with using incident cohorts. We recommend this method be used complementary to the competing risks approach, under which MWT is often inestimable, to fill the present information void concerning the seemingly simple question of how long it takes to get a kidney transplant in the United States.
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Affiliation(s)
| | | | - David Klassen
- Office of the Chief Medical Officer, United Network for Organ Sharing
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9
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Audry B, Savoye E, Pastural M, Bayer F, Legeai C, Macher MA, Kerbaul F, Jacquelinet C. The new French kidney allocation system for donations after brain death: Rationale, implementation, and evaluation. Am J Transplant 2022; 22:2855-2868. [PMID: 36000787 DOI: 10.1111/ajt.17180] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/01/2022] [Accepted: 08/21/2022] [Indexed: 01/25/2023]
Abstract
In recent decades, the allocation policies of many countries have moved from center-based to patient-based approaches. The new French kidney allocation system (KAS) of donations after brain death for adult recipients, implemented in 2015, was principally designed to introduce a unified allocation score (UAS) to be applied locally for one kidney and nationally for the other and to replace regional borders by a new geographical model. The new KAS balances dialysis duration and waiting time to compensate for listing delays and provides more effective longevity matching between donors and recipients with better HLA and age matching. We report these changes, with their rationale and main results. Results show improved HLA matching for young recipients and more rapid access to transplant for older recipients. Young recipients also had better access to transplantation. Transplant access decreased for recipients aged 60-69 and required tuning of KAS parameters. In conclusion, our results strongly indicate that national or adequately broad geographic allocation areas, combined with multiplicative interactions between allocation criteria, permit multivariate optimization of organ allocation and thus improve national kidney sharing and balance HLA matching and age matching, at the price of longer cold ischemic times and more logistical constraints than with local allocation.
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10
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Gragert L, Kadatz M, Alcorn J, Stewart D, Chang D, Gill J, Liwski R, Gebel HM, Gill J, Lan JH. ABO-adjusted calculated panel reactive antibody (cPRA): A unified metric for immunologic compatibility in kidney transplantation. Am J Transplant 2022; 22:3093-3100. [PMID: 35975734 PMCID: PMC10087664 DOI: 10.1111/ajt.17175] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/17/2022] [Accepted: 08/13/2022] [Indexed: 01/25/2023]
Abstract
Implementation of the kidney allocation system in 2014 greatly reduced access disparity due to human leukocyte antigen (HLA) sensitization. To address persistent disparity related to candidate ABO blood groups, herein we propose a novel metric termed "ABO-adjusted cPRA," which simultaneously considers the impact of candidate HLA and ABO sensitization on the same scale. An ethnic-weighted ABO-adjusted cPRA value was computed for 190 467 candidates on the kidney waitlist by combining candidate's conventional HLA cPRA with the remaining fraction of HLA-compatible donors that are ABO-incompatible. Consideration of ABO sensitization resulted in higher ABO-adjusted cPRA relative to conventional cPRA by HLA alone, except for AB candidates since they are not ABO-sensitized. Within cPRA Point Group = 99%, 43% of the candidates moved up to ABO-adjusted cPRA Point Group = 100%, though this proportion varied substantially by candidate blood group. Nearly all O and most B candidates would have elevated ABO-adjusted cPRA values above this policy threshold for allocation priority, but relatively few A candidates displayed this shift. Overall, ABO-adjusted cPRA more accurately measures the proportion of immune-compatible donors compared with conventional HLA cPRA, especially for highly sensitized candidates. Implementation of this novel metric could enable the development of allocation policies permitting more ABO-compatible transplants without compromising equity.
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Affiliation(s)
- Loren Gragert
- Department of Pathology and Laboratory Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Matthew Kadatz
- Vancouver Coastal Health Research Institute, Vancouver, Canada.,Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - James Alcorn
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Darren Stewart
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Doris Chang
- Providence Health Research Institute, Vancouver, Canada
| | - Jagbir Gill
- Division of Nephrology, University of British Columbia, Vancouver, Canada.,Providence Health Research Institute, Vancouver, Canada.,Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, Canada
| | - Robert Liwski
- Department of Pathology, Dalhousie University, Halifax, Canada
| | - Howard M Gebel
- Department of Pathology, Emory University, Atlanta, Georgia, USA
| | - John Gill
- Division of Nephrology, University of British Columbia, Vancouver, Canada.,Providence Health Research Institute, Vancouver, Canada
| | - James H Lan
- Vancouver Coastal Health Research Institute, Vancouver, Canada.,Division of Nephrology, University of British Columbia, Vancouver, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
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11
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Cron DC, Husain SA, Adler JT. The New Distance-Based Kidney Allocation System: Implications for Patients, Transplant Centers, and Organ Procurement Organizations. CURRENT TRANSPLANTATION REPORTS 2022; 9:302-307. [PMID: 36254174 PMCID: PMC9558035 DOI: 10.1007/s40472-022-00384-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 11/12/2022]
Abstract
Purpose of Review The goal of deceased donor kidney allocation policy is to provide objective prioritization for donated kidneys, and policy has undergone a series of revisions in the past decade in attempt to achieve equity and utility in access to kidney transplantation. Most recently, to address geographic disparities in access to kidney transplantation, the Kidney Allocation System changed to a distance-based allocation system—colloquially termed “KAS 250”—moving away from donor service areas as the geographic basis of allocation. We review the early impact of this policy change on access to transplant for patients, and on complexity of organ allocation and transplantation for transplant centers and organ procurement organizations. Recent Findings Broader sharing of kidneys has increased complexity of the allocation system, as transplant centers and OPOs now interact in larger networks. The increased competition resulting from this system, and the increased operational burden on centers and OPOs resulting from greater numbers of organ offers, may adversely affect organ utilization. Preliminary results suggest an increase in transplant rate overall but a trend toward higher kidney discard and increased cold ischemia time. Summary The KAS 250 allocation policy changed the geographic basis of deceased donor kidney distribution in a manner that is intended to reduce geographic disparities in access to kidney transplantation. Close monitoring of this policy’s impact on patients, transplant center behavior, and process measures is critical to the aim of maximizing access to transplant while achieving transplant equity.
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12
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13
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Abstract
BACKGROUND Quality in kidney transplantation is measured using 1-year patient and graft survival. Because 1-year patient and graft survival exceed 95%, this metric fails to measure a spectrum of quality. Textbook outcomes (TO) are a composite quality metric offering greater depth and resolution. We studied TO after living donor (LD) and deceased donor (DD) kidney transplantation. STUDY DESIGN United Network for Organ Sharing data for 69,165 transplant recipients between 2013 and 2017 were analyzed. TO was defined as patient and graft survival of 1 year or greater, 1-year glomerular filtration rate of greater than 40 mL/min, absence of delayed graft function, length of stay of 5 days or less, no readmissions during the first 6 months, and no episodes of rejection during the first year after transplantation. Bivariate analysis identified characteristics associated with TO, and covariates were incorporated into multivariable models. Five-year conditional survival was measured, and center TO rates were corrected for case complexity to allow center-level comparisons. RESULTS The national average TO rates were 54.1% and 31.7% for LD and DD transplant recipients. The hazard ratio for death at 5 years for recipients who did not experience TO was 1.92 (95% CI 1.68 to 2.18, p ≤ 0.0001) for LD transplant recipients and 2.08 (95% CI 1.93 to 2.24, p ≤ 0.0001) for DD transplant recipients. Center-level comparisons identify 18% and 24% of centers under-performing in LD and DD transplantation. High rates of TO do not correlate with transplantation center volume. CONCLUSION Kidney transplant recipients who experience TO have superior long-term survival. Textbook outcomes add value to the current standards of 1-year patient and graft survival.
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14
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Tandukar S, Tandukar Z. Dual impact of donor service area removal from kidney allocation system and Coronavirus Disease 2019 pandemic on access to transplantation. Clin Transplant 2022; 36:e14797. [PMID: 35988050 PMCID: PMC9538084 DOI: 10.1111/ctr.14797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/06/2022] [Accepted: 08/16/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Donor service area was removed from kidney and pancreas allocation system in the United States on March 15, 2021 in favor of a distance based policy to provide geographic equity to access to transplantation. The policy change was introduced at a time when ongoing Coronavirus Disease 2019 (COVID-19) pandemic cases were declining following the first delta wave. METHODS In this Scientific Registry of Transplant Recipients based study, deceased donor kidney transplant recipients between March 15 and December 2 of 2019, 2020 and 2021 were compared representing pre-policy change, pre-COVID cohort; pre-policy change, early COVID cohort; and post-policy change, late COVID cohort. RESULTS There were 11336, 11808, and 12914 kidney transplants in the 2019, 2020, and 2021 cohorts, respectively. Proportion of kidney transplants increased from 8798 (78%) to 9496 (80%) to 11152 (86%), and decreased from 2538 (22%) to 2312 (20%) to 1762 (14%) within and beyond 250 nautical miles in subsequent years. Median distance between donor and transplant hospital increased (73 vs. 63 vs. 119 nautical miles, P < .001) and mean cold ischemia time increased (18.1 vs. 17.8 vs. 19.9 h, P < .001). Access to transplantation did not change for various racial groups (P = .07), pediatric patients (P = .29), dialysis vintage of >5 years (P = .21), veterans (P = .07) and decreased for those with calculated PRA of 99% and 100% (P < .001). Rate of kidney discard (19.6% vs. 20.4% vs. 24%) remained high. Although there were numerical increases in transplants from donors with donation after circulatory death, donor acute kidney injury, kidney donor profile index >85% and donor age >60 years in successive years, rates of kidney discard also increased proportionally. CONCLUSION Improvement in the access to transplantation following the policy change was attenuated by the concurrent prevalence of the COVID-19 pandemic.
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Affiliation(s)
- Srijan Tandukar
- John C. McDonald Regional Transplant Center, Willis‐Knighton Medical CenterShreveportLouisianaUSA
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15
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Ross-Driscoll K, Gunasti J, Lynch RJ, Massie A, Segev DL, Snyder J, Axelrod D, Patzer RE. Listing at non-local transplant centers is associated with increased access to deceased donor kidney transplantation. Am J Transplant 2022; 22:1813-1822. [PMID: 35338697 PMCID: PMC9580509 DOI: 10.1111/ajt.17044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/22/2022] [Accepted: 03/22/2022] [Indexed: 01/25/2023]
Abstract
The ability of kidney transplant candidates to travel outside of their usual place of care varies by sociodemographic factors, potentially exacerbating disparities in access. We used Transplant Referral Regions (TRRs) to overcome previous methodological barriers of using geographic distance to assess the characteristics and outcomes of patients listed for kidney transplant at centers in neighboring TRR or beyond neighboring TRRs. Among listed kidney transplant candidates, 20.9% traveled to a neighbor and 5.6% beyond a neighbor. A higher proportion of travelers were White, had some college education, and lived in ZIP codes with lower poverty. Travel to a neighbor was associated with a 7% increase in likelihood of deceased donor transplant (cHR: 1.07, 95% CI: 1.05, 1.09) and traveling beyond a neighbor with a 19% increase (cHR: 1.19, 95% CI: 1.15, 1.24). Travelers had similar rates of living donor transplant and waitlist mortality as patients who did not travel; those who traveled beyond a neighbor had slightly lower posttransplant mortality (HR: 0.91, 95% CI: 0.83, 0.99). In conclusion, the ability to travel outside of the recipient's assigned TRR increases access to transplantation and improves long-term survival.
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Affiliation(s)
- Katherine Ross-Driscoll
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia,Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia
| | - Jonathan Gunasti
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia,Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia,Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Raymond J. Lynch
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Allan Massie
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Jon Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota,Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota,Department of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - David Axelrod
- Solid Organ Transplant Center, Department of Surgery, University of Iowa, Iowa City, Iowa
| | - Rachel E. Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia,Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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16
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Organ Transportation Innovations and Future Trends. CURRENT TRANSPLANTATION REPORTS 2022. [DOI: 10.1007/s40472-021-00341-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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17
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Rohan VS, Pilch N, McGillicuddy J, White J, Lin A, Dubay D, Taber DJ, Baliga PK. Early Assessment of National Kidney Allocation Policy Change. J Am Coll Surg 2022; 234:565-570. [PMID: 35290276 DOI: 10.1097/xcs.0000000000000096] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The new kidney allocation changes with elimination of donor service areas (DSAs) and Organ Procurement and Transplantation Network regions were initiated to improve equity in organ allocation. The aim of this evaluation was to determine the operational, financial, and recipient-related effect of the new allocation system on a large rural transplantation program. STUDY DESIGN A retrospective, cross-sectional analysis of organ offers, allograft outcomes, and attributed costs in a comparative time cohort, before (December 16, 2020 to March 14, 2021) and after (March 15, 2021 to June 13, 2021) the allocation change was performed. Outcomes were limited to adult, solitary, deceased donor kidney transplantations. RESULTS We received 198,881 organ offers from 3,886 organ donors at our transplantation center from December 16, 2020 to June 31, 2021: 87,643 (1,792 organ donors) before the change and 111,238 (2094 organ donors) after the change, for a difference of +23,595 more offers (+302 organ donors). This resulted in 6.5 more organs transplanted vs a predicted loss of 4.9 per month. Local organ offers dropped from 70% to 23%. There was a statistically significantly increase in donor terminal serum creatinine (1.2 ± 0.86 mg/dL vs 2.2 ± 2.3 mg/dL, p < 0.001), kidney donor profile index (KDPI) (39 ± 20 vs 48 ± 22, p = 0.017), cold ischemia time (16 ± 7 hours vs 21 ± 6 hours, p < 0.001), and delayed graft function rates (23% vs 40%, p = 0.020). CONCLUSION The new kidney allocation policy has led to an increase in KDPI of donors with longer cold ischemia time, leading to higher delayed graft function rates. This has resulted in increasing logistical and financial burdens on the system. Implementing large-scale changes in allocation based predominantly on predictive modeling needs to be intensely reassessed during a longer follow up.
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Affiliation(s)
- Vinayak S Rohan
- From the Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, SC
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18
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Glorioso JM. Kidney Allocation Policy: Past, Present, and Future. Adv Chronic Kidney Dis 2021; 28:511-516. [PMID: 35367019 DOI: 10.1053/j.ackd.2022.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/17/2022] [Accepted: 01/20/2022] [Indexed: 12/13/2022]
Abstract
Despite an increase in the number of kidney transplants performed annually, there remain more than 90,000 individuals awaiting transplantation in the United States. As kidney transplantation has evolved, so has kidney allocation policies. The Kidney Allocation System, which was introduced in 2014, made significant strides to improve utility and equity, but regional and geographic disparities remain. Further modifications eliminating donor service areas have been introduced. Moving forward, systems involving continuous distribution and artificial intelligence may provide further advancement toward an ideal allocation system.
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19
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Abstract
PURPOSE OF REVIEW The Final Rule clearly states that geography should not be a determinant of a chance of a potential candidate being transplanted. There have been multiple concerns about geographic disparities in patients in need of solid organ transplantation. Allocation policy adjustments have been designed to address these concerns, but there is little evidence that the disparities have been solved. The purpose of this review is to describe the main drivers of geographic disparities in solid organ transplantation and how allocation policy changes and other potential actions could impact these inequalities. RECENT FINDINGS Geographical disparities have been reported in kidney, pancreas, liver, and lung transplantation. Organ Procurement and Transplant Network has modified organ allocation rules to underplay geography as a key determinant of a candidates' chance of receiving an organ. Thus, heart, lung, and more recently liver and Kidney Allocation Systems have incorporated broader organ sharing to reduce geographical disparities. Whether these policy adjustments will indeed eliminate geographical disparities are still unclear. SUMMARY Modern allocation policy focus in patients need, regardless of geography. Innovative actions to further reduce geographical disparities are needed.
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20
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Hess NR, Seese LM, Sultan I, Wang Y, Hickey GW, Kilic A. Geographic disparities in heart transplantation persist under the new allocation policy. Clin Transplant 2021; 35:e14459. [PMID: 34398485 DOI: 10.1111/ctr.14459] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 07/25/2021] [Accepted: 08/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study evaluated the impact of the 2018 heart allocation policy change on geographic disparities in United States orthotopic heart transplantation (OHT). METHODS The United Network for Organ Sharing registry was queried to measure geographic disparity in OHT rates between pre-policy and post-policy change eras. We performed multilevel Poisson regression to measure region-level OHT rates. We derived an allocation priority-adjusted median incidence rate ratio (MIRR) for each policy era, a measure of median change in OHT rates between regions. RESULTS 5958.78 waitlist person-years were analyzed, comprising 6596 OHT procedures (3890 pre-policy and 2706 post-policy). Median region-level OHT rate was .94 transplants/person-years before and 1.51 transplants/person-years after the policy change (P < .001). The unadjusted OHT MIRR across regions was 1.29 (95% CI 1.00-1.50) pre-policy change and 1.17 (95% CI 1.00-1.43) post-policy change, suggesting that the region-related variance in OHT rates decreased under the new allocation. After adjustment for allocation priority risk factors, the MIRR pre-policy change was 1.13 (95% CI 1.01-1.32) and post-policy change was 1.15 (95% CI 1.00-1.35). CONCLUSIONS Geography accounts for ∼10% of the disparity among United States OHT rates. Despite broader heart sharing, the updated allocation policy did not substantially alter the existing geographic disparities among OHT recipients.
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Affiliation(s)
- Nicholas R Hess
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Laura M Seese
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gavin W Hickey
- Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arman Kilic
- Division of Cardiac Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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21
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22
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Schold JD, Huml AM, Poggio ED, Sedor JR, Husain SA, King KL, Mohan S. Patients with High Priority for Kidney Transplant Who Are Not Given Expedited Placement on the Transplant Waiting List Represent Lost Opportunities. J Am Soc Nephrol 2021; 32:1733-1746. [PMID: 34140398 PMCID: PMC8425662 DOI: 10.1681/asn.2020081146] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 03/08/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Kidney transplantation is associated with the best outcomes for most patients with ESKD. The national Kidney Allocation System prioritizes patients with Estimated Post-Transplant Survival (EPTS) scores in the top 20% for expedited access to optimal deceased donor kidneys. METHODS We studied adults aged ≥18 years in the United States Renal Data System with top 20% EPTS scores who had been preemptively waitlisted or initiated dialysis in 2015-2017. We evaluated time to waitlist placement, transplantation, and mortality with unadjusted and multivariable survival models. RESULTS Of 42,445 patients with top 20% EPTS scores (mean age, 38.0 years; 57% male; 59% White patients, and 31% Black patients), 7922 were preemptively waitlisted. Among 34,523 patients initiating dialysis, the 3-year cumulative waitlist placement incidence was 37%. Numerous factors independently associated with waitlisting included race, income, and having noncommercial insurance. For example, waitlisting was less likely for Black versus White patients, and for patients in the lowest-income neighborhoods versus those in the highest-income neighborhoods. Among patients initiating dialysis, 61% lost their top 20% EPTS status within 30 months versus 18% of patients who were preemptively listed. The 3-year incidence of deceased and living donor transplantation was 5% and 6%, respectively, for patients who initiated dialysis and 26% and 44%, respectively, for patients who were preemptively listed. CONCLUSIONS Many patients with ESKDqualifying with top 20% EPTS status are not placed on the transplant waiting list in a timely manner, with significant variation on the basis of demographic and social factors. Patients who are preemptively listed are more likely to receive benefits of top 20% EPTS status. Efforts to expedite care for qualifying candidates are needed, and automated transplant referral for patients with the best prognoses should be considered. PODCAST This article contains a podcast athttps://www.asn-online.org/media/podcast/JASN/2021_07_30_JASN2020081146.mp3.
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Affiliation(s)
- Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Anne M. Huml
- Department of Nephrology and Hyptertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Emilio D. Poggio
- Department of Nephrology and Hyptertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - John R. Sedor
- Department of Nephrology and Hyptertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio,Department Immunology and Inflammation, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Syed A. Husain
- Division of Nephrology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York,The Columbia University Renal Epidemiology Group, Columbia University, New York, New York
| | - Kristin L. King
- Division of Nephrology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York,The Columbia University Renal Epidemiology Group, Columbia University, New York, New York
| | - Sumit Mohan
- Division of Nephrology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York,The Columbia University Renal Epidemiology Group, Columbia University, New York, New York
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23
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Adler JT, Husain SA, King KL, Mohan S. Greater complexity and monitoring of the new Kidney Allocation System: Implications and unintended consequences of concentric circle kidney allocation on network complexity. Am J Transplant 2021; 21:2007-2013. [PMID: 33314637 DOI: 10.1111/ajt.16441] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 01/25/2023]
Abstract
The deceased donor kidney allocation system in the United States has undergone several rounds of iterative changes, but these changes were not explicitly designed to address the geographic variation in access to transplantation. The new allocation system, expected to start in December 2020, changes the definition of "local allocation" from the Donation Service Area to 250 nautical mile circles originating from the donor hospital. While other solid organs have adopted a similar approach, the larger number of both kidney transplant centers and transplant candidates is likely to have different consequences. Here, we discuss the incredible increase in complexity in allocation, discuss some of the likely intended and unintended consequences, and propose metrics to monitor the new system.
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Affiliation(s)
- Joel T Adler
- Department of Surgery, Division of Transplant Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Surgery and Public Health at Brigham and Women's Hospital, Boston, Massachusetts
| | - Syed A Husain
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York.,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Kristen L King
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York.,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York.,The Columbia University Renal Epidemiology (CURE) Group, New York, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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24
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Hu A, Stewart C, Craig JC, Wyburn K, Pleass H, Kanellis J, Lim WH, Yang J, Wong G. Jurisdictional inequalities in deceased donor kidney allocation in Australia. Kidney Int 2021; 100:49-54. [PMID: 33961869 DOI: 10.1016/j.kint.2021.04.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/28/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Anne Hu
- Faculty of Science, School of Mathematics and Science, University of Sydney, Sydney, Australia
| | - Cameron Stewart
- Sydney Law School, University of Sydney, Camperdown, Sydney, New South Wales, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Kate Wyburn
- Department of Renal and Transplantation Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Henry Pleass
- Faculty of Health and Medical Science, University of Western Australia, Perth, Australia
| | - John Kanellis
- Department of Nephrology, Monash Health and Centre for Inflammatory Diseases, Melbourne, Australia; Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Wai H Lim
- Specialty of Surgery, University of Sydney, Camperdown, Sydney, New South Wales, Australia
| | - Jean Yang
- Faculty of Science, School of Mathematics and Science, University of Sydney, Sydney, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Camperdown, New South Wales, Australia; Centre for Kidney Research, Kids Research Institute, The Children's Hospital at Westmead, Sydney, New South Wales, Australia; Centre for Transplant and Renal Research, Westmead Hospital, Sydney, New South Wales, Australia.
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25
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Schold JD, Mohan S, Huml A, Buccini LD, Sedor JR, Augustine JJ, Poggio ED. Failure to Advance Access to Kidney Transplantation over Two Decades in the United States. J Am Soc Nephrol 2021; 32:913-926. [PMID: 33574159 PMCID: PMC8017535 DOI: 10.1681/asn.2020060888] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 12/02/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Extensive research and policies have been developed to improve access to kidney transplantation among patients with ESKD. Despite this, wide variation in transplant referral rates exists between dialysis facilities. METHODS To evaluate the longitudinal pattern of access to kidney transplantation over the past two decades, we conducted a retrospective cohort study of adult patients with ESKD initiating ESKD or placed on a transplant waiting list from 1997 to 2016 in the United States Renal Data System. We used cumulative incidence models accounting for competing risks and multivariable Cox models to evaluate time to waiting list placement or transplantation (WLT) from ESKD onset. RESULTS Among the study population of 1,309,998 adult patients, cumulative 4-year WLT was 29.7%, which was unchanged over five eras. Preemptive WLT (prior to dialysis) increased by era (5.2% in 1997-2000 to 9.8% in 2013-2016), as did 4-year WLT incidence among patients aged 60-70 (13.4% in 1997-2000 to 19.8% in 2013-2016). Four-year WLT incidence diminished among patients aged 18-39 (55.8%-48.8%). Incidence of WLT was substantially lower among patients in lower-income communities, with no improvement over time. Likelihood of WLT after dialysis significantly declined over time (adjusted hazard ratio, 0.80; 95% confidence interval, 0.79 to 0.82) in 2013-2016 relative to 1997-2000. CONCLUSIONS Despite wide recognition, policy reforms, and extensive research, rates of WLT following ESKD onset did not seem to improve in more than two decades and were consistently reduced among vulnerable populations. Improving access to transplantation may require more substantial interventions.
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Affiliation(s)
- Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians & Surgeons, New York, New York,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Anne Huml
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Laura D. Buccini
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - John R. Sedor
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Emilio D. Poggio
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
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26
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Padela AI, Duivenbode R, Quinn M, Saunders MR. Informing American Muslims about living donation through tailored health education: A randomized controlled crossover trial evaluating increase in biomedical and religious knowledge. Am J Transplant 2021; 21:1227-1237. [PMID: 32772460 DOI: 10.1111/ajt.16242] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 01/25/2023]
Abstract
Biomedical and religious knowledge affects organ donation attitudes among Muslims. We tested the effectiveness of mosque-based, religiously tailored, ethically balanced education on organ donation among Muslim Americans. Our randomized, controlled, crossover trial took place at 4 mosques randomized to an early arm where organ donation education preceded a control educational workshop or a late arm with the order reversed. Primary outcomes were changes in biomedical (Rotterdam Renal Replacement Knowledge Test living donation subscale, R3KT) and religious (Islamic Knowledge of Living Organ Donation, IK-LOD) living kidney donation knowledge. Statistical analysis employed a 2 (Treatment Arm) X 3 (Time of Assessment) mixed-method analysis of variance. Of 158 participants, 59 were in the early arm and 99 in the late arm. A between group t test comparison at Period 1 (Time 1 - Time 2), demonstrated that the early arm had a significantly higher mean IK-LOD (7.11 v 5.19, P < .05) and R3KT scores (7.65 v 4.90, P < .05) when compared to the late arm. Late arm participants also had significant increases in mean IK-LOD (5.19 v 7.16, P < .05) and R3KT scores (4.90 v. 6.81, P < .05) postintervention (Time 2-Time 3). Our novel program thus yielded significant kidney donation-related knowledge gains among Muslim Americans (NCT04443114 Clinicaltrials.gov).
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Affiliation(s)
- Aasim I Padela
- Initiative on Islam and Medicine, University of Chicago, Chicago, Illinois, USA.,MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA.,Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Rosie Duivenbode
- Initiative on Islam and Medicine, University of Chicago, Chicago, Illinois, USA
| | - Michael Quinn
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Milda R Saunders
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA.,Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
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27
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Karami F, Kernodle AB, Ishaque T, Segev DL, Gentry SE. Allocating kidneys in optimized heterogeneous circles. Am J Transplant 2021; 21:1179-1185. [PMID: 32808468 DOI: 10.1111/ajt.16274] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 07/19/2020] [Accepted: 08/12/2020] [Indexed: 01/25/2023]
Abstract
Recently, the Organ Procurement and Transplant Network approved a plan to allocate kidneys within 250-nm circles around donor hospitals. These homogeneous circles might not substantially reduce geographic differences in transplant rates because deceased donor kidney supply and demand differ across the country. Using Scientific Registry of Transplant Recipients data from 2016-2019, we used an integer program to design unique, heterogeneous circles with sizes between 100 and 500 nm that reduced supply/demand ratio variation across transplant centers. We weighted demand according to wait time because candidates who have waited longer have higher priority. We compared supply/demand ratios and average travel distance of kidneys, using heterogeneous circles and 250 and 500-nm fixed-distance homogeneous circles. We found that 40% of circles could be 250 nm or smaller, while reducing supply/demand ratio variation more than homogeneous circles. Supply/demand ratios across centers for heterogeneous circles ranged from 0.06 to 0.13 kidneys per wait-year, compared to 0.04 to 0.47 and 0.05 to 0.15 kidneys per wait-year for 250-nm and 500-nm homogeneous circles, respectively. The average travel distance for kidneys using heterogeneous, and 250-nm and 500-nm fixed-distance circles was 173 nm, 134 nm, and 269 nm, respectively. Heterogeneous circles reduce geographic disparity compared to homogeneous circles, while maintaining reasonable travel distances.
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Affiliation(s)
- Fatemeh Karami
- Industrial Engineering Department, University of Louisville, Louisville, Kentucky, USA.,Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Amber B Kernodle
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Tanveen Ishaque
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA.,Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
| | - Sommer E Gentry
- Department of Mathematics, United States Naval Academy, Annapolis, Maryland, USA
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28
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Decoteau MA, Stewart DE, Toll AE, Kurian SM, Case J, Marsh CL. The Advantage of Multiple Listing Continues in the Kidney Allocation System Era. Transplant Proc 2021; 53:569-580. [PMID: 33549345 DOI: 10.1016/j.transproceed.2020.10.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/12/2020] [Accepted: 10/30/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Transplant candidates can be listed at multiple transplant centers to increase the probability of receiving an organ. We evaluated the association between multilisting (ML) status and access to a deceased donor kidney transplant (DDKT) to determine if ML provides a long-term advantage regarding wait-list mortality and recipient outcomes. MATERIALS AND METHODS Candidates between January 2010 and October 2017 were identified as either singly or multiply listed using Organ Procurement and Transplantation Network data and cohorts before and after implementation of the Kidney Allocation System (KAS). Cross-sectional logistic regression was used to assess relationships between candidate factors and ML prevalence (5.4%). RESULTS Factors associated with ML pre-KAS included having blood type B (reference, type O; odds ratio [OR], 1.20; P < .001), having private insurance (OR, 1.5; P < .001), wait time (OR, 1.28; P < .001), and increasing calculated panel-reactive antibody (cPRA) (reference, cPRA 0-100; OR for cPRA 80-98, 2.83; OR for cPRA 99, 3.47; OR for cPRA 100, 5.18; P < .001). Transplant rates were double for multilisted vs singly listed recipients (adjusted hazard ratio [aHR], 2.16; P < .001). Extra-donor service area ML candidates received transplants 2.5 years quicker than single-listing (SL) candidates, conferring a 42% wait-list advantage. Recipient death (aHR, 0.94; P = .122) and graft failure (aHR, 0.91; P = .006) rates were also lower for ML recipients. CONCLUSIONS In the KAS era, ML continues to increase the likelihood of receiving a DDKT and lower the incidence of wait-list mortality, and it confers a survival advantages over SL.
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Affiliation(s)
- Mary A Decoteau
- Scripps Center for Organ and Cell Transplantation, Scripps Clinic and Scripps Green Hospital, La Jolla, CA, USA; Department of General Surgery, Naval Medical Center San Diego, San Diego, CA, USA
| | | | - Alice E Toll
- United Network for Organ Sharing, Richmond, VA, USA
| | - Sunil M Kurian
- Scripps Center for Organ and Cell Transplantation, Scripps Clinic and Scripps Green Hospital, La Jolla, CA, USA; Scripps Clinic Bio-Repository and Bio-Informatics Core, Scripps Green Hospital, La Jolla, CA, USA
| | - Jamie Case
- Scripps Center for Organ and Cell Transplantation, Scripps Clinic and Scripps Green Hospital, La Jolla, CA, USA; Scripps Clinic Bio-Repository and Bio-Informatics Core, Scripps Green Hospital, La Jolla, CA, USA
| | - Christopher L Marsh
- Scripps Center for Organ and Cell Transplantation, Scripps Clinic and Scripps Green Hospital, La Jolla, CA, USA; Scripps Clinic Bio-Repository and Bio-Informatics Core, Scripps Green Hospital, La Jolla, CA, USA.
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29
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King KL, Husain SA, Schold JD, Patzer RE, Reese PP, Jin Z, Ratner LE, Cohen DJ, Pastan SO, Mohan S. Major Variation across Local Transplant Centers in Probability of Kidney Transplant for Wait-Listed Patients. J Am Soc Nephrol 2020; 31:2900-2911. [PMID: 33037131 PMCID: PMC7790218 DOI: 10.1681/asn.2020030335] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 08/06/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Geographic disparities in access to deceased donor kidney transplantation persist in the United States under the Kidney Allocation System (KAS) introduced in 2014, and the effect of transplant center practices on the probability of transplantation for wait-listed patients remains unclear. METHODS To compare probability of transplantation across centers nationally and within donation service areas (DSAs), we conducted a registry study that included all United States incident adult kidney transplant candidates wait listed in 2011 and 2015 (pre-KAS and post-KAS cohorts comprising 32,745 and 34,728 individuals, respectively). For each center, we calculated the probability of deceased donor kidney transplantation within 3 years of wait listing using competing risk regression, with living donor transplantation, death, and waiting list removal as competing events. We examined associations between center-level and DSA-level characteristics and the adjusted probability of transplant. RESULTS Candidates received deceased donor kidney transplants within 3 years of wait listing more frequently post-KAS (22%) than pre-KAS (19%). Nationally, the probability of transplant varied 16-fold between centers, ranging from 4.0% to 64.2% in the post-KAS era. Within DSAs, we observed a median 2.3-fold variation between centers, with up to ten-fold and 57.4 percentage point differences. Probability of transplantation was correlated in the post-KAS cohort with center willingness to accept hard-to-place kidneys (r=0.55, P<0.001) and local organ supply (r=0.44, P<0.001). CONCLUSIONS Large differences in the adjusted probability of deceased donor kidney transplantation persist under KAS, even between centers working with the same local organ supply. Probability of transplantation is significantly associated with organ offer acceptance patterns at transplant centers, underscoring the need for greater understanding of how centers make decisions about organs offered to wait-listed patients and how they relate to disparities in access to transplantation.
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Affiliation(s)
- Kristen L King
- Division of Nephrology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- The Columbia University Renal Epidemiology Group, New York, New York
| | - S Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- The Columbia University Renal Epidemiology Group, New York, New York
| | - Jesse D Schold
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Rachel E Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zhezhen Jin
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Lloyd E Ratner
- Department of Surgery, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York
| | - David J Cohen
- Division of Nephrology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Stephen O Pastan
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- The Columbia University Renal Epidemiology Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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30
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Bae S, Massie AB, Caffo BS, Jackson KR, Segev DL. Machine learning to predict transplant outcomes: helpful or hype? A national cohort study. Transpl Int 2020; 33:1472-1480. [PMID: 32996170 PMCID: PMC8269970 DOI: 10.1111/tri.13695] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/30/2019] [Accepted: 06/29/2020] [Indexed: 12/13/2022]
Abstract
An increasing number of studies claim machine learning (ML) predicts transplant outcomes more accurately. However, these claims were possibly confounded by other factors, namely, supplying new variables to ML models. To better understand the prospects of ML in transplantation, we compared ML to conventional regression in a "common" analytic task: predicting kidney transplant outcomes using national registry data. We studied 133 431 adult deceased-donor kidney transplant recipients between 2005 and 2017. Transplant centers were randomly divided into 70% training set (190 centers/97 787 recipients) and 30% validation set (82 centers/35 644 recipients). Using the training set, we performed regression and ML procedures [gradient boosting (GB) and random forests (RF)] to predict delayed graft function, one-year acute rejection, death-censored graft failure C, all-cause graft failure, and death. Their performances were compared on the validation set using -statistics. In predicting rejection, regression (C = 0.601 0.6110.621 ) actually outperformed GB (C = 0.581 0.5910.601 ) and RF (C = 0.569 0.5790.589 ). For all other outcomes, the C-statistics were nearly identical across methods (delayed graft function, 0.717-0.723; death-censored graft failure, 0.637-0.642; all-cause graft failure, 0.633-0.635; and death, 0.705-0.708). Given its shortcomings in model interpretability and hypothesis testing, ML is advantageous only when it clearly outperforms conventional regression; in the case of transplant outcomes prediction, ML seems more hype than helpful.
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Affiliation(s)
- Sunjae Bae
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Allan B Massie
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Brian S Caffo
- Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Kyle R Jackson
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
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31
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Geographic Disparities in Access to Simultaneous Pancreas and Kidney Transplant in the Pre- and Post-Pancreas Allocation System Eras. Transplantation 2020; 104:623-631. [PMID: 31335772 DOI: 10.1097/tp.0000000000002850] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The 2014 pancreas allocation system (PAS) intended to decrease geographic variability in listing practices for simultaneous pancreas and kidney (SPK) transplant and define eligibility criteria for those with type 2 diabetes mellitus (T2DM). Our primary aims were to evaluate geographic disparities in access to SPK and assess T2DM SPK listings in the pre- and post-PAS eras. METHODS Adult listings for SPK and kidney transplant (pre-PAS, January 2010 to October 29, 2014; post-PAS, October 30, 2014, to June 2, 2017) were identified in the Scientific Registry of Transplant Recipients. Multivariable logistic regression models tested associations of geography and/or diabetes mellitus type on the likelihood of SPK versus kidney transplant listing pre- and post-PAS. Competing risk models tested the likelihood of SPK transplantation within 2 years of listing for SPK. RESULTS Among 41 205 listings (27 393 pre-PAS; 24 439 T2DM), univariate analysis showed reduced percentages for SPK post-PAS (22.1%-20.8%; P = 0.003). After adjusting for patient and center characteristics, geographic disparities declined slightly but persisted post-PAS (era by region interaction P < 0.001). The era by type of diabetes mellitus interaction effect was statistically significant (P = 0.039), reflecting that the proportions of SPK listings for T2DM increased in the post-PAS era (3.4%-3.9%; univariate P = 0.038), while those for type 1 diabetes mellitus remained statistically stable (47.9%-48.4%; univariate P = 0.571). Among people listed for SPK, geographic disparities in the cumulative incidence of transplantation within 2 years declined and the overall likelihood of transplantation increased in the post-PAS era (both P < 0.001). CONCLUSIONS Geographic disparities in access to SPK declined slightly but persisted post-PAS. With new allocation change proposals and elimination of listing criteria for T2DM, further monitoring is warranted.
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32
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Hanaway MJ, MacLennan PA, Locke JE. Exacerbating Racial Disparities in Kidney Transplant. JAMA Surg 2020; 155:679-681. [DOI: 10.1001/jamasurg.2020.1455] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Michael J. Hanaway
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham
| | - Paul A. MacLennan
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham
| | - Jayme E. Locke
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham
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33
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Hashimoto D, Poudel S, Hirano S, Kurashima Y, Akiyama H, Eguchi S, Fukui T, Hagiwara M, Hida K, Izaki T, Iwase H, Kawamoto S, Otomo Y, Nagai E, Saito M, Takami H, Takeda Y, Toi M, Yamaue H, Yoshida M, Yoshida S, Ohki T, Kodera Y. Is there disparity between regions and facilities in surgical resident training in Japan? Insights from a national survey. Surg Today 2020; 50:1585-1593. [PMID: 32488479 DOI: 10.1007/s00595-020-02037-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/19/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE This study sought to assess the disparity between regions and facilities in surgical resident training in Japan via a national level needs-assessment. METHODS A survey was sent to all 909 graduating residents of 2016. Residents trained in the six prefectures with a population of 7 million or more were included in the large prefecture (LP) group. Residents trained in the other 41 prefectures were included in the small prefecture (SP) group. Each group was further divided into a university hospital (UH) group and a non-university hospital (NUH) group. RESULTS The response rate was 56.3% (n = 512). Excluding nine residents who did not report their prefectures and facilities, surveys from 503 residents were analyzed. The UH group received significantly more years of training. In the SP and UH groups, there were significantly fewer residents who had performed 150 procedures or more under general anesthesia in comparison to the LP and NUH groups, respectively. Self-assessed competencies for several procedures were significantly lower in the SP and UH groups. CONCLUSION Disparity in surgical resident training was found between regions and facilities in Japan. The surgical residency curriculum in Japan could be improved to address this problem.
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Affiliation(s)
- Daisuke Hashimoto
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata-city, Osaka, 573-1010, Japan. .,Department of Gastroenterological Surgery, Omuta Tenryo Hospital, Fukuoka, Japan. .,Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medicine, Kumamoto, Japan.
| | - Saseem Poudel
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Yo Kurashima
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Hirotoshi Akiyama
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Masaru Hagiwara
- Department of Surgery, Tokyo Medical University, Tokyo, Japan
| | - Koya Hida
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tomoko Izaki
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hirotaka Iwase
- Department of Breast and Endocrine Surgery, Kumamoto University, Kumamoto, Japan
| | - Shunsuke Kawamoto
- Division of Cardiovascular Surgery, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Eishi Nagai
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mitsue Saito
- Department of Breast Oncology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hideki Takami
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuko Takeda
- Division of Medical Education, Juntendo University School of Medicine, Tokyo, Japan
| | - Masakazu Toi
- Department of Breast Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
| | - Motofumi Yoshida
- Department of Medical Education, Graduate School of Medicine, International University of Health and Welfare, Narita, Japan
| | - Shigetoshi Yoshida
- Department of Thoracic Surgery, International University of Health and Welfare School of Medicine, Narita, Japan
| | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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34
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Covarrubias K, Luo X, Massie A, Schwarz KB, Garonzik-Wang J, Segev DL, Mogul DB. Determinants of length of stay after pediatric liver transplantation. Pediatr Transplant 2020; 24:e13702. [PMID: 32212292 PMCID: PMC7260078 DOI: 10.1111/petr.13702] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/07/2020] [Accepted: 03/04/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND We sought to identify factors that are associated with LOS following pediatric (<18 years) liver transplantation in order to provide personalized counseling and discharge planning for recipients and their families. METHODS We identified 2726 infants (≤24 months) and 3210 children (>24 months) who underwent pediatric liver-only transplantation from 2002-2017 using the Scientific Registry of Transplant Recipients. We used multilevel multivariable negative binomial regression to analyze associations between LOS and recipient and donor characteristics and calculated the MLOSR to quantify heterogeneity in LOS across centers. RESULTS In infants, the median LOS (IQR) was 19 (13-32) days. Hospitalization prior to transplant (ICU ratio:1.46 1.591.70 ; non-ICU ratio:1.08 1.161.23 ), public insurance (ratio:1.03 1.091.15 ), and a segmental graft (ratio:1.08 1.151.22 ) were associated with a longer LOS; thus, we would expect a 1.59-fold longer LOS in an infant admitted to the ICU compared to a non-hospitalized infant with similar characteristics. In children, the median LOS (IQR) was 13 (9-21) days. Hospitalization prior to transplant (ICU ratio:1.49 1.621.77 ; non-ICU ratio:1.34 1.441.56 ), public insurance (ratio:1.02 1.071.13 ), a segmental graft (ratio:1.20 1.271.35 ), a living donor graft (ratio:1.27 1.381.51 ), and obesity (ratio:1.03 1.101.17 ) were associated with a longer LOS. The MLOSR was 1.25 in infants and 1.26 in children, meaning if an infant received a transplant at another center with a longer LOS, we would expect a 1.25-fold difference in LOS driven by center practices alone. CONCLUSIONS While center-level practices account for substantial variation in LOS, consideration of donor and recipient factors can help clinicians provide more personalized counseling for families of pediatric liver transplant candidates.
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Affiliation(s)
- Karina Covarrubias
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xun Luo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD
| | - Kathleen B. Schwarz
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD
| | - Douglas B. Mogul
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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35
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Parker WF, Chin MH. Epistemic Authority and Trust in Shared Decision Making About Organ Transplantation. AMA J Ethics 2020; 22:E408-415. [PMID: 32449657 DOI: 10.1001/amajethics.2020.408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Patient epistemic authority acknowledges respect for a patient's knowledge claims, an important manifestation of patient autonomy that facilitates shared decision making in medicine. Given the scarcity of deceased donor organs, transplantation programs state that patient promises of compliance cannot be taken at face value and exclude candidates deemed untrustworthy. This article argues that transplant programs frequently lack the data to make this utilitarian calculation accurately, with the result that, in practice, the psychosocial evaluation of potential transplant candidates is discriminatory and unfair. Historically excluded candidates, such as patients suffering from alcohol use, have turned out to benefit highly from transplantation. Transplant programs should tend to trust patients when they claim to be good potential organ stewards, thereby respecting patient autonomy, advancing justice, and saving more lives.
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Affiliation(s)
- William F Parker
- Instructor of pulmonary and critical care medicine, senior fellow at the MacLean Center for Clinical Medical Ethics at the University of Chicago in Illinois
| | - Marshall H Chin
- Richard Parrillo Family Professor of Healthcare Ethics in the Department of Medicine, associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago in Illinois
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36
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Schold JD, Augustine JJ, Huml AM, O’Toole J, Sedor JR, Poggio ED. Modest rates and wide variation in timely access to repeat kidney transplantation in the United States. Am J Transplant 2020; 20:769-778. [PMID: 31599065 PMCID: PMC7204603 DOI: 10.1111/ajt.15646] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/08/2019] [Accepted: 09/17/2019] [Indexed: 02/06/2023]
Abstract
Success of transplantation is not limited to initial receipt of a donor organ. Many kidney transplant recipients experience graft loss following initial transplantation and the benefits of expedited placement on the waiting list and retransplantation extend to this population. Factors associated with access to repeat transplantation may be unique given experience with the transplant process and prior viability as a candidate. We examined the incidence, risk factors, secular changes, and center-level variation of preemptive relisting or transplantation (PRLT) for kidney transplant recipients in the United States with graft failure (not due to death) using Scientific Registry of Transplant Recipients data from 2007 to 2018 (n = 39 557). Overall incidence of PRLT was 15% and rates of relisting declined over time. Significantly lower PRLT was evident among patients who were African American and Hispanic, males, older, obese, publicly insured, had lower educational attainment, were diabetic, had longer dialysis time prior to initial transplant, shorter graft survival, longer distance to transplant center, and resided in distressed communities. There was significant variation in PRLT by center, median = 13%, 10th percentile = 6%, 90th percentile = 24%. Cumulatively, results indicate that despite prior access to transplantation, incidence of PRLT is modest with pronounced clinical, social, and center-level sources of variation suggesting opportunities to improve preemptive care among patients with failing grafts.
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Affiliation(s)
- Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Anne M. Huml
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - John O’Toole
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - John R. Sedor
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Emilio D. Poggio
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
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37
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Reed RD, Shelton BA, Mustian MN, MacLennan PA, Sawinski D, Locke JE. Geographic Differences in Population Health and Expected Organ Supply in the Gulf Coast Region of the United States Compared to Non-Gulf States. Transplantation 2020; 104:421-427. [PMID: 32004235 PMCID: PMC7000133 DOI: 10.1097/tp.0000000000002831] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Final Rule aimed to reduce geographic disparities in access to transplantation by prioritizing the need for transplant over donor proximity. However, disparities in waiting times persist for deceased donor kidney transplantation. The kidney allocation system implemented in 2014 does not account for potential local supply based on population health characteristics within a donation service area (DSA). We hypothesized that regions with traditionally high rates of comorbid disease, such as the states located along the Gulf of Mexico (Gulf States), may be disadvantaged by limited local supply secondary to poor population health. METHODS Using data from the Robert Wood Johnson Foundation County Health Rankings, the United States Renal Data System, and the Scientific Registry of Transplant Recipients, we compared population-level characteristics and expected kidney donation rates by Gulf States location. RESULTS Prevalence of African American ethnicity, end-stage renal disease, diabetes, fair/poor self-rated health, physical inactivity, food insecurity, and uninsurance were higher among Gulf State DSAs. On unadjusted analyses, Gulf State DSAs were associated with 3.52 fewer expected kidney donors per 100 eligible deaths than non-Gulf States. After adjustment, there was no longer a statistically significant difference in expected kidney donation rate. CONCLUSIONS Although Gulf State DSAs have lower expected donation rates, these differences appear to be driven by the prevalence of health factors negatively associated with donation rate. These data suggest the need to discuss population health characteristics when examining kidney allocation policy, to account for potential lower supply of donors and to further address geographic disparities in access to kidney transplantation.
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Affiliation(s)
- Rhiannon D. Reed
- Department of Surgery, University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL
| | - Brittany A. Shelton
- Department of Surgery, University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL
| | - Margaux N. Mustian
- Department of Surgery, University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL
| | - Paul A. MacLennan
- Department of Surgery, University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL
| | - Deirdre Sawinski
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jayme E. Locke
- Department of Surgery, University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL
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38
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Schinstock CA, Smith BH, Montgomery RA, Jordan SC, Bentall AJ, Mai M, Khamash HA, Stegall MD. Managing highly sensitized renal transplant candidates in the era of kidney paired donation and the new kidney allocation system: Is there still a role for desensitization? Clin Transplant 2019; 33:e13751. [DOI: 10.1111/ctr.13751] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/24/2019] [Accepted: 11/01/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Carrie A. Schinstock
- Division of Nephrology and Hypertension Department of Internal Medicine Mayo Clinic Rochester MN USA
- The William J von Liebig Center for Transplantation and Clinical Regeneration Mayo Clinic Rochester MN USA
| | - Byron H. Smith
- Department of Health Sciences Research Mayo Clinic Rochester MN USA
| | | | | | - Andrew J. Bentall
- Division of Nephrology and Hypertension Department of Internal Medicine Mayo Clinic Rochester MN USA
- The William J von Liebig Center for Transplantation and Clinical Regeneration Mayo Clinic Rochester MN USA
| | - Martin Mai
- Transplant Center Mayo Clinic Jacksonville FL USA
| | - Hasan A. Khamash
- Division of Nephrology and Hypertension Department of Internal Medicine Mayo Clinic Phoenix AZ USA
| | - Mark D. Stegall
- The William J von Liebig Center for Transplantation and Clinical Regeneration Mayo Clinic Rochester MN USA
- Division of Transplantation Surgery Department of Medicine Mayo Clinic Rochester MN USA
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39
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King KL, Husain SA, Mohan S. Geographic Variation in the Availability of Deceased Donor Kidneys per Wait-Listed Candidate in the United States. Kidney Int Rep 2019; 4:1630-1633. [PMID: 31891004 PMCID: PMC6933455 DOI: 10.1016/j.ekir.2019.08.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 08/19/2019] [Accepted: 08/20/2019] [Indexed: 01/30/2023] Open
Affiliation(s)
- Kristen L. King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
- Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - S. Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
- Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
- Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
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40
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Bowring MG, Zhou S, Chow EK, Massie AB, Segev DL, Gentry SE. Geographic Disparity in Deceased Donor Liver Transplant Rates Following Share 35. Transplantation 2019; 103:2113-2120. [PMID: 30801545 PMCID: PMC6699938 DOI: 10.1097/tp.0000000000002643] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The Organ Procurement and Transplantation Network implemented Share 35 on June 18, 2013, to broaden deceased donor liver sharing within regional boundaries. We investigated whether increased sharing under Share 35 impacted geographic disparity in deceased donor liver transplantation (DDLT) across donation service areas (DSAs). METHODS Using Scientific Registry of Transplant Recipients June 2009 to June 2017, we identified 86 083 adult liver transplant candidates and retrospectively estimated Model for End-Stage Liver Disease (MELD)-adjusted DDLT rates using nested multilevel Poisson regression with random intercepts for DSA and transplant program. From the variance in DDLT rates across 49 DSAs and 102 programs, we derived the DSA-level median incidence rate ratio (MIRR) of DDLT rates. MIRR is a robust metric of heterogeneity across each hierarchical level; larger MIRR indicates greater disparity. RESULTS MIRR was 2.18 pre-Share 35 and 2.16 post-Share 35. Thus, 2 candidates with the same MELD in 2 different DSAs were expected to have a 2.2-fold difference in DDLT rate driven by geography alone. After accounting for program-level heterogeneity, MIRR was attenuated to 2.10 pre-Share 35 and 1.96 post-Share 35. For candidates with MELD 15-34, MIRR decreased from 2.51 pre- to 2.27 post-Share 35, and for candidates with MELD 35-40, MIRR increased from 1.46 pre- to 1.51 post-Share 35, independent of program-level heterogeneity in DDLT. DSA-level heterogeneity in DDLT rates was greater than program-level heterogeneity pre- and post-Share 35. CONCLUSIONS Geographic disparity substantially impacted DDLT rates before and after Share 35, independent of program-level heterogeneity and particularly for candidates with MELD 35-40. Despite broader sharing, geography remains a major determinant of access to DDLT.
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Affiliation(s)
- Mary G. Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sheng Zhou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eric K.H. Chow
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
- Scientific Registry of Transplant Recipients, Minneapolis, MN, USA
| | - Sommer E. Gentry
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Mathematics, United States Naval Academy, Baltimore, MD, USA
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41
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Husain SA, King KL, Dube GK, Tsapepas D, Cohen DJ, Ratner LE, Mohan S. Regional Disparities in Transplantation With Deceased Donor Kidneys With Kidney Donor Profile Index Less Than 20% Among Candidates With Top 20% Estimated Post Transplant Survival. Prog Transplant 2019; 29:354-360. [PMID: 31506000 DOI: 10.1177/1526924819874699] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The Kidney Allocation System in the United States prioritizes candidates with Estimated Post-Transplant Survival (EPTS) ≤20% to receive deceased donor kidneys with Kidney Donor Profile Index (KDPI) ≤20%. RESEARCH QUESTION We compared access to KDPI ≤ 20% kidneys for EPTS ≤ 20% candidates across the United States to determine whether geographic disparities in access to these low KDPI kidneys exist. DESIGN We identified all incident adult deceased donor kidney candidates wait-listed January 1, 2015, to March 31, 2018, using United Network for Organ Sharing data. We calculated the proportion of candidates transplanted, final EPTS, and KDPI of transplanted kidneys for candidates listed with EPTS ≤ 20% versus >20%. We compared the odds of receiving a KDPI ≤ 20% deceased donor kidney for EPTS ≤ 20% candidates across regions using logistic regression. RESULTS Among 121 069 deceased donor kidney candidates, 28.5% had listing EPTS ≤ 20%. Of these, 16.1% received deceased donor kidney transplants (candidates listed EPTS > 20%: 17.1% transplanted) and 12.3% lost EPTS ≤ 20% status. Only 49.4% of transplanted EPTS ≤ 20% candidates received a KDPI ≤ 20% kidney, and 48.3% of KDPI ≤ 20% kidneys went to recipients with EPTS > 20% at the time of transplantation. Odds of receiving a KDPI ≤ 20% kidney were highest in region 6 and lowest in region 9 (odds ratio 0.19 [0.13 to 0.28]). The ratio of KDPI ≤ 20% donors per EPTS ≤ 20% candidate and likelihood of KDPI ≤ 20% transplantation were strongly correlated (r 2 = 0.84). DISCUSSION Marked geographic variation in the likelihood of receiving a KDPI ≤ 20% deceased donor kidney among transplanted EPTS ≤ 20% candidates exists and is related to differences in organ availability within allocation borders. Policy changes to improve organ sharing are needed to improve equity in access to low KDPI kidneys.
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Affiliation(s)
- S Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY, USA.,The Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | - Kristen L King
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY, USA.,The Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | - Geoffrey K Dube
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | | | - David J Cohen
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Lloyd E Ratner
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY, USA.,The Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
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Abstract
PURPOSE OF REVIEW Scarcity is a defining feature of the modern transplant landscape, and in light of chronic shortages in donor organs, there is cause for concern about geographic inequities in patients' access to lifesaving resources. Recent policy changes designed to ameliorate unequal donor supply and demand have brought new interest to measuring and addressing disparities at all stages of transplant care. The purpose of this review is to describe an overview of recent literature on geographic inequities in transplant access, focusing on kidney, liver, and lung transplantation and the impact of policy changes on organ allocation. RECENT FINDINGS Despite a major change to the kidney allocation policy in 2014, geographic inequity in kidney transplant access remains. In liver transplantation, the debate has centered on the median acuity score at transplantation; however, a more thorough examination of disparities in access and survival has emerged. SUMMARY Geographic differences in access and quality of transplant care are undeniable, but existing disparity metrics reflect disparities only among candidates who are waitlisted. Future research should address major gaps in our understanding of geographic inequity in transplant access, including patients who may be transplant-eligible but experience a wide variety of barriers in accessing the transplant waiting list.
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43
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Kosztowski M, Zhou S, Bush E, Higgins RS, Segev DL, Gentry SE. Geographic disparities in lung transplant rates. Am J Transplant 2019; 19:1491-1497. [PMID: 30431704 PMCID: PMC6482076 DOI: 10.1111/ajt.15182] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 10/03/2018] [Accepted: 11/06/2018] [Indexed: 01/25/2023]
Abstract
In November 2017, in response to a lawsuit from a New York City lung transplant candidate, an emergency change to the lung allocation policy eliminated the donation service area (DSA) as the first geographic tier of allocation. The lawsuit claimed that DSA borders are arbitrary and that allocation should be based on medical priority. We investigated whether deceased-donor lung transplant (LT) rates differed substantially between DSAs in the United States before the policy change. We estimated LT rates per active person-year using multilevel Poisson regression and empirical Bayes methods. We found that the median incidence rate ratio (MIRR) of transplant rates between DSAs was 2.05, meaning a candidate could be expected to double their LT rate by changing their DSA. This can be compared directly to a 1.54-fold increase in LT rate that we found associated with an increase in lung allocation score (LAS) category from 38-42 to 42-50. Changing a candidate's DSA would have had a greater impact on the candidate's LT rate than changing LAS categories from 38-42 to 42-50. In summary, we found that the DSA of listing was a major determinant of LT rate for candidates across the country before the emergency lung allocation change.
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Affiliation(s)
- Martin Kosztowski
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Sheng Zhou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Errol Bush
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert S Higgins
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota
| | - Sommer E Gentry
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Mathematics, United States Naval Academy, Annapolis, Maryland
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44
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Schaffhausen CR, Bruin MJ, McKinney WT, Snyder JJ, Matas AJ, Kasiske BL, Israni AK. How patients choose kidney transplant centers: A qualitative study of patient experiences. Clin Transplant 2019; 33:e13523. [PMID: 30861199 DOI: 10.1111/ctr.13523] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 02/12/2019] [Accepted: 02/22/2019] [Indexed: 12/20/2022]
Abstract
Little is known about how patients make the critical decision of choosing a transplant center. In the United States, acceptance criteria, waiting times, and mortality vary significantly by geography and center. We sought to understand patients' experiences and perspectives when selecting transplant centers. We included 82 kidney transplant patients in 20 semi-structured interviews, nine focus groups with local candidates, and three focus groups with national recipients. Sites included two local transplant centers in Minneapolis, Minnesota, and national recipients from across the United States. Transcripts were analyzed by two researchers using a thematic analysis. Several themes emerged related to priorities and barriers when choosing a center. Patients were often unfamiliar with options, even with multiple local centers. Patients described being referred to a specific center by a trusted provider. Patients prioritized perceived reputation, comfort, and convenience. Insurance coverage was both a source of information and a barrier to options. Patients underestimated differences across centers and the effects on being waitlisted and receiving a transplant. Barriers in decision making included an overwhelming scope of information and difficulty locating information relevant to patients with unique medical needs. Informed decisions could be improved by the dissemination of understandable information better tailored to individual patient needs.
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Affiliation(s)
| | - Marilyn J Bruin
- College of Design, University of Minnesota, Minneapolis, Minnesota
| | | | - Jon J Snyder
- Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota.,Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Arthur J Matas
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Bertram L Kasiske
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota.,Department of Medicine, Hennepin Healthcare, University of Minnesota (UMN), Minneapolis, Minnesota
| | - Ajay K Israni
- Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota.,Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota.,Department of Medicine, Hennepin Healthcare, University of Minnesota (UMN), Minneapolis, Minnesota
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45
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Jackson KR, Covarrubias K, Holscher CM, Luo X, Chen J, Massie AB, Desai N, Brennan DC, Segev DL, Garonzik-Wang J. The national landscape of deceased donor kidney transplantation for the highly sensitized: Transplant rates, waitlist mortality, and posttransplant survival under KAS. Am J Transplant 2019; 19:1129-1138. [PMID: 30372592 PMCID: PMC6433516 DOI: 10.1111/ajt.15149] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 10/11/2018] [Accepted: 10/14/2018] [Indexed: 02/07/2023]
Abstract
Deceased donor kidney transplantation (DDKT) rates for highly sensitized (HS) candidates increased early after implementation of the Kidney Allocation System (KAS) in 2014. However, this may represent a bolus effect, and a granular investigation of the current state of DDKT for HS candidates remains lacking. We studied 270 722 DDKT candidates from the SRTR from 12/4/2011 to 12/3/2014 ("pre-KAS") and 12/4/2014 to 12/3/2017 ("post-KAS"), analyzing DDKT rates for HS candidates using adjusted negative binomial regression. Post-KAS, candidates with the highest levels of sensitization had an increased DDKT rate compared with pre-KAS (cPRA 98% adjusted incidence rate ratio [aIRR]:1.27 1.772.46 P = .001, cPRA 99% aIRR:3.18 4.365.98 P < .001, cPRA 99.5-99.9% aIRR:16.91 24.2934.89 P < .001, and cPRA 99.9%+ aIRR:8.79 11.5815.26 P < .001). To determine whether these changes produced more equitable access to DDKT, we compared DDKT rates of HS to non-HS candidates (cPRA 0-79%). Post-KAS, cPRA, 98% candidates had an equivalent DDKT rate (aIRR:0.65 0.941.36 , P = .8) to non-HS candidates, whereas 99% candidates had a higher DDKT rate (aIRR:1.19 1.682.38 , P = .02). Although cPRA 99.5-99.9% candidates had an increased DDKT rate (aIRR:2.46 3.504.98 , P < .001) compared to non-HS candidates, cPRA 99.9%+ candidates had a significantly lower DDKT rate (aIRR:0.29 0.400.56 , P < .001). KAS has improved access to DDKT for HS candidates, although substantial imbalance exists between cPRA 99.5-99.9% and 99.9%+ candidates.
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Affiliation(s)
- Kyle R Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Karina Covarrubias
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Courtenay M Holscher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xun Luo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Niraj Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel C Brennan
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota
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46
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Montgomery JR, Mathur AK, Lynch RJ. Databases for surgical health services research: Scientific Registry for Transplant Recipients. Surgery 2018; 165:879-881. [PMID: 30389172 DOI: 10.1016/j.surg.2018.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 08/28/2018] [Indexed: 11/24/2022]
Affiliation(s)
| | - Amit K Mathur
- Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ; Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Phoenix, AZ
| | - Raymond J Lynch
- Department of Transplant Surgery, Emory University, Atlanta, GA
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