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Hickner B, Anand A, Godfrey EL, Dunson J, Reul RM, Cotton R, Galvan NTN, O'Mahony C, Goss JA, Rana A. Trends in Survival for Pediatric Transplantation. Pediatrics 2022; 149:184553. [PMID: 35079811 DOI: 10.1542/peds.2020-049632] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Progress in pediatric transplantation measured in the context of waitlist and posttransplant survival is well documented but falls short of providing a complete perspective for children and their families. An intent-to-treat analysis, in which we measure survival from listing to death regardless of whether a transplant is received, provides a more comprehensive perspective through which progress can be examined. METHODS Univariable and multivariable Cox regression was used to analyze factors impacting intent-to-treat survival in 12 984 children listed for heart transplant, 17 519 children listed for liver transplant, and 16 699 children listed for kidney transplant. The Kaplan-Meier method and log-rank test were used to assess change in waitlist, posttransplant, and intent-to-treat survival. Wait times and transplant rates were compared by using χ2 tests. RESULTS Intent-to-treat survival steadily improved from 1987 to 2017 in children listed for heart (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.96-0.97), liver (HR 0.95, 95% CI 0.94-0.97), and kidney (HR 0.97, 95% CI 0.95-0.99) transplant. Waitlist and posttransplant survival also improved steadily for all 3 organs. For heart transplant, the percentage of patients transplanted within 1 year significantly increased from 1987 to 2017 (60.8% vs 68.7%); however, no significant increase was observed in liver (68.9% vs 72.5%) or kidney (59.2% vs 62.7%) transplant. CONCLUSIONS Intent-to-treat survival, which is more representative of the patient perspective than individual metrics alone, steadily improved for heart, liver, and kidney transplant over the study period. Further efforts to maximize the donor pool, improve posttransplant outcomes, and optimize patient care while on the waitlist may contribute to future progress.
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Affiliation(s)
| | | | - Elizabeth L Godfrey
- Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut
| | | | | | - Ronald Cotton
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Nhu Thao Nguyen Galvan
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Christine O'Mahony
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - John A Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Abbas Rana
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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Butler CR, Reese PP, Perkins JD, Hall YN, Curtis JR, Kurella Tamura M, O'Hare AM. End-of-Life Care among US Adults with ESKD Who Were Waitlisted or Received a Kidney Transplant, 2005-2014. J Am Soc Nephrol 2020; 31:2424-2433. [PMID: 32908000 DOI: 10.1681/asn.2020030342] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/22/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The care of patients in the United States who have ESKD is often shaped by their hopes and prognostic expectations related to kidney transplant. Little is known about how patients' engagement in the transplant process might relate to patterns of end-of-life care. METHODS We compared six measures of intensity of end-of-life care among adults in the United States with ESKD who died between 2005 and 2014 after experiencing differing exposure to the kidney transplant process. RESULTS Of 567,832 decedents with ESKD, 27,633 (5%) had a functioning kidney transplant at the time of death, 14,653 (3%) had a failed transplant, 16,490 (3%) had been removed from the deceased donor waitlist, 17,010 (3%) were inactive on the waitlist, 11,529 (2%) were active on the waitlist, and 480,517 (85%) had never been waitlisted for or received a transplant (reference group). In adjusted analyses, compared with the reference group, patients exposed to the transplant process were significantly more likely to have been admitted to an intensive care unit and to have received an intensive procedure in the last 30 days of life; they were also significantly more likely to have died in the hospital. Those who died on the transplant waitlist were also less likely than those in the reference group to have been enrolled in hospice and to have discontinued dialysis before death. CONCLUSIONS Patients who had engaged in the kidney transplant process received more intensive patterns of end-of-life care than other patients with ESKD. These findings support the relevance of advance care planning, even for this relatively healthy segment of the ESKD population.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine and Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James D Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington
| | - Yoshio N Hall
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and the Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
| | - Manjula Kurella Tamura
- Division of Nephrology, Geriatric Research, Education, and Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Ann M O'Hare
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington.,Division of Nephrology, Department of Medicine, Veterans Affairs Puget Sound Heath Care System, Seattle, Washington
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Kulkarni S, Ladin K, Haakinson D, Greene E, Li L, Deng Y. Association of Racial Disparities With Access to Kidney Transplant After the Implementation of the New Kidney Allocation System. JAMA Surg 2020; 154:618-625. [PMID: 30942882 DOI: 10.1001/jamasurg.2019.0512] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Inactive patients on the kidney transplant wait-list have a higher mortality. The implications of this status change on transplant outcomes between racial/ethnic groups are unknown. Objectives To determine if activity status changes differ among races/ethnicities and levels of sensitization, and if these differences are associated with transplant probability after implementation of the Kidney Allocation System. Design, Setting, and Participants A multistate model was constructed from the Organ Procurement and Transplantation Network kidney transplant database (December 4, 2014, to September 8, 2016). The time interval followed Kidney Allocation System implementation and provided at least 1-year follow-up for all patients. The model calculated probabilities between active and inactive status and the following competing risk outcomes: living donor transplant, deceased donor transplant, and death/other. This retrospective cohort study included 42 558 patients on the Organ Procurement and Transplantation Network kidney transplant wait-list following Kidney Allocation System implementation. To rule out time-varying confounding from relisting, analysis was limited to first-time registrants. Owing to variations in listing practices, primary center listing data were used for dually listed patients. Individuals listed for another organ or pancreatic islets were excluded. Analysis began July 2017. Main Outcome and Measures Probabilities were determined for transitions between active and inactive status and the following outcome states: active to living donor transplant, active to deceased donor transplant, active to death/other, inactive to living donor transplant, inactive to deceased donor transplant, and inactive to death/other. Results The median (interquartile range) age at listing was 55.0 (18.0-89.0) years, and 26 535 of 42 558 (62.4%) were men. White individuals were 43.3% (n = 18 417) of wait-listed patients, while black and Hispanic individuals made up 27.8% (n = 11 837) and 19.5% (n = 8296), respectively. Patients in the calculated plasma reactive antibody categories of 0% or 1% to 79% showed no statistically significant difference in transplant probability among races/ethnicities. White individuals had an advantage in transplant probability over black individuals in calculated plasma reactive antibody categories of 80% to 89% (hazard ratio [HR], 1.8 [95% CI, 1.4-2.2]) and 90% or higher (HR, 2.4 [95% CI, 2.1-2.6]), while Hispanic individuals had an advantage over black individuals in the calculated plasma reactive antibody group of 90% or higher (HR, 2.5 [95% CI, 2.1-2.8]). Once on the inactive list, white individuals were more likely than Hispanic individuals (HR, 1.2 [95% CI, 1.17-1.3]) or black individuals (HR, 1.4 [95% CI, 1.3-1.4]) to resolve issues for inactivity resulting in activation. Conclusions and Relevance For patients who are highly sensitized, there continues to be less access to kidney transplant in the black population after the implementation of the Kidney Allocation System. Health disparities continue after listing where individuals from minority groups have greater difficulty in resolving issues of inactivity.
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Affiliation(s)
- Sanjay Kulkarni
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Keren Ladin
- Department of Community Medicine and Public Health, Tufts University, Boston, Massachusetts
| | | | - Erich Greene
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Luhang Li
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut
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Kataria A, Gowda M, Lamphron BP, Jalal K, Venuto RC, Gundroo AA. The impact of systematic review of status 7 patients on the kidney transplant waitlist. BMC Nephrol 2019; 20:174. [PMID: 31096935 PMCID: PMC6524301 DOI: 10.1186/s12882-019-1362-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 04/29/2019] [Indexed: 12/03/2022] Open
Abstract
Background Increased morbidity and mortality are well documented in Status 7(inactive list) patients. Delays in transplantation secondary to prolonged periods on inactive status also negatively impacts transplant outcomes. We developed an effective system to reduce the proportion of status 7 patients on our kidney transplant waitlist. This can easily be reproduced by other transplant centers since concerns about Status 7 list size are commonplace. Methods Meetings of a dedicated status 7 focus group were undertaken biweekly beginning in April 2016, each lasting for 1 hour or less. The group was led by a transplant physician and comprised of members from all disciplines of the kidney transplant department. Individual patient barriers to activation were systematically evaluated and action plans were developed to overcome those. The formal meetings were supplemented by updates to an electronic database accessible to all members of the team. Results In the first 2 years of the program, we were able to activate and eventually transplant 18% of the formerly inactive patients. Forty percent of all inactive patients were removed from the waitlist due to one or more unsurmountable barriers. The median time patients stayed inactive on the waitlist was shortened from 1344 days at the start of this initiative to 581 days at the end. Conclusion This strategy of systematic reevaluation of status 7 patients resulted in successful disposition of a substantial number of inactive patients. Further, waitlist time was reduced and transplantation expedited for the appropriate individuals. This approach could easily be adapted by other transplant centers with minimum utilization of resources.
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Affiliation(s)
- Ashish Kataria
- Division of Nephrology, University at Buffalo, Erie County Medical Center, 462 Grider Street, Buffalo, NY, 14215, USA.
| | - Madan Gowda
- Division of Nephrology, University at Buffalo, Erie County Medical Center, 462 Grider Street, Buffalo, NY, 14215, USA
| | - Brian Paul Lamphron
- Quality and Patient Safety Department, Erie County Medical Center, Buffalo, NY, USA
| | - Kabir Jalal
- Population Health Observatory, Department of Biostatistics, University at Buffalo, State University of New York, Buffalo, USA
| | - Rocco C Venuto
- Division of Nephrology, University at Buffalo, Erie County Medical Center, 462 Grider Street, Buffalo, NY, 14215, USA
| | - Aijaz A Gundroo
- Division of Nephrology, University at Buffalo, Erie County Medical Center, 462 Grider Street, Buffalo, NY, 14215, USA
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Factors Associated With Waiting Time to Deceased Donor Kidney Transplantation in Transplant Candidates. Transplant Proc 2018; 50:1041-1044. [DOI: 10.1016/j.transproceed.2018.02.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 02/06/2018] [Accepted: 02/19/2018] [Indexed: 11/18/2022]
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Reese PP, Shults J, Bloom RD, Mussell A, Harhay MN, Abt P, Levine M, Johansen KL, Karlawish JT, Feldman HI. Functional status, time to transplantation, and survival benefit of kidney transplantation among wait-listed candidates. Am J Kidney Dis 2015; 66:837-45. [PMID: 26162652 DOI: 10.1053/j.ajkd.2015.05.015] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 05/09/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND In the context of an aging end-stage renal disease population with multiple comorbid conditions, transplantation professionals face challenges in evaluating the global health of patients awaiting kidney transplantation. Functional status might be useful for identifying which patients will derive a survival benefit from transplantation versus dialysis. STUDY DESIGN Retrospective cohort study of wait-listed patients using data for functional status from a national dialysis provider linked to United Network for Organ Sharing registry data. SETTING & PARTICIPANTS Adult kidney transplantation candidates added to the waiting list between 2000 and 2006. PREDICTOR Physical Functioning scale of the Medical Outcomes Study 36-Item Short Form Health Survey, analyzed as a time-varying covariate. OUTCOMES Kidney transplantation; survival benefit of transplantation versus remaining wait-listed. MEASUREMENTS We used multivariable Cox regression to assess the association between physical function with study outcomes. In survival benefit analyses, transplantation status was modeled as a time-varying covariate. RESULTS The cohort comprised 19,242 kidney transplantation candidates (median age, 51 years; 36% black race) receiving maintenance dialysis. Candidates in the lowest baseline Physical Functioning score quartile were more likely to be inactivated (adjusted HR vs highest quartile, 1.30; 95% CI, 1.21-1.39) and less likely to undergo transplantation (adjusted HR vs highest quartile, 0.64; 95% CI, 0.61-0.68). After transplantation, worse Physical Functioning score was associated with shorter 3-year survival (84% vs 92% for the lowest vs highest function quartiles). However, compared to dialysis, transplantation was associated with a statistically significant survival benefit by 9 months for patients in every function quartile. LIMITATIONS Functional status is self-reported. CONCLUSIONS Even patients with low function appear to live longer with kidney transplantation versus dialysis. For wait-listed patients, global health measures such as functional status may be more useful in counseling patients about the probability of transplantation than in identifying who will derive a survival benefit from it.
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Affiliation(s)
- Peter P Reese
- Renal Electrolyte & Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA.
| | - Justine Shults
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA
| | - Roy D Bloom
- Renal Electrolyte & Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Adam Mussell
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA
| | - Meera N Harhay
- Renal Electrolyte & Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA
| | - Peter Abt
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthew Levine
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Kirsten L Johansen
- Division of Nephrology, University of California-San Francisco, San Francisco, CA
| | - Jason T Karlawish
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; Division of Geriatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Harold I Feldman
- Renal Electrolyte & Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA
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7
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Reese PP, Shults J, Bloom RD, Mussell A, Harhay MN, Abt P, Levine M, Johansen KL, Karlawish JT, Feldman HI. Functional status, time to transplantation, and survival benefit of kidney transplantation among wait-listed candidates. Am J Kidney Dis 2015. [PMID: 26162652 DOI: 10.1053/j.ajkd.20 15.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND In the context of an aging end-stage renal disease population with multiple comorbid conditions, transplantation professionals face challenges in evaluating the global health of patients awaiting kidney transplantation. Functional status might be useful for identifying which patients will derive a survival benefit from transplantation versus dialysis. STUDY DESIGN Retrospective cohort study of wait-listed patients using data for functional status from a national dialysis provider linked to United Network for Organ Sharing registry data. SETTING & PARTICIPANTS Adult kidney transplantation candidates added to the waiting list between 2000 and 2006. PREDICTOR Physical Functioning scale of the Medical Outcomes Study 36-Item Short Form Health Survey, analyzed as a time-varying covariate. OUTCOMES Kidney transplantation; survival benefit of transplantation versus remaining wait-listed. MEASUREMENTS We used multivariable Cox regression to assess the association between physical function with study outcomes. In survival benefit analyses, transplantation status was modeled as a time-varying covariate. RESULTS The cohort comprised 19,242 kidney transplantation candidates (median age, 51 years; 36% black race) receiving maintenance dialysis. Candidates in the lowest baseline Physical Functioning score quartile were more likely to be inactivated (adjusted HR vs highest quartile, 1.30; 95% CI, 1.21-1.39) and less likely to undergo transplantation (adjusted HR vs highest quartile, 0.64; 95% CI, 0.61-0.68). After transplantation, worse Physical Functioning score was associated with shorter 3-year survival (84% vs 92% for the lowest vs highest function quartiles). However, compared to dialysis, transplantation was associated with a statistically significant survival benefit by 9 months for patients in every function quartile. LIMITATIONS Functional status is self-reported. CONCLUSIONS Even patients with low function appear to live longer with kidney transplantation versus dialysis. For wait-listed patients, global health measures such as functional status may be more useful in counseling patients about the probability of transplantation than in identifying who will derive a survival benefit from it.
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Affiliation(s)
- Peter P Reese
- Renal Electrolyte & Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA.
| | - Justine Shults
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA
| | - Roy D Bloom
- Renal Electrolyte & Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Adam Mussell
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA
| | - Meera N Harhay
- Renal Electrolyte & Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA
| | - Peter Abt
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthew Levine
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Kirsten L Johansen
- Division of Nephrology, University of California-San Francisco, San Francisco, CA
| | - Jason T Karlawish
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; Division of Geriatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Harold I Feldman
- Renal Electrolyte & Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA
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Tong A, Hanson CS, Chapman JR, Halleck F, Budde K, Josephson MA, Craig JC. 'Suspended in a paradox'-patient attitudes to wait-listing for kidney transplantation: systematic review and thematic synthesis of qualitative studies. Transpl Int 2015; 28:771-87. [PMID: 25847569 DOI: 10.1111/tri.12575] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 02/23/2015] [Accepted: 03/31/2015] [Indexed: 12/21/2022]
Abstract
Patients on waiting lists for kidney transplantation have higher mortality rates and have specific anxieties about their eligibility, process, and outcomes of wait-listing. We aimed to describe patient experiences and attitudes to wait-listing for kidney transplantation. Electronic databases were searched to September 2014. Thematic synthesis was used to analyze the findings. From 22 studies (n = 795 patients), we identified six themes: accepting the only option (chance to regain normality, avoiding guilt, impulsive decision-making); maintaining hope (determined optimism, appreciating a fortuitous gift, enduring for optimal outcomes, trust in clinical judgment); burden of testing (strenuous commitment, losing the battle, medical mistrust); permeating vulnerability (eligibility enigma, being threatened, angst of timing uncertainty, desperate urgency, living in limbo, spiraling doubt and disappointment, residual ambivalence); deprived of opportunity (unfairly dismissed, unexpected disqualification, self-resignation and acceptance, jealousy, suspicious of inequity); and moral guilt (awaiting someone's death, questioning deservingness). The waiting list offered hope of restored normality. However, the demands of workup, uncertainty about eligibility, and waiting times that exceeded expectations impelled patients to disillusionment, despair, and suspicion of inequity. Managing patient expectations and ensuring transparency of wait-listing and allocation decisions may allay patient disappointment and skepticism, to improve patient satisfaction and treatment outcomes.
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Affiliation(s)
- Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Camilla S Hanson
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Fabian Halleck
- Department of Nephrology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
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