Policies to promote timely referral for kidney transplantation

Setting reasonable goals for kidney transplant referral among dialysis facilities

BACKGROUND

Determining whether a patient is eligible for kidney transplantation is complex. In this study, we estimate what proportion of patients with end-stage kidney disease (ESKD) might have been suitable candidates for kidney transplantation but were not referred.

METHODS

We identified 43,952 people initiating dialysis for kidney failure between 2012 and 2017 in the states of Georgia, North Carolina, or South Carolina from the United States Renal Data System and linked to the Early-Steps to Transplant Access Registry to obtain data on referral and waitlisting up until December 2020. We identified 'good transplant candidates' as those who were waitlisted within 2-years of referral, among all patients referred within 1-year of dialysis initiation. Using propensity score cut-offs, logistic regression, and area under the curve (AUC), we then estimated the proportion of individuals who may have been good transplant candidates, but were not referred.

RESULTS

Overall, 42.6% of incident dialysis patients were referred within one year and among them, 32.9% were waitlisted within 2 years of referral. Our model had reasonably good discrimination for identifying good transplant candidates with an AUC of 0.70 (95%CI 0.69-0.71), sensitivity of 0.68 and specificity of 0.61. Overall, 25% of individuals not referred for transplant may have been 'good' transplant candidates. Adding these patients to the existing 18,725 referred patients would increase the proportion of incident ESKD patients being referred within one year from 42.6% to 57.2% (a ~ 14.6% increase).

CONCLUSIONS

In this study, we show that a significant proportion of potentially good transplant candidates are not being referred for transplant. A ~ 14% increase in the proportion of patients being referred from dialysis facilities is both a meaningful and realistic goal and could lead to more qualified patients being referred and subsequently waitlisted for a lifesaving transplant.

Mitigating Health Disparities in Transplantation Requires Equity, Not Equality

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.

The Kidney Transplant Equity Index: Improving Racial and Ethnic Minority Access to Transplantation

OBJECTIVES

To develop a scalable metric which quantifies kidney transplant (KT) centers' performance providing equitable access to KT for minority patients, based on the individualized pre-listing prevalence of End-Stage Renal Disease (ESRD).

SUMMARY BACKGROUND DATA

Racial and ethnic disparities for access to transplant in patients with ESRD are well described; however, variation in care among KT centers remains unknown. Furthermore, no mechanism exists that quantifies how well a KT center provides equitable access to KT for minority patients with ESRD.

METHODS

From 2013-2018, custom datasets from the United States Renal Data System and United Network for Organ Sharing were merged to calculate the Kidney Transplant Equity Index (KTEI), defined as: the number of minority patients transplanted at a center relative to the prevalence of minority patients with ESRD in each center's health service area. Markers of socioeconomic status (SES) and recipient outcomes were compared between high and low KTEI centers.

RESULTS

249 transplant centers performed 111,959 KTs relative to 475,914 non-transplanted patients with ESRD. High KTEI centers performed more KTs for Black (105.5 vs. 24, P<0.001), Hispanic (55.5 vs. 7, P<0.001), and American Indian (1.0 vs. 0.0, P<0.001) patients than low KTEI centers. In addition, high KTEI centers transplanted more patients with higher unemployment (52 vs. 44, P<0.001), worse social deprivation (53 vs. 46, P<0.001), and lower educational attainment (52 vs. 43, P<0.001). While providing increased access to transplant for minority and low SES populations, high KTEI centers had improved patient survival (HR: 0.86, 95% CI: 0.77-0.95).

CONCLUSIONS

The KTEI is the first metric to quantify minority access to KT incorporating the pre-listing ESRD prevalence individualized to transplant centers. KTEIs uncover significant national variation in transplant practices and identify highly equitable centers. This novel metric should be used to disseminate best practices for minority and low socioeconomic patients with ESRD.

Timing of the pre-transplant workup for renal transplantation: is there room for improvement?

Background

Since patient survival after kidney transplantation is significantly improved with a shorter time on dialysis, it is recommended to start the transplant workup in a timely fashion.

Methods

This retrospective study analyses the chronology of actions taken during the care for patients with chronic kidney disease (CKD) stage 5 who were waitlisted for a first kidney transplant at the Antwerp University Hospital between 2016 and 2019. We aimed to identify risk factors for a delayed start of the transplant workup (i.e. after dialysis initiation) and factors that prolong its duration.

Results

Of the 161 patients included, only 43% started the transplant workup before starting dialysis. We identified the number of hospitalization days {odds ratio [OR] 0.79 [95% confidence interval (CI) 0.69-0.89]; P < 0.001}, language barriers [OR 0.20 (95% CI 0.06-0.61); P = 0.005] and a shorter nephrology follow-up before CKD stage 5 [OR 0.99 (95% CI 1.0-0.98); P = 0.034] as factors having a significant negative impact on the probability of starting the transplant screening before dialysis. The workup took a median of 8.6 months (interquartile range 5-14) to complete. The number of hospitalization days significantly prolonged its duration.

Conclusion

The transplant workup was often started too late and the time needed to complete it was surprisingly long. By starting the transplant workup in a timely fashion and reducing the time spent on the screening examinations, we should be able to register patients on the waiting list before or at least at the start of dialysis. We believe that such an internal audit could be of value for every transplant centre.

Impact of socioeconomic deprivation on evaluation for heart transplantation at an urban academic medical center

For patients with advanced heart failure, socioeconomic deprivation may impede referral for heart transplantation (HT). We examined the association of socioeconomic deprivation with listing among patients evaluated at our institution and compared this against the backdrop of our local community. We conducted a retrospective cohort study of patients evaluated for HT between January 2017 and December 2020. Patient demographics and clinical characteristics were recorded. Block group-level area deprivation index (ADI) decile was obtained at each patient's home address and Socioeconomic Status (SES) index was determined by patient zip code. In total, 400 evaluations were initiated; 1 international patient was excluded. Among this population, 111 (27.8%) were women, 219 (54.9%) were White, 94 (23.6%) Black, and 59 (14.8%) Hispanic. 248 (62.2%) patients were listed for transplant. Listed patients had significantly higher SES index and lower ADI compared to those who were not listed. However, after adjustment for clinical factors, ADI and SESi were not predictive of listing. Similarly, patient sex, race, and insurance did not influence the likelihood of listing for HT. Notably, the distribution of the referral cohort based on ADI deciles was not reflective of our center's catchment area, indicating opportunities for improving access to transplant for disadvantaged populations. This article is protected by copyright. All rights reserved.

Managing Patients with Failing Kidney Allograft: Many Questions Remain

Patients who receive a kidney transplant commonly experience failure of their allograft. Transplant failure often comes with complex management decisions, such as when and how to wean immunosuppression and start the transition to a second transplant or to dialysis. These decisions are made in the context of important concerns about competing risks, including sensitization and infection. Unfortunately, the management of the failed allograft is, at present, guided by relatively poor-quality data and, as a result, practice patterns are variable and suboptimal given that patients with failed allografts experience excess morbidity and mortality compared with their transplant-naive counterparts. In this review, we summarize the management strategies through the often-precarious transition from transplant to dialysis, highlighting the paucity of data and the critical gaps in our knowledge that are necessary to inform the optimal care of the patient with a failing kidney transplant.

Non-English Language Resources and Readability of Kidney Transplant Center Websites in the United States

This study examined US kidney transplant center websites for readability and for inclusion of languages other than English.

Changes in excess mortality among adults with diabetes-related end-stage kidney disease: a comparison between the USA and Australia

BACKGROUND

The number of people with diabetes-related end-stage kidney disease (ESKD-DM) has doubled in the last two decades. We examined changes in excess mortality for people with ESKD-DM in the USA and Australia.

METHODS

In this retrospective cohort study, we included adults (ages 20-84 years) receiving renal replacement therapy (RRT) for ESKD-DM in the USA (n = 1 178 860 from the United States Renal Data System, 2002-17) and Australia (n = 10 381 from the Australia and New Zealand Dialysis and Transplant Registry, 2002-13). ESKD-DM was defined as those with diagnosed diabetes at time of RRT initiation and mortality status was captured from national death registries. Annual standardized mortality ratios (SMR) were stratified by treatment modality, and age, sex and race (USA only). Trends were assessed using join point regression and annual percent change (APC) was reported.

RESULTS

Overall, in the dialysis population SMR decreased from 2006 to 2014 in the USA (from 12.0 to 10.1; APC -2.1) and from 2002 to 2013 in Australia (from 12.0 to 9.4; APC -3.4). In the transplant population, SMR decreased from 6.2 to 4.0 from 2002 to 2013 in the USA, and did not significantly change from 2002 to 2013 in Australia. By subgroup, excess mortality was higher in women (versus men), younger (versus older) adults, dialysis (versus transplant) patients, and in Asian or Pacific Islanders and American Indian or Alaskan Natives (AI/AN) (versus Whites and Blacks). SMRs declined similarly across all subgroups excluding AI/AN (USA) and transplant patients (Australia), where relative declines were smaller.

CONCLUSIONS

Excess mortality for people with ESKD-DM treated with dialysis or transplant has decreased in the USA and Australia, but progress has stalled from ∼2013 in the USA. Nevertheless, mortality remains more than nine times higher in ESKD-DM versus the general population, with important variations by subgroups. Given the increasing burden of diabetes in the population, a focus on reducing excess mortality risk in the ESKD-DM population is needed.

Non-medical barriers in access to early steps of kidney transplantation in the United States - A scoping review

BACKGROUND

In the United States (US), barriers in access to later steps in the kidney transplantation process (i.e. waitlisting) have been well documented. Barriers in access to earlier steps (i.e. referral and evaluation) are less well described due to the lack of national surveillance data. In this review, we summarize the available literature on non-medical barriers in access to kidney transplant referral and evaluation.

METHODS

Following PRISMA guidelines, we conducted a scoping review of the literature through June 3, 2021. We included all studies (quantitative and qualitative) reporting on barriers to kidney transplant referral and evaluation in the US published from 1990 onwards in English and among adult end-stage kidney disease (ESKD) patients (PROSPERO registration number: CRD42014015027). We narratively synthesized results across studies.

RESULTS

We retrieved information from 33 studies published from 1990 to 2021 (reporting data between 1990 and 2018). Most studies (n = 28, 85%) described barriers among patient populations, three (9%) among provider populations, and two (6%) included both patients and providers. Key barriers were identified across multiple levels and included patient- (e.g. demographic, socioeconomic, sociocultural, and knowledge), provider- (e.g. miscommunication, staff availability, provider perceptions and attitudes), and system- (e.g. geography, distance to care, healthcare logistics) level factors.

CONCLUSIONS

A multi-pronged approach (e.g. targeted and systemwide interventions, and policy change) implemented at multiple levels of the healthcare system will be necessary to reduce identified barriers in access to early kidney transplant steps. Collection of national surveillance data on these early kidney transplant steps is also needed to enhance our understanding of barriers to referral and evaluation.

Association of Public Reporting of Medicare Dialysis Facility Quality Ratings With Access to Kidney Transplantation

IMPORTANCE

Improving the quality of dialysis care and access to kidney transplantation for patients with end-stage kidney disease is a national clinical and policy priority. The role of dialysis facility quality in increasing access to kidney transplantation is not known.

OBJECTIVE

To determine whether patient, facility, and kidney transplant waitlisting characteristics are associated with variations in dialysis center quality.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study is an analysis of US Renal Data System data and Medicare Dialysis Facility Compare (DFC) data from 2013 to 2018. Participants included all adult (aged ≥18 years) patients in the US Renal Data System beginning long-term dialysis in the US from 2013 to 2017 with follow-up through the end of 2018. Patients with a prior kidney transplant and matched Medicare DFC star ratings to each annual cohort of recipients were excluded. Patients at facilities without a star rating in that year were also excluded. Data analysis was performed from January to April 2021.

EXPOSURES

Dialysis center quality, as defined by Medicare DFC star ratings.

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of patients undergoing incident dialysis who were waitlisted within 1 year of dialysis initiation. Secondary outcomes were patient and facility characteristics.

RESULTS

Of 507 581 patients beginning long-term dialysis in the US from 2013 to 2017, 291 802 (57.4%) were male, 266 517 (52.5%) were White, and the median (interquartile range) age was 65 (55-75) years. Of 5869 dialysis facilities in 2017, 132 (2.2%) were 1-star, 436 (7.4%) were 2-star, 2047 (34.9%) were 3-star, 1660 (28.3%) were 4-star, and 1594 (27.2%) were 5-star. Higher-quality dialysis facilities were associated with 47% higher odds of transplant waitlisting (odds ratio [OR], 1.47; 95% CI, 1.39-1.57 for 5-star facilities vs 1-star facilities; P < .001). Black patients were less likely than White patients to be waitlisted for transplantation (OR, 0.74; 95% CI, 0.72-0.76). In addition, patients at for-profit (OR, 0.78; 95% CI, 0.74-0.81) and rural (OR, 0.63; 95%, CI 0.58-0.68) facilities were less likely to be waitlisted for transplantation compared with those at nonprofit and urban facilities, respectively.

CONCLUSIONS AND RELEVANCE

In this cohort study, patients at higher-quality dialysis facilities had higher odds than patients at lower-quality facilities of being waitlisted for kidney transplantation within 1 year. Waitlisting rates for kidney transplantation should be considered for integration into the current Centers for Medicare & Medicaid Services DFC star ratings to incentivize dialysis facility referral to transplant centers, inform patient choice, and drive quality improvement by increasing transplant waitlisting rates.