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Harford M, Laster M. Progress made toward equitable transplantation in children and young adults with kidney disease. Pediatr Nephrol 2024; 39:2593-2600. [PMID: 38347281 PMCID: PMC11272428 DOI: 10.1007/s00467-024-06309-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 05/16/2024]
Abstract
Racial disparities in pediatric kidney transplantation have been well described over the last two decades and include disparities in preemptive transplantation, waitlisting, time from activation to transplantation, living donation, and graft outcomes. Changes to the organ allocation system including the institution of Share 35 in 2005 and the Kidney Allocation System (KAS) of 2014 have resulted in resolution of some, but not all racial-ethnic disparities. Despite overall improvements in time from waitlist activation to transplant, disparities remain in preemptive transplantation, time to waitlisting, and living donor transplantation. Although improving under the KAS, racial disparities remain in graft survival as well. Racial disparity in kidney transplant access and graft survival is an international problem within pediatric nephrology. Although the racial group affected may differ, various minoritized pediatric groups across the world are affected by transplant disparities. Social determinants of health including financial access, language barriers, and the presence of a healthy living donor play a role in mediating these disparities. Further investigation is needed to better understand and intervene upon modifiable social, biological, and cultural factors driving the remaining disparity in transplant outcomes.
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Affiliation(s)
- Mercedes Harford
- Division of Nephrology, Department of Pediatrics, School of Medicine, Indiana University, 699 Riley Hospital Drive, Rm 230, Indianapolis, IN, 46202, USA
| | - Marciana Laster
- Division of Nephrology, Department of Pediatrics, School of Medicine, Indiana University, 699 Riley Hospital Drive, Rm 230, Indianapolis, IN, 46202, USA.
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2
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Engen RM. Predicting pediatric kidney transplant wait times: The unexplored landscape and pre-allocation transplant policies. Pediatr Nephrol 2024; 39:2275-2278. [PMID: 38302675 DOI: 10.1007/s00467-024-06308-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 02/03/2024]
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Maclay LM, Yu M, Amaral S, Adler JT, Sandoval PR, Ratner LE, Schold JD, Mohan S, Husain SA. Disparities in Access to Timely Waitlisting Among Pediatric Kidney Transplant Candidates. Pediatrics 2024:e2024065934. [PMID: 39086359 DOI: 10.1542/peds.2024-065934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Kidney transplantation with minimal or no dialysis exposure provides optimal outcomes for children with end-stage kidney disease. We sought to understand disparities in timely access to transplant waitlisting. METHODS We conducted a retrospective, registry-based cohort study of candidates ages 3 to 17 added to the US kidney transplant waitlist 2015 to 2019. We defined "preemptive waitlisting" as waitlist addition before receiving dialysis and compared demographics of candidates based on preemptive status. We used competing risk regression to determine the association between preemptive waitlisting and transplantation. We then identified waitlist additions age >18 who initiated dialysis as children, thereby missing pediatric allocation prioritization, and evaluated the association between waitlisting with pediatric prioritization and transplantation. RESULTS Among 4506 pediatric candidates, 48% were waitlisted preemptively. Female sex, Hispanic ethnicity, Black race, and public insurance were associated with lower adjusted relative risk of preemptive waitlisting. Preemptive listing was not associated with time from waitlist activation to transplantation (adjusted hazard ratio 0.94, 95% confidence interval 0.87-1.02). Among transplant recipients waitlisted preemptively, 68% had no pretransplant dialysis, whereas recipients listed nonpreemptively had median 1.6 years of dialysis at transplant. Among 415 candidates initiating dialysis as children but waitlisted as adults, transplant rate was lower versus nonpreemptive pediatric candidates after waitlist activation (adjusted hazard ratio 0.54, 95% confidence interval 0.44-0.66). CONCLUSIONS Disparities in timely waitlisting are associated with differences in pretransplant dialysis exposure despite no difference in time to transplant after waitlist activation. Young adults who experience delays may miss pediatric prioritization, highlighting an area for policy intervention.
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Affiliation(s)
- Lindsey M Maclay
- Departments of Medicine, Division of Nephrology
- Columbia University Renal Epidemiology Group, New York, New York
| | - Miko Yu
- Departments of Medicine, Division of Nephrology
- Columbia University Renal Epidemiology Group, New York, New York
| | - Sandra Amaral
- Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joel T Adler
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - P Rodrigo Sandoval
- Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Lloyd E Ratner
- Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Jesse D Schold
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora
- Department of Epidemiology, School of Public Health, University of Colorado - Anschutz Medical Campus, Aurora
| | - Sumit Mohan
- Departments of Medicine, Division of Nephrology
- Columbia University Renal Epidemiology Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Syed Ali Husain
- Departments of Medicine, Division of Nephrology
- Columbia University Renal Epidemiology Group, New York, New York
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Alachraf K, Tumin D, Hayes D, Benden C. xTrends in racial and ethnic disparities in pediatric lung transplantation in the United States. Pediatr Pulmonol 2024. [PMID: 38990104 DOI: 10.1002/ppul.27175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Racial and ethnic disparities in pediatric lung transplantation (LTx) related to the shifting cystic fibrosis (CF) population receiving highly effective modulator therapy (HEMT) has not been well investigated. METHODS The UNOS Registry was queried for patients age 1-25 years undergoing bilateral LTx between 1 January 2012 and 31 December 2021. Race and ethnicity were classified as non-Hispanic White, non-Hispanic Black, Hispanic, or none of the above. The primary outcome was posttransplant mortality. Trends in the association between race/ethnicity and mortality were examined using transplant year as a continuous variable and stratifying year based on introduction of HEMT (triple combination therapy) in November 2019. RESULTS In the study sample (N = 941), 7% of patients were non-Hispanic Black, 15% were Hispanic, and 2% were some other racial or ethnic group. One hundred (11%) received LTx after approval of triple combination therapy, and 407 (43%) died during follow-up. We identified a statistically significant disparity in mortality hazard (hazard ratio: 1.91; 95% confidence interval: 1.31, 2.80) in non-Hispanic Black compared to non-Hispanic White patients in the pre-triple combination therapy era. CONCLUSIONS We found higher mortality hazard among non-Hispanic Black compared to non-Hispanic White children undergoing LTx in the United States. Further monitoring of LTx outcomes to identify and address disparities is needed in the current era of triple combination therapy for CF.
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Affiliation(s)
- Kamel Alachraf
- Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
- Department of Academic Affairs, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Don Hayes
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Koo DC, Scalise PN, Chiu MZ, Staffa SJ, Demehri FR, Cuenca AG, Kim HB, Lee EJ. Effect of citizenship status on access to pediatric liver and kidney transplantation. Am J Transplant 2024:S1600-6135(24)00381-2. [PMID: 38908484 DOI: 10.1016/j.ajt.2024.06.008] [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: 11/28/2023] [Revised: 05/09/2024] [Accepted: 06/11/2024] [Indexed: 06/24/2024]
Abstract
Transplantation of non-US citizen residents remains controversial. We evaluate national trends in transplant activity among pediatric noncitizen residents (PNCR). Pediatric liver and kidney transplant data were obtained from the Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients. Data on transplanted organs, region, waitlist additions, procedures, and citizenship status were analyzed from 2012-2022. Rates of PNCR transplantation activity were compared with population rates from the US Census Bureau. On average, 713 ± 47 pediatric liver and 1039 ± 51 kidney patients were added to the waitlist, with 544 ± 32 liver and 742 ± 33 kidney transplants performed annually. Of these, PNCR comprised 1.5% and 3.3% of liver and kidney waitlist additions and 1.5% and 2.9% of liver and kidney transplant procedures, respectively. There were no significant changes in waitlist or transplant activity nationwide over the study period. There was a significant geographic variation in the percentage of waitlist additions and transplants across the United Network for Organ Sharing regions among the PNCR for liver and kidney transplantation. This is the first study to evaluate national trends in transplantation activity among PNCRs. The significant regional variation in transplantation activity for PNCR may suggest multilevel structural and systemic barriers to transplant accessibility.
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Affiliation(s)
- Donna C Koo
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - P Nina Scalise
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Megan Z Chiu
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alex G Cuenca
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Pediatric Transplant Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Pediatric Transplant Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Eliza J Lee
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Pediatric Transplant Center, Boston Children's Hospital, Boston, Massachusetts, USA.
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Ashoor IF, Engen RM, Puliyanda D, Hayde N, Peterson CG, Zahr RS, Solomon S, Kallash M, Garro R, Jain A, Harshman LA, McEwen ST, Mansuri A, Gregoski MJ, Twombley KE. Antibody-mediated rejection in pediatric kidney transplant recipients: A report from the Pediatric Nephrology Research Consortium. Pediatr Transplant 2024; 28:e14734. [PMID: 38602171 PMCID: PMC11013566 DOI: 10.1111/petr.14734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/22/2024] [Accepted: 02/20/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) is a major cause of kidney allograft loss. There is a paucity of large-scale pediatric-specific data regarding AMR treatment outcomes. METHODS Data were obtained from 14 centers within the Pediatric Nephrology Research Consortium. Kidney transplant recipients aged 1-18 years at transplant with biopsy-proven AMR between 2009 and 2019 and at least 12 months of follow-up were included. The primary outcome was graft failure or an eGFR <20 mL/min/1.73 m2 at 12 months following AMR treatment. AMR treatment choice, histopathology, and DSA class were also examined. RESULTS We reviewed 123 AMR episodes. Median age at diagnosis was 15 years at a median 22 months post-transplant. The primary outcome developed in 27.6%. eGFR <30 m/min/1.73 m2 at AMR diagnosis was associated with a 5.6-fold higher risk of reaching the composite outcome. There were no significant differences in outcome by treatment modality. Histopathology scores and DSA class at time of AMR diagnosis were not significantly associated with the primary outcome. CONCLUSIONS In this large cohort of pediatric kidney transplant recipients with AMR, nearly one-third of patients experienced graft failure or significant graft dysfunction within 12 months of diagnosis. Poor graft function at time of diagnosis was associated with higher odds of graft failure.
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Affiliation(s)
- Isa F Ashoor
- Department of Pediatrics, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachel M Engen
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Dechu Puliyanda
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nicole Hayde
- Department of Pediatrics, Children's Hospital at Montefiore, Bronx, New York, USA
| | - Caitlin G Peterson
- Division of Pediatric Nephrology and Hypertension, University of Utah, Salt Lake City, Utah, USA
| | - Rima S Zahr
- Department of Pediatrics, Division of Pediatric Nephrology and Hypertension, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Sonia Solomon
- Department of Pediatrics, Maria Fareri Children's Hospital, New York Medical College, Boston Children's Health Physicians, Valhalla, New York, USA
| | - Mahmoud Kallash
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Rouba Garro
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Amrish Jain
- Department of Pediatrics, Central Michigan University and Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Lyndsay A Harshman
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
| | - Scott T McEwen
- Division of Pediatric Nephrology, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Asifhusen Mansuri
- Department of Pediatrics, Children's Hospital of Georgia, Augusta University, Augusta, Georgia, USA
| | - Mathew J Gregoski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Katherine E Twombley
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
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Krissberg JR, Verghese PS. Kidney paired donation. Pediatr Transplant 2024; 28:e14667. [PMID: 38054539 DOI: 10.1111/petr.14667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/20/2023] [Indexed: 12/07/2023]
Affiliation(s)
- Jill R Krissberg
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Pediatrics, Division of Nephrology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Priya S Verghese
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Pediatrics, Division of Nephrology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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8
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Verbesey J, Thomas AG, Waterman AD, Karhadkar S, Cassell VR, Segev DL, Hogan J, Cooper M. Unrecognized opportunities: The landscape of pediatric kidney-paired donation in the United States. Pediatr Transplant 2024; 28:e14657. [PMID: 38317337 PMCID: PMC10857737 DOI: 10.1111/petr.14657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/31/2023] [Accepted: 11/13/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Pediatric (age < 18 years) kidney transplant (KT) candidates face increasingly complex choices. The 2014 kidney allocation system nearly doubled wait times for pediatric recipients. Given longer wait times and new ways to optimize compatibility, more pediatric candidates may consider kidney-paired donation (KPD). Motivated by this shift and the potential impact of innovations in KPD practice, we studied pediatric KPD procedures in the US from 2008 to 2021. METHODS We describe the characteristics and outcomes of pediatric KPD recipients with comparison to pediatric non-KPD living donor kidney transplants (LDKT), pediatric LDKT recipients, and pediatric deceased donor (DDKT) recipients. RESULTS Our study cohort includes 4987 pediatric DDKTs, 3447 pediatric non-KPD LDKTs, and 258 pediatric KPD transplants. Fewer centers conducted at least one pediatric KPD procedure compared to those that conducted at least one pediatric LDKT or DDKT procedure (67, 136, and 155 centers, respectively). Five centers performed 31% of the pediatric KPD transplants. After adjustment, there were no differences in graft failure or mortality comparing KPD recipients to non-KPD LDKT, LDKT, or DDKT recipients. DISCUSSION We did not observe differences in transplant outcomes comparing pediatric KPD recipients to controls. Considering these results, KPD may be underutilized for pediatric recipients. Pediatric KT centers should consider including KPD in KT candidate education. Further research will be necessary to develop tools that could aid clinicians and families considering the time horizon for future KT procedures, candidate disease and histocompatibility characteristics, and other factors including logistics and donor protections.
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Affiliation(s)
| | - Alvin G Thomas
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
- Department of Surgery, New York University Langone Health, New York, New York, USA
| | - Amy D Waterman
- Department of Surgery, Houston Methodist, Houston, Texas, USA
| | - Sunil Karhadkar
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Dorry L Segev
- Department of Surgery, New York University Langone Health, New York, New York, USA
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
| | - Julien Hogan
- Université Paris Cité, INSERM, UMR-S970, PARCC, Paris Translational Research Center for Organ Transplantation, Paris, France
- Pediatric Nephrology Department, Robert Debré Hospital, APHP, Paris, France
| | - Matt Cooper
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Charnaya O, Zeiser L, Yisar D, Goldberg A, Segev DL, Massie A, Garonzik-Wang J, Verghese P. The unfinished journey toward transplant equity: an analysis of racial/ethnic disparities for children after the implementation of the Kidney Allocation System in 2014. Pediatr Nephrol 2023; 38:1275-1289. [PMID: 35816202 PMCID: PMC10848995 DOI: 10.1007/s00467-022-05676-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Disparities in pediatric kidney transplantation (KT) result in reduced access and worse outcomes for minority children. We assessed the impact of recent systems changes on these disparities. METHODS This is a retrospective cohort study of pediatric patients utilizing data from the US Renal Data System (n = 7547) and Scientific Registry of Transplant Recipients (n = 6567 waitlisted and n = 6848 transplanted patients). We compared access to transplantation, time to deceased donor kidney transplant (DDKT), and allograft failure (ACGF) in the 5 years preceding implementation of the Kidney Allocation System (KAS) to the 5 years post-KAS implementation 2010-2014 vs. 2015-2019, respectively. RESULTS Compared to the pre-KAS era, post-KAS candidates were more likely to be pre-emptively listed (26.8% vs. 38.1%, p < 0.001), pre-emptively transplanted (23.8% vs. 28.0%, p < 0.001), and less likely to have private insurance (35.6% vs. 32.3%, p = 0.01), but these were not uniform across racial groups. Compared to white children, Black and Hispanic children had a lower likelihood of transplant listing within 2 years of first dialysis service (aHR 0.590.670.76 and 0.730.820.92, respectively) in the post-KAS era. Time to DDKT was comparable across all racial groups in the post-KAS era. Compared to white children, Black DDKT recipients have more 5-year ACGF (aHR 1.001.432.06 p = 0.05) while there was no difference in 3- or 5-year ACGF among LDKT recipients. CONCLUSIONS After KAS implementation, there is equity in time to DDKT. Pre-KAS increased hazard of ACGF among Black children has decreased in the post-KAS era; however, persistent disparities exist in time to transplant listing among Black and Hispanic children when compared to white children. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Olga Charnaya
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Laura Zeiser
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Dolev Yisar
- Medical School for International Health, Ben-Gurion University of the Negev, Be-er Sheva, Israel
| | - Aviva Goldberg
- Department of Pediatric Nephrology, University of Manitoba, Winnipeg, Canada
| | - Dorry L Segev
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
- Scientific Registry of Transplant Recipients, Minneapolis, MN, USA
| | - Allan Massie
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Jacqueline Garonzik-Wang
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Priya Verghese
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Northwestern University, Chicago, IL, USA
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10
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Engen RM, Smith JM, Bartosh SM. The kidney allocation system and pediatric transplantation at 5 years. Pediatr Transplant 2022; 26:e14369. [PMID: 35919967 DOI: 10.1111/petr.14369] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/07/2022] [Accepted: 07/17/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND A new Kidney Allocation System (KAS) was implemented in the United States in 2014 with the goal of improving equity and utility. METHODS In this study, we compare outcomes for kidney-alone candidates less than 18 years of age, at the time of listing, in the 5 years prior to and following policy implementation using Organ Procurement and Transplantation Network data. RESULTS While the pediatric deceased donor transplant rate increased under KAS, this increase was due solely to improved access for children aged 11-17 years; there was an 18.9% decrease in the deceased donor transplant rate among children 0-5 years old, from 117.94 to 95.8 transplants per 100 person-years (p = .001). The cumulative incidence of deceased donor transplantation by 1 year after listing decreased from 39.3% in the pre-KAS era to 35.5% in the post-KAS era (p = .004), a decline that was driven entirely by longer wait times for children 0-5 years old (p = .017). Candidates with a calculated panel reactive antibody of 98%-100% experienced a significant increase in transplant rate, but there was no change in transplant rate for Black or Hispanic candidates. CONCLUSION Overall, KAS increased transplantation access for teenaged and highly sensitized candidates but resulted in decreased access for the youngest children with no improvement in racial/ethnic equality.
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Affiliation(s)
- Rachel M Engen
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Jodi M Smith
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Sharon M Bartosh
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
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11
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Charnaya O, Levy Erez D, Amaral S, Monos DS. Pediatric Kidney Transplantation-Can We Do Better? The Promise and Limitations of Epitope/Eplet Matching. Front Pediatr 2022; 10:893002. [PMID: 35722502 PMCID: PMC9204054 DOI: 10.3389/fped.2022.893002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/16/2022] [Indexed: 12/02/2022] Open
Abstract
Kidney transplant is the optimal treatment for end-stage kidney disease as it offers significant survival and quality of life advantages over dialysis. While recent advances have significantly improved early graft outcomes, long-term overall graft survival has remained largely unchanged for the last 20 years. Due to the young age at which children receive their first transplant, most children will require multiple transplants during their lifetime. Each subsequent transplant becomes more difficult because of the development of de novo donor specific HLA antibodies (dnDSA), thereby limiting the donor pool and increasing mortality and morbidity due to longer time on dialysis awaiting re-transplantation. Secondary prevention of dnDSA through increased post-transplant immunosuppression in children is constrained by a significant risk for viral and oncologic complications. There are currently no FDA-approved therapies that can meaningfully reduce dnDSA burden or improve long-term allograft outcomes. Therefore, primary prevention strategies aimed at reducing the risk of dnDSA formation would allow for the best possible long-term allograft outcomes without the adverse complications associated with over-immunosuppression. Epitope matching, which provides a more nuanced assessment of immunological compatibility between donor and recipient, offers the potential for improved donor selection. Although epitope matching is promising, it has not yet been readily applied in the clinical setting. Our review will describe current strengths and limitations of epitope matching software, the evidence for and against improved outcomes with epitope matching, discussion of eplet load vs. variable immunogenicity, and conclude with a discussion of the delicate balance of improving matching without disadvantaging certain populations.
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Affiliation(s)
- Olga Charnaya
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Daniella Levy Erez
- Schneider Children's Medical Center, Institute of Pediatric Nephrology, Petah Tikvah, Israel
- Departments of Pediatric Nephrology and Biostatistics, Epidemiology and Informatics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sandra Amaral
- Departments of Pediatric Nephrology and Biostatistics, Epidemiology and Informatics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Dimitrios S. Monos
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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12
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Laster M, Norris KC. Equitable Transplantation: A Modifiable Risk Factor for Disparities in Mortality in ESKD. J Am Soc Nephrol 2022; 33:1240-1241. [PMID: 35365573 PMCID: PMC9257812 DOI: 10.1681/asn.2022030273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Marciana Laster
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Keith C Norris
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
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