Failure to Advance Access to Kidney Transplantation over Two Decades in the United States

Jesse D. Schold; Sumit Mohan; Anne Huml; Laura D. Buccini; John R. Sedor; Joshua J. Augustine; Emilio D. Poggio

doi:10.1681/ASN.2020060888

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Visual Abstract

Significance Statement

There have been numerous research studies and policies developed to improve access to kidney transplantation among patients with ESKD over past decades. In this retrospective cohort study, the authors evaluated the longitudinal pattern of rates of placement on the transplant waiting list and transplantation among the ESKD population, as well as whether patterns were consistent in the population or varied among patient groups with historically low rates of access to transplantation. The study’s primary findings indicated no improvement in the incidence of placement on the transplant waiting list over a two-decade period from 1997 to 2016. In addition, rates of wait list placement and transplantation were consistently reduced among vulnerable populations. These results indicate that more effective interventions are needed to improve access to transplantation in the United States.

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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