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New Kidney Allocation System has not ended socioeconomic disparities in preemptive transplant
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Despite the implementation of the Kidney Allocation System in 2014, black and Hispanic patients — as well as those receiving Medicare instead of holding private insurance —continue to have lower odds of preemptive kidney transplantation, according to a recently published study.
“Despite the benefits of preemptive transplantation, including improved outcomes, fewer complications and system-wide economic benefits, most patients are waitlisted after initiating dialysis,” Kristen L. King, MPH, of Columbia University Medical Center, and colleagues wrote. “Significant racial disparities have been described in kidney transplantation, including preemptive waitlisting, duration of pretransplant dialysis, rates of kidney transplantation and post-transplant outcomes ... The new Kidney Allocation System (KAS) was designed in part to address racial and other disparities in kidney transplantation. Although there appears to be substantial progress made toward certain goals related to kidney disease, the proportion of preemptive transplants being performed after the 2014 introduction of KAS has not been studied previously.”
Using the Scientific Registry of Transplant Recipients, researchers identified 157,073 patients who received a deceased donor kidney transplant between 2000 and 2018 (14,620 with preemptive transplant; 142,453 with non-preemptive transplant).
They compared preemptive kidney transplant rates — considering recipient sociodemographic characteristics, transplant characteristics, donor characteristics and transplant complications — between pre- and post-KAS policy changes (noting that transplants that occurred during 2014 were excluded to account for the transition period).
Researchers found the proportion of preemptive transplants increased from 9% to 9.8% after the implementation of KAS, with 1.10-times higher odds of preemptive transplantation post KAS.
Patients who received preemptive transplants were more likely to be white, older, female, more educated, have private insurance and to have ESKD cause other than diabetes or hypertension. Researchers emphasized that, compared with recipients with private insurance, those with Medicaid became even less likely to receive their transplant preemptively in the post-KAS era.
“Significant disparities in preemptive kidney transplantation persist and appear to have been exacerbated after KAS, especially regarding race and insurance, despite an overall increase in the proportion of kidneys transplanted preemptively,” the researchers wrote. “Increased disparity between those with private insurance and those without suggests larger health policy issues around equal access to care. Because preemptive transplantation is associated with improved patient and graft outcomes, further efforts to reduce disparities on the basis of sociodemographic characteristics are needed to achieve more equitable outcomes for patients with ESKD.”
In a related editorial, Tanjala S. Purnell, PhD, MPH, and Deidra C. Crews, MD, ScM, both of the Johns Hopkins Center for Medical Equity, wrote: “With their focus on preemptive deceased donor kidney transplantation rates after a policy change, King et al. offer a timely analysis as the United States policies surrounding kidney disease care come into sharper focus ... Signed by executive order, ‘Advancing American Kidney Health’ aims to double the number of kidneys available for transplant by 2030, and optional care models will include incentives for health care providers whose patients are preemptively transplanted. As kidney care models aimed at achieving this and other goals of the order are launched, the potential effect on disparities in access to preemptive (and non-preemptive) transplants should be a focus. Thoughtfully developed, executed, and monitored, the programs stemming from this initiative could offer an opportunity to mitigate disparities.” – by Melissa J. Webb
Disclosures: King reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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