Recent strategies, including policy changes, have not improved access to kidney transplant
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Despite research and policy changes from an increasing awareness that access to kidney transplantation is limited for many Americans with kidney failure, researchers found no improvements in access to transplant in 2 decades.
“These findings suggest that the cumulative efforts to improve access to transplantation have had minimal effect in the overall population and more effective strategies are needed,” first author Jesse Schold, PhD, MStat, MEd, of the Cleveland Clinic, said in a press release. “In addition, disparities in access to transplantation are striking and suggest that many factors beyond clinical risks and viability for the procedure impact patients’ ability to receive a transplant.”
For the study, researchers identified 1,309,998 adults from the U.S. Renal Data System who had end-stage kidney disease onset, were placed on the wait list or were transplanted between 1997 and 2016. Time was divided into the following five eras: 1997 to 2000, 2001 to 2004, 2005 to 2008, 2009 to 2012 and 2013 to 2016.
“We used a composite endpoint of time to the earliest date of either placement on the kidney transplant waiting list or receipt of living donor transplantation (WLT) if this occurred prior to placement on the waiting list,” the researchers wrote. “Policy changed over the study period such that in earlier years patients could receive a living donor transplant without being placed on the waiting list while in more recent years (since September 1, 2014) all patients are placed on the waiting list even if the intent is to receive a living donor transplant.”
Results showed the overall incidence of WLT within 1 year of ESKD was 19%, which proved to be consistent over time. Similarly, the researchers found the incidence of waitlisting or transplantation within 4 years of ESKD was 29.7% and also remained “unchanged” over time.
In addition, the adjusted hazard of WLT after dialysis significantly declined over time (adjusted hazard ratio =0.80).
“The primary findings of the study demonstrate that there has been no measurable progress in improving access to kidney transplantation over the past [2] decades,” the researchers wrote. “The [4]-year incidence of placement on the waiting list or transplantation following initial ESRD onset has been stagnant at approximately 30% for the entire [20]-year study period.”
Regarding disparities, the researchers found WLT incidence was substantially lower among patients in lower-income communities with no improvement over time; African American patients were least likely to be waitlisted or transplanted throughout each era.
“These disappointing results exist despite vast research literature depicting barriers to transplantation, numerous interventional studies demonstrating effective modalities for improving access to care, significant advances in clinical transplant medicine and surgery and robust empirical studies validating the benefits of transplantation including relatively high-risk populations,” Schold and colleagues concluded of the findings. “While results of the study indicate increased rates of preemptive access to transplantation, the majority of patients do not gain access to transplant until after dialysis initiation and access to transplantation declined over time following dialysis initiation. In addition, results indicated prominent socioeconomic barriers to transplantation which did not change over the study period.”
In the press release, Schold proposed strategies that could lead to improvements in kidney transplantation.
“These may include systematic capture of patients referred and evaluated for transplantation, automated referral of patients for transplantation based on eligibility criteria, and incentive policies such as those initiated by the Executive Order for Advancing American Kidney Health,” he said.
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