Racial disparities, poor insurance restrict access for younger patients seeking transplant
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The kidney transplant waitlist in the U.S. has shrunk over the last 2 decades, partly because racial disparities and economics prevent younger patients from gaining access, a speaker said during the virtual American Transplant Congress.
“Despite the fact that we have 500,000 patients with end-stage kidney disease, we have fewer than 100,000 patients currently on the waitlist,” Sumit Mohan, MD, MPH, an associate professor of medicine at Columbia University Vagelos College of Physicians and Surgeons and of epidemiology at Mailman School of Public Health, said during a presentation. “A small fraction of these individuals will eventually get a transplant.”
The path for patients to get waitlisted for a kidney transplant is long, according to Mohan. Patients “must be educated about their transplant options, they must be referred for transplantation [and] undergo an extensive evaluation before they’re going to get waitlisted,” Mohan said. “There is attrition at each step of the way.”
Waitlist declines
The decline in the number of patients on the waitlist can be traced to changes in the kidney allocation system that were introduced in 2014, Mohan said.
“It was designed essentially to eliminate the disadvantage that is associated with late referrals for those individuals who are referred late for transplant, often many years after being started on dialysis,” he said. “(Although) that was very effective in eliminating that disparity, what it has done instead is eliminated the sense of urgency to waitlist patients. And so, when you eliminate the sense of urgency to waitlist patients, it should come as no surprise that the proportion of patients who have been waitlisted has started to decline.
“In fact, the waitlist in the United States now contains the lowest number of prevalent ESKD patients over the past 2 decades,” Mohan said.
Dialysis center selection
The reasons for the drop in patients on the kidney transplant waitlist cannot be pinpointed to transplant centers only; dialysis unit ownership has had a significant impact on access to the waitlist. “And this isn’t just a fringe set of patients; among patients under the age of 60 [years], we have seen a relative decrease in the proportion of patients who are on the waitlist,” Mohan said.
That selectivity, Mohan said, can be traced to certain geographic areas of the country, where transplants are fewer — namely, the South and Southeast regions of the country, he said.
Other factors impede access to the waitlist, as well, Mohan said. Residential median household income “plays a significant role,” he said. “ So, the higher the median household income, the greater the incidence of waitlist placement or organ transplantation by ZIP code, and this is a trend that has remained essentially unchanged over the last 2 decades.”
Likewise, disparities are impacting preemptive transplantation; whether the patient is on public insurance or private insurance appears to influence whether the transplant occurs.
“Large disparities, both racial and socioeconomic, exist in access to the waitlist and to transplant, even for the youngest patients,” Mohan said. “Waitlist access has not improved in 2 decades and economic factors continue to contribute to these disparities. Our youngest patients with ESKD are also being left behind, which should trouble all of us.”
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Mohan S. “We don’t know what we don’t know: Lack of access, kidney waiting list and the transplant patient.” Presented at: American Transplant Congress; June 4-9, 2021 (Virtual meeting).
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